Threats to international travellers posed by tick-borne diseases

Emerging tick-borne spotted fever group rickettsioses in the Balkans

The impact of tick-borne pathogens (TBPs) on human health has increased in the last decades, since the incidence of emerging and re-emerging infectious and zoonotic tick-borne diseases has increased worldwide. Tick-borne rickettsiae of the Spotted Fever group (SFGR) are considered as emerging pathogens that can infect humans and cause a variety of non-specific clinical symptoms. Here, we report nine cases of atypical tick-borne diseases (9/460; 1.95%) that occurred over a period of four months (from 15 April 2021 to 16 August 2021) in Serbia, from which five cases were classified as confirmed SFGR infection, two cases as probable SFGR infection and two cases as suspected SFGR infection. Within cases of confirmed SFGR infection, R. helvetica was detected as the causative agent in two cases. The most common clinical finding was non-expanding persistent circular redness, followed by eschar and enlargement of regional lymph nodes, and pain at lesion site. Rickettsia outer membrane protein B (ompB) and citrate synthase (gltA) gene fragments were amplified from clinical samples and ticks attached to patients and IgG reacting with Rickettsia conorii antigen were detected in sera samples of patients, which are highly suggestive of exposure to SFGR. Surveillance and monitoring of rickettsial diseases in Serbia should continue and extended to new areas due to the increasing trend of clinical infections caused by SFGR in the country.

Rickettsia africae and Rickettsia massiliae in ixodid ticks infesting small ruminants in agro-pastoral settlements in Plateau State, Nigeria

Arthropods, especially ixodid ticks, have been incriminated in the epidemiology of Spotted Fever Group rickettsioses globally leading to an increasing spectrum of emerging and re-emerging zoonoses with attendant consequences on trade and tourism. The objective of this study was to determine the role of ixodid ticks infesting small ruminants in Plateau State, Nigeria, in the epidemiology of Spotted Fever Group Rickettsiae (SFGR) in the study area. DNA from 130 out of 323 ixodid ticks collected from 179 goats and 121 sheep owned by agro-pastoralists in Plateau State were screened for the evidence of SFGR by molecular methods. Six tick species from four genera were identified: Amblyomma, Hyalomma, Rhipicephalus (Boophilus) and Rhipicephalus. Rhipicephalus sanguineus sensu lato (s.l.) was the predominant (54.5%) species among collected ticks. Tick infestation was significantly associated with the species of small ruminants, the sex of the animals and the sampling locations except for Jos South. Conventional PCR targeting the 381 bp of the citrate synthase (gltA) and 820 bp of the outer membrane protein B (ompB) genes detected DNA of SFGR in nine and eight samples, respectively. Sequence analysis revealed that five sequences obtained from Amblyomma variegatum were 99-100% identical to Rickettsia africae and three sequences from Rh. sanguineus (s.l.) were 100% identical to Rickettsia massiliae reported from Spain. To our knowledge, this is the first report of the detection of R. africae DNA in Am. variegatum collected from small ruminants in Plateau State. Ixodid ticks infesting small ruminants in Plateau state harbor DNA of SFGR with potential veterinary and public health implications.

Epidemiology of Ticks and Tick-Borne Pathogens in Domestic Ruminants across Southern African Development Community (SADC) Region from 1980 until 2021: A Systematic Review and Meta-Analysis

