Haemaphysalis longicornis Ticks as Reservoir and Vector of Severe Fever with Thrombocytopenia Syndrome Virus in China

Current insights into human pathogenic phenuiviruses and the host immune system

Phenuiviruses are a class of segmented negative-sense single-stranded RNA viruses, typically consisting of three RNA segments that encode four distinct proteins. The emergence of pathogenic phenuivirus strains, such as Rift Valley fever phlebovirus (RVFV) in sub-Saharan Africa, Severe Fever with Thrombocytopenia Syndrome Virus (SFTSV) in East and Southeast Asia, and Heartland Virus (HRTV) in the United States has presented considerable challenges to global public health in recent years. The innate immune system plays a crucial role as the initial defense mechanism of the host against invading pathogens. In addition to continued research aimed at elucidating the epidemiological characteristics of phenuivirus, significant advancements have been made in investigating its viral virulence factors (glycoprotein, non-structural protein, and nucleoprotein) and potential host-pathogen interactions. Specifically, efforts have focused on understanding mechanisms of viral immune evasion, viral assembly and egress, and host immune networks involving immune cells, programmed cell death, inflammation, nucleic acid receptors, etc. Furthermore, a plethora of technological advancements, including metagenomics, metabolomics, single-cell transcriptomics, proteomics, gene editing, monoclonal antibodies, and vaccines, have been utilized to further our understanding of phenuivirus pathogenesis and host immune responses. Hence, this review aims to provide a comprehensive overview of the current understanding of the mechanisms of host recognition, viral immune evasion, and potential therapeutic approaches during human pathogenic phenuivirus infections focusing particularly on RVFV and SFTSV.

Seasonal dynamics of Haemaphysalis tick species as SFTSV vectors in South Korea

Ticks pose a significant public health threat due to their ability to transmit various pathogens, including emerging tick-borne diseases. This study conducted a comprehensive surveillance of Haemaphysalis tick species and their severe fever with thrombocytopenia syndrome virus (SFTSV) infection rates in South Korea throughout the year 2023, from January to December. To ensure accurate and rapid identification of the prevalent Haemaphysalis tick species in South Korea, we designed PCR primer sets targeting the ITS1 gene, specifically distinguishing Haemaphysalis longicornis from Haemaphysalis flava. Among the 10,343 ticks collected from wild animals, H. longicornis constituted the majority, accounting for 65.5% (6,784/10,343 ticks), followed by H. flava at 33.8% (3,491/10,343 ticks), and Ixodes nipponensis at 0.7% (68/10,343 ticks). These identified ticks were then categorized into 811 pools, with 63 pools testing positive for SFTSV. Remarkably, the prevalence of SFTSV-positive H. longicornis ticks peaked during the summer months, aligning with heightened human outdoor activities and, consequently, an increased risk of human exposure. Conversely, it is noteworthy that H. flava exhibited a higher prevalence during the winter season, reaching its peak in January, with an SFTSV minimum infection rate similar to that of H. longicornis. These findings underscore the year-round presence of Haemaphysalis ticks as potential vectors for SFTSV, extending the temporal window for potential human exposure. Consequently, these results emphasize the necessity for active and continuous field surveillance to comprehensively understand and mitigate the public health risks associated with these tick-borne pathogens.

IMPORTANCE

To date, the majority of tick surveillance studies have primarily focused on warmer seasons, which are considered optimal periods for ticks to actively seek hosts and transmit pathogens through blood-feeding activities. Consequently, tick species active during winter have often been overlooked, leading to an underestimation of their significance in transmitting severe fever with thrombocytopenia syndrome virus (SFTSV). In this study, we aimed to examine year-round tick prevalence with SFTSV and illuminate the role of the winter-dominant species, Haemaphysalis flava, in South Korea. Through rigorous identification facilitated by a primer set designed specifically for this purpose, we emphasize that H. flava, a competent vector species, harbors SFTSV in the winter season, thereby acting as an overwintering reservoir for the virus. This phenomenon may contribute to a higher infection rate among ticks in the following year.

Identification of severe fever with thrombocytopenia syndrome virus isolates in the northwest of Hubei Province, China

Severe fever with thrombocytopenia syndrome (SFTS) is a tick-borne viral disease that is increasingly affecting human being worldwide. The clinical manifestations and mortality rates of SFTS can vary depending on the geographic region and the specific genotype of the SFTS virus (SFTSV). From July 2022 to August 2023, we collected serum samples from 83 patients with suspected SFTSV infection in the northwest of Hubei Province, China. From which, 13 patients tested positive for SFTSV. Phylogenetic analysis of the SFTSV L, M, and S gene segments was performed using the maximum likelihood method to determine the genetic diversity of the isolates. At least 2 SFTSV genotypes (A and F) were identified in the northwest of Hubei Province. The clinical manifestations and laboratory findings on the first day of admission were investigated. Results showed that bleeding and disturbance of consciousness, and significant elevated AST and APTT, are valuable for assessing the prognosis for SFTS patients. This study disclosed the genomic sequences and genotypes of SFTSV spreading in the northwest of Hubei Province for the first time, providing information of genetically etiology for SFTS in the local district. Furthermore, certain symptoms and/or laboratory findings may indicate adverse clinical outcomes, highlighting the importance of identifying the symptoms and monitoring specific laboratory markers. Future research is needed to investigate the threshold values of these markers and to closely observe the indicative symptoms in order to early identify and timely management of critically ill patients within clinical settings.

Toxicity and enzymatic mechanism of Citrus spp. essential oils and major constituents on Haemaphysalis longicornis (Acari: Ixodidae) and non-target Harmonia axyridis (Coleoptera: Coccinellidae)

Plant essential oils (EOs)-based acaricides have been recognized as environmentally-friendly alternatives to synthetic acaricides because of their low toxicity against non-target species. Despite this, there are knowledge gaps regarding the toxicity mechanisms of plant EOs against non-target species. Here, the toxicology and enzymatic mechanism of Citrus reticulata and Citrus lemon EOs were evaluated against the vector pest, Haemaphysalis longicornis, and non-target ladybird beetle, Harmonia axyridis. Both EOs were mainly composed of d-Limonene, followed by β-Myrcene and γ-Terpinene in C. reticulata, and (-)-β-Pinene and γ-Terpinene in C. lemon. Citrus reticulata and C. lemon EOs were toxic to Hae. longicornis, with 50 % lethal concentration (LC50) values estimated at 0.43 and 0.98 μL/mL via nymphal immersion test, and 42.52 and 46.38 μL/mL via spray application, respectively. Among the constituents tested, β-Myrcene was the most effective, with LC50 values of 0.17 and 47.87 μL/mL via immersion and spray treatment, respectively. A significant mortality of non-target Har. axyridis was found when treated by the EOs at concentrations two times greater than LC50 estimated against H. longicornis. The biochemical assay revealed that the EOs induced changes in the antioxidant enzyme activity of superoxide dismutases, catalase, and glutathione peroxidase in Hae. longicornis and Har. axyridis. The results demonstrated the acaricidal potential of citrus EOs and their major constituents for tick control, revealed the risk of the EOs to non-target species, and provided relevant insights into the mechanisms underlying their toxicity.

Japanese spotted fever in an area endemic to SFTS virus: Case report and review of the literature

RATIONALE

The geographic spread of Japanese spotted fever (JSF) in China is gradually expanding, particularly in regions where severe fever with thrombocytopenia syndrome (SFTS) is highly prevalent, with both diseases sharing similarities in epidemiology and clinical presentation. The microbiological diagnosis of JSF is challenging, compounded by low awareness among healthcare professionals in newly affected areas. Moreover, primary healthcare facilities without polymerase chain reaction (PCR) testing capabilities for SFTS often misdiagnose JSF as SFTS.

PATIENT CONCERNS

All 3 patients had a history of working in the fields, with cold like symptoms in the early fever stages, but the fever did not improve after a few days. The accompanying symptoms were also very different. Physical examination revealed enlarged lymph nodes, different forms of rash, with or without eschar. Laboratory tests showed thrombocytopenia, eosinophilia, elevated lactate dehydrogenase, and transaminase, with 1 patient experiencing renal damage. It is worth noting that these 3 patients reside in an area where SFTS is endemic, and there have been no prior reports of JSF. They exhibited clinical symptoms and laboratory test results closely resembling those of SFTS. Therefore, they were initially misdiagnosed with SFTS in their local hospitals.

DIAGNOSES

The 3 patients who arrived at our hospital 7 days after symptom onset and were subsequently diagnosed with JSF by metagenomic next-generation sequencing (mNGS).

INTERVENTIONS

Doxycycline treatment for 1 week.

OUTCOMES

The patients' symptoms quickly improved with no side effects, and the results of laboratory tests went back to normal.

LESSONS

By comparing the clinical characteristics of JSF patients and SFTS patients comprehensively, we found that APTT and procalcitonin levels may be valuable in assisting in the identification of SFTS and JSF. In all areas where tick-borne diseases are endemic, include SFTS-epidemic areas, we recommend using the Weil-Felix test to screen for potential rickettsiosis in patients presenting with fever and thrombocytopenia with or without rash in primary healthcare settings, as well as simultaneous testing for the SFTS virus and spotted fever group rickettsioses sequence. Additionally, mNGS sequencing should be used to confirm the diagnosis and provide information for epidemiological investigations in patients who are suspected of having spotted fever group rickettsiosis.

