The epidemiology, clinical presentation, and predictors of severe Tick-borne encephalitis in Lithuania, a highly endemic country: A retrospective study of 1040 patients

Clinical Characteristics of Tick-Borne Encephalitis in Adult Patients: A 10-year Retrospective Study in Stockholm, Sweden

BACKGROUND

The incidence of tick-borne encephalitis (TBE) has increased during the last decades in Europe. Our aim was to assess the clinical characteristics and outcome of patients with TBE in Region Stockholm, as a high-risk area in Sweden.

METHODS

The notification database at the regional Department of Communicable Disease Control and Prevention was used to identify TBE cases during 2006-2015. Clinical data were retrieved from the included patients' medical records. The associations of specific variables to predefined outcomes of disease severity were evaluated with multivariate logistic regression models.

RESULTS

Of 1004 identified TBE cases, 703 adult patients were included. Sixty-one percent were men, and the median age was 50 years (range, 18-94 years). The majority of patients were nonvaccinated. Comorbidity was present in 34%, and 4% were receiving immunomodulatory therapy. Seventy-five percent were hospitalized, and 11% had severe disease. More than 70% of the 79 patients followed up for >6 months had persisting symptoms. The case fatality rate was 1.4%, 15% in the group with immunomodulatory treatment. In the multivariate analysis, severe disease was associated with underlying comorbid conditions, age ≥50 years, and previous complete TBE vaccination.

CONCLUSIONS

This is the largest cohort of patients with TBE in Scandinavia. Our findings of a more severe course of disease in older patients, those receiving immunomodulatory therapy, those with comorbid conditions, and those with vaccination breakthrough infections must be interpreted in the context of hospitalized patients. Optimized prevention is needed for patients receiving immunomodulatory therapy, given the considerable case fatality rate. Follow-up visits and rehabilitation should be better standardized.

Anti-Tick-Bourne Encephalitis IgM Intrathecal Synthesis as a Prediction Marker in Tick-Borne Encephalitis Patients

The aim of this study was to evaluate the usefulness of IgM anti-Tick-Borne Encephalitis (anti-TBE) intrathecal synthesis in the diagnosis and prediction of the clinical course of the disease. Thirty-six patients were included in the study (patients reported symptoms such as fever, headache, fatigue, and nausea/vomiting). CRP, White Blood Cells (WBC), pleocytosis, Cerebrospinal Fluid (CSF) protein concentration, CSF albumin concentration, serum IgM, serum IgG, CSF IgM, CSF IgG, IgM Index, IgG Index, and IgG Index/IgM Index ratio were the parameters which were examined in the individuals. An analysis of correlation presented statistical significance between IgM Index and pleocytosis and protein concentration in CSF in the whole group of individuals. IgM Index and IgG Index/IgM Index ratio may be used in the prediction of severity of TBE. The most probable link between the IgM intrathecal production and severity of TBE may be a result of delayed seroconversion to IgG, and therefore not an adequate response to the virus presence.

Severe Cases of Tick-Borne Encephalitis in Northeastern Poland

Tick-borne encephalitis (TBE) is the most prevalent viral infection of the central nervous system (CNS) in Poland. The disease is characterized by the presence of two stages. The first phase, called the viremic stage, presents with flu-like symptoms, while the second stage of TBE is characterized by damage to the nervous system and may follow a severe and dramatic course. The aim of this paper is to increase the awareness of the potential sequelae after TBE. In this study, we report cases of severe TBE in 36-year-old and 57-year-old female patients. The outcome of TBE varies from patient to patient, but there are some factors that can help to predict the severity of TBE infection. The risk factors presented in these patients were as follows: the monophasic course of TBE, high pleocytosis in cerebrospinal fluid (CSF) and older age. Both of our patients were not vaccinated despite the World Health Organization's (WHO's) recommendations. Both patients had no history of travel outside their region of residence prior to the onset of illness. The few risk factors shown in our patients and the serious sequelae of the disease may indicate the need to test patients for possible gene mutations.

