Spatial risk analysis for the introduction and circulation of six arboviruses in the Netherlands

Multi-antigen serology and a diagnostic algorithm for the detection of arbovirus infections as novel tools for arbovirus preparedness in southeast Europe (MERMAIDS-ARBO): a prospective observational study

BACKGROUND

Arboviruses are increasingly affecting Europe, partly due to the effects of climate change. This increase in range and impact emphasises the need to improve preparedness for emerging arboviral infections that often co-circulate and might have overlapping clinical syndromes. We aimed to strengthen surveillance networks for four clinically relevant arboviruses in southeast Europe.

METHODS

This study reports an in-depth analysis of the MERMAIDS-ARBO prospective observational study in adults (ie, aged ≥18 years) hospitalised with an arbovirus-compatible disease syndrome in 21 hospitals in seven countries in southeast Europe over four arbovirus seasons (May 1-Oct 31, 2016-19) to obtain arbovirus prevalence outcomes. The main objectives of the MERMAIDS-ARBO study, describing the clinical management and outcomes of four arboviruses endemic to southeast Europe, including Crimean-Congo haemorrhagic fever virus (CCHFV), tick-borne encephalitis virus (TBEV), Toscana virus, and West Nile virus (WNV), are reported elsewhere. In this analysis, given the challenges associated with arbovirus diagnostics, we developed a diagnostic algorithm accounting for serology outcomes and sample timing to study arbovirus prevalence in southeast Europe. Serum samples were collected on days 0, 7, 28, and 60 after hospital admission and tested for anti-CCHFV IgG and IgM antibodies with ELISAs (confirmed with an indirect immunofluorescence test) and for IgG and IgM antibodies specific to TBEV, Toscana virus, and WNV with custom-printed protein microarrays (confirmed with virus neutralisation tests). All acute-phase samples were tested by PCR for all four viruses. Descriptive analyses were performed for virus-reactive cases by geography and year, and possible factors (eg, age, sex, and insect bites) associated with virus reactivity were assessed.

FINDINGS

Of 2896 individuals screened, 913 were eligible for inclusion, of whom 863 (514 men, 332 women, and 17 unknown) had samples sent to the study reference laboratories and were included in molecular and serological analyses. Some individuals had insufficient clinical data to be included in the clinical analysis, but met the eligibility criteria for and were included here. Serum sampling was incomplete (eg, samples missing from one or more timepoints or no data on time since symptom onset) for 602 (70%) patients, and the timing of collection was often heterogeneous after symptom onset up to 40 days (average median delay of 5-6 days across all timepoints), affecting the ability to diagnose arbovirus infection by serology. By use of an interpretation table incorporating timing and completeness of sampling, one (<1%) participant had a confirmed recent infection with CCHFV, ten (1%) with TBEV, 40 (5%) with Toscana virus, and 52 (6%) with WNV. Most acute confirmed infections of Toscana virus were found in Albania (25 [63%] of 40), whereas WNV was primarily identified in Romania (36 [69%] of 52). Albania also had the highest overall Toscana virus seropositivity (168 [60%] of 282), mainly explained by patients confirmed to be exposed or previously exposed (104 [62%] of 168). Patients without antibodies to WNV or Toscana virus were significantly younger than patients with antibodies (mean difference -8·48 years [95% CI -12·31 to -4·64] for WNV, and -6·97 years [-9·59 to -4·35] for Toscana virus). We found higher odds of Toscana virus reactivity in men (odds ratio 1·56 [95% CI 1·15 to 2·11]; p=0·0055), WNV reactivity with mosquito bites versus no mosquito bites (2·47 [1·54 to 3·97]; p=0·0002), and TBEV reactivity with tick bites versus no tick bites (2·21 [1·19 to 4·11]; p=0·018).

INTERPRETATION

This study shows that despite incomplete and heterogeneous data, differential diagnosis of suspected arbovirus infections is possible, and the diagnostic interpretation algorithm we propose could potentially be used to strengthen routine diagnostics in clinical settings in areas at risk for arboviral diseases. Our data highlight potential hotspots for arbovirus surveillance and risk factors associated with these particular arbovirus infections.

FUNDING

European Commission and Versatile Emerging infectious disease Observatory.

TRANSLATIONS

For the Greek, Albanian, Romanian, Bosnian, Serbian, and Croatian translation of the summary see Supplementary Materials section.