Factors Associated With the Spatial Distribution of Severe Fever With Thrombocytopenia Syndrome in Zhejiang Province, China: Risk Analysis Based on Maximum Entropy

Background

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease that was first identified in mainland China in 2009 and has been reported in Zhejiang Province, China, since 2011. However, few studies have focused on the association between ticks, host animals, and SFTS.

Objective

In this study, we analyzed the influence of meteorological and environmental factors as well as the influence of ticks and host animals on SFTS. This can serve as a foundational basis for the development of strategic policies aimed at the prevention and control of SFTS.

Methods

Data on SFTS incidence, tick density, cattle density, and meteorological and environmental factors were collected and analyzed using a maximum entropy-based model.

Results

As of December 2019, 463 laboratory-confirmed SFTS cases were reported in Zhejiang Province. We found that the density of ticks, precipitation in the wettest month, average temperature, elevation, and the normalized difference vegetation index were significantly associated with SFTS spatial distribution. The niche model fitted accurately with good performance in predicting the potential risk areas of SFTS (the average test area under the receiver operating characteristic curve for the replicate runs was 0.803 and the SD was 0.013). The risk of SFTS occurrence increased with an increase in tick density, and the response curve indicated that the risk was greater than 0.5 when tick density exceeded 1.4. The risk of SFTS occurrence decreased with increased precipitation in the wettest month, and the risk was less than 0.5 when precipitation exceeded 224.4 mm. The relationship between elevation and SFTS occurrence showed a reverse V shape, and the risk peaked at approximately 400 m.

Conclusions

Tick density, precipitation, and elevation were dominant influencing factors for SFTS, and comprehensive intervention measures should be adjusted according to these factors to reduce SFTS incidence in Zhejiang Province.

Identification and phylogenetic analysis of Nairobi sheep disease virus from Haemaphysalis longicornis ticks in Shandong Province, China

Nairobi Sheep Disease (NSD) is a typical tick-borne syndrome characterized by severe hemorrhagic gastroenteritis, spontaneous abortion, and a high case fatality rate in small ruminants. The pathogenic agent, Nairobi sheep disease virus (NSDV), has also been associated with human infections, indicating its possible zoonotic potential. Prior to this study, NSDV has been detected from ticks collected in Jilin, Hubei, and Liaoning provinces in China. In the present study, a total of 343 ticks (Haemaphysalis longicornis) were collected in Shandong province, China in 2020, and pooled into 16 libraries. Analysis of the meta-transcriptomic sequencing data identified NSDV strains SDWL07, SDWL08, and SDWL16 from three pools. The SDWL07 and SDWL16 strains were detected from unfed ticks, while SDWL08 was detected from cattle-feeding ticks. Phylogenetic analyses showed higher sequence identities between the three strains and other Chinese NSDV strains than those from India and Kenya. Phylogenetic analyses also revealed that they clustered together and fell within the China lineage, suggesting no potential genetic reassortment among them. In summary, this is the first report of the identification of NSDV in Shandong province, highlighting the continually expanding endemic regions of this pathogen. Surveillance of NSDV should be intensified in China, especially in areas where H. longicornis is endemic.

Haemaphysalis longicornis (Acari: Ixodidae) does not transmit Babesia bovis, a causative agent of cattle fever

The Asian longhorned tick (Haemaphysalis longicornis) was first reported in the United States in 2017 and has since been detected in at least 17 states. This tick infests cattle and can produce large populations quickly due to its parthenogenetic nature, leading to significant livestock mortalities and economic losses. While H. longicornis has not been detected in Texas, species distribution models have identified southern Texas as a possible hospitable region for this tick. Southern Texas is currently home to the southern cattle tick (Rhipicephalus microplus), which can transmit the causative agent of cattle fever (Babesia bovis). With the potential for H. longicornis and B. bovis to overlap in southern Texas and their potential to negatively impact the national and global livestock industry, it is imperative to identify the role H. longicornis may play in the cattle fever disease system. A controlled acquisition and transmission experiment tested whether H. longicornis is a vector for B. bovis, with the R. microplus-B. bovis system used as a positive control. Transstadial (nymphs to adults) and transovarial (adults to larvae) transmission and subsequent transstadial maintenance (nymphs and adults) routes were tested in this study. Acquisition-fed, splenectomized animals were used to increase the probability of tick infection. Acquisition nymphs were macerated whole and acquisition adults were dissected to remove midguts and ovaries at five time points (4, 6, 8, 10, and 12 days post-repletion), with 40 ticks processed per time point and life stage. The greatest percentage of nymphs with detectable B. bovis DNA occurred six days post-repletion (20.0 %). For adults, the percentage of positive midguts and ovaries increased as days post-repletion progressed, with day 12 having the highest percentage of positive samples (67.5 % and 60.0 %, respectively). When egg batches were tested in triplicate, all H. longicornis egg batches were negative for B. bovis, while all R. microplus egg batches were positive for B. bovis. During the transmission phase, the subsequent life stages for transstadial (adults) and transovarial transmission/transstadial maintenance (larvae, nymphs, and adults) were fed on naïve, splenectomized calves. All life stages of H. longicornis ticks tested during transmission were negative for B. bovis. Furthermore, the transmission fed animals were also negative for B. bovis and did not show signs of bovine babesiosis during the 45-day post tick transmission period. Given the lack of successful transstadial or transovarial transmission, it is unlikely that H. longicornis is a vector for B. bovis.

Global epidemiology of severe fever with thrombocytopenia syndrome virus in human and animals: a systematic review and meta-analysis

Background

Since the initial identification of the Severe Fever with Thrombocytopenia Syndrome (SFTS) in ticks in rural areas of China in 2009, the virus has been increasingly isolated from a diverse array of hosts globally, exhibiting a rising trend in incidence. This study aims to conduct a systematic analysis of the temporal and spatial distribution of SFTS cases, alongside an examination of the infection rates across various hosts, with the objective of addressing public concerns regarding the spread and impact of the disease.

Methods

In this systematic review and meta-analysis, an exhaustive search was conducted across multiple databases, including PubMed, Web of Science, Embase, and Medline, CNKI, WanFang, and CQVIP. The literature search was confined to publications released between January 1, 2009, and May 29, 2023. The study focused on collating data pertaining to animal infections under natural conditions and human infection cases reported. Additionally, species names were unified using the National Center for Biotechnology Information (NCBI) database. The notification rate, notification death rate, case fatality rate, and infection rates (or MIR) were assessed for each study with available data. The proportions were pooled using a generalized linear mixed-effects model (GLMM). Meta-regressions were conducted for subgroup analysis. This research has been duly registered with PROSPERO, bearing the registration number CRD42023431010.

Findings

We identified 5492 studies from database searches and assessed 238 full-text studies for eligibility, of which 234 studies were included in the meta-analysis. For human infection data, the overall pooled notification rate was 18.93 (95% CI 17.02-21.05) per ten million people, the overall pooled notification deaths rate was 3.49 (95% CI 2.97-4.10) per ten million people, and the overall pooled case fatality rate was 7.80% (95% CI 7.01%-8.69%). There was an increasing trend in notification rate and deaths rate, while the case fatality rate showed a significant decrease globally. Regarding animal infection data, among 94 species tested, 48 species were found to carry positive nucleic acid or antibodies. Out of these, 14 species were classified under Arthropoda, while 34 species fell under Chordata, comprising 27 Mammalia and 7 Aves.

Interpretation

This systematic review and meta-analysis present the latest global report on SFTS. In terms of human infections, notification rates and notification deaths rates are on the rise, while the case fatality rate has significantly decreased. More SFTSV animal hosts have been discovered than before, particularly among birds, indicating a potentially broader transmission range for SFTSV. These findings provide crucial insights for the prevention and control of SFTS on a global scale.

Funding

None.

Structural snapshots of phenuivirus cap-snatching and transcription

Severe fever with thrombocytopenia syndrome virus (SFTSV) is a human pathogen that is now endemic to several East Asian countries. The viral large (L) protein catalyzes viral transcription by stealing host mRNA caps via a process known as cap-snatching. Here, we establish an in vitro cap-snatching assay and present three high-quality electron cryo-microscopy (cryo-EM) structures of the SFTSV L protein in biologically relevant, transcription-specific states. In a priming-state structure, we show capped RNA bound to the L protein cap-binding domain (CBD). The L protein conformation in this priming structure is significantly different from published replication-state structures, in particular the N- and C-terminal domains. The capped-RNA is positioned in a way that it can feed directly into the RNA-dependent RNA polymerase (RdRp) ready for elongation. We also captured the L protein in an early-elongation state following primer-incorporation demonstrating that this priming conformation is retained at least in the very early stages of primer extension. This structural data is complemented by in vitro biochemical and cell-based assays. Together, these insights further our mechanistic understanding of how SFTSV and other bunyaviruses incorporate stolen host mRNA fragments into their viral transcripts thereby allowing the virus to hijack host cell translation machinery.

