The Willingness to Pay for Vaccination against Tick-Borne Encephalitis and Implications for Public Health Policy: Evidence from Sweden

The increasing incidence of tick-borne encephalitis (TBE) in Sweden and several other European countries has sparked a discussion about the need for a public vaccination strategy. However, TBE vaccination coverage is incomplete and there is little knowledge about the factors influencing vaccination behavior. Based on a survey of 1,500 randomly selected respondents in Sweden, we estimate vaccination coverage in areas with different TBE risk levels and analyze the role of vaccine price and other factors influencing the demand for vaccination. First, we find that the average rate of TBE vaccination in Sweden is 33% in TBE risk areas and 18% elsewhere. Income, age and risk-related factors such as incidence of TBE in the area of residence, frequency of visits to areas with TBE risk, and experience with tick bites are positively associated with demand for TBE vaccine. Next, using contingent valuation methodology, we estimate the willingness to pay for TBE vaccination among the unvaccinated respondents and the effect of a possible subsidy. Among the unvaccinated respondents in TBE risk areas, we estimate the mean willingness to pay for the recommended three doses of TBE vaccine to be 465 SEK (approximately 46 euros or 40% of the current market price). We project that a subsidy making TBE vaccines free of charge could increase the vaccination rate in TBE risk areas to around 78%, with a larger effect on low-income households, whose current vaccination rate is only 15% in risk areas. However, price is not the only factor affecting demand. We find significant effects on vaccination behavior associated with trust in vaccine recommendations, perceptions about tick bite-related health risks and knowledge about ticks and tick-borne diseases. Hence, increasing knowledge and trust, as well as ease of access to vaccinations, can also be important measures for public health agencies that want to increase the vaccination rate.     

The clinico-epidemiological characteristics of Powassan encephalitis in the southern Soviet Far East]

The present communication deals with the analysis of 14 cases of Powassan encephalitis. As shown in this study, the course of this infection may be accompanied by symptoms indicating the presence of cerebral and meningeal lesions (in 7 cases meningoencephalitic forms with one fatal outcome and in 2 cases meningeal forms were registered) or take febrile and inapparent forms (5 cases). Powassan encephalitis was found to give characteristic symptoms of cerebellovestibular lesions, differentiating this disease from tick-borne encephalitis (TBE). The cases of mixed infections caused by TBE virus, Powassan encephalitis virus and tick-born Borrelia were found to be possible.     

The possible role of alpha 2-macroglobulin in regulating the immune components of the brain in tick-borne encephalitis

In tick-borne encephalitis certain immunopathological reactions develop in the tissues of the central nervous system; alpha 2-macroglobulin may serve as the marker of the activity of these reactions. The dynamic study of liquor taken from 16 patients with the meningeal and focal forms of tick-borne encephalitis (TBE), 8 patients with severe craniocerebral traumas accompanied by meningitis and 10 patients with osteochondrosis was made. As revealed in this study, in TBE patients the level of alpha 2-macroglobulin increases 3.5-fold and remains stable during the acute period of the disease.     

Results of the 20-year study of tick-borne encephalitis in Crimea

The history of tick-borne encephalitis (TBE) study in the Crimea was retraced and the possibility of introduction of TBE virus to the Crimea in the process of the acclimatization of vertebrates from areas enzootic for TBE is discussed. The foci of TBE were found throughout the whole of the mountain forest zone of the Crimea and coincided with the habitat area of lxodes ricinus, the main vector of TBE. Such ticks as Dermacentor reticulatus, D. marginatus and Hyalomma marginatum were also found to take part in the circulation of the virus. Among the residents of the mountain forest zone, 13.9% were found to have immunity to TBE, testifying to the wide contact of the population with the pathogen. TBE morbidity had pronounced seasonal character and the morbidity rate was low with the prevalence of mild clinical forms. The characteristic feature of the virus population was polymorphism: strains identical to the Far-Eastern strains Sofyin (about 60-70%) and strains differing in their antigenic structure circulated here.     