Ticks are hematophagous ectoparasites that are capable of infesting a wide range of mammals, including domestic animals, ruminants, wildlife, and humans across the world, and they transmit disease-causing pathogens. Numerous individual epidemiological studies have been conducted on the distribution and prevalence of ticks and tick-borne diseases (TBDs) in the Southern African Developing Community (SADC) region, but no effort has been undertaken to synchronize findings, which would be helpful in the implementation of consolidated tick control measures. With the aim of generating consolidated pooled prevalence estimates of ticks and TBDs in the SADC region, we performed a systematic review and meta-analysis of published articles using the PRISMA 2020 guidelines. A deep search was performed on five electronic databases, namely, PubMed, ScienceDirect, Google Scholar, AJOL, and Springer Link. Of the 347 articles identified, only 61 of the articles were eligible for inclusion. In total, 18,355 tick specimens were collected, belonging to the genera Amblyomma, Haemaphysalis, Hyalomma, and Rhipicephalus (including Boophilus) across several countries, including South Africa (n = 8), Tanzania (n = 3), Zambia (n = 2), Zimbabwe (n = 2), Madagascar (n = 2), Angola (n = 2), Mozambique (n = 1), and Comoros (n = 1). The overall pooled prevalence estimate (PPE) of TBPs in livestock was 52.2%, with the highest PPE in cattle [51.2%], followed by sheep [45.4%], and goats [29.9%]. For bacteria-like and rickettsial TBPs, Anaplasma marginale had the highest PPE of 45.9%, followed by A. centrale [14.7%], A. phagocytophilum [2.52%], and A. bovis [0.88%], whilst Ehrlichia ruminantium had a PPE of 4.2%. For piroplasmids, Babesia bigemina and B. bovis had PPEs of 20.8% and 20.3%, respectively. Theileria velifera had the highest PPE of 43.0%, followed by T. mutans [29.1%], T. parva [25.0%], and other Theileria spp. [14.06%]. Findings from this study suggest the need for a consolidated scientific approach in the investigation of ticks, TBPs, and TBDs in the whole SADC region, as most of the TBDs are transboundary and require a regional control strategy.

Molecular Interactions During Borrelia burgdorferi Migration from the Vector to the Mammalian Nervous System

Lyme disease (LD) is an infectious disease caused by the spirochetes of genus borrelia, which are transmitted by the ticks of the genus ixodes. LD is transmitted by the spirochete B. burgdorferi sensu lato. Once in contact with the host through a tick bite, the pathogen comes into contact with the host defense, and must escape this machinery to establish LD, thus using a large number of mechanisms involving the vector of the pathogen, the pathogen itself and also the host. The initial diagnosis of the disease can be made based on the clinical symptoms of LD and the disease can be treated and cured with antibiotics if the diagnosis is made early in the beginning of the disease. Contrariwise, if LD is left untreated, the pathogen disseminates throughout the tissues and organs of the body, where it establishes different types of disease manifestations. In the nervous system, the inflammation caused by B. burgdorferi is known as Lyme neuroborreliosis (LNB). LNB is one of the principal manifestations of LD. In this review, we systematically describe the different molecular interactions among B. burgdorferi, the vector (tick) and the mammalian host.

Host immunogenetics in tick-borne encephalitis virus infection-The CCR5 crossroad

The human Tick-borne encephalitis virus (TBEV) infection is a complex event encompassing factors derived from the virus itself, the vectors, the final host, and the environment as well. Classically, genetic traits stand out among the human factors that modify the susceptibility and progression of infectious diseases. However, and although this is a changing scenario, studies evaluating the genetic factors that affect the susceptibility specifically to TBEV infection and TBEV-related diseases are still scarce. There are already some interesting pieces of evidence showing that some genes and polymorphisms have a real impact on TBEV infection. Also, the inflammatory processes involving tick-human interactions began to be understood in greater detail. This review focuses on the immunogenetic and inflammatory aspects concerning tick-host interactions, TBEV infections, and tick-borne encephalitis. Of note, it has been described that polymorphisms in CD209, GSTM1, IL-10, IL-28B, MMP9, OAS2, OAS3, and TLR3 have a statistically significant impact on TBEV infection. Besides, CCR5, its ligands, and the CCR5Δ32 genetic variant seem to have a very important influence on the infection and its immune responses. Taking this information into consideration, a special discussion regarding the effects of CCR5 on TBEV infection and tick-borne encephalitis will be presented. Emerging topics (such as exosomes, evasins, and CCR5 blockers) involving immunological and inflammatory aspects of TBEV-human interactions will also be addressed. Lastly, the current picture of TBEV infection and the importance to address the TBEV-associated problems through the One Health perspective will be discussed.

