Monitoring human babesiosis emergence through vector surveillance New England, USA

Assessing the impact of areal unit selection and the modifiable areal unit problem on associative statistics between cases of tick-borne disease and entomological indices

The modifiable areal unit problem (MAUP) is a cause of statistical and visual bias when aggregating data according to spatial units, particularly when spatial units may be changed arbitrarily. The MAUP is a concern in vector-borne disease research when entomological metrics gathered from point-level sampling data are related to epidemiological data aggregated to administrative units like counties or ZIP Codes. Here, we assess the statistical impact of the MAUP when calculating correlations between randomly aggregated cases of anaplasmosis in New York State during 2017 and a geostatistical layer of an entomological risk index for Anaplasma phagocytophilum in blacklegged ticks (Ixodes scapularis Say, Acari: Ixodidae) collected during the fall of 2017. Correlations were also calculated using various administrative boundaries for comparison. We also demonstrate the impact of the MAUP on data visualization using choropleth maps and offer pycnophylactic interpolation as an alternative. Polygon simulations indicate that increasing the number of polygons decreases correlation coefficients and their variability. Correlation coefficients calculated using ZIP Code tabulation area and Census tract polygons were beyond 4 standard deviations from the mean of the simulated correlation coefficients. These results indicate that using smaller polygons may not best incorporate the geographical context of the tick-borne disease system, despite the tendency of researchers to strive for more granular spatial data and associations.

Prevalence of five human pathogens in host-seeking Ixodes scapularis and Ixodes pacificus by region, state, and county in the contiguous United States generated through national tick surveillance

The majority of vector-borne disease cases reported in the United States (U.S.) are caused by pathogens spread by the blacklegged tick, Ixodes scapularis. In recent decades, the geographic ranges of the tick and its associated human pathogens have expanded, putting an increasing number of communities at risk for tick-borne infections. In 2018, the U.S. Centers for Disease Control and Prevention (CDC) initiated a national tick surveillance program to monitor changes in the distribution and abundance of ticks and the presence and prevalence of human pathogens in them. We assessed the geographical representativeness of prevalence data submitted to CDC as part of the national tick surveillance effort. We describe county, state, and regional variation in the prevalence of five human pathogens (Borrelia burgdorferi sensu stricto (s.s.), Borrelia mayonii, Borrelia miyamotoi, Anaplasma phagocytophilum, and Babesia microti) in host-seeking I. scapularis and I. pacificus nymphs and adults. Although I. scapularis and I. pacificus are widely distributed in the eastern and western U.S., respectively, pathogen prevalence was estimated predominantly in ticks collected in the Northeast, Ohio Valley, and Upper Midwest regions, where human Lyme disease cases are most commonly reported. Within these regions, we found that state and regional estimates of pathogen prevalence generally reached predictable and stable levels, but variation in prevalence estimates at the sub-state level was considerable. Borrelia burgdorferi s.s. was the most prevalent and widespread pathogen detected. Borrelia miyamotoi and A. phagocytophilum shared a similarly broad geographic range, but were consistently detected at much lower prevalence compared with B. burgdorferi s.s. Babesia microti was detected at similar prevalence to A. phagocytophilum, where both pathogens co-occurred, but was reported over a much more limited geographic range compared with A. phagocytophilum or B. burgdorferi s.s. Borrelia mayonii was identified at very low prevalence with a focal distribution within the Upper Midwest. National assessments of risk for tick-borne diseases need to be improved through collection and testing of ticks in currently under-represented regions, including the West, South, Southeast, and eastern Plains states.

Human-Biting Ixodes scapularis Submissions to a Crowd-Funded Tick Testing Program Correlate with the Incidence of Rare Tick-Borne Disease: A Seven-Year Retrospective Study of Anaplasmosis and Babesiosis in Massachusetts

Tick-borne zoonoses pose a serious burden to global public health. To understand the distribution and determinants of these diseases, the many entangled environment-vector-host interactions which influence risk must be considered. Previous studies have evaluated how passive tick testing surveillance measures connect with the incidence of human Lyme disease. The present study sought to extend this to babesiosis and anaplasmosis, two rare tick-borne diseases. Human cases reported to the Massachusetts Department of Health and submissions to TickReport tick testing services between 2015 and 2021 were retrospectively analyzed. Moderate-to-strong town-level correlations using Spearman's Rho (ρ) were established between Ixodes scapularis submissions (total, infected, adult, and nymphal) and human disease. Aggregated ρ values ranged from 0.708 to 0.830 for anaplasmosis and 0.552 to 0.684 for babesiosis. Point observations maintained similar patterns but were slightly weaker, with mild year-to-year variation. The seasonality of tick submissions and demographics of bite victims also correlated well with reported disease. Future studies should assess how this information may best complement human disease reporting and entomological surveys as proxies for Lyme disease incidence in intervention studies, and how it may be used to better understand the dynamics of human-tick encounters.

Identifying suitable habitat for Ixodes scapularis (Acari: Ixodidae) infected with Anaplasma phagocytophilum (Rickettsiales: Anaplasmataceae), Babesia microti (Piroplasmida: Babesiidae), and Borrelia miyamotoi (Spirochaetales: Spirochaetaceae) to guide surveillance efforts in the eastern United States

Understanding the distribution of infected ticks is informative for the estimation of risk for tickborne diseases. The blacklegged tick, Ixodes scapularis (Acari: Ixodidae), is the primary vector for 7 medically significant pathogens in United States. However, knowledge of the ranges of these pathogens in host-seeking ticks is incomplete, particularly for those occurring at low prevalence. To aid in prioritizing costly field sampling efforts, we estimated ranges of suitable habitat for Anaplasma phagocytophilum, Babesia microti, and Borrelia miyamotoi in the eastern United States based on existing county-level surveillance records. The resulting suitability maps were compared against those developed previously for Bo. burgdorferi s.s., which shares similar ecology but has been detected in a greater number of counties. The overall accuracy of the habitat suitability models was high (AUC ≥ 0.92) for all 4 pathogens. The most important predictors were related to temperature and moisture. The upper midwestern and northeastern states were predicted to be highly suitable for all 4 pathogens. Based on our models, we prioritized sampling in 431, 275, and 539 counties currently lacking pathogen records that our models classified as suitable for A. phagocytophilum, Ba. microti, and Bo. miyamotoi, respectively. As a second-tier priority, we identified 311 (A. phagocytophilum), 590 (Ba. microti), and 252 (Bo. miyamotoi) counties, based on high suitability scores for Bo. burgdorferi. Our models can be used to improve cost-effectiveness of field sampling efforts aimed at improving accuracy and completeness of pathogen distribution maps.