Effects of deer density on tick infestation of rodents and the hazard of tick-borne encephalitis. I: empirical assessment

Tick borne encephalitis (TBE) is endemic to eastern and central Europe with broad temporal and spatial variation in infection risk. Although many studies have focused on understanding the environmental and socio-economic factors affecting exposure of humans to TBE, comparatively little research has been devoted to assessing the underlying ecological mechanisms of TBE occurrence in enzootic cycles, and therefore TBE hazard. The aim of this study was to evaluate the effect of the main ungulate tick hosts on the pattern of tick infestation in rodents and TBE occurrence in rodents and questing adult ticks. In this empirical study, we considered three areas where endemic human TBE occurs and three control sites having no reported human TBE cases. In these six sites located in Italy and Slovakia, we assessed deer density using the pellet group count-plot sampling technique, collected questing ticks, live-trapped rodents (primarily Apodemus flavicollis and Myodes glareolus) and counted ticks feeding on rodents. Both rodents and questing ticks were screened for TBE infection. TBE infection in ticks and rodents was positively associated with the number of co-feeding ticks on rodents and negatively correlated with deer density. We hypothesise that the negative relationship between deer density and TBE occurrence on a local scale (defined by the minimum overlapping area of host species) could be attributed to deer (incompetent hosts) diverting questing ticks from rodents (competent hosts), know as the 'dilution effect hypothesis'. We observed that, after an initial increase, the number of ticks feeding on rodents reached a peak for an intermediate value of estimated deer density and then decreased. Therefore, while at a regional scale, tick host availability has already been shown to be directly correlated with TBE distribution, our results suggest that the interactions between deer, rodents and ticks are much more complex on a local scale, supporting the possibility of a dilution effect for TBE.     

Tick-borne encephalitis virus prevalence in Ixodes ricinus ticks collected in high risk habitats of the south-Bohemian region of the Czech Republic

A survey for tick-borne encephalitis virus in Ixodes ricinus ticks was conducted in May 2000 in two districts of the South-Bohemian region of the Czech Republic with a high occurrence of tick-borne encephalitis (TBE) in humans. Homogenized ticks were tested on PS cells, which were examined for any cytopathic effect, plaque assay and indirect fluorescent antibody test (IFT). The IFT has proved to be the most sensitive and most rapid test to demonstrate the virus in ticks. TBE virus was found in 17 of 187 pooled samples, consisting of a total of 2,968 ticks. The mean minimum infection rate was 0.6% for all tick stages combined. Infection rates in nymphs collected indifferent locations varied between 0.2 and 1.3% and between 5.9 and 11.1% in adult ticks. The observed TBE prevalence in ticks was compared with data obtained elsewhere in the Czech Republic. It is concluded that screening of ticks for TBE virus prevalence using IFT is a valuable indicator for the degree of risk to contract TBE in as particular habitat. This revised version was published online in July 2006 with corrections to the Cover Date.     

Mixed infection by tick-borne encephalitis virus and Borrelia in ticks

To investigate the relationships between tick-borne encephalitis (TBE) virus and the bacterial spirochaete Borrelia burgdorferi sensu lato in vectors with mixed infections, unfed adult Ixodes persulcatus ticks were collected by flagging from vegetation in southern-taiga forests of the Pre-Urals region of Russia where both infections circulate sympatrically. Prevalences of TBE and Borrelia infections in a total of 4234 ticks were compared over 5 years. No significant differences were revealed between the prevalence of Borrelia infection in ticks with and without TBE virus (29.4+/-7.8% vs 23+/-3.6%), or between the prevalence of TBE virus infection in ticks with and without Borrelia (24.0+/-6.6% vs 18.4+/-3.4%). In ticks with mixed infection (40/689 = 5.8%), concentrations of TBE virus and Borrelia were not significantly correlated with one another. Field observations showed parallel trends in the prevalence of these pathogens in tick populations from year to year (1993-1997) indicating that, in I. persulcatus with mixed infection, Borrelia and TBE virus do not seem to interfere with each other and are apparently not involved in any antagonistic relationships.     

