Incidence and prevalence of infection with human granulocytic ehrlichiosis agent in Germany. A prospective study in young healthy subjects

Seroepidemiology of Borrelia burgdorferi s.l. among German National Cohort (NAKO) Participants, Hanover

Lyme borreliosis is the leading tick-related illness in Europe, caused by Borrelia Burgdorferi s.l. Lower Saxony, Germany, including its capital, Hanover, has a higher proportion of infected ticks than central European countries, justifying a research focus on the potential human consequences. The current knowledge gap on human incident infections, particularly in Western Germany, demands serological insights, especially regarding a potentially changing climate-related tick abundance and activity. We determined the immunoglobulin G (IgG) and immunoglobulin M (IgM) serostatuses for 8009 German National Cohort (NAKO) participants from Hanover, examined in 2014-2018. We used an enzyme-linked immunosorbent assay (ELISA) as the screening and a line immunoblot as confirmation for the Borrelia Burgdorferi s.l. antibodies. We weighted the seropositivity proportions to estimate general population seropositivity and estimated the force of infection (FOI). Using logistic regression, we investigated risk factors for seropositivity. Seropositivity was 3.0% (IgG) and 2.1% (IgM). The FOI varied with age, sharply increasing in participants aged ≥40 years. We confirmed advancing age and male sex as risk factors. We reported reduced odds for seropositivity with increasing body mass index and depressive symptomatology, respectively, pointing to an impact of lifestyle-related behaviors. The local proportion of seropositive individuals is comparable to previous estimates for northern Germany, indicating a steady seroprevalence.

Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis

Introduction

Borrelia burgdorferi sensu lato (Bb) infection, the most frequent tick-transmitted disease, is distributed worldwide. This study aimed to describe the global seroprevalence and sociodemographic characteristics of Bb in human populations.

Methods

We searched PubMed, Embase, Web of Science and other sources for relevant studies of all study designs through 30 December 2021 with the following keywords: ‘Borrelia burgdorferi sensu lato’ AND ‘infection rate’; and observational studies were included if the results of human Bb antibody seroprevalence surveys were reported, the laboratory serological detection method reported and be published in a peer-reviewed journal. We screened titles/abstracts and full texts of papers and appraised the risk of bias using the Cochrane Collaboration-endorsed Newcastle-Ottawa Quality Assessment Scale. Data were synthesised narratively, stratified by different types of outcomes. We also conducted random effects meta-analysis where we had a minimum of two studies with 95% CIs reported. The study protocol has been registered with PROSPERO (CRD42021261362).

Results

Of 4196 studies, 137 were eligible for full-text screening, and 89 (158 287 individuals) were included in meta-analyses. The reported estimated global Bb seroprevalence was 14.5% (95% CI 12.8% to 16.3%), and the top three regions of Bb seroprevalence were Central Europe (20.7%, 95% CI 13.8% to 28.6%), Eastern Asia (15.9%, 95% CI 6.6% to 28.3%) and Western Europe (13.5%, 95% CI 9.5% to 18.0%). Meta-regression analysis showed that after eliminating confounding risk factors, the methods lacked western blotting (WB) confirmation and increased the risk of false-positive Bb antibody detection compared with the methods using WB confirmation (OR 1.9, 95% CI 1.6 to 2.2). Other factors associated with Bb seropositivity include age ≥50 years (12.6%, 95% CI 8.0% to 18.1%), men (7.8%, 95% CI 4.6% to 11.9%), residence of rural area (8.4%, 95% CI 5.0% to 12.6%) and suffering tick bites (18.8%, 95% CI 10.1% to 29.4%).

Conclusion

The reported estimated global Bb seropositivity is relatively high, with the top three regions as Central Europe, Western Europe and Eastern Asia. Using the WB to confirm Bb serological results could significantly improve the accuracy. More studies are needed to improve the accuracy of global Lyme borreliosis burden estimates.

PROSPERO registration number

CRD42021261362.