Molecular detection of Rickettsia spp., Anaplasma platys and Theileria equi in ticks collected from horses in Tayrona National Park, Colombia

Horses are among the domestic animals that closely interact with humans and are highly parasitized by ticks, which are the primary vectors of zoonoses. As horses in Tayrona National Natural Park (PNNT) are used as a means of transporting goods, luggage and people, they are in constant contact with wild animals, workers and tourists from different countries. These factors increase the transmission risk of hemoparasites. The purpose of this study was to determine the presence of Rickettsia sp., Anaplasma sp., and Theileria sp., in horse ticks in this protected area using conventional PCR. We collected 343 ticks of genera Amblyomma, Rhipicephalus and Dermacentor. Of the 61 samples analyzed by PCR, 18 (29.5%) individuals were positive for Rickettsia sp., 15 (24.5%) for Anaplasma sp. and 4 (6.6%) for Theileria sp. This is the first report of these hemoparasite genera in ticks associated with horses in this preserved natural area, demonstrating the importance of additional studies on the presence and epidemiology of hemoparasites and their vectors in domestic and wild animals in conserved areas with a high flow of tourists.

Non-vaccine-Preventable Infections

There are many potentially serious infections that may pose a risk to travellers for which no vaccines are available. Following discussions on vaccines, malaria prevention and travellers’ diarrhoea at the consultation, the travel-medicine practitioner should identify other infectious risks that may apply to the traveller, whether because of destination/s and duration of travel, occupational or other activities, or individual susceptibility. Information should be provided about these infections, their relevance, modes of transmission and methods of prevention, or the traveller should be referred to an authoritative source of information. In this chapter, advice will be given on both destination- and activity-related infections. The risk, distribution, clinical features and methods of prevention of a number of specific infections for which no vaccines are available are then outlined. This includes information on emerging viral infections such as Zika, MERS, Ebola and Chikungunya.

Emerging infectious diseases in Africa in the 21st century

Many infectious diseases have emerged or reemerged in Africa in the 21st century. Some of them are associated with newly discovered microorganisms such as Rickettsia felis and Tropheryma whipplei; others are known, historical diseases such as plague and cholera. In addition are diseases related to previously known microorganisms which recently have been involved for the first time in massive outbreaks with worldwide impacts (such as Ebola virus, Zika virus and Chikungunya virus). Research on emerging infectious diseases needs to be identified as a priority.

Evidence for transovarial transmission of tick-borne rickettsiae circulating in Northern Mongolia

Transstadial transmission of tick-borne rickettsiae has been well documented. Few studies, however, have evaluated the role of transovarial transmission of tick-borne rickettsiae, particularly in nature within the host-vector ecosystem. This cross-sectional study aimed to understand the role of transovarial transmission of tick-borne rickettsiae among feeding ticks at different life stages. Tick eggs laid by engorged wild-caught adult female ticks were pooled and tested for Rickettsia spp. and Anaplasma/Ehrlichia spp. using molecular techniques, while adult fed ticks were tested individually. Additionally, larval and nymphal ticks were collected in the wild from small mammals, pooled and tested for Rickettsia spp. and Anaplasma/Ehrlichia spp. There were 38 fed adult and 618 larvae/nymphs (60 pools total) Dermacentor spp. ticks collected from livestock and rodents. All individual adult ticks and tick pools were positive for Rickettsia spp. While none of the larvae/nymphs were positive for Anaplasma/Ehrlichia spp., two adult fed ticks were positive. Rickettsia spp. DNA was detected in 91% (30/33) of the pooled eggs tested, and one pool of eggs tested positive for Anaplasma/Ehrlichia spp. Sequencing data revealed Rickettsia spp. shared ≥99% identity with R. raoultii ompA. Anaplasma/Ehrlichia spp. shared ≥89% identity with A. ovis 16S ribosomal RNA. This study identified potential transovarial transmission of Rickettsia spp. and Anaplasma spp. among D. nuttalli ticks. Additional studies are needed to further assess the proportion of transovarial transmission occurring in nature to better understand the burden and disease ecology of tick-borne rickettsiae in Mongolia.

In this study, we evaluate the probability or likelihood that tick-borne rickettsiae might be transmitted vertically from wild engorged adult female ticks collected throughout the Northern region of Mongolia during the summer of 2016. While significant effort has been directed to study tick-borne rickettsiae, this public health challenge is complicated by the limited knowledge and understanding of tick and tick-borne rickettsiae ecology within Mongolia. Tick-borne rickettsiae of concern to humans and animals in this region of the world are Rickettsia spp., Anaplasma spp., and Ehrlichia spp. Using molecular techniques, we detected rickettsiae among all Dermacentor spp. tick life stages and demonstrated potential vertical transmission of Rickettsia spp., and Anaplasma spp. among wild engorged adult female Dermacentor nuttalli ticks. We believe our findings provide important information regarding the ecology of key rickettsiae associated with tick-borne disease in Mongolia.