Deployment of a Reservoir-Targeted Vaccine Against Borrelia burgdorferi Reduces the Prevalence of Babesia microti Coinfection in Ixodes scapularis Ticks

In the Northeast and upper Midwest of the United States, Babesia microti and Borrelia burgdorferi use Ixodes scapularis ticks as vector and Peromyscus leucopus mice as major reservoir host. We previously established, in a 5-year field trial, that a reservoir-targeted outer surface protein A vaccine reduces the prevalence of B. burgdorferi-infected ticks. We accessed ticks and mouse blood samples collected during the trial, extracted total DNA, and amplified the B. microti 18S rRNA gene. Vaccine deployment reduced the prevalence of ticks coinfected with B. microti and that of mice infected with B. microti. Breaking the enzootic cycle of B. burgdorferi may reduce the incidence of babesiosis.

Passive collection of ticks in New Hampshire reveals species-specific patterns of distribution and activity

Ticks and tick-borne diseases are increasing in the United States, including New Hampshire (NH). We report on the findings of an ongoing free crowdsourcing program spanning four years within NH. The date of tick's submission was recorded along with species, sex, stage, location they were collected (translated into latitude and longitude), the activity the individual was doing when the tick was found, and host species. A total of 14,252 ticks belonging to subclass Acari, family Ixodidae and genera Ixodes, Dermacentor, Amblyomma, and Haemaphysalis was recorded from the period 2018-2021 throughout NH. A total of 2,787 Ixodes scapularis and 1,041 Dermacentor variabilis, were tested for the presence of Borrelia sp. (Spirochaetales: Spirochaetaceae), B. burgdorferi sensu lato, B. miyamotoi, B. mayonii, Babesia microti (Piroplasmida: Babesiidae), Anaplasma phagocytophilum (Rickettsiales: Anaplasmataceae), Francisella tularensis (Thiotrichales: Francisellaceae), and Rickettsia rickettsii (Rickettsiales: Rickettsiaceae) by PCR. For the I. scapularis ticks tested, the pathogen prevalence was 37% B. burgdorferi s.l. 1% B. miyamotoi, 6% A. phagocytophilum, and 5% Ba. microti. Only one D. variabilis resulted positive to F. tularensis. We created state-wide maps informing the differences of ticks as detailed by administrative divisions. Dermacentor variabilis peaked in June and I. scapularis peaked in May and October. The most reported activity by people with tick encounters was while walking/hiking, and the least was biking. Using the reported distribution of both species of ticks, we modeled their climate suitability in the target territory. In NH, I. scapularis and D. variabilis have distinct patterns of emergence, abundance, and distribution. Tick prevention is important especially during April-August when both tick species are abundant and active.

Importance of Host Abundance and Microhabitat in Tick Abundance

To reduce the risk of zoonoses, it is necessary to understand the infection process, including the ecology of animals and vectors (i.e., the 'One Health' approach). In temperate climates, ticks are the major vectors of zoonoses, so factors determining their abundance, such as host mammal abundance and microhabitat conditions, should be clarified. Sika deer (Cervus nippon) are a major tick host and are rapidly expanding their distribution in Japan. We established 12 plots along a gradient of sika deer abundance in Tochigi Prefecture, Japan. We monitored the occurrence of mammal species with camera traps and sampled questing ticks on a monthly basis by flagging along three transects (center of a trail, forest edge, and forest interior) at each site from April to November 2018. The camera traps recorded 12 mammal species, predominantly sika deer. Five Haemaphysalis species and three Ixodes species were sampled. The numbers of ticks sampled were explained by the photographic frequency of sika deer, and partly by that of other mammal species, depending on tick species and their developmental stages. The numbers of sampled adult and nymphal ticks were the highest at the forest edge, where vegetation cover was greatest. Thus, vegetation management in tick habitats and the control of sika deer populations may reduce tick abundance.

Molecular Detection of Anaplasma phagocytophilum and Ehrlichia Species in Ticks Removed from Humans in the Republic of Korea

Human granulocytic anaplasmosis (HGA) and human monocytic ehrlichiosis (HME) are zoonotic tick-borne diseases transmitted via tick bites. To determine the state of human Anaplasma and Ehrlichia infections caused by tick bites in the Republic of Korea (ROK), we conducted a nationwide investigation of human cases of tick bites in 2020. A total of 180 ticks were obtained, comprising Haemaphysalis longicornis (70.0%), Amblyomma testudinarium (17.8%), Ixodes nipponensis (6.1%), H. flava (4.4%), and I. persulcatus (1.7%). In three cases (1.7%; 95% CI: 0.3-4.9), A. phagocytophilum was detected in Ixodes ticks using primers for Anaplasma-specific genes (16s rRNA, ankA, and msp4). Conversely, Ehrlichia sp. was only detected in H. longicornis, in two cases (1.1%; 95% CI: 0.1-4.0). To the best of our knowledge, this is the first record of Ehrlichia sp. in ticks parasitizing humans in the ROK. As concerns remain about the possibility of HGA and HME transmission, continuous monitoring and management of the pathogens and vectors are necessary.

Epidemiology of Hospitalized Patients with Babesiosis, United States, 2010-2016

Babesia spp. are tickborne parasites that cause the clinical infection babesiosis, which has an increasing incidence in the United States. We performed an analysis of hospitalizations in the United States during 2010-2016 in which babesiosis was listed as a diagnosis. We used the National Inpatient Sample database to characterize the epidemiology of Babesia-associated admissions, reflecting severe Babesia-related disease. Over a 7-year period, a total of 7,818 hospitalizations listed babesiosis as a primary or secondary admitting diagnosis. Hospitalizations were seasonal (71.2% occurred during June-August) and situated overwhelmingly in the Northeast and Midwest. The patients were predominantly male and of advanced age, which is consistent with the expected epidemiology. Despite a higher severity of illness in more than (58.5%), the mortality rate was low (1.6%). Comparison with state reporting data suggests that the number of hospitalized persons with babesiosis increased modestly during the observation period.