Pathogenic microorganisms in ticks removed from Slovakian residents over the years 2008-2018

A total of 750 ticks feeding on humans were collected during the years 2008-2018. The majority of ticks (94.8 %) came from Slovakia, with 3.5 % from the Czech Republic, 0.9 % from Austria, and 0.3 % from Hungary. Travellers from Ukraine, Croatia, France, and Cuba also brought one tick from each of these countries. The majority of the analysed ticks were identified as Ixodes ricinus (94.3 %). Dermacentor reticulatus (0.93 %), Haemaphysalis concinna (0.1 %), Haemaphysalis sp. (0.1 %), Ixodes arboricola (0.1 %), and Rhipicephalus sp. (0.1 %) were also encountered. The most frequently found stage of I. ricinus was the nymph (69.9 %) followed by adult females (20.4 %) and larvae (8.3 %). Ticks were predominantly found on children younger than 10 years (46.3 %) and adults between 30-39 years (21.4 %). In children younger than 10 years, the ticks were usually found on the head, while in other age categories, the ticks were predominantly attached to legs. Ticks were further individually analysed for the presence of Rickettsia spp., Coxiella burnetii, Borrelia burgdorferi sensu lato, Anaplasma phagocytophilum, Neoehrlichia mikurensis, Bartonella spp. and Babesia spp. The overall prevalences of tick-borne bacteria assessed in I. ricinus ticks acquired in Slovakia were: rickettsiae 25.0 % (95 % CI: 21.7-28.2), B. burgdorferi s.l. 20.5 % (95 % CI: 17.4-23.5), A. phagocytophilum 13.5 % (95 % CI: 10.9-16.0), Babesia spp. 5.2 % (95 % CI: 3.5-6.9), C. burnetii 3.0 % (95 % CI: 1.5-4.6), and N. mikurensis 4.4 % (95 % CI: 2.0-6.8). Pathogenic species Rickettsia raoultii, Rickettsia helvetica, Rickettsia monacensis, A. phagocytophilum, Borrelia garinii, Borrelia afzelii, Borrelia valaisiana, Babesia microti, and Babesia divergens were identified in D. reticulatus and I. ricinus ticks.

Seroprevalence of Borrelia burgdorferi, Anaplasma phagocytophilum, and Francisella tularensis Infections in Belgium: Results of Three Population-Based Samples

To estimate the seroprevalence of Borrelia burgdorferi (Bb), Anaplasma phagocytophilum (Ap), and Francisella tularensis (Ft) in Belgium, we tested sera from three population-based samples in which exposure to pathogen is assumed to vary: 148 samples from workers professionally exposed, 209 samples from rural blood donors, and 193 samples from urban blood donors. Sera were tested using ELISA or the immunofluorescence assay test. The seroprevalence of Bb was 5.4% in workers professionally exposed, 2.9% in rural blood donors, and 2.6% in urban blood donors, which is similar to other studies. The fraction of negative results decreases significantly from urban blood donors and rural blood donors to workers. Regarding the seroprevalence of Ap, the cutoff titer of 1:64 recommended by the manufacturer may be set too low and produces artificially high seroprevalence rates. Using a cutoff titer of 1:128, the seroprevalence of Ap was estimated at 8.1% for workers professionally exposed, 6.2% for rural blood donors, and 5.7% for urban blood donors. Tularemia sera confirmed the presence of the pathogen in Belgium at 2.0% for workers and 0.5% for rural and urban blood donors. Our study is one of the few providing an estimation of the seroprevalences of Bb, Ap, and Ft in three different populations in Belgium, filling the gap in seroprevalence data among those groups. Our findings provide evidence that the entire Belgian population is exposed to Bb, Ap, and Ft infections, but a higher exposure is noticed for professionals at risk. Education on the risk factors for tick bites and preventive measures for both professionals exposed and the general population is needed.

Evaluating frequency, diagnostic quality, and cost of Lyme borreliosis testing in Germany: a retrospective model analysis

Background. Data on the economic impact of Lyme borreliosis (LB) on European health care systems is scarce. This project focused on the epidemiology and costs for laboratory testing in LB patients in Germany. Materials and Methods. We performed a sentinel analysis of epidemiological and medicoeconomic data for 2007 and 2008. Data was provided by a German statutory health insurance (DAK) company covering approx. 6.04 million members. In addition, the quality of diagnostic testing for LB in Germany was studied. Results. In 2007 and 2008, the incident diagnosis LB was coded on average for 15,742 out of 6.04 million insured members (0.26%). 20,986 EIAs and 12,558 immunoblots were ordered annually for these patients. For all insured members in the outpatient sector, a total of 174,820 EIAs and 52,280 immunoblots were reimbursed annually to health care providers (cost: 2,600,850€). For Germany, the overall expected cost is estimated at 51,215,105€. However, proficiency testing data questioned test quality and standardization of diagnostic assays used. Conclusion. Findings from this study suggest ongoing issues related to care for LB and may help to improve future LB disease management.