Clinical manifestations and outcomes of Tick-borne encephalitis: A systematic literature review

Tick-borne encephalitis (TBE) is caused by a viral infection and can lead to acute and persistent damage to the central and peripheral nervous systems. Recently, the incidence of TBE in Europe has risen, and epidemiological patterns of disease have changed, emphasising the need for improved understanding of this vaccine-preventable disease. Although TBE is endemic in many countries, the disease spectrum of TBE is not well described. We sought to characterise the clinical manifestations and outcomes of TBE by estimating the proportions of TBE patients with each type of manifestation and the risk of adverse outcomes for children and adults separately. A systematic literature review was conducted on 2 August 2022 for articles published in any language since 1 January 2007. Additional relevant studies were found in reference lists of identified articles. The review was limited to countries where only the European subtype of TBEV circulates. Of the 1,632 unique titles and abstracts identified and reviewed, 21 were retained for data analysis. The 21 studies were split into a main analysis (15 studies reporting patients hospitalised with laboratory-confirmed TBE) and a secondary analysis (6 studies reporting hospitalised and non-hospitalised patients who sought medical treatment for laboratory-confirmed TBE). The main analysis included 5,012 adults and 640 children. The predominant clinical manifestation in adults was encephalitis (61 %), followed by meningitis (33 %), radiculitis (14 %), and myelitis (6 %) (the manifestations were evaluated independently, so they will not sum to 100 %). With outliers removed, similar proportions of adults had encephalitis (48 %) and meningitis (44 %). Among cases in children, meningitis (77 %) was the most common manifestation, whereas encephalitis (23 %) and myelitis (1.3 %) were less frequent. Among hospitalised patients with TBE, the proportion of intensive care unit (ICU) admissions and deaths were similar for adults (15.5 % and 0.9 %, respectively) and children (16.4 % and 0 %, respectively.) The percentage of patients with sequelae when examined >12 months from acute TBE was 39.5 % for adults and 16.2 % for children. The evidence was challenging to aggregate due to study heterogeneity, variability in categorising clinical manifestations of central nervous system disease, variability of denominator populations, and differences in healthcare systems and diagnostic practices across countries. Our study disclosed distinct patterns of clinical manifestation among hospitalised adult and child patients with TBE and a high proportion of ICU admissions and long-term neurological sequelae across both age groups. These findings reinforce the continued need for preventive measures in the populations at risk. Moreover, variability of study admission criteria, including difficulty with clinical manifestation categorisation, calls for a more standardised approach to summarising TBE manifestations and outcomes across Europe.

The Re-Emergence of Neuroinvasive Flaviviruses in Croatia During the 2022 Transmission Season

(Re-)emerging arboviruses, such as tick-borne encephalitis virus (TBEV), West Nile virus (WNV), and Usutu virus (USUV), are continuously increasing in incidence. We analyzed the epidemiological characteristics of flavivirus infections in humans, sentinel animals, and mosquitoes detected in the 2022 transmission season in Croatia. From April to November 2022, 110 hospitalized patients with neuroinvasive diseases (NID) were tested for the presence of arboviruses. RT-qPCR was used to detect TBEV, WNV, and USUV RNA. An ELISA and virus neutralization tests were used for the detection of flavivirus antibodies. TBEV infection was confirmed in 22 patients with NID. WNV NID was detected in six patients. TBE showed male predominance (81.8%; male-to-female ratio of 4.5:1). All but one WNV patients were males. TBE occurred from April to August, with the majority of patients (83.3%) being detected during the May-June-July period. WNV infections were recorded in August and September. In addition to human cases, asymptomatic WNV infections (IgM positive) were reported in 10 horses. For the first time in Croatia, WNV NID was observed in one horse that presented with neurological symptoms. Furthermore, USUV was confirmed in one dead blackbird that presented with neurological symptoms. A total of 1984 mosquitoes were collected in the City of Zagreb. Two Ae. albopictus pools tested positive for flavivirus RNA: one collected in July (USUV) and the other collected in August (WNV). A phylogenetic analysis of detected human and avian strains confirmed WNV lineage 2 and the USUV Europe 2 lineage. The presented results confirm the endemic presence of neuroinvasive flaviviruses in continental Croatia. The continuous monitoring of virus circulation in humans, sentinel animals, and mosquitoes is needed to reduce the disease burden.