Global meta-analysis on Babesia infections in human population: prevalence, distribution and species diversity

Human babesiosis is an emerging tick-borne protozoan zoonosis caused by parasites of the genus Babesia and transmitted by ixodid ticks. It was thought to be a public health problem mainly for the immunocompromised, however the increasing numbers of documented cases among immunocompetent individuals is a call for concern. In this systematic review and meta-analysis, we reported from 22 countries and 69 studies, an overall pooled estimate (PE) of 2.23% (95% CI: 1.46-3.39) for Babesia infections in humans. PEs for all sub-groups varied significantly (p < 0.05) with a continental range of 1.54% (95% CI: 0.89-2.65) in North America to 4.17% (95% CI: 2.11-8.06) in Europe. PEs for country income levels, methods of diagnosis, study period, sample sizes, Babesia species and targeted population ranged between 0.43% (95% CI: 0.41-0.44) and 7.41% (95% CI: 0.53-54.48). Babesia microti recorded the widest geographic distribution and was the predominant specie reported in North America while B. divergens was predominantly reported in Europe. Eight Babesia species; B. bigemina, B. bovis, B. crassa-like, B. divergens, B. duncani, B. microti, B. odocoilei and B. venatorum were reported in humans from different parts of the world with the highest prevalence in Europe, lower middle income countries and among individuals with history of tick bite and other tick-borne diseases. To control the increasing trend of this emerging public health threat, tick control in human settlements, the use of protective clothing by occupationally exposed people and the screening of transfusion blood in endemic countries are recommended.Abbreviations AJOL: African Journals OnLine, CI: Confidence interval, CIL: Country income level, df: Degree of freedom, HIC: Higher-income countries, HQ: High quality, I²: Inverse variance index, IFAT: Indirect fluorescent antibody test, ITBTBD: Individuals with tick-bite and tick-borne diseases, JBI: Joanna Briggs Institute, LIC: Lower-income countries, LMIC: Lower middle-income countries, MQ: Medium quality, NA: Not applicable, N/America: North America, OEI: Occupational exposed individuals, OR: Odds ratio, PE: Pooled estimates, PCR: Polymerase chain reaction, Prev: Prevalence, PRISMA: Preferred Reporting System for Systematic Reviews and Meta-Analyses, Q: Cochran's heterogeneity statistic, QA: Quality assessment, Q-p: Cochran's p-value, qPCR: Quantitative polymerase chain reaction, S/America: South America, Seq: Sequencing, UMIC: Upper middle-income countries, USA: United States of America.

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.

Coinfection of Ixodes scapularis (Acari: Ixodidae) Nymphs With Babesia spp. (Piroplasmida: Babesiidae) and Borrelia burgdorferi (Spirochaetales: Spirochaetaceae) in Wisconsin

Borrelia burgdorferi, the spirochete that causes Lyme disease, is endemic and widespread in Wisconsin. Research in the northeastern United States has revealed a positive association between Babesia microti, the main pathogen that causes babesiosis in humans, and Bo. burgdorferi in humans and in ticks. This study was conducted to examine associations between the disease agents in the Upper midwestern United States. Ixodes scapularis Say nymphs (N = 2,858) collected between 2015 and 2017 from nine locations in Wisconsin were tested for Babesia spp. and Borrelia spp. using real-time PCR. Two species of Babesia were detected; Ba. microti and Babesia odocoilei (a parasite of members of the family Cervidae). Prevalence of infection at the nine locations ranged from 0 to 13% for Ba. microti, 11 to 31% for Bo. burgdorferi sensu stricto, and 5.7 to 26% for Ba. odocoilei. Coinfection of nymphs with Bo. burgdorferi and Ba. odocoilei was detected in eight of the nine locations and significant positive associations were observed in two of the eight locations. The prevalence of nymphal coinfection with both and Bo. burgdorferi and Ba. microti ranged from 0.81 to 6.5%. These two pathogens were significantly positively associated in one of the five locations where both pathogens were detected. In the other four locations, the observed prevalence of coinfection was higher than expected in all but one site-year. Clinics and healthcare providers should be aware of the association between Ba. microti and Bo. burgdorferi pathogens when treating patients who report tick bites.

The Contribution of Wildlife Hosts to the Rise of Ticks and Tick-Borne Diseases in North America

Wildlife vertebrate hosts are integral to enzootic cycles of tick-borne pathogens, and in some cases have played key roles in the recent rise of ticks and tick-borne diseases in North America. In this forum article, we highlight roles that wildlife hosts play in the maintenance and transmission of zoonotic, companion animal, livestock, and wildlife tick-borne pathogens. We begin by illustrating how wildlife contribute directly and indirectly to the increase and geographic expansion of ticks and their associated pathogens. Wildlife provide blood meals for tick growth and reproduction; serve as pathogen reservoirs; and can disperse ticks and pathogens-either through natural movement (e.g., avian migration) or through human-facilitated movement (e.g., wildlife translocations and trade). We then discuss opportunities to manage tick-borne disease through actions directed at wildlife hosts. To conclude, we highlight key gaps in our understanding of the ecology of tick-host interactions, emphasizing that wildlife host communities are themselves a very dynamic component of tick-pathogen-host systems and therefore complicate management of tick-borne diseases, and should be taken into account when considering host-targeted approaches. Effective management of wildlife to reduce tick-borne disease risk further requires consideration of the 'human dimensions' of wildlife management. This includes understanding the public's diverse views and values about wildlife and wildlife impacts-including the perceived role of wildlife in fostering tick-borne diseases. Public health agencies should capitalize on the expertise of wildlife agencies when developing strategies to reduce tick-borne disease risks.

Pathogenesis of Borrelia burgdorferi and Babesia microti in TLR4-Competent and TLR4-dysfunctional C3H mice

Toll‐like receptors (TLRs) are a class of membrane‐spanning proteins of host cells. TLR2 and TLR4 are displayed on the surface of macrophages, neutrophils and dendritic cells and recognise structurally conserved microbial signatures defined as Pathogen associated molecular patterns (PAMPs). C3H mice are susceptible to tick‐borne pathogens; Lyme disease causing Borrelia burgdorferi that manifests arthritis and carditis and Apicomplexan protozoan, Babesia microti (Bm) that causes significant parasitemia associated with erythrocytopenia and haemoglobinuria. B. burgdorferi lacks typical TLR4 ligand lipopolysaccharides (LPS) and Bm TLR ligand(s) remain unknown. Only Borrelia lipoproteins that signal through TLR2 are established as PAMPs of these pathogens for TLR2/TLR4. Infection of C3H mice with each pathogen individually resulted in increase in the percentage of splenic B, T and FcR+ cells while their co‐infection significantly diminished levels of these cells and caused increased B. burgdorferi burden in the specific organs. The most pronounced inflammatory arthritis was observed in co‐infected C3H/HeJ mice. Parasitemia levels and kinetics of resolution of Bm in both mice strains were not significantly different. Transfected HEK293 cells showed pronounced signalling by B. burgdorferi through TLR2 and to some extent by TLR4 while Bm and infected erythrocytes did not show any response confirming our results in mice.

