Northern European Conference on Travel Medicine (NECTM)

Northern European Conference on Travel Medicine (NECTM), Hamburg May 26 – 29, 2010

Thursday, May 27, 14.30 – 16.00, Room E; CCH in Hamburg Workshop 6:

Tick-borne diseases in Europe

1. Prof. J. Suess, Friedrich-Loeffler Institute, Jena, Germany Ticks in Europe: go and win

2.Dr A.Kotłowski, dr J.Stańczak, MIMMiT Gdynia GUM, Poland Borreliosis in Poland: risk for tourists and local population

3.Prof. L. Lindquist, Karolinska Univ.Hosp. Stockholm, Sweden Prof. F. von Sonneburg, University of Munich, Germany TBE vaccine – for and against

Session objectives: Clinical and practical utility in everyday practice: Epidemiology, risk factors Clinical manifestations (Lyme, TBE) Indications for immunization of TBE

Chair: Prof. J. Suess, F-L I, Jena Germany Prof. B. Jaremin, MIMMiT GUM Gdynia, Poland Questions and problems for workshop: 1. Epidemiology:

1.1. > TBD as the emerging infectious diseases (EID); the spread in Europe and the world; are some countries free of risk? What kind of biotops is typical for ticks and dangerous for visitors: tourists, workers and local population? Why seasonal tops and downs of infections?

1.2. > Zoonotic diseases; pathogens transmitted: Borrellia sp.( Spirochet.), SFG (Ricketts.), TBEV(Flavovir.), HGA( anaplasmosis, Ricketts.), Babesia sp. ( Piroplasmidae)

1.3. > Ticks: both the vector and reservoir for TBD, the spread in Europe and world. Does other vector/reservoir play role? What is the role of: rodents, cattle , dogs as chain of transmission? Vertical vs horizontal transmission? Infectivity, density of pathogens/vectors/reservoir, changing climate as the factors influencing epidemiology and risk?

1.4. > Who, how and when do humans become infected as an occasional host? Frequency, incidence rate, reporting? Do some sexual contact, breast-feeding play any role? Occupational or recreational exposure ( fleece-gatherers, hunters, forest- workers, wood-cutters, campers, tourists – prevalence?)

1.5. > Are co-infections, mixed infections rare, increase risk? Prevalence, yearly morbidity/mortality across Europe Problem of under-reporting. Other questions? 2. Clinical manifestation, diagnosing: Lyme ( LB):

2.1. > What is incubation period after tick bite? ( 1-3 weeks)

2.2. > What are symptomatic phases: I. acute: 1-4 weeks, cutaneous EM ( ~ 50% of patients) II. sub-chronic, 2 weeks-several months, systematic błood dissemination: arthritis, neuro-borreliosis; lymphocytic mengitis and radiculitis, heart, sight and hearing location, other III. chronic stage, organ dissemination, min 1 year of symptoms; ACA (acrodermatitis chronica atrophicans) + all other organs as possible target Is it ever curable/ fatal disease? 2.3. > Are there differences in LB manifestation related to some B. pathogens: burgdorferi, garrini, afzeli? Are any specific clinical manifestations of high positive value, inciting early LB suspicion/ diagnose? Early: epidemiology, tick on skin, EM presence Later: epidemiology, EM in anamnesis, fever, organ symptoms: arthritis, neurological signs.

2.4. > How to confirm the etiology? Tests to be recommended? When? Low, high: Sensitivity, specificity? Accessibility? Price? I. Serologic; OIP, ELISA, Western Blot II. PCR III. LUAT (Lyme Urine Antigen Test) ? LDA ( Lyme Dot-Blot Assay for Antigen) ? IV.QRIBB ( Quantitative Rapid Identification of B.b)

Attention: No 100% of sensitivity! Clinic is essential. 3. Controversies on LB treatment:

3.1. > Are there standards or recommendations only? General principles: treatment postulated if; - tick on skin for more than 24(72) h. - tick filled with blood before removing - more than 20% ticks infected in the territory - EM present - infection in immunological depressed person commonly accepted?

3.2. > IDSA ( Infection Diseases Society of America); Infection possible to be cured by one antibiotic within few weeks Post-borreliosis syndrome; symptomatic treatment, with no indication for antibiotic-therapy. ( Brarson D and all., APMIS,1998,106(12),1131-1141)

3.3. > ILADS (International Lyme and Associated Diseases Society); Infection possible to be cured by long-lasting, poly- antibiotic-therapy, including use of antibiotics in chronic phase, resistant or atypical illness. ( Burrascano JJ, Guidelines for Lyme Disease…, Fifteenth Edit. ILADS, Sept.2005 )

3.4. > value of so named Marshall protocol? provided for diseases with immune reaction type Th1; - phase 1: blocker of angiotensin receptor + antibiotic + vit.D - phase 2: combination of different antibiotics. ( www.marshallprotocol.com) 3.5. > Is vaccination possible as a preventive mean in LB? No. 4. Clinical manifestation and prevention of TBE:

4.1. > What is incubation period ? (7 – 14 days)

4.2. > Symptomatic phase, acute manifestation as: - mild, febrile illness ( sometimes) - mild ( European type) or severe ( Asiatic type) inflammation of brain and meninges, with typical dispersed neurological signs and bi-phasic febrile course ( most often) with prolonged convalescence - chronic neurological sequeleae in 10-50% of cases.

4.3. > Are other ways of infection but by tick bite? May follows consumption of raw milk from infected domestic animals.

4.4. > What is mortality rate?: variable, death occurring in 1-2% of persons within 5-7 days. Large outbreaks of TBE observed in some countries, representing major public health risk.

4.5. > Is any specific treatment recommended? No specific therapy, except recommended bed-regime, hospitalization, supportive unspecific treatment related to general state and symptoms – in severe case ventilation support.

4.6. > Is active prevention possible? Effectiveness, cost vs risk? Recommended TBE vaccination ( purified, inactivated virus) for group of risk, commonly accessible. What are pro and against? The national regulation for TBE vaccination exists in most of endemic countries. The coverage by vaccination differs between countries.

5. General prevention against tick-bites and TBD; what can we do?

5.1 General information on endemic spread of ticks and TBD in the world.

5.2 Education of the potential group of risk; local population, tourists and campers, occupationally exposed workers; delivered by: mass-media, lectures, leaflets, precisely addressed warning.

5.3. Recommended vaccination for potential group of risk, if possible and necessary.

5.4. Instruction related to; - the proper dressing, shoes, hats etc. before visiting woodlands, forest meadows, parks etc. biotops of ticks.

5.5. Use of skin-repellents against arthropods and mosquitoes, removing tick off the skin immediately, collar for dog and removing ticks from his hair before letting him enter home.

5.6. Exact watching and revision of skin and dress after coming back home, Removing tick by use of proper instrument. 5.7. Reporting and medical consultation after tick-bite, recommended or necessary if EM occurs or other symptoms arise within period of incubation.

5.8 Early treatment if TBD diagnosed, confirmed.