Spring fever: early spring predicts Ixodes pacificus (Acari: Ixodidae) activity in northwestern California

In the far western United States, the bacterial agent of Lyme disease, Borrelia burgdorferi sensu lato, is primarily transmitted to humans by the nymphal stage of the western black-legged tick, Ixodes pacificus. Predicting nymphal tick abundance would benefit public health but is complicated by the tick's complex multi-year life cycle and data limitations. To address this, we used readily available climate data, a long-term dataset from northwestern California, and time lags based on the tick's life cycle. Our model showed that warmer early spring temperatures during non-drought conditions the year prior predicted higher nymphal tick densities, while hot, dry springs the year prior were linked to earlier peaks in their abundance. Incorporating human-induced climate change projections, we predicted earlier peaks of nymphal tick activity over the next century, with the potential for an initial doubling in questing nymph numbers. This approach provides a valuable tool for public health and offers insights into the changing dynamics of Lyme disease ecology in the far-western US.

Spatial inference of Culex pipiens abundance and biting activity distribution in the Netherlands using citizen science

BACKGROUND

The expanding geographical spread of mosquito-borne diseases (MBDs) has intensified the need for effective mosquito surveillance. Additional surveillance, particularly of species such as Culex pipiens, is essential as this species is a key vector of West Nile and Usutu viruses. Citizen science offers an innovative approach to monitoring Cx. pipiens populations.

METHODS

Our study utilized data from the Mosquito Alert mobile app to model the spatial distribution and abundance of Cx. pipiens and mosquito bites during the summer of 2021 in the Netherlands. Using generalized linear mixed models, climatic and non-climatic factors were analyzed to create two distribution models of adult Cx. pipiens and mosquito bites as outcomes.

RESULTS

Population density, income, and agricultural areas (P ≤ 0.007) were identified as key determinants for both models. Blackbird population density, precipitation, and the interaction between artificial surfaces and temperature were also covariates for the Culex model, whereas sand and tree coverage were determinants for the bite model. The study controlled for biases in sampling effort to ensure robust predictions, revealing higher Cx. pipiens abundance in the central eastern areas of the country and widespread mosquito biting activity across the Netherlands.

CONCLUSIONS

These findings underscore the importance of sociodemographic and environmental factors in mosquito distribution and biting dynamics, with citizen science emerging as a valuable tool for enhancing traditional surveillance. Future research integrating longer temporal datasets and human behavioral factors will further improve predictive accuracy and support more effective MBD prevention efforts.

Identifying hotspots and risk factors for tick-borne encephalitis virus emergence at its range margins to guide interventions, Great Britain

BackgroundTick-borne encephalitis virus (TBEV) is expanding its range in Europe, with increasing human cases reported. Since the first detection of TBEV in ticks in the United Kingdom in 2019, one possible, two probable and two confirmed autochthonous cases in humans have been reported.AimWe aimed to understand the environmental and ecological factors limiting TBEV foci at their range edge and predict suitable areas for TBEV establishment across Great Britain (GB) by modelling patterns of exposure to TBEV in deer.MethodsWe developed spatial risk models for TBEV by integrating data between 2018 and 2021 on antibodies against tick-borne flavivirus in fallow, muntjac, red and roe deer with data on potential risk factors, including climate, land use, forest connectivity and distributions of bank voles and yellow-necked mice. We overlayed modelled suitability for TBEV exposure across GB with estimations on number of visitors to predict areas of high human exposure risk.ResultsModels for fallow, muntjac and roe deer performed well in independent validation (Boyce index > 0.92). Probable exposure to TBEV was more likely to occur in sites with a greater percentage cover of coniferous woodland, with multiple deer species, higher winter temperatures and rates of spring warming.ConclusionThe resulting TBEV suitability maps can be used by public health bodies in GB to tailor surveillance and identify probable high-risk areas for human exposure to guide awareness raising and vaccination policy. Combining animal surveillance and iterative spatial risk modelling can enhance preparedness in areas of tick-borne disease emergence.

A species-independent lateral flow microarray immunoassay to detect WNV and USUV NS1-specific antibodies in serum

Arboviruses such as West Nile Virus (WNV) and Usutu Virus (USUV) are emerging pathogens that circulate between mosquitoes and birds, occasionally spilling over into humans and horses. Current serological screening methods require access to a well-equipped laboratory and are not currently available for on-site analysis. As a proof of concept, we propose here a species-independent lateral flow microarray immunoassay (LMIA) able to quickly detect and distinguish between WNV Non-Structural 1 (NS1) and USUV NS1-specific antibodies. A double antigen approach was used to test sera collected from humans, horses, European jackdaws (Corvus monedula), and common blackbirds (Turdus merula). Optimization of the concentration of capture antigen spotted on the LMIA membrane and the amount of detection antigen conjugated to detector particles indicated that maximizing both parameters increased assay sensitivity. Upon screening of a larger serum panel, the optimized LMIA showed significantly higher spot intensity for a homologous binding event. Using a Receiver Operating Characteristics (ROC) curve, WNV NS1 LMIA results in humans, horses, and C. monedula showed good correlation when compared to "gold standard" WNV FRNT90. The most optimal derived sensitivity and specificity of the WNV NS1 LMIA relative to corresponding WNV FRNT90-confirmed sera were determined to be 96% and 86%, respectively. While further optimization is required, this study demonstrates the feasibility of developing a species-independent LMIA for on-site analysis of WNV, USUV, and other arboviruses. Such a tool would be useful for the on-site screening and monitoring of relevant species in more remote or low-income regions.