Serologic evidence of Anaplasma phagocytophilum infections in patients with a history of tick bite in central Slovakia

The aim of this study was to determine the risks of human anaplasmosis in an area of central Slovakia endemic for Lyme borreliosis. The circulation of Anaplasma phagocytophilum in ticks and wild animals has been observed in natural foci in this area for several years. Samples of human sera from patients with Lyme borreliosis and persons with a history of recent tick bite and clinical symptoms indicating Lyme borreliosis were collected in central Slovakia. A total of 76 human sera were analyzed using an indirect HGE IgG immunofluorescent assay kit. IgG antibodies against A. phagocytophilum were found in 19 (25%) sera (15 female, 4 male patients). A. phagocytophilum infection was serologically confirmed in one (3.8%) child, 12 (38.7%) persons aged 22-56 and six (31.6%) persons older than 56. A statistically significant difference in seroprevalence (P < 0.01) was observed between children (3.8%, 1/26) and adults (36%, 18/50). Antibodies against A. phagocytophilum were detected in seven patients with clinically diagnosed Lyme borreliosis and in another seven individuals with assessed antiborrelia antibodies. IgG antibodies against A. phagocytophilum were detected in five persons seronegative for borrelia. The most frequent clinical symptoms in patients with positive A. phagocytophilum serology were cephalalgia, arthralgia, myalgia, fever, exanthema, neurological symptoms and lymphadenopathy. Positive sera were obtained from patients living in villages and towns in the orographic entities Vtácnik (5/19), Stiavnické vrchy (1/19), Kremnické vrchy (10/19) and Ziarska kotlina (3/19). Our results demonstrate the risk of acquiring A. phagocytophilum infection in natural foci in central Slovakia. Human anaplasmosis should be considered in the differential diagnosis, especially in cases of acute febrile illness with tick-bite history.

Prevalence of seropositivity to spotted fever group rickettsiae and Anaplasma phagocytophilum in a large, demographically diverse US sample

BACKGROUND

Most epidemiologic studies of tick-borne rickettsial diseases in the United States are small and have limited demographic scope, making broader risk assessment difficult.

METHODS

We conducted a seroprevalence study of spotted fever group rickettsiae and Anaplasma phagocytophilum, the agent of human granulocytic anaplasmosis. Specimens were selected randomly from the Department of Defense Serum Repository for 10,000 diverse military personnel at various stages in their careers who were serving with active duty status in 1997. Antibody testing included enzyme-linked immunosorbent assay for Rickettsia rickettsii and A. phagocytophilum, and Western blot confirmation for A. phagocytophilum. Risk factors were assessed using logistic regression.

RESULTS

Subjects were mostly male and young and were diverse ethnically and geographically. Spotted fever group rickettsiae seropositivity was 6.0% (95% confidence interval, 5.5%-6.4%). In univariable logistic regression, seroprevalence was significantly higher among older subjects, men (6.5%, compared with 3.3% among women), black individuals (8.7%, compared with 5.6% among white individuals), subjects from states with above-average Rocky Mountain spotted fever incidence, and subjects in ground combat specialties. Associations remained significant in multivariable analysis for age, sex, black versus white race, home state with high incidence, and ground combat specialty. Among 696 subjects with serum samples obtained within 7 days after entering the military, the rate of seropositivity was 3.4% (95% confidence interval, 2.1%-4.8%). Seroprevalence was nonsignificantly lower in men (3.4%, compared with 3.7% in women ) and in black individuals (3.4%, compared with 4.1% in white individuals). A. phagocytophilum seropositivity, as determined by by enzyme-linked immunosorbent assay and Western blot, was 2.6% and 0.11% (95% confidence interval, 0.05%-0.18%), respectively. Western blot seropositivity was not significantly associated with subject characteristics in univariable analysis.

CONCLUSIONS

Spotted fever group rickettsiae exposure was common and A. phagocytophilum exposure was rare in a US population with broad demographic diversity.