Autoantibodies neutralizing type I IFNs underlie severe tick-borne encephalitis in ∼10% of patients

Tick-borne encephalitis (TBE) virus (TBEV) is transmitted to humans via tick bites. Infection is benign in >90% of the cases but can cause mild (<5%), moderate (<4%), or severe (<1%) encephalitis. We show here that ∼10% of patients hospitalized for severe TBE in cohorts from Austria, Czech Republic, and France carry auto-Abs neutralizing IFN-α2, -β, and/or -ω at the onset of disease, contrasting with only ∼1% of patients with moderate and mild TBE. These auto-Abs were found in two of eight patients who died and none of 13 with silent infection. The odds ratios (OR) for severe TBE in individuals with these auto-Abs relative to those without them in the general population were 4.9 (95% CI: 1.5-15.9, P < 0.0001) for the neutralization of only 100 pg/ml IFN-α2 and/or -ω, and 20.8 (95% CI: 4.5-97.4, P < 0.0001) for the neutralization of 10 ng/ml IFN-α2 and -ω. Auto-Abs neutralizing type I IFNs accounted for ∼10% of severe TBE cases in these three European cohorts.

An Overview of Tick-Borne Encephalitis Epidemiology in Endemic Regions of Continental Croatia, 2017-2023

Tick-borne encephalitis (TBE) represents an important public health problem in Europe. We analyzed the epidemiology of TBE based on data from humans, animals, and Ixodes ricinus ticks in endemic regions of continental Croatia. In the period from 2017 to 2023, cerebrospinal fluid (CSF) and serum samples of 684 patients with neuroinvasive diseases, 2240 horse serum samples, and 300 sheep serum samples were tested for TBEV. In addition, 8751 I. ricinus ticks were collected. CSF samples were tested using RT-PCR. Serological tests (serum, CSF) were performed using commercial ELISA, with confirmation of cross-reactive samples by a virus neutralization test. Eighty-four autochthonous human TBEV cases were confirmed. The majority of patients were in the age group of 40-69 years (58.3%) with a male predominance (70.2%). TBE showed a bimodal seasonality with a large peak in April-August and a small one in October-November. In addition to humans, TBEV IgG antibodies were found in 12.2% of horses and 9.7% of sheep. Seasonal tick abundance corresponds to the reported number of human infections. Continental Croatia is still an active natural focus of TBE. Continuous monitoring of infections in humans, sentinel animals, and ticks is needed for the implementation of preventive measures.

Tick-Borne Encephalitis Vaccine: Recommendations of the Advisory Committee on Immunization Practices, United States, 2023

Tick-borne encephalitis (TBE) virus is focally endemic in parts of Europe and Asia. The virus is primarily transmitted to humans by the bites of infected

Ixodes species ticks but can also be acquired less frequently by alimentary transmission. Other rare modes of transmission include through breastfeeding, blood transfusion, solid organ transplantation, and slaughtering of viremic animals. TBE virus can cause acute neurologic disease, which usually results in hospitalization, often permanent neurologic or cognitive sequelae, and sometimes death. TBE virus infection is a risk for certain travelers and for laboratory workers who work with the virus. In August 2021, the Food and Drug Administration approved Ticovac TBE vaccine for use among persons aged ≥1 year. This report summarizes the epidemiology of and risks for infection with TBE virus, provides information on the immunogenicity and safety of TBE vaccine, and summarizes the recommendations of the Advisory Committee on Immunization Practices (ACIP) for use of TBE vaccine among U.S. travelers and laboratory workers.