Reported County-Level Distribution of Lyme Disease Spirochetes, Borrelia burgdorferi sensu stricto and Borrelia mayonii (Spirochaetales: Spirochaetaceae), in Host-Seeking Ixodes scapularis and Ixodes pacificus Ticks (Acari: Ixodidae) in the Contiguous United States

Lyme disease is the most common vector-borne disease in the United States. While Lyme disease vectors are widespread, high incidence states are concentrated in the Northeast, North Central and Mid-Atlantic regions. Mapping the distribution of Lyme disease spirochetes in ticks may aid in providing data-driven explanations of epidemiological trends and recommendations for targeting prevention strategies to communities at risk. We compiled data from the literature, publicly available tickborne pathogen surveillance databases, and internal CDC pathogen testing databases to map the county-level distribution of Lyme disease spirochetes reported in host-seeking Ixodes pacificus and Ixodes scapularis across the contiguous United States. We report B. burgdorferi s.s.-infected I. scapularis from 384 counties spanning 26 eastern states located primarily in the North Central, Northeastern, and Mid-Atlantic regions, and in I. pacificus from 20 counties spanning 2 western states, with most records reported from northern and north-coastal California. Borrelia mayonii was reported in I. scapularis in 10 counties in Minnesota and Wisconsin in the North Central United States, where records of B. burgdorferi s.s. were also reported. In comparison to a broad distribution of vector ticks, the resulting map shows a more limited distribution of Lyme disease spirochetes.

Impact of Babesia microti infection on the initiation and course of pregnancy in BALB/c mice

Background

Protozoa in the genus Babesia are transmitted to humans through tick bites and cause babesiosis, a malaria-like illness. Vertical transmission of Babesia spp. has been reported in mammals; however, the exact timing and mechanisms involved are not currently known. The aims of this study were to evaluate the success of vertical transmission of B. microti in female mice infected before pregnancy (mated during the acute or chronic phases of Babesia infection) and that of pregnant mice infected during early and advanced pregnancy; to evaluate the possible influence of pregnancy on the course of parasite infections (parasitaemia); and to assess pathological changes induced by parasitic infection.

Methods

The first set of experiments involved two groups of female mice infected with B. microti before mating, and inseminated on the 7th day and after the 40th day post infection. A second set of experiments involved female mice infected with B. microti during pregnancy, on the 4th and 12th days of pregnancy. Blood smears and PCR targeting the 559 bp 18S rRNA gene fragment were used for the detection of B. microti. Pathology was assessed histologically.

Results

Successful development of pregnancy was recorded only in females mated during the chronic phase of infection. The success of vertical transmission of B. microti in this group was 63%. No evidence of pregnancy was found in females mated during the acute phase of infection or on the 4th day of pregnancy. In the group infected on the 12th day of pregnancy, numerous complications including loss of pregnancy and stillbirths were recorded. During the acute phase of infection, parasitaemia was lower in pregnant females in comparison to infected, non-pregnant control females.

Conclusions

Acute B. microti infection prevents the initiation of pregnancy and embryonic development if it occurs during the first trimester, and causes severe complications in foetal BALB/c mice in the second and third trimesters of pregnancy. Chronic B. microti infection has no detrimental impact on the initiation and development of pregnancy, but results in congenital infection of the offspring. Further study is required to determine the extent to which maternal anti-babesial immune responses contribute to compromise pregnancy in the murine model of congenital Babesia infection.

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.

Establishment of a stable transfection method in Babesia microti and identification of a novel bidirectional promoter of Babesia microti

Babesia microti, an emerging human pathogen, is primarily transmitted through a bite of an infected tick and blood transfusions in human. Stable transfection technique has been reported in many protozoan parasites over the past few years. However, in vivo transient and stable transfection method has not been established for Babesia microti. Here, for the first time, we present a method of transient as well as stable transfection of the Babesia microti (B. microti) in the in vivo conditions. We have identified a novel promoter of B. microti. We also demonstrated that Plasmodium berghei DHFR promoter is recognized and functional in B. microti. We show that BM-CTQ41297 promoter control the expression of two genes, which are present on either side and thus represents a bi-functional promoter in B. microti. The predicted promoter activity values using Promoter 2.0 program is higher for BM- CTQ41297 promoter than strong promoters such as β-actin, ef-1β, and many other promoters. Furthermore, we discovered a non-essential locus for the genetic manipulation of the parasite, allowing us to stably integrate foreign genes; GFP, mCherry, into the B. microti. The transfection using an electroporation method and genetic manipulation of B. microti is now achievable and it is possible to obtain transfected viable parasites under in vivo growing conditions. The growth curve analysis of transfected and WT B. microti are similar indicating no defects in the transgenic parasites. This study will enable other researchers in understanding the B. microti biology, host modulation and diverse parasite developmental stages using reverse genetics and holds great potential to identify novel drug targets and vaccine development.

Vertical Transmission: A Vector-Independent Transmission Pathway of Babesia microti in the Natural Reservoir Host Peromyscus leucopus

BACKGROUND

Babesia microti, a malaria-like pathogen, is increasing in mammal and human populations in endemic areas and is unlikely to be the sole result of horizontal pathogen transmission.

METHODS

Peromyscus leucopus mice, natural reservoir hosts, were infected via Ixodes scapularis nymphs. Infected parental females (n = 6) produced F1 offspring (n = 36) that were screened for B. microti using quantitative PCR. Xenodiagnostic larvae were fed on infected offspring to determine horizontal transmission and pathogen viability. Fifty engorged larvae were screened; the rest were allowed to molt and then screened to determine transstadial transmission. Infected F1 generation offspring were placed in breeding groups, producing 34 F2 offspring and screened for B. microti infection. Chronic infection was monitored in parental females since time of initial vector infection.

RESULTS

Vertical transmission of B. microti was 74% efficient in offspring born in the first 6 months. Horizontal transmission occurred in larvae (61% prevalence) and molted nymphs (58% prevalence); these nymphs were able to infect susceptible hosts. F2 generation offspring infection prevalence was 38%. Chronic infection persisted for 1 year in some adults.

CONCLUSIONS

These results demonstrate that vertical transmission is an important nonvector-mediated pathway of B. microti transmission in the natural reservoir host.

Evaluation of the speed of kill of a novel orally administered combination product containing sarolaner, moxidectin and pyrantel (Simparica Trio™) against induced infestations of Ixodes scapularis on dogs

Background

The black-legged (or deer) tick, Ixodes scapularis, commonly infests dogs in the USA and is the vector of important zoonotic pathogens, including Borrelia burgdorferi, the causative agent of Lyme disease. Rapid onset of activity is important in reducing the feeding activity of ticks, thereby reducing the possibility of transmission of infections. The speed of kill of a novel oral combination product, Simparica Trio™ containing sarolaner, moxidectin and pyrantel was evaluated in a well-controlled laboratory study against an existing infestation and subsequent weekly induced infestations of I. scapularis ticks on dogs.

Methods

Dogs were allocated randomly based on host suitability tick counts to treatment with a single dose of either placebo or Simparica Trio™ at the minimum label dose of 1.2 mg/kg sarolaner, 24 µg/kg moxidectin and 5 mg/kg pyrantel (as pamoate salt). All dogs were infested with approximately 50 unfed adult I. scapularis ticks at a 1:1 sex ratio on Days −2, 7, 14, 21, 28 and 35. Tick counts were conducted at 8, 12 and 24 h after treatment on Day 0 and after each subsequent infestation.