Diagnosis of Spotted Fever Group Rickettsioses in U.S. Travelers Returning from Africa, 2007-2016

Spotted fever group rickettsioses (SFGRs), such as African tick bite fever (ATBF), are among the most commonly diagnosed diseases for ill travelers returning from southern Africa. We summarized demographic, clinical, and diagnostic features of imported SFGR cases in U.S. travelers returning from Africa who had laboratory specimens submitted to the Centers for Disease Control and Prevention. Diagnosis of SFGR was performed by indirect immunofluorescence antibody assay, immunohistochemical staining, polymerase chain reaction (PCR), or culture. Cases were defined as probable SFGR, confirmed SFGR, or confirmed ATBF. Clinical and epidemiological categorical variables were described as counts and proportions; continuous variables were described using geometric mean titers, median, and range. One hundred and twenty-seven patients satisfied laboratory criteria for confirmed or probable SFGR. Fever was the most common symptom (N = 88; 69%), followed by ≥ 1 eschars (N = 70; 55%). Paired serums were submitted for 36 patients (28%); 12 patients (33%) had nonreactive initial serum sample but converted to a titer ≥ 64 with the convalescent sample. Twenty-seven patients (21%) had infection with Rickettsia africae based on PCR analysis of eschar swab (N = 8) or biopsy (N = 23). Fifteen patients had eschar biopsy or swab samples and serum sample(s) submitted together; 9 (60%) had PCR-positive eschar results and nonreactive acute serology. Health-care providers should consider SFGR when evaluating patients for a febrile illness with eschar and compatible foreign travel history. Polymerase chain reaction testing of eschar biopsies or swabs provides a confirmed diagnosis in early stages of disease; eschar swabs or biopsies are an underutilized diagnostic technique.

Tick-borne encephalitis: What travelers should know when visiting an endemic country

Tick-borne encephalitis (TBE) is an acute febrile illness with neurological manifestations that is prevalent in forested areas of moderate climate in Europe and Asia. TBE virus is transmitted by ticks and rarely by unpasteurized milk and dairy products. The disease burden is attributed mainly to resulting long-term disability, especially in individuals over 50 y of age. Currently, there is no causative treatment, but a very effective vaccination is available with a good safety profile. The vaccination requires 3 basic doses to be fully effective and regular boosters afterwards. An accelerated vaccination schedule enables a patient to reach reasonably protective titres within 3 to 4 weeks from the first injection. The risk of travel-related TBE is estimated to be less than the risk of acquiring typhoid fever while visiting highly endemic regions in South Asia, but more than the risk of acquiring Japanese encephalitis, meningococcal invasive disease, or rabies. The pre-travel risk assessment of acquiring TBE should consider known risk factors which include 1) the country and regions to be visited; 2) April to November season; 3) altitude less than 1500 m above the sea level; 4) duration of stay; 5) the extent of tick-exposure associated activities including leisure and professional outdoor activities within the endemic area; and 6) age and comorbidities of the traveler. A major challenge, however, is the very low awareness of the risk of contracting TBE in those who travel to industrialized European countries.

Emerging Infections and Pertinent Infections Related to Travel for Patients with Primary Immunodeficiencies

In today's global economy and affordable vacation travel, it is increasingly important that visitors to another country and their physician be familiar with emerging infections, infections unique to a specific geographic region, and risks related to the process of travel. This is never more important than for patients with primary immunodeficiency disorders (PIDD). A recent review addressing common causes of fever in travelers provides important information for the general population Thwaites and Day (N Engl J Med 376:548-560, 2017). This review covers critical infectious and management concerns specifically related to travel for patients with PIDD. This review will discuss the context of the changing landscape of infections, highlight specific infections of concern, and profile distinct infection phenotypes in patients who are immune compromised. The organization of this review will address the environment driving emerging infections and several concerns unique to patients with PIDD. The first section addresses general considerations, the second section profiles specific infections organized according to mechanism of transmission, and the third section focuses on unique phenotypes and unique susceptibilities in patients with PIDDs. This review does not address most parasitic diseases. Reference tables provide easily accessible information on a broader range of infections than is described in the text.