The risk for TBE for most U.S. travelers to areas where the disease is endemic is very low. The risk for exposure to infected ticks is highest for persons who are in areas where TBE is endemic during the main TBE virus transmission season of April–November and who are planning to engage in recreational activities in woodland habitats or who might be occupationally exposed. All persons who travel to areas where TBE is endemic should be advised to take precautions to avoid tick bites and to avoid the consumption of unpasteurized dairy products because alimentary transmission of TBE virus can occur. TBE vaccine can further reduce infection risk and might be indicated for certain persons who are at higher risk for TBE. The key factors in the risk-benefit assessment for vaccination are likelihood of exposure to ticks based on activities and itinerary (e.g., location, rurality, season, and duration of travel or residence). Other risk-benefit considerations should include 1) the rare occurrence of TBE but its potentially high morbidity and mortality, 2) the higher risk for severe disease among certain persons (e.g., older persons aged ≥60 years), 3) the availability of an effective vaccine, 4) the possibility but low probability of serious adverse events after vaccination, 5) the likelihood of future travel to areas where TBE is endemic, and 6) personal perception and tolerance of risk

ACIP recommends TBE vaccine for U.S. persons who are moving or traveling to an area where the disease is endemic and will have extensive exposure to ticks based on their planned outdoor activities and itinerary. Extensive exposure can be considered based on the duration of travel and frequency of exposure and might include shorter-term (e.g., <1 month) travelers with daily or frequent exposure or longer-term travelers with regular (e.g., a few times a month) exposure to environments that might harbor infected ticks. In addition, TBE vaccine may be considered for persons who might engage in outdoor activities in areas where ticks are likely to be found, with a decision to vaccinate made on the basis of an assessment of their planned activities and itinerary, risk factors for a poor medical outcome, and personal perception and tolerance of risk. In the laboratory setting, ACIP recommends TBE vaccine for laboratory workers with a potential for exposure to TBE virus

Recovery and sequelae in 523 adults and children with tick-borne encephalitis in Germany

PURPOSE

Despite being vaccine-preventable, tick-borne encephalitis (TBE) continues to cause considerable morbidity in Germany. Limited insight into potentially debilitating consequences of TBE may partially underly low (~ 20%) TBE vaccine uptake. We aimed to systematically assess TBE sequelae and other consequences.

METHODS

Routinely notified TBE patients from 2018 to 2020 from Southern Germany were invited to telephone interviews acutely and again after 18 months. Duration of acute symptoms was prospectively assessed. Recovery was defined as score 0 on the modified RANKIN scale. Determinants of time to recovery were analysed with cox regression, adjusted for covariates identified using directed acyclic graphs, yielding hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Of 558 cases, 523 (93.7%) completed follow-up. Full recovery was reported by 67.3% (children: 94.9%, adults: 63.8%). Sequelae included fatigue (17.0%), weakness (13.4%), concentration deficit (13.0%), and impaired balance (12.0%). Compared with 18-39-year-olds, recovery rates were 44% lower in ≥ 50-year-olds (HR: 0.56, 95%CI 0.42-0.75) and 79% higher in children (HR: 1.79, 95%CI 1.25-2.56). The recovery rate was 64% lower after severe TBE (compared to mild; HR: 0.36, 95%CI 0.25-0.52) and 22% lower with comorbidities (HR: 0.78, 95%CI 0.62-0.99). Substantial health-care use was reported (90.1% hospitalisation, 39.8% rehabilitation). Of employed cases, 88.4% required sick leave; 10.3% planned/reported premature retirement due to sequelae.

CONCLUSION

Half the adult and 5% of paediatric patients reported persisting sequelae after 18 months. Improved prevention could alleviate both individual (morbidity) and societal TBE burden (health-care costs, productivity losses). Insights into sequelae can help guide at-risk populations towards tick-avoidant strategies and encourage TBE vaccination.

Tick-borne encephalitis: Acute clinical manifestations and severity in 581 cases from Germany, 2018-2020

OBJECTIVES

Tick-borne encephalitis (TBE) is a growing public health problem with an average of 361 cases notified annually to Germany's passive surveillance system since 2001. We aimed to assess clinical manifestations and identify covariates associated with severity.

METHODS

We included cases notified 2018-2020 in a prospective cohort study and collected data with telephone interviews, questionnaires to general practitioners, and hospital discharge summaries. Covariates' causal associations with severity were evaluated with multivariable logistic regression, adjusted for variables identified via directed acyclic graphs.