Predictive map of Ixodes ricinus high-incidence habitats and a tick-borne encephalitis risk assessment using satellite data

The main objective of this project was to predict Ixodes ricinus abundant habitats reliably as a means of tick-borne encephalitis (TBE) risk assessment for the prevention of this disease. The vegetation types were used as the indicators of an ecosystem suitable for tick occurrence, for TBE virus circulation and, accordingly, for the existence of natural foci of this infection. Remote sensing methods were used to determine the indicative plant cover. Satellite data covering an experimental area of 70 × 70 km in Central Bohemia, the Czech Republic, was acquired by the Landsat 5 TM scanner. Nine forest classes were recognized in the experimental area by successive supervised and unsupervised classifications and identified in a field-checking botanical survey. An epidemiological TBE map based on human cases contracted in the territory under study was exploited for the evaluation of risk in particular forest classes. Predictive maps are expressed both in digital and in printed forms at a scale of 1 : 300 000 for an overall risk evaluation and at a scale of 1 : 25 000 for a detailed local orientation.     

Tick-borne encephalitis in a northern zone of coniferous and broad-leaved forests of a focal region of the Amur River basin

The geographical variability of the population of tick-borne encephalitis (TBE) virus in the northern part of the zone of combined coniferous and broad-leaved forests was established; this variability was manifested by higher virulence and homogeneity of TBE virus strains, as shown in experiments on white mice receiving the virus extraneurally, in comparison with the southern part of the zone and by higher virus carriership of the ticks Ixodes persulcatus. With the epizootic situation remaining tense and the danger of TBE virus infection still present, TBE morbidity and mortality rates decreased in the years of the construction of the Baikal-Amur Railroad, which was due to greater attention given to measures for the prophylaxis of TBE during this period.     

Interrelations between Ixodes persulcatus ticks and the tick-borne encephalitis virus of the red vole (Clethrionomys rutilis) in western Siberia

We present the data of 12-year survey (1989-2001) of the red vole population in southeastern West Siberia, including estimation of host relative numbers, abundance of immature taiga ticks, and percentage of animals with antigemagglutitnins against tick-borne encephalitis (TBE) virus. We discuss the role of demographic groups of voles as tick's hosts and their participation in the maintenance of TBE causative agent population. The estimation of spontaneous TBE infection rate in summer as well as in winter and early spring seasons, which have been made using a set of molecular-biological, serological and virological methods, demonstrates that a high proportion of red voles maintain non-pathogenic TBE causative agent over a long time, presumably, in the form of persistent infection.     

Polymorphisms in Chemokine Receptor 5 and Toll-Like Receptor 3 Genes Are Risk Factors for Clinical Tick-Borne Encephalitis in the Lithuanian Population

Background

Tick-borne encephalitis virus (TBEV) infections can be asymptomatic or cause moderate to severe injuries of the nervous system. We previously reported that a nonfunctional chemokine receptor 5 (CCR5) and a functional Toll-like receptor 3 (TLR3) predispose adults to clinical tick-borne encephalitis (TBE). This study expands our previous findings and further examines polymorphisms in CCR5 and TLR3 genes in different age and disease severity groups.

Methods

117 children and 129 adults, stratified into mild, moderate and severe forms of TBE, and 103 adults with severe TBE were analyzed. 135 healthy individuals and 79 patients with aseptic meningoencephalitis served as controls. CCR5 delta 32 and rs3775291 TLR3 genotypes were established by pyrosequencing, and their frequencies were analyzed using recessive genetic, genotype and allelic models.

Findings

The prevalence of CCR5Δ32 homozygotes was higher in children (2.5%), in adults with severe TBE (1.9%), and in the combined cohort of TBE patients (2.3%) than in controls (0%) (p<0.05). The nonfunctional homozygous TLR3 genotype was less prevalent among the combined TBE cohort (11.5%) than among controls (19.9%) (p = 0.025), but did not differ between children TBE and controls. The genotype and allele prevalence of CCR5 and TLR3 did not differ in children nor adult TBE cohorts stratified by disease severity. However, in the severe adult TBE cohort, homozygous functional TLR3 genotype and wt allele were less prevalent compared to the adult cohort with the whole disease severity spectrum (44.4% vs 59.8% p = 0.022 and 65.2% vs 76.4% p = 0.009; respectively).

Conclusions

Independently of age, nonfunctional CCR5Δ32 mutation is a significant risk factor for development of clinical TBE, but not for disease severity. The polymorphism of TLR3 gene predisposes to clinical TBE in adults only and may be associated with disease severity. Further studies are needed to clarify the role of these polymorphisms in susceptibility to TBEV infection.     