Results

No treatment-related adverse events occurred during the study. Dogs in the placebo-treated group maintained adequate tick infestations for the duration of the study. Day 0 tick counts at 8 h after treatment with Simparica Trio™ were reduced relative to placebo against an existing infestation with efficacy of 67.5%, demonstrating that Simparica Trio™ started killing ticks soon after treatment. Efficacy was 98.4 % at 12 h and 99.4% at 24 h. Rapid speed of kill was maintained throughout the month, with efficacy of ≥ 94.2% at 24 h after re-infestation through Day 28.

Conclusions

A single dose of Simparica Trio™ administered orally to dogs at the minimum label dose of 1.2 mg/kg sarolaner, 24 µg/kg moxidectin and 5 mg/kg pyrantel (as pamoate salt) was safe and began to kill existing I. scapularis ticks within 8 h after treatment and resulted in ≥ 94.2% efficacy within 24 h against re-infestations for a month.

Evaluating the effectiveness of an integrated tick management approach on multiple pathogen infection in Ixodes scapularis questing nymphs and larvae parasitizing white-footed mice

We investigated the effectiveness of integrated tick management (ITM) approaches in reducing the burden of infection with Borrelia burgdorferi, Babesia microti, and Anaplasma phagocytophilum in Ixodes scapularis. We found a 52% reduction in encountering a questing nymph in the Metarhizium anisopliae (Met52) and fipronil rodent bait box treatment combination as well as a 51% reduction in the combined white-tailed deer (Odocoileus virginianus) removal, Met52, and fipronil rodent bait box treatment compared to the control treatment. The Met52 and fipronil rodent bait box treatment combination reduced the encounter potential with a questing nymph infected with any pathogen by 53%. Compared to the control treatment, the odds of collecting a parasitizing I. scapularis infected with any pathogen from a white-footed mouse (Peromyscus leucopus) was reduced by 90% in the combined deer removal, Met52, and fipronil rodent bait box treatment and by 93% in the Met52 and fipronil rodent bait box treatment combination. Our study highlights the utility of these ITM measures in reducing both the abundance of juvenile I. scapularis and infection with the aforementioned pathogens.

Advancing the Science of Tick and Tick-Borne Disease Surveillance in the United States

Globally, vector-borne diseases are an increasing public health burden; in the United States, tick-borne diseases have tripled in the last three years. The United States Centers for Disease Control and Prevention (CDC) recognizes the need for resilience to the increasing vector-borne disease burden and has called for increased partnerships and sustained networks to identify and respond to the most pressing challenges that face vector-borne disease management, including increased surveillance. To increase applied research, develop communities of practice, and enhance workforce development, the CDC has created five regional Centers of Excellence in Vector-borne Disease. These Centers are a partnership of public health agencies, vector control groups, academic institutions, and industries. This special issue on tick and tick-borne disease surveillance is a collection of research articles on multiple aspects of surveillance from authors that are affiliated with or funded by the CDC Centers of Excellence. This body of work illustrates a community-based system of research by which participants share common problems and use integrated methodologies to produce outputs and effect outcomes that benefit human, animal and environmental health.

Splenic infarction in babesiosis: A rare presentation

Babesiosis is a protozoan parasitic infection transmitted by the Ixodes tick. Splenic infarction is a rare, but potentially life-threatening complication of babesiosis; it is therefore vital that this complication is recognized.

Increasing Babesiosis in Southeastern Pennsylvania, 2008-2017

Tick-borne illnesses are increasing but are often underreported. Few cases of babesiosis have been reported from Pennsylvania. Our 4-hospital system in southeastern Pennsylvania saw a rise in cases from 7 or fewer yearly in 2008–2014 to 26 cases in 2015. There appear to be multiple potential causes of this increase in frequency.

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.

Transfusion-Transmitted Babesiosis

Babesiosis is most commonly caused by Babesia microti and is transmitted via the bite of an infected Ixodes spp tick. However, Babesia is also transmitted via blood transfusion. In the United States, the first case of transfusion-transmitted babesiosis was recognized in 1979, and in recent years, the incidence has rapidly increased. Because most of the infected blood donors do not experience any symptoms, they pose a significant risk to the blood supply. Donor deferral for a history of babesiosis is currently performed but is ineffective. In March 2018, the FDA licensed a DNA PCR and antibody assay that were used in tandem in pivotal trials for screening blood donors for B microti; with other assays still being evaluated under investigational new drug protocols. Blood donation screening is essential to reducing the risk of transfusion-transmitted babesiosis, which is why blood centers collecting in geographic regions of highest risk have been testing since approximately 2010. Investigational NAT assays of higher sensitivity are pending FDA review. Further, in July 2018, the FDA issued a draft guidance for reducing the risk of transfusion-transmitted babesiosis. Release of the final guidance may be postponed until sensitivities and specificities of all current and potential strategies have been properly evaluated.

Investigating disease severity in an animal model of concurrent babesiosis and Lyme disease

The incidence of babesiosis, Lyme disease and other tick-borne diseases has increased steadily in Europe and North America during the last five decades. Babesia microti is transmitted by species of Ixodes, the same ticks that transmit the Lyme disease-causing spirochete, Borrelia burgdorferi. B. microti can also be transmitted through transfusion of blood products and is the most common transfusion-transmitted infection in the U.S.A. Ixodes ticks are commonly infected with both B. microti and B. burgdorferi, and are competent vectors for transmitting them together into hosts. Few studies have examined the effects of coinfections on humans and they had somewhat contradictory results. One study linked coinfection with B. microti to a greater number of symptoms of overall disease in patients, while another report indicated that B. burgdorferi infection either did not affect babesiosis symptoms or decreased its severity. Mouse models of infection that manifest pathological effects similar to those observed in human babesiosis and Lyme disease offer a unique opportunity to thoroughly investigate the effects of coinfection on the host. Lyme disease has been studied using the susceptible C3H mouse infection model, which can also be used to examine B. microti infection to understand pathological mechanisms of human diseases, both during a single infection and during coinfections. We observed that high B. microti parasitaemia leads to low haemoglobin levels in infected mice, reflecting the anaemia observed in human babesiosis. Similar to humans, B. microti coinfection appears to enhance the severity of Lyme disease-like symptoms in mice. Coinfected mice have lower peak B. microti parasitaemia compared to mice infected with B. microti alone, which may reflect attenuation of babesiosis symptoms reported in some human coinfections. These findings suggest that B. burgdorferi coinfection attenuates parasite growth while B. microti presence exacerbates Lyme disease-like symptoms in mice.