Prevalence and genetic diversity of Anaplasma and Ehrlichia in ticks and domesticated animals in Suizhou County, Hubei Province, China

Anaplasma and Ehrlichia are tick-borne bacterial pathogens that cause anaplasmoses and ehrlichioses in humans and animals. In this study, we examined the prevalence of Anaplasma and Ehrlichia species in ticks and domesticated animals in Suizhou County, Hubei Province in the central China. We used PCR amplification and DNA sequencing of the 16S rRNA, groEL, and gltA genes to analyze. We collected 1900 ticks, including 1981 Haemaphysalis longicornis and 9 Rhipicephalus microplus, 159 blood samples of goats (n = 152), cattle (n = 4), and dogs (n = 3) from May to August of 2023. PCR products demonstrated that Anaplasma bovis, Anaplasma capra, and an Ehrlichia species were detected in the H. longicornis with the minimum infection rates (MIR) of 1.11%, 1.32%, and 0.05%, respectively; A. bovis, A. capra, and unnamed Anaplasma sp. were detected in goats with an infection rate of 26.31%, 1.31% and 1.97%, respectively. Anaplasma and Ehrlichia species were not detected from cattle, dogs and R. microplus ticks. The genetic differences in the groEL gene sequences of the Anaplasma in the current study were large, whereas the 16S rRNA and gltA gene sequences were less disparate. This study shows that ticks and goats in Suizhou County, Hubei Province carry multiple Anaplasma species and an Ehrlichia species, with relatively higher infection rate of A. bovis in goats. Our study indicates that multiple Anaplasma and Ehrlichia species exist in ticks and goats in the central China with potential to cause human infection.

Hematological and plasma profiles and ticks and tick-borne pathogens in wild Formosan black bears (Ursus thibetanus formosanus)

BACKGROUND

The endangered Formosan black bear (Ursus thibetanus formosanus) is the largest native carnivorous mammal in Taiwan. Diseases, poor management, illegal hunting, and habitat destruction are serious threats to the survival of bear populations. However, studies on the impact of diseases on bear populations are limited. Therefore, this study aimed to establish a database of the hematological and plasma profiles of free-ranging Formosan black bears and investigate the occurrence of ectoparasites, blood parasites, and vector-borne pathogens.

METHODS

Formosan black bears were captured in Yushan National Park (YNP) and Daxueshan Forest Recreation Area (DSY) in Taiwan. Blood samples were collected from each bear for hematological analysis and plasma biochemistry using a hematology analyzer. Parasites and pathogens were detected using a thin blood smear with Wright-Giemsa staining and polymerase chain reaction (PCR) assay. Additionally, macroscopic ectoparasites were collected from bears to detect blood parasites and other pathogens. Moreover, the relationships between the bear variables (sex, age, and occurrence of parasites or pathogens), ectoparasites, and infectious agents were also analyzed.

RESULTS

In all, 21 wild bears (14 in YNP and 7 in DSY) were captured and released during the satellite tracking studies. Hematological analysis and plasma biochemistry indicated significant differences in white blood cells (WBC), segments, creatine kinase (CK), and lactate dehydrogenase (LDH) levels between foot snare and culvert-captured bears. Additionally, there were significant differences in total plasma protein (TPP), creatinine, Ca2+, Mg2+, and K+ levels between male and female bears. Moreover, pathogen-infected bears had significantly higher erythrocyte sedimentation rate (ESR; 30 min and 1 h) and globulin levels than uninfected bears. In total, 240 ticks were collected from 13 bears, among which eight adult tick species were identified, including Haemaphysalis flava, Haemaphysalis hystricis, Amblyomma testudinarium, Ixodes ovatus, Dermacentor taiwanensis, Haemaphysalis longicornis, Ixodes acutitarsus, Amblyomma javanense, and nymphs belonging to Haemaphysalis spp. PCR revealed that 13 (61.90%) and 8 (38.10%) bears harbored Hepatozoon ursi and Babesia DNA, respectively. Among the ticks examined, 157 (65.41%) and 128 (53.33%) samples were positive for H. ursi and Babesia, respectively.

CONCLUSIONS

To the best of our knowledge, this is the first study to establish a database of the hematological and plasma profiles of wild Formosan black bears and investigate ectoparasite infestation and Hepatozoon and Babesia spp.

INFECTION

In conclusion, these findings may serve as a reference for monitoring the health and population of locally endangered bears.

Construction of an early differentiation diagnosis model for patients with severe fever with thrombocytopenia syndrome and hemorrhagic fever with renal syndrome

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease with a high mortality rate. Differentiating between SFTS and hemorrhagic fever with renal syndrome (HFRS) is difficult and inefficient. Retrospective analysis of the medical records of individuals with SFTS and HFRS was performed. Clinical and laboratory data were compared, and a diagnostic model was developed based on multivariate logistic regression analyzes. Receiver operating characteristic curve analysis was used to evaluate the diagnostic model. Among the 189 patients, 113 with SFTS and 76 with HFRS were enrolled. Univariate analysis revealed that more than 20 variables were significantly associated with SFTS. Multivariate logistic regression analysis revealed that gender, especially female gender (odds ratio [OR]: 4.299; 95% confidence interval [CI]: 1.163-15.887; p = 0.029), age ≥65 years (OR: 16.386; 95% CI: 3.043-88.245; p = 0.001), neurological symptoms (OR: 12.312; 95% CI: 1.638-92.530; p = 0.015), leukopenia (<4.0 × 109/L) (OR: 17.355; 95% CI: 3.920-76.839; p < 0.001), and normal Cr (OR: 97.678; 95% CI: 15.483-616.226; p < 0.001) were significantly associated with SFTS but not with HFRS. The area under the curve of the differential diagnostic model was 0.960 (95% CI: 0.936-0.984), which was significantly better than that of each single factor. In addition, the model exhibited very excellent sensitivity and specificity (92.9% and 85.5%, respectively). In cases where HFRS and SFTS are endemic, a diagnostic model based on five parameters, such as gender, age ≥65 years, neurological symptoms, leukopenia and normal Cr, will facilitate the differential diagnosis of SFTS and HFRS in medical institutions, especially in primary care settings.

Vaccine Development for Severe Fever with Thrombocytopenia Syndrome Virus in Dogs

Severe fever with thrombocytopenia syndrome (SFTS) is a life-threatening viral zoonosis. The causative agent of this disease is the Dabie bandavirus, which is usually known as the SFTS virus (SFTSV). Although the role of vertebrates in SFTSV transmission to humans remains uncertain, some reports have suggested that dogs could potentially transmit SFTSV to humans. Consequently, preventive measures against SFTSV in dogs are urgently needed. In the present study, dogs were immunized three times at two-week intervals with formaldehyde-inactivated SFTSV with two types of adjuvants. SFTSV (KCD46) was injected into all dogs two weeks after the final immunization. Control dogs showed viremia from 2 to 4 days post infection (dpi), and displayed white pulp atrophy in the spleen, along with a high level of terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling assay (TUNEL) positive area. However, the inactivated SFTSV vaccine groups exhibited rare pathological changes and significantly reduced TUNEL positive areas in the spleen. Furthermore, SFTSV viral loads were not detected at any of the tested dpi. Our results indicate that both adjuvants can be safely used in combination with an inactivated SFTSV formulation to induce strong neutralizing antibodies. Inactivated SFTSV vaccines effectively prevent pathogenicity and viremia in dogs infected with SFTSV. In conclusion, our study highlighted the potential of inactivated SFTSV vaccination for SFTSV control in dogs.

Severe fever with thrombocytopenia syndrome virus infection shapes gut microbiome of the tick vector Haemaphysalis longicornis

BACKGROUND

Ticks serve as vectors for a diverse array of pathogens, including viruses responsible for both human and livestock diseases. Symbiotic bacteria hold significant potential for controlling tick-borne disease. However, the alteration of tick gut bacterial community in response to pathogen infection has not been analyzed for any tick-borne viruses. Here, the impact of severe fever with thrombocytopenia syndrome virus (SFTSV) infection on bacterial diversity in the gut of Haemaphysalis longicornis is investigated.

METHODS

Unfed tick females were artificially infected with SFTSV. The gut samples were collected and the genomic DNA was extracted. We then investigated alterations in gut bacterial composition in response to SFTSV infection through 16S rRNA gene sequencing.

RESULTS

The study found that a reduction in the number of operational taxonomic units (OTUs) in the tick gut following SFTSV infection. However, there were no significant changes in alpha diversity indices upon infection. Four genera, including Corynebacterium, Arthrobacter, Sphingomonas, and Escherichia, were identified as biomarkers for the tick gut without SFTSV infection. Notably, the predicted correlation network indicated that the biomarkers Sphingomonas and Escherichia exhibited positive correlations within the same subcommunity, which was altered upon viral infection.

CONCLUSIONS

These findings revealed that the change in tick gut bacterial composition upon SFTSV infection and could facilitate the discovery new target for tick-borne viral disease control.

Difference in Intraspecies Transmissibility of Severe Fever with Thrombocytopenia Syndrome Virus Depending on Abrogating Type 1 Interferon Signaling in Mice

Severe fever with thrombocytopenia syndrome (SFTS), a tick-borne zoonotic disease, is caused by infection with SFTS virus (SFTSV). A previous study reported that human-to-human direct transmission of SFTSV can occur. However, potential animal-to-animal transmission of SFTSV without ticks has not been fully clarified. Thus, the objective of this study was to investigate potential mice-to-mice transmission of SFTSV by co-housing three groups of mice [i.e., wild-type mice (WT), mice injected with an anti-type I interferon-α receptor-blocking antibody (IFNAR Ab), and mice with knockout of type I interferon-α receptor (IFNAR KO)] as spreaders or recipients with different immune competence. As a result, co-housed IFNAR Ab and IFNAR KO mice showed body weight loss with SFTS viral antigens detected in their sera, extracorporeal secretions, and various organs. Based on histopathology, white pulp atrophy in the spleen was observed in all co-housed mice except WT mice. These results obviously show that IFNAR Ab and IFNAR KO mice, as spreaders, exhibited higher transmissibility to co-housed mice than WT mice. Moreover, IFNAR KO mice, as recipients, were more susceptible to SFTSV infection than WT mice. These findings suggest that type I interferon signaling is a pivotal factor in mice intraspecies transmissibility of SFTSV in the absence of vectors such as ticks.