An uncommon severe clinical course of European tick-borne encephalitis

Tick-borne encephalitis (TBE) is the major European arbovirosis. Man is often infected by the tick bite; laboratory infections as well as infections after consumption of nonpasteurized milk have occasionally been reported. TBE typically takes a biphasic course. After an incubation period (7-14 days usually), the prodromal symptoms occur. The first stage of the disease lasts 1-8 days. After an afebrile asymptomatic interval of approximately 1-week the second stage develops, in which TBE may manifest as isolated meningitis, meningoencephalitis, meningoencephalomyelitis and/or radiculitis. The mortality rate is 0-3.3%. There is high frequency of sequelae. Patients who have suffered from a TBE infection are immune for the rest of their lives. At present there is no effective antiviral therapy and management is strictly supportive. Active immunization against TBE is recommended for all subjects living in and travelling to areas of risk. Passive immunization is recommended only within 48 hours after a tick bite. The authors present the case report of 75-years old female subject, who suffered from the uncommon severe clinical course of TBE--with the development of consciousness impairment, tetraplegia, and dyspnoea (demanding ventilatory support). Her state was complicated by the transient left side faciobrachial motor Jackson's convulsions, blood pressure instability, heart arrhythmia, respiratory infection, anemia, and by the development of critical illness neuropathy. Although she made slow progress during treatment, she died on the 114th day because of suspected aspiration.     

Are Patients with Erythema Migrans Who Have Leukopenia and/or Thrombocytopenia Coinfected with Anaplasma phagocytophilum or Tick-Borne Encephalitis Virus?

Lyme borreliosis (LB), tick-borne encephalitis (TBE) and human granulocytic anaplasmosis (HGA) are endemic in central part of Slovenia. We tested the hypothesis that patients with erythema migrans (EM) from this region, who have leukopenia and/or thrombocytopenia (typical findings in HGA and in the initial phase of TBE but not in patients with LB) are coinfected with Anaplasma phagocytophilum and/or with TBE virus, i.e. that cytopenia is a result of concomitant HGA or the initial phase of TBE. Comparison of clinical and laboratory findings for 67 patients with EM who disclosed leukopenia/thrombocytopenia with the corresponding results in sex- and age-matched patients with EM and normal blood cell counts revealed no differences. In addition, patients with typical EM and leukopenia and/or thrombocytopenia tested negative for the presence of IgM and IgG antibodies to TBE virus by ELISA as well as for the presence of specific IgG antibodies to A. phagocytophilum antigens by IFA in acute and convalescent serum samples. Thus, none of 67 patients (95% CI: 0 to 5.3%) with typical EM (the presence of this skin lesion attests for early Lyme borreliosis and is the evidence for a recent tick bite) was found to be coinfected with A. phagocytophilum or had a recent primary infection with TBE virus. The findings in the present study indicate that in Slovenia, and probably in other European countries endemic for LB, TBE and HGA, patients with early LB are rarely coinfected with the other tick-transmitted agents.     

Breakdown of the blood-brain barrier during tick-borne encephalitis in mice is not dependent on CD8+ T-cells

Tick-borne encephalitis (TBE) virus causes severe encephalitis with serious sequelae in humans. The disease is characterized by fever and debilitating encephalitis that can progress to chronic illness or fatal infection. In this study, changes in permeability of the blood-brain barrier (BBB) in two susceptible animal models (BALB/c, and C57Bl/6 mice) infected with TBE virus were investigated at various days after infection by measuring fluorescence in brain homogenates after intraperitoneal injection of sodium fluorescein, a compound that is normally excluded from the central nervous system. We demonstrate here that TBE virus infection, in addition to causing fatal encephalitis in mice, induces considerable breakdown of the BBB. The permeability of the BBB increased at later stages of TBE infection when high virus load was present in the brain (i.e., BBB breakdown was not necessary for TBE virus entry into the brain), and at the onset of the first severe clinical symptoms of the disease, which included neurological signs associated with sharp declines in body weight and temperature. The increased BBB permeability was in association with dramatic upregulation of proinflammatory cytokine/chemokine mRNA expression in the brain. Breakdown of the BBB was also observed in mice deficient in CD8(+) T-cells, indicating that these cells are not necessary for the increase in BBB permeability that occurs during TBE. These novel findings are highly relevant to the development of future therapies designed to control this important human infectious disease.     