Molecular surveillance of spotted fever group rickettsioses in wildlife and detection of <i>Rickettsia sibirica</i> in a Topi (<i>Damaliscus lunatus</i> ssp. <i>jimela</i>) in Kenya

Spotted fever group rickettsioses are a group of tick-borne zoonotic diseases caused by intracellular bacteria of the genus Rickettsia. The diseases are widely reported amongst international travellers returning from most sub-Saharan Africa with fever, yet their importance in local populations largely remains unknown. Although this has started to change and recently there have been increasing reports of the diseases in livestock, ticks and humans in Kenya, they have not been investigated in wildlife. We examined the presence, prevalence and species of Rickettsia present in wildlife in two regions of Kenya with a unique human–wildlife–livestock interface. For this purpose, 79 wild animals in Laikipia County and 73 in Maasai Mara National Reserve were sampled. DNA extracted from blood was tested using the polymerase chain reaction (PCR) to amplify the intergenic spacer rpmE-tRNA^fMet and the citrate synthase-encoding gene gltA. Rickettsial DNA was detected in 2 of the 79 (2.5%) animals in Laikipia and 4 of the 73 (5.5%) in Maasai Mara. The PCR-positive amplicons of the gltA gene were sequenced to determine the detected Rickettsia species. This revealed Rickettsia sibirica in a Topi (Damaliscus lunatus ssp. jimela). This is the first report of spotted fever group rickettsioses in wildlife and the first to report R. sibirica in Kenya. The finding demonstrates the potential role of wild animals in the circulation of the diseases.

Rare Cause of Facial Palsy: Case Report of Tick Paralysis by Ixodes Holocyclus Imported by a Patient Travelling into Singapore from Australia

BACKGROUND

Ticks are blood-sucking arachnids that feed on all classes of vertebrates, including humans. Ixodes holocyclus, also known as the Australian Paralysis Tick, is capable of causing a myriad of clinical issues in humans and companion animals, including the transmission of infectious agents, toxin-mediated paralysis, allergic and inflammatory reactions, and mammalian meat allergies in humans. The Australian Paralysis Tick is endemic to Australia, and only two other exported cases have been reported in the literature.

CASE REPORT

We report the third exported case of tick paralysis caused by I. holocyclus, which was imported on a patient into Singapore. We also discuss the clinical course of the patient, the salient points of management, and the proper removal of this tick species. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With increasing air travel, emergency physicians need to be aware of and to identify imported cases of tick paralysis to institute proper management and advice to the patient. We also describe the tick identification features and proper method of removal of this tick species.

Health risks facing travelers to Russia with special reference to natural-focal diseases

BACKGROUND

Russia, an enormous country almost completely located within temperate latitudes, has a broad spectrum of natural landscapes which attract increasing numbers of tourists, from arctic deserts in the north to steppes and deserts in the south. Currently, tourism is undergoing active development in Russia: new travel routes, including ones that involve visiting the wilderness, are steadily appearing. Among the multitude of infectious diseases that can endanger travelers, natural-focal diseases, whose agents and/or carriers are integral to natural landscapes, are especially prominent. Some of the results of the study of natural-focal infections and parasitoses, which are necessary to evaluate the recreational and travel potential of the Russian Federation, are presented and discussed in this article.

METHOD

A cartographical and statistical analysis of infectious and parasitic natural-focal diseases, spanning more than a decade (1997-2013), is the basis of this article.

RESULTS

This analysis, along with that of additional cartographical and textual sources, reveals that natural-focal infections are most diverse between 48° N and 60° N and least diverse in the northern regions of the Far East of Russia. Different regions have different numbers of nosoforms and different morbidity level, which signifies an irregularity in the distribution of parasitic diseases.

CONCLUSIONS

This medico-geographical information may be useful both for individual tourists planning trips to Russia and tour agencies organizing tour groups. It also can be used by health advisers when they consult people before a trip, to assess the actual risks, suggest a number of precautions and pick the particular diseases out of those listed that actually constitute a risk in certain regions, and suggest a suitable preventative treatment if needed.