Nationwide survey of ticks on domesticated animals in Taiwan: Revealing the hidden threat to animal and public health

Ticks are not only bloodsucking ectoparasites but also important vectors of tick-borne diseases (TBDs), posing significant threats to public and animal health. Domesticated animals serve as critical hosts for numerous ticks, highlighting the importance of understanding tick infestations in Taiwan. To address this knowledge gap, we conducted a nationwide survey to identify ticks on domesticated animals and associated environments in 2018 and 2019. A total of 6,205 ticks were collected from 1,337 host animals, revealing the presence of seven tick species, with Rhipicephalus microplus, and Rhipicephalus sanguineus being the dominant species. High infestation rates and widespread distribution of ticks were observed on domesticated animals, especially on dogs and cattle (yellow cattle and angus cattle), and the neighbouring grassland of yellow cattle. While this study has certain limitations, it provides valuable insights into the distribution and prevalence of ticks on domesticated animals in Taiwan and their implications for controlling TBDs. Further research is needed to comprehensively understand the complex interactions among ticks, hosts and pathogens.

The Vector Competence of Asian Longhorned Ticks in Langat Virus Transmission

Haemaphysalis longicornis (the longhorned tick), the predominant tick species in China, serves as a vector for a variety of pathogens, and is capable of transmitting the tick-borne encephalitis virus (TBEV), the causative agent of tick-borne encephalitis. However, it is unclear how these ticks transmit TBEV. Langat virus (LGTV), which has a reduced pathogenicity in humans, has been used as a surrogate for TBEV. In this study, we aimed to investigate the vector competence of H. longicornis to transmit LGTV and demonstrate the efficient acquisition and transmission of LGTV between this tick species and mice. LGTV localization was detected in several tick tissues, such as the midgut, salivary glands, and synganglion, using quantitative PCR and immunohistochemical staining with a polyclonal antibody targeting the LGTV envelope protein. We demonstrated the horizontal transmission of LGTV to different developmental stages within the same generation but did not see evidence of vertical transmission. It was interesting to note that we observed mice acting as a bridge, facilitating the transmission of LGTV to neighboring naïve ticks during blood feeding. In conclusion, the virus-vector-host model employed in this study provides valuable insights into the replication and transmission of LGTV throughout its life cycle.

Potent immunogenicity and neutralization of recombinant adeno-associated virus expressing the glycoprotein of severe fever with thrombocytopenia virus

Severe fever with thrombocytopenia syndrome (SFTS) is an infectious disease caused by a tick-borne virus called severe fever with thrombocytopenia syndrome virus (SFTSV). In recent years, human infections through contact with ticks and through contact with the bodily fluids of infected dogs and cats have been reported; however, no vaccine is currently available. SFTSV has two glycoproteins (Gn and Gc) on its envelope, which are vaccine-target antigens involved in immunogenicity. In the present study, we constructed novel SFTS vaccine candidates using an adeno-associated virus (AAV) vector to transport the SFTSV glycoprotein genome. AAV vectors are widely used in gene therapy and their safety has been confirmed in clinical trials. Recently, AAV vectors have been used to develop influenza and SARS-CoV-2 vaccines. Two types of vaccines (AAV9-SFTSV Gn and AAV9-SFTSV Gc) carrying SFTSV Gn and Gc genes were produced. The expression of Gn and Gc proteins in HEK293T cells was confirmed by infection with vaccines. These vaccines were inoculated into mice, and the collected sera produced anti-SFTS antibodies. Furthermore, sera from AAV9-SFTSV Gn infected mice showed a potent neutralizing ability, similar to previously reported SFTS vaccine candidates that protected animals from SFTSV infection. These findings suggest that this vaccine is a promising candidate for a new SFTS vaccine.

Distribution characteristics and influencing factors of Haemaphysalis longicornis around goat sheds in Jinan city, East China

As one of the most important disease vectors worldwide, ticks can transmit a number of pathogenic organisms to humans and domestic animals and cause a variety of important natural focal diseases and zoonoses. Domestic livestock play a vital role in the dispersal of ticks from the field environment to the human settlement, contributing to the prevalence of tick-borne diseases. Identification of the tick control region could contribute a vital role in strategic planning and cost-effective tick control measures. However, little is known about the spatial distribution characteristics of ticks around livestock sheds, which will lead to abusage and overuse of insecticides. Therefore, this study aimed to explore spatial distribution characteristics and correlation factors of ticks around goat sheds. A total of 3898 ticks were collected from eight goat sheds from April to June in Jinan city. All the sampled ticks belonged to the same species, namely Haemaphysalis longicornis, and 88.8% of them were nymphs. A significant positive correlation was noted between free-living ticks and parasitic ticks (r = 0.411, P < 0.001). However, there was a significant negative correlation between number of free-living ticks and distance from the goat sheds (r = -0.622, P < 0.001). Within 20 m from the goat sheds, 2211 ticks were collected respectively, representing 56.7% of the total free-living ticks. At a distance of 30 m, 57.6% decline in the tick density was found with a significant difference (q = 5.534, P < 0.001). In conclusion, focusing control efforts near the goat sheds should be recommend for tick prevention and control.

Seroprevalence and transmission of severe fever with thrombocytopenia syndrome virus in a coastal endemic area in Southeastern China

Severe fever with thrombocytopenia syndrome (SFTS) is a newly emerged tick-borne viral zoonosis and widely prevalent in China, Japan and South Korea. Most reported SFTS cases have been identified in mountainous and hilly areas, with a few in island areas. In this study, we conducted a systematic investigation about natural infection of SFTS virus (SFTSV) among humans, animals and ticks in a coastal endemic prefecture, containing island, plains and mountain settings, in Zhejiang Province, Southeastern China. From July 2020 to June 2021, 1117 participants completed a survey with questionnaire interview and serum testing. Meanwhile, 862 serum samples of domestic animals, 275 spleen tissue samples of wild animals and 829 ticks representing five species (predominantly Haemaphysalis longicornis and Rhipicephalus sanguineus sensu lato) were collected. The seroprevalence of anti-SFTSV total antibody and IgM antibody among the participants was 4.8 % (54/1117) and 0.6 % (7/1117), respectively. Multivariate logistic regression analysis indicated that living in the island area (OR=2.66; 95 %CI: 1.04-6.80; P = 0.041) was significantly associated with seropositivity of total antibody to SFTSV. Furthermore, a higher seroprevalence was observed in domestic animals (36.1 %), while the SFTSV-RNA infection rate was 0.4 % in wild animals and the minimum infection rate (MIR) was 0.8 % for all tick species combined. The only tick species infected with SFTSV was H. longicornis. The prevalence of SFTSV infection in the island area, manifested by anti-SFTSV total antibody (P = 0.012) and IgM antibody (P = 0.004) among humans, anti-SFTSV total antibody (P<0.001) among domestic animals, and SFTSV-RNA among ticks (P = 0.022), was significantly higher than that in the mountainous area and the plain area. Furthermore, phylogenetic analysis showed that SFTSV sequences obtained from ticks in the island area were clustered with reported strains in Japan and South Korea. These results suggest that islands in the study area might be an important natural focus of SFTSV.

Association of Deforestation With Severe Fever With Thrombocytopenia Syndrome

BACKGROUND

Severe fever with thrombocytopenia syndrome (SFTS) virus was first isolated in China in 2009 and has since spread to several Asian countries. SFTS is closely related to environmental factors that accelerate vector growth. We evaluated the associations of SFTS and deforestation with environmental variables.

METHODS

For this observational study, we generated multiple Poisson models using national SFTS outbreak data (2013-2018) and official environmental data for Korea. We included established risk factors as variables. Deforestation was used as the main variable. All variables were analyzed according to their spatial characteristics using the R-INLA package.

RESULTS

SFTS cases increased over time and peaked in 2017, at 272, followed by a decrease in 2018. Disease mapping showed a high incidence of SFTS nationwide, with particular risks in Gangwon and Gyeonggi Provinces in the north, and Jeju in the south of South Korea. Deforestation was significantly associated with a higher risk of SFTS in the final model (relative risk, 1.751 [95% confidence interval, 1.125-2.743]).

CONCLUSIONS

SFTS outbreaks are associated with deforestation. Therefore, deforestation in Gyeonggi, Gangwon, and Jeju provinces of South Korea needs to be considered in vector-control strategies and active surveillance of SFTS occurrence.

Projecting spatiotemporal dynamics of severe fever with thrombocytopenia syndrome in the mainland of China

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease with increasing incidence and geographic extent. The extent to which global climate change affects the incidence of SFTS disease remains obscure. We use an integrated multi-model, multi-scenario framework to assess the impact of global climate change on SFTS disease in China. The spatial distribution of habitat suitability for the tick Haemaphysalis longicornis was predicted by applying a boosted regression tree model under four alternative climate change scenarios (RCP2.6, RCP4.5, RCP6.0, and RCP8.5) for the periods 2030-2039, 2050-2059, and 2080-2089. We incorporate the SFTS cases in the mainland of China from 2010 to 2019 with environmental variables and the projected distribution of H. longicornis into a generalized additive model to explore the current and future spatiotemporal dynamics of SFTS. Our results demonstrate an expanded geographic distribution of H. longicornis toward Northern and Northwestern China, showing a more pronounced change under the RCP8.5 scenario. In contrast, the environmental suitability of H. longicornis is predicted to be reduced in Central and Eastern China. The SFTS incidence in three time periods (2030-2039, 2050-2059, and 2080-2089) is predicted to be increased as compared to the 2010s in the context of various RCPs. A heterogeneous trend across provinces, however, was observed, when an increased incidence in Liaoning and Shandong provinces, while decreased incidence in Henan province is predicted. Notably, we predict possible outbreaks in Xinjiang and Yunnan in the future, where only sporadic cases have been reported previously. These findings highlight the need for tick control and population awareness of SFTS in endemic regions, and enhanced monitoring in potential risk areas.