Amplification of tick-borne encephalitis virus infection during co-feeding of ticks

Abstract. Following engorgement of Rhipicephalus appendiculatus larvae on guinea-pigs infected with tick-borne encephalitis (TBE) virus, none of the engorged larvae or emergent nymphs contained detectable infectious virus. However, one of twelve pools, each containing three of the unfed nymphs, was positive when screened by polymerase chain reaction (PCR), indicating a low prevalence of TBE virus infection in the unfed nymphs. After engorgement of the nymphs on four uninfected guinea-pigs, 19/24 (79%) fed nymphs from one guinea-pig and 4/25 (16%) fed nymphs from a second guinea-pig were infected; all the ticks examined from the other two guinea-pigs were uninfected. The results suggest that TBE virus was transmitted from a low proportion of infected nymphs (infected as larvae) to uninfected nymphs as they fed together on an uninfected guinea-pig. Such amplification of the initial infection, at the population level, could play an important role in maintaining TBE virus infections in nature, particularly if there is a low level of vertical transmission from one tick generation to the next.     

Relationships between the content of circulating immune complexes, the concentration of serum immunoglobulins and the titers of specific antibodies in patients with tick-borne encephalitis

In the blood serum of tick-borne encephalitis (TBE) patients the detection rate and concentration of circulating immune complexes, as well as the content of serum IgA, IgM and IgG, were evaluated. The formation of immune complexes was found to depend on IgM and IgG specific antibodies to TBE virus, the period of the disease and the clinical form of virus infection.     

Antibodies to DNA in the Blood of Patients with Tick-Borne Encephalitis

The relative levels of autoantibodies to native and denatured DNA (nDNA and dDNA, respectively) in the blood were compared in 55 patients with tick-borne encephalitis (TBE). Compared to healthy donors, the titers of antibodies (Ab) to nDNA and dDNA were significantly higher in 31% and 40% of TBE patients, respectively. The proportion of patients with an increased concentration of anti-nDNA Ab in the case of TBE (32%) was higher than among patients with multiple sclerosis (18%) and some other autoimmune diseases (6–18%) but comparable with that among patients with systemic lupus erythematosus (38%) and polymyositis (42%). In contrast to the patients with systemic lupus erythematosus and multiple sclerosis, the level of antibodies to nDNA in TBE patients was higher than that of anti-dDNA Ab. The coefficients of correlation between the levels of Ab to nDNA and dDNA were estimated for the entire group of TBE patients and for subgroups with different forms of the disease (temperature reactions, febrile form, and meningeal form). Analysis of correlation between the anti-DNA antibody titers and three standard biochemical markers of TBE (aspartate aminotransferase and alanine aminotransferase activities and total bilirubin) was carried out for 22 patients. A statistically significant correlation was revealed only between the level of Ab to nDNA and the marker enzyme activities, with the respective correlation coefficients being +0.44 and +0.48, respectively.     

Evaluation of the European tick‐borne encephalitis vaccine against Omsk hemorrhagic fever virus

This study focused on the antigenic cross‐reactivity between tick‐borne encephalitis virus (TBEV) and Omsk hemorrhagic fever virus (OHFV) to assess the efficacy of the commercial TBE vaccine against OHFV infection. Neutralization tests performed on sera from OHFV‐ and TBEV‐infected mice showed that neutralizing antibodies are cross‐protective. The geometric mean titers of antibodies against TBEV and OHFV from TBEV‐infected mice were similar. However, the titers of anti‐TBEV antibodies in OHFV‐infected mice were significantly lower than those of anti‐OHFV antibodies in the same animals. In mouse vaccination and challenge tests, the TBE vaccine provided 100% protection against OHFV infection. Eighty‐six percent of vaccinees seroconverted against OHFV following complete vaccination, and the geometric mean titers of neutralizing antibodies against OHFV were comparable to those against TBEV. These data suggest that the TBE vaccine can prevent OHFV infection.     