RESULTS

Of 1220 eligible cases, 581 (48%) participated. Of these, 97.1% were not (fully) vaccinated. TBE was severe in 20.3% of cases (children: 9.1%, ≥70-year-olds: 48.6%). Routine surveillance data underreported the proportion of cases with central nervous system involvement (56% vs. 84%). Ninety percent required hospitalization, 13.8% intensive care, and 33.4% rehabilitation. Severity was most notably associated with age (odds ratio (OR): 1.04, 95% confidence interval (CI): 1.02-1.05), hypertension (OR: 2.27, 95%CI: 1.37-3.75), and monophasic disease course (OR: 1.67, 95%CI: 1.08-2.58).

CONCLUSIONS

We observed substantial TBE burden and health service utilization, suggesting that awareness of TBE severity and vaccine preventability should be increased. Knowledge of severity-associated factors may help inform patients' decision to get vaccinated.

A Perspective on Current Flavivirus Vaccine Development: A Brief Review

The flavivirus genus contains several clinically important pathogens that account for tremendous global suffering. Primarily transmitted by mosquitos or ticks, these viruses can cause severe and potentially fatal diseases ranging from hemorrhagic fevers to encephalitis. The extensive global burden is predominantly caused by six flaviviruses: dengue, Zika, West Nile, yellow fever, Japanese encephalitis and tick-borne encephalitis. Several vaccines have been developed, and many more are currently being tested in clinical trials. However, flavivirus vaccine development is still confronted with many shortcomings and challenges. With the use of the existing literature, we have studied these hurdles as well as the signs of progress made in flavivirus vaccinology in the context of future development strategies. Moreover, all current licensed and phase-trial flavivirus vaccines have been gathered and discussed based on their vaccine type. Furthermore, potentially relevant vaccine types without any candidates in clinical testing are explored in this review as well. Over the past decades, several modern vaccine types have expanded the field of vaccinology, potentially providing alternative solutions for flavivirus vaccines. These vaccine types offer different development strategies as opposed to traditional vaccines. The included vaccine types were live-attenuated, inactivated, subunit, VLPs, viral vector-based, epitope-based, DNA and mRNA vaccines. Each vaccine type offers different advantages, some more suitable for flaviviruses than others. Additional studies are needed to overcome the barriers currently faced by flavivirus vaccine development, but many potential solutions are currently being explored.

Activation of Early Proinflammatory Responses by TBEV NS1 Varies between the Strains of Various Subtypes

Tick-borne encephalitis (TBE) is an emerging zoonosis that may cause long-term neurological sequelae or even death. Thus, there is a growing interest in understanding the factors of TBE pathogenesis. Viral genetic determinants may greatly affect the severity and consequences of TBE. In this study, nonstructural protein 1 (NS1) of the tick-borne encephalitis virus (TBEV) was tested as such a determinant. NS1s of three strains with similar neuroinvasiveness belonging to the European, Siberian and Far-Eastern subtypes of TBEV were studied. Transfection of mouse cells with plasmids encoding NS1 of the three TBEV subtypes led to different levels of NS1 protein accumulation in and secretion from the cells. NS1s of TBEV were able to trigger cytokine production either in isolated mouse splenocytes or in mice after delivery of NS1 encoding plasmids. The profile and dynamics of TNF-α, IL-6, IL-10 and IFN-γ differed between the strains. These results demonstrated the involvement of TBEV NS1 in triggering an immune response and indicated the diversity of NS1 as one of the genetic factors of TBEV pathogenicity.

Tick-Talk: Parental online discourse about TBE vaccination

This study aimed to understand parental discourse about vaccination, and to provide guidance for communication that addresses the needs of parents. We analyzed parental discourse on child vaccination in general and tick-borne encephalitis (TBE) specifically in a Swiss parental online community. For this purpose, a data set containing 105k posts written by parents between 2007 and 2019 was analyzed using a combination of linguistic discourse analysis and qualitative content analysis. Results show that parents enter into a multidimensional decision-making process, characterized by elaborate practices of negotiation, consideration of vaccination recommendations as well as six distinct influencing thematic factors (vaccination safety, development and control, effectiveness, epidemiology, necessity, alternatives or additional prevention methods). The study shows a clear pattern of seasonality, with parents talking about TBE vaccination mostly triggered by events such as tick bites in spring and summer. From a public health perspective, the study emphasizes the need for sufficient, balanced, and tailored information about TBE vaccination. Online forums provide valuable information about what matters to parents and when, which can help public health authorities and practitioners provide information according to these concerns and enhance health literacy among parents.