Infection and transovarial transmission of severe fever with thrombocytopenia syndrome virus in Rhipicephalus sanguineus in Hainan Island, China

Severe fever with thrombocytopenia syndrome virus (SFTSV) RNA level increased in female ticks after injection with SFTSV. Furthermore, SFTSV RNA was detected in the eggs and larvae that originated from the virus-infected female ticks.

Ticks without borders: Microbial communities of immature Neotropical tick species parasitizing migratory landbirds along northern Gulf of Mexico

The long-distance, seasonal migrations of birds make them an effective ecological bridge for the movement of ticks. The introduction of exotic tick species to new geographical regions can lead to the emergence of novel tick-borne pathogens or the re-emergence of previously eradicated ones. This study assessed the prevalence of exotic tick species parasitizing resident, short-distance, and long-distance songbirds during spring and autumn at stopover sites in the northern Gulf of Mexico using the mitochondrial 12S rDNA gene. Birds were captured for tick collection from six different sites from late August to early November in both 2018 and 2019. The highest number of ticks were collected in the 2019 season. Most ticks were collected off the Yellow-breasted Chat (Icteria virens) and Common Yellowthroat (Geothlypis trichas), and 54% of the total ticks collected were from Grand Chenier, LA. A high throughput 16S ribosomal RNA sequencing approach was followed to characterize the microbial communities and identify pathogenic microbes in all tick samples. Tick microbial communities, diversity, and community structure were determined using quantitative insight into microbial ecology (QIIME). The sparse correlations for compositional data (SparCC) approach was then used to construct microbial network maps and infer microbial correlations. A total of 421 individual ticks in the genera Amblyomma, Haemaphysalis, and Ixodes were recorded from 28 songbird species, of which Amblyomma and Amblyomma longirostre was the most abundant tick genus and species, respectively. Microbial profiles showed that Proteobacteria was the most abundant phylum. The most abundant bacteria include the pathogenic Rickettsia and endosymbiont Francisella, Candidatus Midichloria, and Spiroplasma. BLAST analysis and phylogenetic reconstruction of the Rickettsia sequences revealed the highest similarities to pathogenic spotted and non-spotted fever groups, including R. buchneri, R. conorii, R. prowazekii, R. bellii, R. australis, R. parkeri, R. monacensis, and R. monteiroi. Permutation multivariate analysis of variance revealed that the relative abundance of Francisella and Rickettsia drives microbial patterns across the tick genera. We also observed a higher percentage of positive correlations in microbe-microbe interactions among members of the microbial communities. Network analysis suggested a negative correlation between a) Francisella and Rickettsia and, b) Francisella and Cutibacterium. Lastly, mapping the distributions of bird species parasitized during spring migrations highlighted geographic hotspots where migratory songbirds could disperse ticks and their pathogens at stopover sites or upon arrival to their breeding grounds, the latter showing means dispersal distances from 421-5003 kilometers. These findings strongly highlight the potential role of migratory birds in the epidemiology of tick-borne pathogens.

Severe fever with thrombocytopenia syndrome virus genotype B in Thailand

Severe fever with thrombocytopenia syndrome virus (SFTSV) has been reported in many countries in Southeast Asia, which expands the original geographic range of China, Korea, and Japan. Here, we report the complete genome sequences of two Thai SFTSV strains previously identified in patients with undifferentiated febrile illness in 2020. Phylogenetically, both clustered with SFTSV genotype B strains and were most closely related to those previously reported in central China (≥99.0% nucleotide sequence identity) in the L, M, and S gene segments. Nine amino acid residues encoded by one or more Thai SFTSV genomes differed from those found in global strains. Interestingly, the observed differences in numerous residues between the Thai strains suggest possible separate introductions of different variants into the region.

Emerging Tick-Borne Dabie bandavirus: Virology, Epidemiology, and Prevention

Severe Fever with Thrombocytopenia Syndrome (SFTS), caused by Dabie bandavirus (SFTSV), is an emerging infectious disease first identified in China. Since its discovery, infections have spread throughout East Asian countries primarily through tick bites but also via transmission between animals and humans. The expanding range of ticks, the primary vectors for SFTSV, combined with migration patterns of tick-carrying birds, sets the stage for the global spread of this virus. SFTSV rapidly evolves due to continuous mutation and reassortment; currently, no approved vaccines or antiviral drugs are available. Thus, the threat this virus poses to global health is unmistakable. This review consolidates the most recent research on SFTSV, including its molecular characteristics, transmission pathways through ticks and other animals, as well as the progress in antiviral drug and vaccine development, encompassing animal models and clinical trials.

Genome-informed investigation of the molecular evolution and genetic reassortment of severe fever with thrombocytopenia syndrome virus

BACKGROUND

Severe fever with thrombocytopenia syndrome virus (SFTSV) is a viral pathogen causing significant clinical signs from mild fever with thrombocytopenia to severe hemorrhages. World Health Organization has paid special attention to the dramatic increase in human SFTS cases in China, Japan, and South Korea since the 2010s. The present study investigated the molecular evolution and genetic reassortment of SFTSVs using complete genomic sequences.

METHODS/PRINCIPAL FINDING

We collected the complete genome sequences of SFTSVs globally isolated until 2019 (L segment, n = 307; M segment, n = 326; and S segment, n = 564) and evaluated the evolutionary profiles of SFTSVs based on phylogenetic and molecular selection pressure analyses. By employing a time-scaled Bayesian inference method, we found the geographical heterogeneity of dominant SFTSV genotypes in China, Japan, and South Korea around several centuries before and locally spread by tick-born spillover with infrequent long-distance transmission. Purifying selection predominated the molecular evolution of SFTSVs with limited gene reassortment and fixed substitution, but almost all three gene segments appeared to harbor at least one amino acid residue under positive selection. Specifically, the nonstructural protein and glycoprotein (Gn/Gc) genes were preferential selective targets, and the Gn region retained the highest number of positively selected residues.

CONCLUSION/SIGNIFICANCE

Here, the large-scale genomic analyses of SFTSVs improved prior knowledge of how this virus emerged and evolved in China, Japan, and South Korea. Our results highlight the importance of SFTSV surveillance in both human and non-human reservoirs at the molecular level to fight against fatal human infection with the virus.

Multiple piroplasm parasites (Apicomplexa: Piroplasmida) in northeastern populations of the invasive Asian longhorned tick, Haemaphysalis longicornis Neumann (Ixodida: Ixodidae), in the United States

Piroplasms, which include the agents of cattle fever and human and dog babesiosis, are a diverse group of blood parasites of significant veterinary and medical importance. The invasive Asian longhorned tick, Haemaphysalis longicornis, is a known vector of piroplasms in its native range in East Asia and invasive range in Australasia. In the USA, H. longicornis has been associated with Theileria orientalis Ikeda outbreaks that caused cattle mortality. To survey invasive populations of H. longicornis for a broad range of piroplasms, 667 questing H. longicornis collected in 2021 from 3 sites in New Jersey, USA, were tested with generalist piroplasm primers targeting the 18S small subunit rRNA (395–515 bp, depending on species) and the cytochrome b oxidase loci (1009 bp). Sequences matching Theileria cervi type F (1 adult, 5 nymphs), an unidentified Theileria species (in 1 nymph), an undescribed Babesia sensu stricto (‘true’ Babesia, 2 adults, 2 nymphs), a Babesia sp. Coco (also a ‘true Babesia’, 1 adult, 1 nymph), as well as Babesia microti S837 (1 adult, 4 nymphs) were recovered. Babesia microti S837 is closely related to the human pathogen B. microti US-type. Additionally, a 132 bp sequence matching the cytochrome b locus of deer, Odocoileus virginanus, was obtained from 2 partially engorged H. longicornis. The diverse assemblage of piroplasms now associated with H. longicornis in the USA spans 3 clades in the piroplasm phylogeny and raises concerns of transmission amplification of veterinary pathogens as well as spillover of pathogens from wildlife to humans.

Rabbits as Animal Models for Anti-Tick Vaccine Development: A Global Scenario

Studies evaluating candidate tick-derived proteins as anti-tick vaccines in natural hosts have been limited due to high costs. To overcome this problem, animal models are used in immunization tests. The aim of this article was to review the use of rabbits as an experimental model for the evaluation of tick-derived proteins as vaccines. A total of 57 tick proteins were tested for their immunogenic potential using rabbits as models for vaccination. The most commonly used rabbit breeds were New Zealand (73.8%), Japanese white (19%), Californians (4.8%) and Flemish lop-eared (2.4%) rabbits. Anti-tick vaccines efficacy resulted in up to 99.9%. Haemaphysalis longicornis (17.9%) and Ornithodoros moubata (12.8%) were the most common tick models in vaccination trials. Experiments with rabbits have revealed that some proteins (CoAQP, OeAQP, OeAQP1, Bm86, GST-Hl, 64TRP, serpins and voraxin) can induce immune responses against various tick species. In addition, in some cases it was possible to determine that the vaccine efficacy in rabbits was similar to that of experiments performed on natural hosts (e.g., Bm86, IrFER2, RmFER2, serpins and serine protease inhibitor). In conclusion, results showed that prior to performing anti-tick vaccination trials using natural hosts, rabbits can be used as suitable experimental models for these studies.