Metatranscriptomics Reveals the RNA Virome of Ixodes Persulcatus in the China-North Korea Border, 2017

In recent years, numerous viruses have been identified from ticks, and some have been linked to clinical cases of emerging tick-borne diseases. Chinese northeast frontier is tick infested. However, there is a notable lack of systematic monitoring efforts to assess the viral composition in the area, leaving the ecological landscape of viruses carried by ticks not clear enough. Between April and June 2017, 7101 ticks were collected to perform virus surveillance on the China-North Korea border, specifically in Tonghua, Baishan, and Yanbian. A total of 2127 Ixodes persulcatus were identified. Further investigation revealed the diversity of tick-borne viruses by transcriptome sequencing of Ixodes persulcatus. All ticks tested negative for tick-borne encephalitis virus. Transcriptome sequencing expanded 121 genomic sequence data of 12 different virus species from Ixodes persulcatus. Notably, a new segmented flavivirus, named Baishan Forest Tick Virus, were identified, closely related to Alongshan virus and Harz mountain virus. Therefore, this new virus may pose a potential threat to humans. Furthermore, the study revealed the existence of seven emerging tick-borne viruses dating back to 2017. These previously identified viruses included Mudanjiang phlebovirus, Onega tick phlebovirus, Sara tick phlebovirus, Yichun mivirus, and three unnamed viruses (one belonging to the Peribunyaviridae family and the other two belonging to the Phenuiviridae family). The existence of these emerging tick-borne viruses in tick samples collected in 2017 suggests that their history may extend further than previously recognized. This study provides invaluable insights into the virome of Ixodes persulcatus in the China-North Korea border region, enhancing our ongoing efforts to manage the risks associated with tick-borne viruses.

Interactive effects of climate, land use and soil type on Culex pipiens/torrentium abundance

The incidence and risk of mosquito-borne disease outbreaks in Northwestern Europe has increased over the last few decades. Understanding the underlying environmental drivers of mosquito population dynamics helps to adequately assess mosquito-borne disease risk. While previous studies have focussed primarily on the effects of climatic conditions (i.e., temperature and precipitation) and/or local environmental conditions individually, it remains unclear how climatic conditions interact with local environmental factors such as land use and soil type, and how these subsequently affect mosquito abundance. Here, we set out to study the interactive effects of land use, soil type and climatic conditions on the abundance of Culex pipiens/torrentium, highly abundant vectors of West Nile virus and Usutu virus. Mosquitoes were sampled at 14 sites throughout the Netherlands. At each site, weekly mosquito collections were carried out between early July and mid-October 2020 and 2021. To assess the effect of the aforementioned environmental factors, we performed a series of generalized linear mixed models and non-parametric statistical tests. Our results show that mosquito abundance and species richness consistently differ among land use- and soil types, with peri-urban areas with peat/clay soils having the highest Cx. pipiens/torrentium abundance and sandy rural areas having the lowest. Furthermore, we observed differences in precipitation-mediated effects on Cx. pipiens/torrentium abundance between (peri-)urban and other land uses and soil types. In contrast, effects of temperature on Cx. pipiens/torrentium abundance remain similar between different land use and soil types. Our study highlights the importance of both land use and soil type in conjunction with climatic conditions for understanding mosquito abundances. Particularly in relation to rainfall events, land use and soil type has a marked effect on mosquito abundance. These findings underscore the importance of local environmental parameters for studies focusing on predicting or mitigating disease risk.

Continued Circulation of Tick-Borne Encephalitis Virus Variants and Detection of Novel Transmission Foci, the Netherlands

Tick-borne encephalitis virus (TBEV) is an emerging pathogen that was first detected in ticks and humans in the Netherlands in 2015 (ticks) and 2016 (humans). To learn more about its distribution and prevalence in the Netherlands, we conducted large-scale surveillance in ticks and rodents during August 2018-September 2020. We tested 320 wild rodents and >46,000 ticks from 48 locations considered to be at high risk for TBEV circulation. We found TBEV RNA in 3 rodents (0.9%) and 7 tick pools (minimum infection rate 0.02%) from 5 geographically distinct foci. Phylogenetic analyses indicated that 3 different variants of the TBEV-Eu subtype circulate in the Netherlands, suggesting multiple independent introductions. Combined with recent human cases outside known TBEV hotspots, our data demonstrate that the distribution of TBEV in the Netherlands is more widespread than previously thought.