Ticks and Tick-Borne Infections: Complex Ecology, Agents, and Host Interactions

Ticks transmit the most diverse array of infectious agents of any arthropod vector. Both ticks and the microbes they transmit are recognized as significant threats to human and veterinary public health. This article examines the potential impacts of climate change on the distribution of ticks and the infections they transmit; the emergence of novel tick-borne pathogens, increasing geographic range and incidence of tick-borne infections; and advances in the characterization of tick saliva mediated modulation of host defenses and the implications of those interactions for transmission, establishment, and control of tick infestation and tick-borne infectious agents.

A Walk in the Park: A Case of Babesiosis in the South Bronx

Babesiosis, mainly endemic within the Northeastern and upper Midwestern regions of the United States, is a zoonotic disease that invades and lyses red blood cells, which can result in hemolytic anemia. Its decreased incidence in comparison to Lyme disease is often attributed to the greater asymptomatic infection proportion and insufficient physician awareness or suspicion of this disease. Here we describe a case of undifferentiated febrile illness with hemolytic anemia that yielded the diagnosis of babesiosis.

Reconciling the Entomological Hazard and Disease Risk in the Lyme Disease System

Lyme disease (LD) is a commonly cited model for the link between habitat loss and/or fragmentation and disease emergence, based in part on studies showing that forest patch size is negatively related to LD entomological risk. An equivalent relationship has not, however, been shown between patch size and LD incidence (LDI). Because entomological risk is measured at the patch scale, while LDI is generally assessed in relation to aggregate landscape statistics such as forest cover, we posit that the contribution of individual patches to human LD risk has not yet been directly evaluated. We design a model that directly links theoretical entomological risk at the patch scale to larger-scale epidemiological data. We evaluate its predictions for relative LD risk in artificial landscapes with varying composition and configuration, and test its ability to predict countywide LDI in a 12-county region of New York. On simulated landscapes, we find that the model predicts a unimodal relationship between LD incidence and forest cover, mean patch size, and mean minimum distance (a measure of isolation), and a protective effect for percolation probability (a measure of connectivity). In New York, risk indices generated by this model are significantly related to countywide LDI. The results suggest that the lack of concordance between entomological risk and LDI may be partially resolved by this style of model.

Efficient detection of symptomatic and asymptomatic patient samples for Babesia microti and Borrelia burgdorferi infection by multiplex qPCR

BACKGROUND

Tick-borne infections have been increasing steadily over the years, with co-infections with Borrelia burgdorferi and Babesia microti/divergens emerging as a serious health problem. B. burgdorferi is a spirochetal bacterium that causes Lyme disease while protozoan pathogens belonging to Babesia species are responsible for babesiosis. Currently used serological tests do not always detect acute Lyme disease or babesiosis, and fail to differentiate cured patients from those who get re-infected. This is a major problem for proper diagnosis particularly in regions endemic for tick-borne diseases. Microscopy based evaluation of babesiosis is confirmatory but is labor intensive and insensitive such that many asymptomatic patients remain undetected and donate blood resulting in transfusion transmitted babesiosis.

RESULTS

We conducted multiplex qPCR for simultaneous diagnosis of active Lyme disease and babesiosis in 192 blood samples collected from a region endemic for both diseases. We document qPCR results obtained from testing of each sample three times to detect infection with each pathogen separately or together. Results for Lyme disease by qPCR were also compared with serological tests currently used for Lyme disease when available. Considering at least two out of three test results for consistency, 18.2% of patients tested positive for Lyme disease, 18.7% for co-infection with B. burgdorferi and B. microti and 6.3% showed only babesiosis.

CONCLUSIONS

With an 80% sensitivity for detection of Lyme disease, and ability to detect co-infection with B. microti, multiplex qPCR can be employed for diagnosis of these diseases to start appropriate treatment in a timely manner.

Transplacental transmission of tick-borne Babesia microti in its natural host Peromyscus leucopus

Background

Babesia microti is an emerging tick-borne pathogen and the causative agent of human babesiosis. Mathematical modeling of the reproductive rate of B. microti indicates that it cannot persist in nature by horizontal tick-host transmission alone. We hypothesized that transplacental transmission in the reservoir population contributes to B. microti persistence and emergence in North American rodent populations.

Methods

Peromyscus leucopus were collected from Connecticut and Block Island, Rhode Island and analyzed using a highly specific quantitative PCR (qPCR) assay for infection with B. microti.

Results

In April, 100% (n = 103) of mice were infected with B. microti. Females exhibited significantly higher parasitemia than their offspring (P < 0.0001) and transplacental transmission was observed in 74.2% of embryos (n = 89). Transplacental transmission of B. microti is thus a viable and potentially important infectious pathway in naturally infected rodent species and should be considered in future theoretical and empirical studies.

Conclusions

To our knowledge, this study is the first to report transplacental transmission of B. microti occurring in its natural reservoir host, P. leucopus, in the United States and the only study that provides a quantitative estimate of parasitemia. This vector-independent pathway could contribute to the increased geographic range of B. microti or increase its abundance in endemic areas.

Electronic supplementary material

The online version of this article (10.1186/s13071-018-2875-8) contains supplementary material, which is available to authorized users.

Superior real-time polymerase chain reaction detection of Babesia microti parasites in whole blood utilizing high-copy BMN antigens as amplification targets

BACKGROUND

Babesiosis is a zoonotic disease transmitted to humans by the bite of infected ticks and caused by apicomplexan parasites, most commonly Babesia microti. Additionally, blood and blood products collected from asymptomatically infected blood donors may cause transfusion-transmitted infections in recipients. Highly sensitive molecular assays that detect parasite nucleic acid are needed for laboratory diagnosis and to identify and defer clinically silent but parasitemic blood donors.

STUDY DESIGN AND METHODS

Here we report the development and analytical and clinical characterization of a real-time polymerase chain reaction (RT-PCR)-based assay for the detection of B. microti genomic DNA in whole blood. We evaluate the detection of Babesia parasites using two separate targets, the traditional18S ribosomal subunit gene (Bm18S) and members of the abundant BMN family of seroreactive antigens (BmBMN).

RESULTS

Analytical sensitivity determination using a probit analysis demonstrated an analytical sensitivity of 30.9 parasites/mL for 18S amplification and 10.0 parasites/mL for BMN amplification The BMN primer set also demonstrates superior sensitivity for serial dilution panels prepared from clinically diagnosed Babesia-infected blood samples, generally detecting 10-fold more dilute nucleic acid.

CONCLUSIONS

Cumulatively, our data demonstrate that RT-PCR detection of the BMN family of seroreactive antigens reflects a sensitive and superior assay for the detection of B. microti in whole blood samples.