The genome-wide characterization and associated cold-tolerance function of the superoxide dismutase in the cold response of the tick Haemaphysalis longicornis

Accumulating evidence suggests that superoxide dismutase (SOD) is the first line of antioxidant defense in organisms and plays an important role in scavenging reactive oxygen species produced during environmental stress. However, limited information is available regarding the response of SOD genes to cold stress in ticks. Therefore, in the present study, SOD genes were cloned and identified from the genome of Haemaphysalis longicornis, and the function of SOD during the cold response was further explored. Seven SOD genes were characterized: HlCCS1, HlCCS2, HlMSD, HlCSD1, HlCSD2, HlCSD3, and HlCSD4. Bioinformatics analysis showed that HlCCS1 and HlCCS2 are copper chaperones of SODs. HlCSD1-HlCSD4 belong to the Cu/Zn SOD, whereas HlMSD belongs to the Mn SOD gene family. Fluorescence quantitative PCR showed that the expression of HlCCS2, HlMSD, and HlCSD1-3 was upregulated, whereas HlCCS1 and HlCSD4 were downregulated during the cold response of H. longicornis. Western blotting confirmed changes in the relative expression of HlCSD3 and HlMSD in H. longicornis after cold treatment. Mortality of H. longicornis increased significantly after dsRNA injection of HlCCS2, HlMSD, HlCSD1, and HlCSD3. The above results show that SODs have different regulatory functions during the cold response in H. longicornis, and there might be an interaction between treatment temperature and duration. Furthermore, the results lay a foundation for subsequent research on the molecular mechanism of cold tolerance in H. longicornis and shed light on the population distribution and diffusion limit of ticks.

Association of low HDL-c levels with severe symptoms and poor clinical prognosis in patients with severe fever and thrombocytopenia syndrome

Background

Severe fever with thrombocytopenia syndrome (SFTS) is an acute infectious disease caused by a novel bunyavirus, characterized by high fever, thrombocytopenia, and multiple organ damage. Disturbances in lipid metabolism often occur during viral infections, but the changes and clinical significance of lipid profiles in SFTS patients remain unclear. This study aimed to investigate the alterations in lipid profiles and their clinical significance in SFTS patients.

Methods

A total of 157 SFTS patients and 157 healthy controls were enrolled in this study. Serum lipid levels were collected and analyzed among different groups and prognosis categories. Receiver operating characteristic (ROC) curve analysis was performed to assess the ability of lipid levels in distinguishing between severe and mild cases, as well as surviving and non-surviving patients. Pearson correlation analysis was used to examine the associations between lipid levels and clinical laboratory parameters.

Results

SFTS patients exhibited significantly lower levels of HDL-c, LDL-c, cholesterol, APoAI, and ApoB compared to healthy controls, while triglyceride levels were significantly higher. Serum HDL-c and ApoAI demonstrated good performance as indicators for distinguishing between survivors and non-survivors (AUC of 0.87 and 0.85, respectively). Multivariate regression analysis indicated that HDL-c independently acts as a protective factor in patients with SFTS. HDL-c levels showed decline in non-survivors but recovered in survivors. Moreover, HDL-c exhibited significant correlations with various clinical laboratory parameters (IL-6, CRP, AST, TT, APTT, PLT, ALB, and CD4).

Conclusion

This study identified abnormalities in serum lipid metabolism among SFTS patients. HDL-c and ApoAI levels hold potential as biomarkers for distinguishing survivors from non-survivors. Additionally, HDL-c and ApoAI may serve as therapeutic targets for the management of SFTS patients.

Pathogenic Rickettsia, Anaplasma, and Ehrlichia in Rhipicephalus microplus ticks collected from cattle and laboratory hatched tick larvae

BACKGROUND

The order Rickettsiales contains a group of vector-borne gram-negative obligate intracellular bacteria, which often cause human emerging infectious diseases and economic losses for dairy and meat industries. The purpose of this study is to investigate the distribution of the pathogens including Rickettsia spp., Anaplasma spp., and Ehrlichia spp. in the order Rickettsiales in ticks from Yueyang, a prefecture-level city of Hunan Province in Sothern China, and assess the potentiality of transovarial transmission of these rickettsial organisms.

METHODS

Ticks were collected from cattle in a farm in Yueyang City and the tick DNA was used as template to amplify the htrA, rrs, gltA, ompA and ompB genes of Rickettsia as well as rrs and groEL genes of Anaplasma and Ehrlichia.

RESULTS

All ticks (465) collected were the cattle tick, Rhipicephalus microplus. PCR showed the minimum infection rate (MIR) was 1.5% (7/465) for Candidatus Rickettsia xinyangensis, 1.9% (9/465) for C. Anaplasma boleense, 1.3% (6/465) for Anaplasma platys, 0.6% (3/465) for A. marginale, and 1.17% (2/465) for each of A. bovis, Ehrlichia minasensis, and a non-classified Ehrlichia sp. A human pathogen, C. Rickettsia xinyangensis and A. platys were detected in 100% (3/3) and 33.3% (2/6) laboratory-hatched larval pools from infected females respectively.

CONCLUSION

Our study revealed a diversity of pathogenic rickettsial species in R. microplus ticks from Hunan Province suggesting a threat to people and animals in China. This study also provided the first molecular evidence for the potential transovarial transmission of C. Rickettsia xinyangensis and A. platys in R. microplus, indicating that R. microplus may act as the host of these two pathogens.

Diversity analysis of the endosymbiotic bacterial community in field-collected Haemaphysalis ticks on the tropical Hainan Island, China

Ticks are important vectors of various pathogens that cause infectious diseases in humans. Endosymbiotic bacteria have been explored as targets for tick and tick-borne disease control. However, the tick bacterial community on Hainan Island, which is the largest tropical island in China and has an environment favourable to ticks, has not yet been studied. In this study, we surveyed the bacterial community of ticks collected from grass in one village in Haikou. A total of 20 ticks were morphologically and molecularly identified as Haemaphysalis spp. The tick bacterial 16S rRNA hypervariable region amplicon libraries were sequenced on an Illumina MiSeq platform. A total of 10 possible bacterial genera were detected, indicating a low-diversity bacterial community profile. The dominant bacterial genus, Massilia, accounted for 97.85% of the population. Some other bacterial genera, including Arsenophonus and Pseudomonas, have been reported to play a role in tick development and tick-borne pathogen transmission in other tick species. Overall, the study highlights the first descriptive understanding of the tick bacterial community on Hainan Island and provides a basis for deciphering the interactions between the tick microbiome and tick-borne pathogens.

Molecular characterization and immune efficacy of fructose-1,6-bisphosphate aldolase from Haemaphysalis longicornis (Acari: Ixodidae)

BACKGROUND

Ticks are obligate hematophagous ectoparasites that transmit a variety of pathogens to humans, wildlife and domestic animals. Vaccination is an effective and environmentally friendly method for tick control. Fructose-1,6-bisphosphate aldolase (FBA) is an important glycometabolism enzyme that is a candidate vaccine against parasites. However, the immune protection of FBA in ticks is unclear. METHODS AND RESULTS: The 1092-bp open reading frame (ORF) of FBA from Haemaphysalis longicornis (HlFBA), encoding a 363-amino acid protein, was cloned using PCR methodology. The prokaryotic expression vector pET32a(+)-HlFBA was constructed and transformed into cells of Escherichia coli BL21(DE3) strain for protein expression. The recombinant HlFBA protein (rHlFBA) was purified by affinity chromatography, and the western blot results suggested that the rHlFBA protein was immunogenic.

RESULTS

Results of the enzyme-linked immunosorbent assay showed that rabbits immunized with rHlFBA produced a humoral immune response specific to rHlFBA. A tick infestation trial indicated that, compared to the ticks in the histidine-tagged thioredoxin (Trx) group, the engorged tick weight and oviposition of female ticks and egg hatching rate of those in the rHlFBA group was reduced by 22.6%, 45.6% and 24.1%, respectively. Based on the cumulative effect of the these three parameters, the overall immune efficacy of rHlFBA was estimated to be 68.4%.

CONCLUSIONS

FBA is a candidate anti-tick vaccine that can significantly reduce the engorged tick weight, oviposition, and egg hatching rate. The use of enzymes involved in glucose metabolism is a new strategy in the development of anti-tick vaccines.

Rapid invasion and expansion of the Asian longhorned tick (Haemaphysalis longicornis) into a new area on Long Island, New York, USA

Since its discovery in the United States in 2017, the Asian longhorned tick (Haemaphysalis longicornis) has been detected in most eastern states between Rhode Island and Georgia. Long Island, east of New York City, a recognized high-risk area for tick-borne diseases, is geographically close to New Jersey and New York sites where H. longicornis was originally found. However, extensive tick surveys conducted in 2018 did not identify H. longicornis on Long Island. In stark contrast, our 2022 tick survey suggests that H. longicornis has rapidly invaded and expanded in multiple surveying sites on Long Island (12 out of 17 sites). Overall, the relative abundance of H. longicornis was similar to that of lone star ticks, Amblyomma americanum, a previously recognized tick species abundantly present on Long Island. Interestingly, our survey suggests that H. longicornis has expanded within the Appalachian forest ecological zone of Long Island's north shore compared to the Pine Barrens located on the south shore of Long Island. The rapid invasion and expansion of H. longicornis into an insular environment are different from the historical invasion and expansion of two native tick species, Ixodes scapularis (blacklegged tick or deer tick) and A. americanum, in Long Island. The implications of H. longicornis transmitting or introducing tick-borne pathogens of public health importance remain unknown.