An overview: tularemia and travel medicine

Tularemia is a bacterial zoonotic infection. The disease is endemic in most parts of the world, has been reported through the northern hemisphere between 30 and 71° N latitude. Francisella tularensis causes infection in a wide range of vertebrates (rodents, lagomorphs) and invertebrates (ticks, mosquitoes and other arthropods). Humans can acquire this infection through several routes including; a bite from an infected tick, deerfly or mosquito, contact with an infected animal or its dead body. It can also be spread to human by drinking contaminated water or breathing contaminated dirt or aerosol. Clinical manifestation of this disease varies depending on the biotype, inoculum and port of entry. Infection is potentially life threatening, but can effectively be treated with antibiotics. Travelers visiting rural and agricultural areas in endemic countries may be at greater risk. Appropriate clothing and use of insect repellants is essential to prevent tick borne illness. Travelers also should be aware of food and waterborne disease; avoid consuming potentially contaminated water and uncooked meat. Physicians should be aware of any clinical presentation of tularemia in the patients returning from endemic areas.

Tick-borne pathogens and associated co-infections in ticks collected from domestic animals in central China

Background

Ticks can transmit a number of pathogens to humans and domestic animals. Tick borne diseases (TBDs), which may lead to organ failure and death have been recently reported in China. 98.75% of the total cases (>1000) in Henan provinces have been reported in Xinyang city. Therefore, the aims of this study were to investigate the fauna of ticks and detect the potential pathogens in ticks in Xinyang, the region of central China.

Methods

Ticks were collected from 10 villages of Xinyang from April to December 2012, from domestic animals including sheep, cattle and dogs. Then identification of ticks and detection of tick-borne pathogens, including Babesia spp., Theileria spp., Anaplasma spp., Ehrlichia spp., Rickettsia spp., tick-borne encephalitis virus (TBEV), Borrelia burgdorferi sensu lato, Leishmania infantum, were undertaken by using polymerase chain reaction assay (PCR) and sequence analysis. Moreover, the co-infection patterns of various pathogens were compared among locations where ticks were collected.

Results

A total of 308 ticks were collected. Two species of Ixodidae were found, namely Haemaphysalis longicornis (96.75%) and Rhipicephalus microplus (3.25%). Five genera of pathogens, namely Theileria spp. (3.25%), Anaplasma spp. (2.92%), Babesia spp. (1.95%), Ehrlichia spp. (2.92%) and Rickettsia spp. (0.65%), were detected in 7 villages. Co-infections by two pathogens were diagnosed in 11.11% of all infected ticks.

Conclusions

Both human and animal pathogens were abundant in ticks in the study areas. Humans and animals in these regions were at a high risk of exposure to piroplasmosis, since piroplasm had the highest rates of infection and co-infection in positive ticks.

Update on tick-borne rickettsioses around the world: a geographic approach

Tick-borne rickettsioses are caused by obligate intracellular bacteria belonging to the spotted fever group of the genus Rickettsia. These zoonoses are among the oldest known vector-borne diseases. However, in the past 25 years, the scope and importance of the recognized tick-associated rickettsial pathogens have increased dramatically, making this complex of diseases an ideal paradigm for the understanding of emerging and reemerging infections. Several species of tick-borne rickettsiae that were considered nonpathogenic for decades are now associated with human infections, and novel Rickettsia species of undetermined pathogenicity continue to be detected in or isolated from ticks around the world. This remarkable expansion of information has been driven largely by the use of molecular techniques that have facilitated the identification of novel and previously recognized rickettsiae in ticks. New approaches, such as swabbing of eschars to obtain material to be tested by PCR, have emerged in recent years and have played a role in describing emerging tick-borne rickettsioses. Here, we present the current knowledge on tick-borne rickettsiae and rickettsioses using a geographic approach toward the epidemiology of these diseases.