Anti-TBE Intrathecal Synthesis as a Prediction Marker in TBE Patients

Tick-borne encephalitis (TBE) is an emerging vector-borne disease in Europe caused by tick-borne encephalitis virus (TBEV), which belongs to Flaviviridae. Although most of the patients quickly recover from TBE, some require further neurological and psychiatric treatment due to persistent symptoms. The aim of the study was to evaluate the usefulness of an antibodies index for predicting the course of the disease and potential persistent sequalae. Sixty-six patients (49 males and 17 females, mean age 45.97 ± 13.69 years) with TBE hospitalized in the Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Poland, in years 2016–2019 were included to the study. TBE antibodies titer in serum and CSF samples were measured with an Anti-TBEV ELISA (IgM, IgG) EUROIMMUN test. Patients who developed persistent sequelae after TBE had significantly lower IgG intrathecal index at admission. Additionally, IgG2/IgG1was significantly higher in patients who developed sequelae. IgG intrathecal index might be a useful tool for the prediction of TBE sequelae development.

Incidence of Tick-Borne Encephalitis during the COVID-19 Pandemic in Selected European Countries

Ixodes ricinus ticks are one of the most important vectors and reservoirs of infectious diseases in Europe, and tick-borne encephalitis (TBE) is one of the most dangerous human diseases transmitted by these vectors. The aim of the present study was to investigate the TBE incidence in some European countries during the COVID-19 pandemic. To this end, we analyzed the data published by the European Center for Disease Prevention and Control (ECDC) and Eurostat on the number of reported TBE and COVID-19 cases in 2020 and TBE cases in 2015–2019 (reference period). Significant differences in the TBE incidence were found between the analyzed countries. The highest TBE incidence was found in Lithuania (25.45/100,000 inhabitants). A high TBE incidence was also observed in Central European countries. In 12 of the 23 analyzed countries, there was significant increase in TBE incidence during the COVID-19 pandemic during 2020 compared to 2015–2019. There was no correlation between the incidence of COVID-19 and TBE and between the availability of medical personnel and TBE incidence in the studied countries. In conclusion, Central Europe and the Baltic countries are areas with a high risk of TBE infection. Despite the COVID-19 pandemic and imposed restrictions, the incidence of TBE is increasing in more than half of the analyzed countries.

Clinical and Laboratory Characteristics and Outcome of Illness Caused by Tick-Borne Encephalitis Virus without Central Nervous System Involvement

Illness progressed to encephalitis in 84% of patients within 18 days after defervescence.

Information on febrile illness caused by tick-borne encephalitis virus (TBEV) without central nervous system involvement is limited. We characterized 98 patients who had TBEV RNA in their blood but no central nervous system involvement at the time of evaluation. Median duration of illness was 7 days; 37 (38%) patients were hospitalized. The most frequent findings were malaise or fatigue (98%), fever (97%), headache (86%), and myalgias (54%); common laboratory findings were leukopenia (88%), thrombocytopenia (59%), and abnormal liver test results (63%). During the illness, blood leukocyte counts tended to improve, whereas thrombocytopenia and liver enzymes tended to deteriorate. At the time of positive PCR findings, 0/98 patients had serum IgG TBEV and 7 serum IgM TBEV; all patients later seroconverted. Viral RNA load was higher in patients with more severe illness but did not differ substantially in relation to several other factors. Illness progressed to tick-borne encephalitis in 84% of patients within 18 days after defervescence.

Tick-borne encephalitis related uveitis: a case report

BACKGROUND

Tick-borne encephalitis (TBE) is an infectious disease of the central nervous system caused by the TBE virus (TBEV), which is usually transmitted by a tick-bite, with increasing incidence in northeastern Europe and eastern Asia during the past decade. Ocular involvement has not been described in the literature to date.