Microhabitat modeling of the invasive Asian longhorned tick (Haemaphysalis longicornis) in New Jersey, USA

The Asian longhorned tick (Haemaphysalis longicornis) is a vector of multiple arboviral and bacterial pathogens in its native East Asia and expanded distribution in Australasia. This species has both bisexual and parthenogenetic populations that can reach high population densities under favorable conditions. Established populations of parthenogenetic H. longicornis were detected in the eastern United States in 2017 and the possible range of this species at the continental level (North America) based on climatic conditions has been modeled. However, little is known about factors influencing the distribution of H. longicornis at geographic scales relevant to local surveillance and control. To examine the importance of local physiogeographic conditions such as geology, soil characteristics, and land cover on the distribution of H. longicornis we employed ecological niche modeling using three machine learning algorithms - Maxent, Random Forest (RF), and Generalized Boosting Method (GBM) to estimate probability of finding H. longicornis in a particular location in New Jersey (USA), based on environmental predictors. The presence of H. longicornis in New Jersey was positively associated with Piedmont physiogeographic province and two soil types - Alfisols and Inceptisols. Soil hydraulic conductivity was the most important predictor explaining H. longicornis habitat suitability, with more permeable sandy soils with higher hydraulic conductivity being less suitable than clay or loam soils. The models were projected over the state of New Jersey creating a probabilistic map of H. longicornis habitat suitability at a high spatial resolution of 90×90 meters. The model's sensitivity was 87% for locations sampled in 2017-2019 adding to the growing evidence of the importance of soil characteristics to the survival of ticks. For the 2020-2022 dataset the model fit was 57%, suggestive of spillover to less optimal habitats or, alternatively, heterogeneity in soil characteristics at the edges of broad physiographic zones. Further modeling should incorporate abundance and life-stage information as well as detailed characterization of the soil at collection sites. Once critical parameters that drive the survival and abundance of H. longicornis are identified they can be used to guide surveillance and control strategies for this invasive species.

Haemaphysalis flava ticks as a competent vector of severe fever with thrombocytopenia syndrome virus

Severe fever with thrombocytopenia syndrome virus (SFTSV), a tick-borne Bunyavirus, causes an emerging hemorrhagic fever in humans with a high fatality in Asia. The tick vectors and hosts of SFTSV are not well studied. We evaluated SFTSV transmission in laboratory reared Haemaphysalis flava ticks. RT-PCR demonstrated that after acquisition feeding in SFTSV-infected rabbits, 10 % (4/40) engorged larvae, 25% (5/20) engorged nymphs, and 50% (5/10) engorged females of H. flava became SFTSV RNA positive; after engorged larvae and nymphs molted into nymphs and adults, respectively, 12.5% (3/24) newly molted nymphs and 20% (2/10) newly molted adults were SFTSV RNA positive. Among 30 engorged females that oviposited, 10% (3/30) clutches of eggs and 3.3% (1/30) colonies of larvae were RNA positive for SFTSV. RT-PCR also showed that 6 days after being infested with SFTSV-infected ticks, 100% (3/3) rabbits infested with larvae, 100% (2/2) rabbits infested with nymphs, and 100% (2/2) rabbits infested with adult ticks became SFTSV RNA positive. In conclusion, H. flava can acquire SFTSV from infected rabbits by feeding; there is transstadial and transovarial transmission of the virus and all three stages of H. flava can transmit SFTSV to rabbits by feeding. Thus, H. flava tick is an effective vector of SFTSV and may play a role in the transmission of SFTSV in wild animals and humans.

Severe fever with thrombocytopenia syndrome virus from ticks: a molecular epidemiological study of a patient in the Republic of Korea

Severe fever with thrombocytopenia syndrome (SFTS) is a tick-borne infectious disease caused by Dabie bandavirus, commonly called SFTS virus (SFTSV). In the Republic of Korea (ROK), 1,504 cases of SFTS have been reported since the first human case was identified in 2013 until 2021. However, no case exists to provide molecular evidence between questing tick and patients with confirmed SFTS in the same living environment. In this study, we investigated the presence of ticks near the area of a patient infected with SFTSV. Ticks were collected by flagging and dry ice-baited traps at three spots in the vegetation around the patients' residence in Chuncheon City, Gangwon Province (ROK). Among the tick samples collected, the presence of SFTSV was genetically determined using reverse transcription PCR, followed by the phylogenetic analysis of the tick virus sequences and SFTSV found in the patient. In total 1,212 Haemaphysalis longicornis ticks were collected, and SFTSV was detected at a minimum infection rate of 5.3% (33 pools/618 tested ticks). The sequences of SFTSV in ticks were 99.6-100% identical with the patient's SFTSV in the M segment. To the best of our knowledge, this study is the first case to provide a molecular correlation between SFTSV in questing ticks collected from residence and patient with SFTS in the ROK. The present results provide useful information for the epidemiological investigation of patients with SFTS using ticks as vectors of SFTSV.

Localization of secreted ferritin (FER2) in the embryos of the tick Haemaphysalis longicornis

Despite the absence of a blood meal, embryogenesis involves many processes that require nutrients and other essential elements, including iron. Due to the lack of an external source of these nutrients, these requirements are acquired maternally. Because of the toxic nature of iron, they are transferred through iron transport molecules such as secreted ferritin (FER2). Here we tried to follow the trail of the FER2 through indirect immunofluorescence, and we observed an apparent shift of FER2 from the germ layer at the early part of development to the appendages during the late stage of embryogenesis. FER2 is also found in the middle part of the legs of the embryo. The apparent movement not only sheds light on iron processing events during embryogenesis but also indirectly guides organogenesis in the tick.

Pseudotyped Virus for Bandavirus

The genus Bandavirus, belonging to family Phenuiviridae, order Bunyavirales, consists of eight tick-borne bunyaviruses. The Dabie bandavirus, formerly known as severe fever with thrombocytopenia virus (SFTSV), belongs to the genus Bandavirus. This emerging pathogen was first identified in central China in 2009. In recent years, the disease has been reported to cause several outbreaks in eastern Asia areas, including China, Japan, Korea, and Vietnam. Tick-to-human transmission is the main route of infection in humans, and transmission via the contact of body fluids from person-to-person was also reported. Despite its high fatality rate, there is currently no vaccine or antiviral therapy available. The therapeutic efficacies of several antiviral agents against Dabie bandavirus are still being evaluated. However, the virus is a potent pathogen with high biosafety experimental conditions. Therefore, replication-incompetent pseudotyped viruses play an important role. In this chapter, we succinctly summarize the basic features concerning Dabie bandavirus, including virion structure, genome characteristics, especially the characteristics of glycoprotein, and probable pathogenic mechanism. And, we put an important part in expounding the construction of pseudoviruses and its application.

Akkermansia muciniphila protects mice against an emerging tick-borne viral pathogen

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging tick-borne disease caused by a phlebovirus in the Bunyaviridae family. Infection can result in systemic inflammatory response syndrome with a high fatality rate, and there are currently no treatments or vaccines available. The microbiota has been implicated in host susceptibility to systemic viral infection and disease outcomes, but whether the gut microbiota is implicated in severe fever with thrombocytopenia syndrome virus (SFTSV) infection is unknown. Here, we analysed faecal and serum samples from patients with SFTS using 16S ribosomal RNA-sequencing and untargeted metabolomics, respectively. We found that the gut commensal Akkermansia muciniphila increased in relative abundance over the course of infection and was reduced in samples from deceased patients. Using germ-free or oral antibiotic-treated mice, we found that A. muciniphila produces the β-carboline alkaloid harmaline, which protects against SFTSV infection by suppressing NF-κB-mediated systemic inflammation. Harmaline indirectly modulated the virus-induced inflammatory response by specifically enhancing bile acid-CoA: amino acid N-acyltransferase expression in hepatic cells to increase conjugated primary bile acids, glycochenodeoxycholic acid and taurochenodeoxycholic acid. These bile acids induced transmembrane G-protein coupled receptor-5-dependent anti-inflammatory responses. These results indicate the probiotic potential of A. muciniphila in mitigating SFTSV infection.

Virus-host interactions during tick-borne bunyavirus infection

The Bunyavirales order is the largest grouping of RNA viruses, comprising emerging and re-emerging human, plant and animal pathogens. Bunyaviruses have a global distribution and many members of the order are transmitted by arthropods. They have evolved a plethora of mechanisms to manipulate the regulatory processes of the infected cell to facilitate their own replicative cycle, in hosts of disparate phylogenies. Interest in virus-vector interactions is growing rapidly. However, current understanding of tick-borne bunyavirus cellular interaction is heavily biased to studies conducted in mammalian systems. In this short review, we summarise current understandings of how tick-borne bunyaviruses utilise major cellular pathways (innate immunity, apoptosis and RNAi responses) in mammalian or tick cells to facilitate virus replication.