Tick-borne encephalitis: a disease neglected by travel medicine

Tick-borne encephalitis (TBE) is a vector-borne disease that is primarily transmitted to humans by infected ticks and causes infection of the central nervous system. Clinical presentations range from meningitis to encephalitis with or without myelitis, and infection may result in death or long-term neurological sequelae. TBE is endemic in regions of at least 27 European as well as in some Asian countries. Infection and disease, however, can be averted successfully by tick-bite prevention and active vaccination. The risk of infection has shifted from daily life and occupational exposure to leisure-time activities, including travelling. Outdoor activities during the tick season with contact with nature increase the risk of tick bites. Although the number of travel-associated cases is unknown, it is certainly under-estimated because there is hardly any awareness of TBE in non-endemic countries. Therefore, the majority of cases remain undiagnosed, also because of the lack of diagnostic serology, as there is no routine screening for TBE in non-endemic regions. Because of the increasing number of travellers from TBE non-endemic to endemic regions, and in view of the fact that TBE was included in the list of notifiable diseases in the European Union in September 2012, this disease needs to become an important issue in travel medicine.

Come fly with me: review of clinically important arboviruses for global travelers

Western tourists are increasingly traveling to exotic locations often located in tropical or subtropical regions of the world. The magnitude of international travel and the constantly changing dynamics of arbovirus diseases across the globe demand up-to-date information about arbovirus threats to travelers and the countries they visit. In this review, the current knowledge on arbovirus threats to global travelers is summarized and prioritized per region. Based on most common clinical syndromes, currently known arboviruses can be grouped to develop diagnostic algorithms to support decision-making in diagnostics. This review systematically combines and structures the current knowledge on medically important travel-related arboviruses and illustrates the necessity of a detailed patient history (travel history, symptoms experienced, vaccination history, engaged activities, tick or mosquito bite and use of repellent and onset of symptoms), to guide the diagnosis.

Tick-borne relapsing fever with cutaneous eschar and radiculopathy, Ethiopia

We report the first confirmed case of tick-borne borreliosis by molecular tools in a French traveler returning from Ethiopia with unusual presentation: the presence of cutaneous eschar after a hard tick-bite suggesting firstly to clinicians a diagnosis of tick-borne rickettsiosis.

Effect of deer density on tick infestation of rodents and the hazard of tick-borne encephalitis. II: population and infection models

Tick-borne encephalitis is an emerging vector-borne zoonotic disease reported in several European and Asiatic countries with complex transmission routes that involve various vertebrate host species other than a tick vector. Understanding and quantifying the contribution of the different hosts involved in the TBE virus cycle is crucial in estimating the threshold conditions for virus emergence and spread. Some hosts, such as rodents, act both as feeding hosts for ticks and reservoirs of the infection. Other species, such as deer, provide important sources of blood for feeding ticks but they do not support TBE virus transmission, acting instead as dead-end (i.e., incompetent) hosts. Here, we introduce an eco-epidemiological model to explore the dynamics of tick populations and TBE virus infection in relation to the density of two key hosts. In particular, our aim is to validate and interpret in a robust theoretical framework the empirical findings regarding the effect of deer density on tick infestation on rodents and thus TBE virus occurrence from selected European foci. Model results show hump-shaped relationships between deer density and both feeding ticks on rodents and the basic reproduction number for TBE virus. This suggests that deer may act as tick amplifiers, but may also divert tick bites from competent hosts, thus diluting pathogen transmission. However, our model shows that the mechanism responsible for the dilution effect is more complex than the simple reduction of tick burden on competent hosts. Indeed, while the number of feeding ticks on rodents may increase with deer density, the proportion of blood meals on competent compared with incompetent hosts may decrease, triggering a decline in infection. As a consequence, using simply the number of ticks per rodent as a predictor of TBE transmission potential could be misleading if competent hosts share habitats with incompetent hosts.

An integrated database on ticks and tick-borne zoonoses in the tropics and subtropics with special reference to developing and emerging countries