CASE PRESENTATION

A 58-year-old patient presented to the emergency department with occipital headaches and poor balance for 5 days. He reported a tick-bite 6 weeks before without erythema migrans followed by a flu-like syndrome. Serological testing was negative for Borreliosis and TBEV. At presentation, he was febrile with neck stiffness and signs of ataxia. Three days later, he presented unilateral visual loss in his right eye. Examination revealed non granulomatous anterior uveitis, vitreous inflammation, and retinal haemorrhages at the posterior pole without macular oedema or papillitis. Polymerase chain reaction (PCR) of the cerebrospinal fluid returned negative for all Herpes family viruses. No clinical evidence of other infection nor malignancy was identified. A seroconversion of the TBEV- immunoglobulin titres was observed 2 weeks later while the serum antibodies for Borrelia were still not detected. Magnetic resonance imaging was unremarkable. We concluded to the diagnosis of TBE-related uveitis. Under supportive treatment, there was complete resolution of the neurological symptoms and the intraocular inflammation without sequelae within the following weeks.

CONCLUSIONS

We describe a new association of TBEV with uveitis. In view of the growing number of TBE cases and the potential severity of the disease we aim at heightening awareness to achieve prompt recognition, prevention, and treatment.

Effect of all-in-one nursing model on ICU ventilator-associated pneumonia

OBJECTIVE

To study the effect of an all-in-one nursing model on ICU ventilator-associated pneumonia (VAP).

METHODS

A total of 100 ICU patients needing ventilator assistance who were admitted to our hospital from March 2018 to December 2019 were equally randomized into two groups by a lottery system, with 50 cases in each group. Patients in the control group received routine nursing, and patients in the experimental group received all-in-one nursing. The number of ICU VAP patients, time transferring from ICU to an ordinary ward, hospital stay, mechanical ventilation time, nursing efficiency, and the changes of blood pressure, heart rate and oxygen saturation during nursing was compared between the two groups.

RESULTS

Regarding the number of cases of VAP, the length of stay in the ICU, and the length of hospital stay, and the mechanical ventilation time, the experimental group was markedly shorter than that of the control group (P<0.05). With respect to the effective rates of nursing care, the experimental group (96%) was better than the control group (80%) (P<0.05). When considering the changes of hemodynamic indexes during the nursing process, the two groups exhibited no marked difference (P>0.05). After intervention, the control group was inferior in terms of the oxygen partial pressure and carbon dioxide partial pressure compared to the experimental group (P<0.05).

CONCLUSION

All-in-one nursing can reduce the incidence of VAP in ICU patients, significantly shorten the length of ICU stay, hospital stay and mechanical ventilation time, thus improving overall nursing efficiency.

Comparison of Clinical, Laboratory and Immune Characteristics of the Monophasic and Biphasic Course of Tick-Borne Encephalitis

The biphasic course of tick-borne encephalitis (TBE) is well described, but information on the monophasic course is limited. We assessed and compared the clinical presentation, laboratory findings, and immune responses in 705 adult TBE patients: 283 with monophasic and 422 with biphasic course. Patients with the monophasic course were significantly (p ≤ 0.002) older (57 vs. 50 years), more often vaccinated against TBE (7.4% vs. 0.9%), more often had comorbidities (52% vs. 37%), and were more often treated in the intensive care unit (12.4% vs. 5.2%). Multivariate logistic regression found strong association between the monophasic TBE course and previous TBE vaccination (OR = 18.45), presence of underlying illness (OR = 1.85), duration of neurologic involvement before cerebrospinal fluid (CSF) examination (OR = 1.39), and patients’ age (OR = 1.02). Furthermore, patients with monophasic TBE had higher CSF levels of immune mediators associated with innate and adaptive (Th1 and B-cell) immune responses, and they had more pronounced disruption of the blood–brain barrier. However, the long-term outcome 2–7 years after TBE was comparable. In summary, the monophasic course is a frequent and distinct presentation of TBE that is associated with more difficult disease course and higher levels of inflammatory mediators in CSF than the biphasic course; however, the long-term outcome is similar.