Anaplasma phagocytophilum in Dogs in Germany

A total number of 111 dogs were included in the present prospective study investigating the prevalence of Anaplasma phagocytophilum in dogs in Germany. Dogs were divided into two groups. Dogs of group 1 (n = 49) showed clinical and/or haematological signs seen in infections with A. phagocytophilum, whereas those of group 2 (n = 62) did not have any evidence of anaplasmosis. For each dog, an A. phagocytophilum 16S rRNA-nested polymerase chain reaction (PCR) of ethylenediaminetetraacetic acid (EDTA)-anticoagulated whole blood analysis, a microscopic evaluation of a buffy coat and a serum indirect fluorescent antibody test (IFAT) were performed. Forty-eight seroreactive dogs were identified altogether, which amounts to an overall point prevalence of 43.2%. There was no significant difference between the seroreactivity to A. phagocytophilum antigens among group 1 (44.9%) and 2 (41.9%) (P > 0.5). Seven dogs (6.3%) had positive PCR results. All of them were seroreactive. Six belonged to group 1. Morulae in neutrophilic granulocytes were found in two dogs of group 1 but in none of group 2. Both dogs were seroreactive. Very high antibody titres (> or =1:1024) were detected significantly more frequently in dogs with clinical signs attributable to infection with A. phagocytophilum (group 1) than in those without (group 2) (P < 0.001). There was no significant correlation of overall positives or antibody titres to age, breed, sex, or whether the dogs were family or working dogs. Dogs with high tick infestation were significantly more often seroreactive to A. phagocytophilum than those with no or low tick infestation (P = 0.007). In conclusion, there seems to be a high risk of infection with A. phagocytophilum in Germany. Results of this study suggest that severe illness solely caused by A. phagocytophilum may be possible although definitive evidence does not exist. Very high antibody titres (>1:1024) may be associated with clinical anaplasmosis.

Seroprevalence of human granulocytic anaplasmosis in Berlin/Brandenburg, Germany: an 8-year survey

This study investigated the seroprevalence of antibodies against Anaplasma phagocytophilum in Berlin/Brandenburg, north-eastern Germany. During 1994-2001, 422 sera from patients with proven tick-exposure (specimens with antibodies against Borrelia burgdorferi) were compared with 249 control sera. Using indirect fluorescent antibody testing, significantly more positive samples were detected among Borrelia antibody-positive specimens (4.5%, 95% CI 2.5-6.5%) than among controls (1.2%, 95% CI 0.5-1.9%; p < 0.05). While six (2.2%, 95% CI 1.3-3.1%) samples were positive among Borrelia antibody-positive sera between 1994 and 1997, 13 (8.7%, 95% CI 6.9-10.5%) were positive between 1998 and 2001 (p < 0.01), indicating an uneven annual seroprevalence.

Clinical Diagnosis and Treatment of Human Granulocytotropic Anaplasmosis

Tick-borne rickettsiae in the genera Ehrlichia and Anaplasma are intracellular bacteria that infect wild and domestic mammals and, more recently, man. The increased desire of humans for recreational activities outdoors has increased the exposure to potential human pathogens that previously cycled almost exclusively within natural, nonhuman enzootic hosts. Anaplasma phagocytophilum causes an acute, nonspecific febrile illness of humans previously known as human granulocytotropic ehrlichiosis (HGE) and now called human granulocytotropic anaplasmosis (HGA). The first patient to have recognized HGA was hospitalized at St Mary's Hospital in Duluth, Minnesota, USA in 1990. However, the clinical and laboratory presentation of this infection remained undefined until 1994, when Bakken and collaborators published their experience with 12 patients who had HGA. By the end of December 2004, at least 2,871 cases of HGA had been reported from 13 U.S. states to the Centers for Disease Control and Prevention (CDC). A limited number of laboratory-confirmed cases have been reported from countries in Europe, including Austria, Italy, Latvia, the Netherlands, Norway, Poland, Slovenia, Spain, and Sweden. Ixodes persulcatus-complex ticks are the arthropod hosts for Borrelia burgdorferi, the agent of Lyme borreliosis, and are also the arthropod hosts for A. phagocytophilum. Most cases of HGA have been contracted in geographic regions that are endemic for Lyme borreliosis. Male patients outnumber female patients by a factor of 3 to 1 and as many as 75% of patients with HGA have had a tick bite prior to their illness. Seroepidemiologic studies have demonstrated that HGA for the most part is a mild or even asymptomatic illness. However, older individuals and patients who are immunocompromised by natural disease processes or medications may develop an acute, influenza-like illness characterized by high fever, rigors, generalized myalgias, and severe headache. Local skin reactions at the site of the tick bite have not been described, and nonspecific skin rashes have been reported only occasionally. Anaplasmosis is associated with variable but suggestive changes in routine laboratory test parameters. Most patients develop transient reductions in total leukocyte and platelet concentrations. Relative granulocytosis accompanied by a left shift and lymphopenia during the first week of illness has been reported frequently. Serum hepatic transaminase concentrations usually increase two- to fourfold, and inflammatory markers, such as C-reactive protein and the erythrocyte sedimentation rate, rise during the acute phase. Abnormal laboratory findings may return toward normal range for patients who have been ill for more than 7 days, which may obfuscate the clinical decision making. Characteristic clusters of bacteria (morulae) are observed in the cytoplasm of peripheral blood granulocytes in 20% to 80% of infected patients during the acute phase of illness. The clinical diagnosis may be confirmed retrospectively by specific laboratory tests, which include positive polymerase chain reaction (PCR), identification of A. phagocytophilum in culture of acute-phase blood, or the detection of specific antibodies to A. phagocytophilum in convalescent serum. Virtually all patients have developed serum antibodies to A. phagocytophilum after completion of antibiotic therapy, and demonstration of seroconversion by indirect immunofluorescent antibody testing of acute-phase and convalescent-phase serum samples is currently the most sensitive and specific tool for laboratory confirmation of HGA. Treatment with doxycycline usually results in rapid improvement and cure. Most patients with HGA have made an uneventful recovery even without specific antibiotic therapy. However, delayed diagnosis in older and immunocompromised patients may place those individuals at risk for an adverse outcome, including death. Thus, prompt institution of antibiotic therapy is advocated for any patient who is suspected to have HGA and for all patients who have confirmed HGA.