Long-Term Effects of Berberis thunbergii (Ranunculales: Berberidaceae) Management on Ixodes scapularis (Acari: Ixodidae) Abundance and Borrelia burgdorferi (Spirochaetales: Spirochaetaceae) Prevalence in Connecticut, USA

Japanese barberry (Berberis thunbergii de Candolle; Ranunculales: Berberidaceae) is an exotic invasive shrub that escaped cultivation in the United States and is now permanently established in many eastern and midwestern states. This study examined the long-term impacts of Japanese barberry management on blacklegged tick (Ixodes scapularis Say; Acari: Ixodidae) abundances and associated prevalence of Borrelia burgdorferi (Johnson, Schmid, Hyde, Steigerwalt, and Brenner; Spirochaetales: Spirochaetaceae), the etiologic agent of Lyme disease. At six locations across Connecticut, adult I. scapularis were sampled for up to 10 yr. At each location, we sampled an area where barberry infestations were unmanipulated, adjacent areas where barberry was virtually nonexistent, and areas where barberry was managed utilizing a variety of techniques. Barberry management reduced B. burgdorferi-infected adult I. scapularis (BBIAIS) abundances (191/ha ± 64 SE) over 6 yr to statistically indifferent from that of no barberry areas (140/ha ± 47 SE; P = 0.080) and significantly less than intact barberry stands (458/ha ± 80 SE; P = 0.026). Over 9 yr, BBIAIS abundances in managed barberry remained lower than intact barberry stands (P = 0.037), but increased to be significantly greater than no barberry areas (P = 0.007) as cover increased over time. Longer-term data further document that Japanese barberry infestations are favorable habitat for I. scapularis. Control of Japanese barberry and other invasives should be at least on a 5-yr rotation to maintain low levels of invasive cover and eliminate humidity refugia to expose juvenile I. scapularis to more hostile environmental conditions in the interest of public health.

Screening of patient blood samples for babesiosis using enzymatic assays

Human babesiosis is an emerging tick-borne disease in the United States and Europe. Transmitted by Ixodes ticks, the causative agent Babesia microti is an intraerythrocytic parasite that causes mild to deadly disease. Transmission of B. microti can also occur by transfusion of infected blood and blood products resulting in transfusion-transmitted babesiosis (TTB), which carries a high risk of fatality. To effectively manage this rise in B. microti infections, better screening tools are needed, which require minimal manipulation of the samples before testing. To this end, we tested two enzymatic assays, aspartate aminotransferase (AST) and alanine aminotransferase (ALT), for efficacy in diagnosis of babesiosis. The results show that AST and ALT activity is significantly higher in the plasma of B. microti-infected patients. Moreover, statistical analysis revealed that these assays have high sensitivity and positive predictive values, which highlights their usefulness as diagnostics for babesiosis. These standardized enzymatic assays can be used to perform high-throughput, large-scale screens of blood and blood products before they are certified safe for transfusion.

Inactivation of Babesia microti in red blood cells and platelet concentrates

BACKGROUND

With an increasing number of recognized transfusion-transmitted (TT) babesiosis cases, Babesia microti is the most frequently TT parasite in the United States. We evaluated the inactivation of B. microti in red blood cells (RBCs) prepared in Optisol (AS-5) using amustaline and glutathione (GSH) and in platelet components (PCs) in 100% plasma using amotosalen and low-energy ultraviolet A (UVA) light.

STUDY DESIGN AND METHODS

Individual RBCs and apheresis PCs were spiked with B. microti-infected hamster RBCs (iRBCs) to a final concentration of 10⁶ iRBCs/mL and treated with the respective inactivation systems according to the manufacturer's instruction. Samples were collected before (control) and after (test) each treatment. Dilutions of the control samples to 10^-6 were inoculated into hamsters, while the test samples were inoculated neat or at 10^-1 dilution. At 3 and 5 weeks postinoculation, hamsters were evaluated for B. microti infection by microscopic observation of blood smears and 50% infectivity titers (ID₅₀ ) were determined. Log reduction was calculated as control log ID₅₀ minus test log ID₅₀ .

RESULTS

Parasitemia was detected in hamsters injected with as low as 100,000-fold diluted control samples, while no parasites were detectable in the blood smears of any hamsters receiving neat test samples. Mean log reduction was more than 5 log/mL by amustaline/GSH for RBCs and more than 4.5 log/mL by amotosalen/UVA for PCs.

CONCLUSION

B. microti was inactivated to the limit of detection in RBCs and PCs after the respective inactivation treatment. Complete inactivation of B. microti was achieved in this animal infectivity model, and pathogen reduction treatment inhibited transmission of infection.

High-resolution melting PCR assay, applicable for diagnostics and screening studies, allowing detection and differentiation of several Babesia spp. infecting humans and animals

The goal of the study was to design a single tube PCR test for detection and differentiation of Babesia species in DNA samples obtained from diverse biological materials. A multiplex, single tube PCR test was designed for amplification of approximately 400 bp region of the Babesia 18S rRNA gene. Universal primers were designed to match DNA of multiple Babesia spp. and to have low levels of similarity to DNA sequences of other intracellular protozoa and Babesia hosts. The PCR products amplified from Babesia DNA isolated from human, dog, rodent, deer, and tick samples were subjected to high-resolution melting analysis for Babesia species identification. The designed test allowed detection and differentiation of four Babesia species, three zoonotic (B. microti, B. divergens, B. venatorum) and one that is generally not considered zoonotic—Babesia canis. Both detection and identification of all four species were possible based on the HRM curves of the PCR products in samples obtained from the following: humans, dogs, rodents, and ticks. No cross-reactivity with DNA of Babesia hosts or Plasmodium falciparum and Toxoplasma gondii was observed. The lack of cross-reactivity with P. falciparum DNA might allow using the assay in endemic malaria areas. The designed assay is the first PCR-based test for detection and differentiation of several Babesia spp. of medical and veterinary importance, in a single tube reaction. The results of the study show that the designed assay for Babesia detection and identification could be a practical and inexpensive tool for diagnostics and screening studies of diverse biological materials.

Babesia microti: from Mice to Ticks to an Increasing Number of Highly Susceptible Humans

Babesia microti, a zoonotic intraerythrocytic parasite, is the primary etiological agent of human babesiosis in the United States. Human infections range from subclinical illness to severe disease resulting in death, with symptoms being related to host immune status. Despite advances in our understanding and management of B. microti, the incidence of infection in the United States has increased. Therefore, research focused on eradicating disease and optimizing clinical management is essential. Here we review this remarkable organism, with emphasis on the clinical, diagnostic, and therapeutic aspects of human disease.

Babesia microti from humans and ticks hold a genomic signature of strong population structure in the United States

Background

Babesia microti is an emerging tick-borne apicomplexan parasite with increasing geographic range and incidence in the United States. The rapid expansion of B. microti into its current distribution in the northeastern USA has been due to the range expansion of the tick vector, Ixodes scapularis, upon which the causative agent is dependent for transmission to humans.