A One Health Evaluation of the Surveillance Systems on Tick-Borne Diseases in the Netherlands, Spain and Italy

Simple Summary

Ixodid ticks and tick-borne diseases are expanding their geographical range, but surveillance activities vary among countries. We analysed the surveillance systems in place in the Netherlands, Spain and Italy, to identify ideal elements to monitor tick-borne diseases, by using a One Health evaluation protocol. We identified differences among the three surveillance systems, with the Dutch initiative showing a high level of transdisciplinary collaboration, good identification of the actors and engagement of the public in research and education. Measurable outcomes have been generated, such as the reduction in tick bites and the discovery of new pathogens and tick species. In Italy and Spain, surveillance systems are based on compulsory notification to health authorities; legislation seems relevant but law enforcement alongside the availability of economic resources is rather fragmented and limited to the most severe diseases. The non-scientific community is marginally considered and collaborations are limited to local initiatives. Research activities in both countries have mostly contributed to gaining knowledge on the distribution of tick species and the discovery of new pathogens. Although all TBD surveillance plans comply with the EU regulations, the initiatives characterised by trans-disciplinary collaboration may be more effective for the surveillance and prevention of tick-transmitted diseases.

Abstract

To identify ideal elements for the monitoring and prevention of tick-borne diseases (TBD), we analysed the surveillance systems in place in the Netherlands, Spain and Italy. We applied a semi-quantitative evaluation to identify outcomes and assess the degree of One Health implementation. Differences emerged in the surveillance initiatives, as well as the One Health scores. The Dutch surveillance is dominated by a high level of transdisciplinary and trans-sectoral collaboration, enabling communication and data sharing among actors. Different project-based monitoring, research and educational activities are centrally coordinated and the non-scientific community is actively involved. All this yielded measurable health outcomes. In Italy and Spain, TBD surveillance and reporting systems are based on compulsory notification. Law enforcement, alongside dedicated time and availability of economic resources, is fragmented and limited to the most severe health issues. Veterinary and human medicine are the most involved disciplines, with the first prevailing in some contexts. Stakeholders are marginally considered and collaborations limited to local initiatives. Research activities have mostly contributed to gaining knowledge on the distribution of tick vectors and discovery of new pathogens. Although all TBD surveillance plans comply with EU regulations, initiatives characterised by transdisciplinary collaboration may be more effective for the surveillance and prevention of TBD.

Spatial Analysis of Mosquito-Borne Diseases in Europe: A Scoping Review

Mosquito-borne infections are increasing in endemic areas and previously unaffected regions. In 2020, the notification rate for Dengue was 0.5 cases per 100,000 population, and for Chikungunya <0.1/100,000. In 2019, the rate for Malaria was 1.3/100,000, and for West Nile Virus, 0.1/100,000. Spatial analysis is increasingly used in surveillance and epidemiological investigation, but reviews about their use in this research topic are scarce. We identify and describe the methodological approaches used to investigate the distribution and ecological determinants of mosquito-borne infections in Europe. Relevant literature was extracted from PubMed, Scopus, and Web of Science from inception until October 2021 and analysed according to PRISMA-ScR protocol. We identified 110 studies. Most used geographical correlation analysis (n = 50), mainly applying generalised linear models, and the remaining used spatial cluster detection (n = 30) and disease mapping (n = 30), mainly conducted using frequentist approaches. The most studied infections were Dengue (n = 32), Malaria (n = 26), Chikungunya (n = 26), and West Nile Virus (n = 24), and the most studied ecological determinants were temperature (n = 39), precipitation (n = 24), water bodies (n = 14), and vegetation (n = 11). Results from this review may support public health programs for mosquito-borne disease prevention and may help guide future research, as we recommended various good practices for spatial epidemiological studies.

First autochthonous human West Nile virus infections in the Netherlands, July to August 2020

In October 2020, the first case of autochthonous West Nile virus neuroinvasive disease was diagnosed in the Netherlands with a presumed infection in the last week of August. Investigations revealed five more cases of local West Nile virus (WNV) infection. The cases resided in a region where WNV was detected in a bird and mosquitoes in August 2020. Molecular analysis was successful for two cases and identified the presence of WNV lineage 2.

Detection of West Nile virus in a common whitethroat (Curruca communis) and Culex mosquitoes in the Netherlands, 2020

On 22 August, a common whitethroat in the Netherlands tested positive for West Nile virus lineage 2. The same bird had tested negative in spring. Subsequent testing of Culex mosquitoes collected in August and early September in the same location generated two of 44 positive mosquito pools, providing first evidence for enzootic transmission in the Netherlands. Sequences generated from the positive mosquito pools clustered with sequences that originate from Germany, Austria and the Czech Republic.