Human granulocytic ehrlichiosis in Europe

Human granulocytic ehrlichiosis (HGE) is a tick-borne zoonosis caused by Anaplasma phagocytophilum. A MEDLINE literature search revealed that the European story of HGE began in 1995 with an article on the presence of serum antibodies to A. phagocytophilum. At present, there is seroepidemiological information indicating the presence of infection with HGE agent(s) for several European countries; seroprevalence rates range from zero or very low to up to 28%. The proportion of seropositive persons increases with age and is higher in persons exposed to ticks. Knowledge of the causative agent of HGE and of animal reservoirs in Europe is limited. Ixodes ricinus is a recognized vector of A. phagocytophilum in Europe. Prevalence of the agent in questing I. ricinus is usually higher in adult ticks than in nymphs and ranges from zero or very low to > 30%. Pronounced differences between countries and marked variability by localities were established. Up to March 2003 about 65 human patients (all but one were adults) with confirmed HGE and several patients fulfilling criteria for probable HGE had been reported. The majority of them came from Central Europe (Slovenia) and Scandinavia (Sweden) but there are individual reports from several other European countries. The patients presented with an acute febrile illness that as a rule occurred after a tick bite; the majority had leukopenia and/or thrombocytopenia, elevated concentration of C-reactive protein and mild abnormalities of liver function test results. A small number of patients does not permit reliable conclusions on the clinical features of European HGE; however, there is an impression that at least in central Europe (but maybe not in Scandinavia) the disease is, from the clinical angle, only mild to moderately severe and (most likely) self-limited. The relatively high proportion of the population with HGE serum antibodies and the presence of A. phagocytophilum (like) agent(s) in ticks, small mammals and deer as found in several European countries are discordant with the rather low number of patients with proven HGE. The discordance may indicate inadequate awareness among European physicians, limited recording and reporting of the disease, and/or the presence of and the infection of humans with nonpathogenic A. phagocytophilum (like) strains present in ticks. Additional studies are needed to better define the biological and public health significance of HGE in Europe.

New real-time PCR-based method for in vitro susceptibility testing of Anaplasma phagocytophilum against antimicrobial agents

Up to now, only a few isolates of Anaplasma phagocytophilum have been tested for their susceptibility against a small number of antimicrobial agents. In addition, as with other fastidious or intracellular bacteria, the test methods are laborious and neither minimal inhibitory concentration (MIC) definitions, nor the test conditions and the inocula are standardised to date. A new 16S-rDNA-based real-time PCR assay has been developed and used under standardised conditions to analyse the activity of seven antimicrobial agents against two A. phagocytophilum isolates. After 72 h incubation, MICs were determined by software-assisted calculation of bacterial growth in samples and controls from semi-quantitative PCR results. In our study, the rank order of potency on a mg/l basis for the antimicrobial agents with enhanced in vitro activity against A. phagocytophilum was moxifloxacin (MIC: < or = 0.03 mg/l) > doxycycline (MIC: < or = 0.125 mg/l) > ciprofloxacin (MIC: 0.125 mg/l). Gentamicin, ampicillin, azithromycin and cethromycin showed no activity against the isolates tested in this investigation. Our new 16S-rDNA-PCR-based microdilution test system was shown to be sensitive, reproducible and reliable. The assay is capable of testing larger numbers of isolates and antimicrobial agents under standardised and very precise test conditions and may therefore offer a competent technical solution of the difficulties known to be associated with in vitro testing of other bacterial pathogens that grow intracellularly, such as chlamydia or rickettsia.