Tick-borne zoonoses (TBZ) are emerging diseases worldwide. A large amount of information (e.g. case reports, results of epidemiological surveillance, etc.) is dispersed through various reference sources (ISI and non-ISI journals, conference proceedings, technical reports, etc.). An integrated database-derived from the ICTTD-3 project ( http://www.icttd.nl )-was developed in order to gather TBZ records in the (sub-)tropics, collected both by the authors and collaborators worldwide. A dedicated website ( http://www.tickbornezoonoses.org ) was created to promote collaboration and circulate information. Data collected are made freely available to researchers for analysis by spatial methods, integrating mapped ecological factors for predicting TBZ risk. The authors present the assembly process of the TBZ database: the compilation of an updated list of TBZ relevant for (sub-)tropics, the database design and its structure, the method of bibliographic search, the assessment of spatial precision of geo-referenced records. At the time of writing, 725 records extracted from 337 publications related to 59 countries in the (sub-)tropics, have been entered in the database. TBZ distribution maps were also produced. Imported cases have been also accounted for. The most important datasets with geo-referenced records were those on Spotted Fever Group rickettsiosis in Latin-America and Crimean-Congo Haemorrhagic Fever in Africa. The authors stress the need for international collaboration in data collection to update and improve the database. Supervision of data entered remains always necessary. Means to foster collaboration are discussed. The paper is also intended to describe the challenges encountered to assemble spatial data from various sources and to help develop similar data collections.

A clear and present danger: tick-borne diseases in Europe

Ticks can transmit a variety of viruses, bacteria or parasites that can cause serious infections or conditions in humans and animals. While tick-borne diseases are becoming an increasing and serious problem in Europe, tick-borne diseases are also responsible for major depressions in livestock production and mortality in sub-Saharan Africa, Latin America and Asia. This review will focus on the most important circulating tick-transmitted pathogens in Europe (Borrelia spp., Anaplasma phagocytophilum, Babesia spp., tick-borne encephalitis virus, Rickettsia spp. and Crimean-Congo hemorrhagic fever virus).

Public health threat of new, reemerging, and neglected zoonoses in the industrialized world

Improving our capacity to respond to these pathogens is essential.

Microbiologic infections acquired from animals, known as zoonoses, pose a risk to public health. An estimated 60% of emerging human pathogens are zoonotic. Of these pathogens, >71% have wildlife origins. These pathogens can switch hosts by acquiring new genetic combinations that have altered pathogenic potential or by changes in behavior or socioeconomic, environmental, or ecologic characteristics of the hosts. We discuss causal factors that influence the dynamics associated with emergence or reemergence of zoonoses, particularly in the industrialized world, and highlight selected examples to provide a comprehensive view of their range and diversity.

Lyme neuroborreliosis: manifestations of a rapidly emerging zoonosis

Lyme disease has a worldwide distribution and is the most common vector-borne disease in the United States. Incidence, clinical manifestations, and presentations vary by geography, season, and recreational habits. Lyme neuroborreliosis (LNB) is neurologic involvement secondary to systemic infection by the spirochete Borrelia burgdorferi in the United States and by Borrelia garinii or Borrelia afzelii species in Europe. Enhanced awareness of the clinical presentation of Lyme disease allows inclusion of LNB in the imaging differential diagnosis of facial neuritis, multiple enhancing cranial nerves, enhancing noncompressive radiculitis, and pediatric leptomeningitis with white matter hyperintensities on MR imaging. The MR imaging white matter appearance of successfully treated LNB and multiple sclerosis display sufficient similarity to suggest a common autoimmune pathogenesis for both. This review highlights differences in the epidemiology, clinical manifestations, diagnosis, and management of Lyme disease in the United States, Europe, and Asia, with an emphasis on neurologic manifestations and neuroimaging.

Is there a need for a travel vaccination against tick-borne encephalitis?

Tick - borne encephalitis is a vector-borne disease primarily transmitted to humans by the bite of infected ticks. Clinical presentations range from mild meningitis to severe encephalitis with or without myelitis and may result in long-term neurological equelae or death. The disease can successfully be prevented through active immunization. BE is endemic in regions of at least 26 European countries. The risk of contracting TBE in the most affected countries has increased in the past 20 to 30 years, between 1974 and 2003, the number of reported clinical TBE cases increased by an appalling 400%, the only exception having been Austria. Because of increasing international travel streams of tourists from non-endemic countries to TBE risk areas, the infection is now becoming a more important issue of travel medicine.The risk depends on both the travelling season and the degree of unprotected outdoor exposure to forest areas (e.g. bicycling, camping, hiking, etc.). Tourists are by no means aware of the actual risk potential, especially when travelling to a knowingly 'safe' Europe. Vaccination against tick-borne encephalitis may be required for some tourists, depending on travel destination and behaviour. Implementing general guidelines for the use of TBE travel vaccination should be put on the agenda for travel medicine.