Results

To reconstruct the history of B. microti in the continental USA and clarify the evolutionary origin of human strains, we used multiplexed hybrid capture of 25 B. microti isolates obtained from I. scapularis and human blood. Despite low genomic variation compared with other Apicomplexa, B. microti was strongly structured into three highly differentiated genetic clusters in the northeastern USA. Bayesian analyses of the apicoplast genomes suggest that the origin of the current diversity of B. microti in northeastern USA dates back 46 thousand years with a signature of recent population expansion in the last 1000 years. Human-derived samples belonged to two rarely intermixing clusters, raising the possibility of highly divergent infectious phenotypes in humans.

Conclusions

Our results validate the multiplexed hybrid capture strategy for characterizing genome-wide diversity and relatedness of B. microti from ticks and humans. We find strong population structure in B. microti samples from the Northeast indicating potential barriers to gene flow.

Electronic supplementary material

The online version of this article (doi:10.1186/s12864-016-3225-x) contains supplementary material, which is available to authorized users.

Severe Babesia microti Infection in an Immunocompetent Host in Pennsylvania

Babesiosis, due to infection by a tick-borne protozoan (predominantly Babesia microti in North America), is an emerging health risk that is expanding into new areas and may be unfamiliar to clinicians in locations not previously considered endemic. Manifestations of infection can range from asymptomatic to life threatening, with severe disease more likely in those who have had a splenectomy, are immunocompromised, have chronic medical conditions, or are over 50 years of age. In this article, we describe an elderly but otherwise healthy man from an area not generally considered endemic for babesiosis who presented with severe hemolysis, acute renal failure, and high-level Babesia microti parasitemia; serological results suggestive of possible coinfection by Borrelia burgdorferi (the agent of Lyme disease, which is carried by the same tick as is Babesia microti) also was found. This report highlights that severe babesiosis can occur in an apparently normal host and underscores the continued geographic expansion of this pathogen and the need for early recognition and therapy.

Invasion of two tick-borne diseases across New England: harnessing human surveillance data to capture underlying ecological invasion processes

Modelling the spatial spread of vector-borne zoonotic pathogens maintained in enzootic transmission cycles remains a major challenge. The best available spatio-temporal data on pathogen spread often take the form of human disease surveillance data. By applying a classic ecological approach-occupancy modelling-to an epidemiological question of disease spread, we used surveillance data to examine the latent ecological invasion of tick-borne pathogens. Over the last half-century, previously undescribed tick-borne pathogens including the agents of Lyme disease and human babesiosis have rapidly spread across the northeast United States. Despite their epidemiological importance, the mechanisms of tick-borne pathogen invasion and drivers underlying the distinct invasion trajectories of the co-vectored pathogens remain unresolved. Our approach allowed us to estimate the unobserved ecological processes underlying pathogen spread while accounting for imperfect detection of human cases. Our model predicts that tick-borne diseases spread in a diffusion-like manner with occasional long-distance dispersal and that babesiosis spread exhibits strong dependence on Lyme disease.

Human pathogens associated with the blacklegged tick Ixodes scapularis: a systematic review

BACKGROUND

The blacklegged tick Ixodes scapularis transmits Borrelia burgdorferi (sensu stricto) in eastern North America; however, the agent of Lyme disease is not the sole pathogen harbored by the blacklegged tick. The blacklegged tick is expanding its range into areas of southern Canada such as Ontario, an area where exposure to blacklegged tick bites and tick-borne pathogens is increasing. We performed a systematic review to evaluate the public health risks posed by expanding blacklegged tick populations and their associated pathogens.

METHODS

We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for conducting our systematic review. We searched Ovid MEDLINE, Embase, BIOSIS, Scopus and Environment Complete databases for studies published from 2000 through 2015, using subject headings and keywords that included "Ixodes scapularis", "Rickettsia", "Borrelia", "Anaplasma", "Babesia" and "pathogen." Two reviewers screened titles and abstracts against eligibility criteria (i.e. studies that included field-collected blacklegged ticks and studies that did not focus solely on B. burgdorferi) and performed quality assessments on eligible studies.

RESULTS

Seventy-eight studies were included in the final review, 72 were from the US and eight were from Canada (two studies included blacklegged ticks from both countries). Sixty-four (82%) studies met ≥ 75% of the quality assessment criteria. Blacklegged ticks harbored 91 distinct taxa, 16 of these are tick-transmitted human pathogens, including species of Anaplasma, Babesia, Bartonella, Borrelia, Ehrlichia, Rickettsia, Theileria and Flavivirus. Organism richness was highest in the Northeast (Connecticut, New York) and Upper Midwest US (Wisconsin); however, organism richness was dependent on sampling effort. The primary tick-borne pathogens of public health concern in Ontario, due to the geographic proximity or historical detection in Ontario, are Anaplasma phagocytophilum, Babesia microti, B. burgdorferi, Borrelia miyamotoi, deer tick virus and Ehrlichia muris-like sp. Aside from B. burgdorferi and to a much lesser concern A. phagocytophilum, these pathogens are not immediate concerns to public health in Ontario; rather they represent future threats as the distribution of vectors and pathogens continue to proliferate.

CONCLUSIONS

Our review is the first systematic assessment of the literature on the human pathogens associated with the blacklegged tick. As Lyme disease awareness continues to increase, it is an opportune time to document the full spectrum of human pathogens transmittable by blacklegged ticks.

Infection with Babesia microti in humans with non-specific symptoms in North East Poland

AIM

The aim of the study was to evaluate the clinical course and effectiveness of diagnostics tools for Babesia spp. infection in patients bitten by ticks.

MATERIALS AND METHODS

Five hundred and forty-eight patients hospitalised or seen in outpatients department because of various symptoms after a tick bite were included in the study. PCR, nucleotide sequencing of Babesia 18S rRNA gene fragment, blood smears and serological tests for Babesia spp., TBEV, A. phagocytophilum and B. burgdorferi were performed in all patients. Six patients infected with Babesia were included in the final analysis. They had PCR, Babesia 18S rRNA gene fragment nucleotide sequencing, blood smears and serological tests for Babesia spp., TBEV, A. phagocytophilum and B. burgdorferi performed twice.

RESULTS

Tick-borne infection with Babesia microti in six immunocompetent patients with non-specific symptoms was confirmed for the first time in Poland. No severe course of the disease was seen. No piroplasm forms were noticed within erythrocytes on blood smear. Three patients developed a serological response.

CONCLUSIONS

Immunocompetent patients may be unaware of infection with Babesia microti after a tick bite. It must be included in the differential diagnosis after the tick bite. In patients with low parasitaemia PCR and serology seem useful when blood smear is negative. Self-elimination of Babesia spp. is possible, especially in cases with low parasitaemia.