Hedgehogs as Amplifying Hosts of Severe Fever with Thrombocytopenia Syndrome Virus, China

Severe fever with thrombocytopenia syndrome virus (SFTSV) is a tickborne bandavirus mainly transmitted by Haemaphysalis longicornis ticks in East Asia, mostly in rural areas. As of April 2022, the amplifying host involved in the natural transmission of SFTSV remained unidentified. Our epidemiologic field survey conducted in endemic areas in China showed that hedgehogs were widely distributed, had heavy tick infestations, and had high SFTSV seroprevalence and RNA prevalence. After experimental infection of Erinaceus amurensis and Atelerix albiventris hedgehogs with SFTSV, we detected robust but transitory viremias that lasted for 9-11 days. We completed the SFTSV transmission cycle between hedgehogs and nymph and adult H. longicornis ticks under laboratory conditions with 100% efficiency. Furthermore, naive H. longicornis ticks could be infected by SFTSV-positive ticks co-feeding on naive hedgehogs; we confirmed transstadial transmission of SFTSV. Our study suggests that the hedgehogs are a notable wildlife amplifying host of SFTSV in China.

The Genus Haemaphysalis (Acari: Ixodidae) in Laos: An Update of Species Records and a Review of Taxonomic Challenges

Haemaphysalis Koch, 1844, is the largest genus of ticks in Southeast Asia, but little information is available concerning the species present in Laos. Recent research has yielded records for 10 Haemaphysalis species in Laos, including 5 new records, as well as 3 morphological entities of uncertain status. Further morphological and molecular studies are needed to clarify our taxonomic understanding of this genus in Southeast Asia.

First Detection of the Invasive Asian Longhorned Tick (Acari: Ixodidae) on Migratory Passerines in the Americas

The Asian longhorned tick (Haemaphysalis longicornis Neumann), native to East Asia, was first reported in the United States in 2017 and is now established in at least 17 states. Haemaphysalis longicornis feeds on birds in its range outside of the United States, and migratory birds disperse this tick and tick-borne pathogens. However, early studies in the United States did not find H. longicornis on migrating passerine birds. The transport of the parthenogenetic H. longicornis on birds has the potential to greatly expand its range. We report the first discovery of H. longicornis on migratory passerine birds in the Americas.

Spatiotemporal analysis of severe fever with thrombocytopenia syndrome in Shandong Province, China, 2014-2018

BACKGROUND

Due to recent emergence, severe fever with thrombocytopenia syndrome (SFTS) is becoming one of the major public health problems in Shandong Province, China. The numbers of reported SFTS cases in general and the area with reported SFTS cases are both continuously increasing in recent years. However, spatiotemporal patterns and clusters of SFTS in Shandong Province have not been investigated yet.

METHODS

The surveillance data of SFTS in Shandong Province, China, during 2014-2018 were extracted from China Information System for Disease Control and Prevention (CISDCP). Geoda software was used to explore spatial autocorrelation analysis, and Satscan software was used to identify spatio-temporal clustering of cases. The results were presented in ArcMap.

RESULTS

The annual average incidence was 0.567/100,000 in Shandong Province during 2014-2018. Results showed that the distribution of SFTS was not random but clustered in space and time. A most likely cluster including 15 counties was observed in the northeastern region of Shandong Province from January 1, 2015 to December 31, 2015 (Relative risk = 5.13, Log likelihood ratio = 361.266, P < 0.001).

CONCLUSIONS

The number of SFTS cases in Shandong Province increased overall. Geographic information system analysis coupled with spatial analysis illustrated regions with SFTS clusters. Our results provide a sound evidence base for future prevention and control programs of SFTS such as allocation of the health resources, surveillance in high-risk regions, health education, improvement of diagnosis and so on.

Antiviral activity and mechanism of the antifungal drug, anidulafungin, suggesting its potential to promote treatment of viral diseases

BACKGROUND

The severe fever with thrombocytopenia syndrome disease (SFTS), caused by the novel tick-borne SFTS virus (SFTSV), was listed among the top 10 priority infectious disease by World Health Organization due to the high fatality rate of 5-30% and the lack of effective antiviral drugs and vaccines and therefore raised the urgent need to develop effective anti-SFTSV drugs to improve disease treatment.

METHODS

The antiviral drugs to inhibit SFTSV infection were identified by screening the library containing 1340 FDA-approved drugs using the SFTSV infection assays in vitro. The inhibitory effect on virus entry and the process of clathrin-mediated endocytosis under different drug doses was evaluated based on infection assays by qRT-PCR to determine intracellular viral copies, by Western blot to characterize viral protein expression in cells, and by immunofluorescence assays (IFAs) to determine virus infection efficiencies. The therapeutic effect was investigated in type I interferon receptor defective A129 mice in vivo with SFTSV infection, from which lesions and infection in tissues caused by SFTSV infection were assessed by H&E staining and immunohistochemical analysis.

RESULTS

Six drugs were identified as exerting inhibitory effects against SFTSV infection, of which anidulafungin, an antifungal drug of the echinocandin family, has a strong inhibitory effect on SFTSV entry. It suppresses SFTSV internalization by impairing the late endosome maturation and decreasing virus fusion with the membrane. SFTSV-infected A129 mice had relieving symptoms, reduced tissue lesions, and improved disease outcomes following anidulafungin treatment. Moreover, anidulafungin exerts an antiviral effect in inhibiting the entry of other viruses including SARS-CoV-2, SFTSV-related Guertu virus and Heartland virus, Crimean-Congo hemorrhagic fever virus, Zika virus, and Herpes simplex virus 1.

CONCLUSIONS

The results demonstrated that the antifungal drug, anidulafungin, could effectively inhibit virus infection by interfering with virus entry, suggesting it may be utilized for the clinical treatment of infectious viral diseases, in addition to its FDA-approved use as an antifungal. The findings also suggested to further evaluate the anti-viral effects of echinocandins and their clinical importance for patients with infection of viruses, which may promote therapeutic strategies as well as treatments and improve outcomes pertaining to various viral and fungal diseases.

Analysis of risk factors associated with fatal outcome among severe fever with thrombocytopenia syndrome patients from 2015 to 2019 in Shandong, China

To better understand the progression of severe fever with thrombocytopenia syndrome (SFTS), identify early predictors of mortality, and improve the cure rate, the present study aimed to analyze the demographic feature, clinical characteristics, and laboratory parameters of patients with SFTS and to explore the risk factors associated with fatal outcome. We retrospectively analyzed demographic feature, clinical characteristics, and laboratory parameters of 216 laboratory-confirmed SFTS patients in Shandong province between January 2015 and December 2019. Univariate analysis was used to assess the relevance between these factors and fatal outcome. Factors with P < 0.05 in univariate analysis were further analyzed using multivariable logistic regression analysis to identify the independent risk factors for mortality of SFTS. Age, five complications (including CNS symptoms, pulmonary infection, heart failure, arrhythmia, and bleeding events), and ten abnormal laboratory parameters (including serum viral load, blood platelet, ALT, AST, LDH, CK, CK-MB, Cr, serum Ca²⁺, and APTT) were statistically significant by univariate analysis. These factors were further analyzed by multivariable logistic regression analysis, and the results indicated that coma, pulmonary infection, high viral load, and prolonged APTT were associated with fatal outcome in SFTS patients. Our study identified four independent risk factors associated with fatal outcome for SFTS patients. The results were hoped to provide help for active treatment of SFTS. However, the identification of risk factors is not absolutely associated with fatal outcome. Patients' risk should be assessed by dynamic observation of the changes in risk factor indicators.

Transmission and mortality risk assessment of severe fever with thrombocytopenia syndrome in China: results from 11-years' study

Background

The transmission and fatal risk of severe fever with thrombocytopenia syndrome (SFTS), an emerging infectious disease first discovered in China in 2009, still needed further quantification. This research aimed to analyze the SFTS clusters and assess the transmission and mortality risk for SFTS.

Methods

Both epidemiological investigation and case reports regarding SFTS clusters in China during 2011–2021 were obtained from the Public Health Emergency Information Management System of the Chinese Center for Disease Control and Prevention Information System. The transmission risk was evaluated by using the secondary attack rate (SAR) and relative risk (RR). Mortality risk factors were analyzed using a logistic regression model.

Results

There were 35 SFTS clusters during 2011–2021 involving 118 patients with a fatality rate of 22.0%. The number of clusters annually increased seasonally from April to September. The clusters mainly occurred in Anhui (16 clusters) and Shandong provinces (8 clusters). The SAR through contact with blood or bloody fluids was much higher than that through contact with non-bloody fluids (50.6% vs 3.0%; χ² = 210.97, P < 0.05), with an RR of 16.61 [95% confidence interval (CI): 10.23–26.97]. There was a statistically significant difference in the SAR between exposure to the blood of a deceased person during burial preparation and exposure to the living patients’ blood (66.7% vs 34.5%; χ² = 6.40, P < 0.05), with an RR of 1.93 (95% CI: 1.11–3.37). The mortality risk factors were a long interval from onset to diagnosis [odds ratio (OR) = 1.385), 95% CI: 1.083–1.772, P = 0.009) and advanced age (OR: 1.095, 95% CI: 1.031–1.163, P = 0.01).

Conclusions

The SFTS clusters showed a high mortality rate and resulted in a high SAR. Contact with a bleeding corpse was associated with a higher infection risk, compared with contacting the blood from living patients. It is important to promote early detection and appropriate case management of patients with SFTS, as well as improved handling of their corpses, to prevent further transmission and mortality.

Graphical abstract