Ixodes ricinus, transmitted diseases and reservoirs

The tick Ixodes ricinus has been recorded in most Italian regions especially in thermo-mesophilous woods and shrubby habitats where the relative humidity allow the tick to complete its 3 year developmental cycle, as predicted for the European climatic ranges. This tick acts both as vector and reservoir for a series of wildlife zoonotic pathogens, especially the agents of Lyme diseases, Tick borne encephalitis and Human Granulocytic Ehrlichiosis, which are emerging in most of Europe. To assess the spatial distribution of these pathogens and the infection risk for humans and animals within the territory of the Province of Trento, we carried out a long term study using a combination of eco-epidemiological surveys and mathematical modelling. An extensive tick collection with a GIS based habitat suitability analysis allowed us to identify the areas where tick occurs at various density. To identify the areas with higher infection risk, we estimated the values of R0 for Borrelia burgdorferi s.l., TBE virus and Anaplasma phagocytophila under different ecological conditions. We assessed the infection prevalence in the vector and in the wildlife reservoir species that play a central role in the persistence of these infections, ie the small mammals A. flavicollis and C. glareolus. We also considered the double effect of roe deer (Capreolus capreolus) which act as reservoir for A. phagocytophila but is an incompetent host for B. burgdorferi and TBE virus, thus reducing the infection prevalence in ticks of these last two pathogens. Infection prevalence with B. burgdorferi and A. phagocytophila in the vector was assessed by PCR screening 1212 I. ricinus nymphs collected by dragging in six main study areas during 2002. The mean infection prevalence recorded was 1.32% for B. burgdorferi s.l. and 9.84% for A. phagocytophila. Infection prevalence in nymphs with TBE virus, as assessed in a previous study was 0.03%. Infection prevalence in rodents was assessed by screening (with ELISA and PCR) tissues and blood samples collected from 367 rodent individuals trapped extensively during 2002 within 6 main study areas. A. flavicollis (N=238) was found to be infected with all three pathogens investigated, with infection prevalence ranging from 3.3% for TBE virus to 11.7% for A. phagocytophila, and 16.6% with B. burgdorferi s.l. C. glareolus (N=108) showed an infection prevalence of 6.5% with A. phagocytophila and 12.7% with B. burgdorferi s.l., while no individuals were infected with TBE virus. We also screened 98 spleen samples collected from roe deer with PCR, resulting in a mean prevalence of infection with A. phagocytophila of 19.8%. Using a deterministic model we explored the condition for diseases persistence under different rodent and roe deer densities. R0 values resulted largely above 1 for B. burgdorferi s.l. in the vast majority of the areas classified as suitable for I. ricinus occurrence in Trentino, while the condition for TBE persistence appeared to be more restricted by a combination of climatic condition and host densities.     

Arbovirological survey in Silica plateau area, Roznava District, Czechoslovakia

The serosurveys conducted in the Silica plateau area of the Slovak karst region revealed the presence of specific neutralizing antibody against tick-borne encephalitis (TBE) virus in 18% of local inhabitants (33 examined, mostly goats and sheep farmers), 54% of goats (26 examined), 18% of sheep (120 examined) and 13% of cattle (60 examined), against Lipovník (LIP) virus in 30% of inhabitants, 88% of goats, 55% of sheep and 45% of cattle, and against Bhanja (BHA) virus in 27% of inhabitants, 46% of goats, 29% of sheep and 23% of cattle. The results of hemagglutination-inhibition tests with TBE and BHA antigens were analogous. A detailed analysis of these serologic data points to a recent enhancement of the circulation of LIP and BHA viruses and to a very low TBE virus activity in this natural focus of arboviral infections. The immunological surveys of the 32 former "Roznava disease" patients, conducted 25 years after an extensive epidemic of a TBE virus infection that originated in Roznava in 1951, revealed the presence of neutralizing (and also hemagglutination-inhibiting) antibodies against TBE virus in as many as 78% of cases. Antibodies against LIP and BHA viruses were also detectable in the sera of 16% and 9%, respectively, of these individuals. Populations of the ectoparasites examined for the presence of arbovirus comprised 231 Ixodes ricinus, 806 Dermacentor marginatus and 204 Haemaphysalis punctata ticks and 117 specimens of the louse-flies Melophagus ovinus. Two strains of arbivirus that were antigenically related to Lipovník and Tribec viruses belonging to a group of Kemerovo viruses were isolated from male and female I. ricinus ticks collected from cattle.