Back to Top Skip to main content Skip to sub-navigation

Editorial: Mitigating the Risk of Disease From Tick-borne Encephalitis in U.S. Military Populations

Female Ixodes ricinus Tick ©ECDC/Photo by Francis Schaffner Female Ixodes ricinus Tick ©ECDC/Photo by Francis Schaffner

Recommended Content:

Medical Surveillance Monthly Report

Tick-borne encephalitis (TBE) has been a recognized threat to public health and force health protection (FHP) among U.S. military service members and other beneficiaries since at least the 1970s. TBE is caused by TBE virus, which is transmitted to humans within minutes of attachment by infected Ixodes ricinus ticks.1 Chiefly endemic in wooded areas in central and eastern Europe and the Baltic and Nordic countries, transmission occurs mainly in the spring through early autumn.2 There is no treatment beyond supportive care, and the vast majority of those infected fully recover. However, despite intensive care intervention, the case fatality rate ranges from 0.5 to 20% depending on the subtype of TBE virus.3–5 In addition, incomplete recovery with long-term neurologic sequelae can occur in 26–46% of those symptomatic cases in Europe.4 Primary prevention for tick bites includes the use of protective clothing, such as long pants/sleeves, and the use of insect repellent,6 such as DEET (chemical name: N,N-diethyl-meta-toluamide; 20 to 50% concentration) and picaridin (at least 20% concentration), on the skin. Added protection is provided by treating clothing, tents, and other gear (but not skin) with the repellent permethrin. Several TBE vaccines are available for use in Europe but have not been widely used by U.S. military personnel residing in or deployed to endemic areas because of lack of licensure by the U.S. Food and Drug Administration (FDA).

The U.S. military has been involved in studying the impact of TBE among service members since the 1980s.7,8 In 1983, Immuno AG submitted an investigational new drug (IND) application to the FDA for the TBE vaccine FSME-Immun Inject® following 25 years of use in Europe.9,10 In February 1996, TBE guidance for the U.S. Commander in Chief, Europe, regarding personnel supporting Operation Joint Endeavor stressed adherence to personal protective measures and, if at high risk, consideration for voluntary receipt of an accelerated, 3-dose TBE vaccine series under an IND protocol.11 Findings from that protocol revealed a 20%, 60%, and 80% seroconversion in the 954 individuals who had received 1, 2, or 3 doses of TBE vaccine, respectively.12 Of the 959 unvaccinated individuals, 4 (0.42%) demonstrated seroconversion and all were asymptomatic.

In subsequent years, additional publications from Europe demonstrated the scope of TBE and the efficacy of TBE vaccine.13–17 In 2011, the World Health Organization published its first position paper on TBE vaccines, and in 2012, TBE became a reportable disease entity among countries in the European Union.13,18,19 Collectively, these reports, along with a few recent high-profile cases among U.S. military service members and beneficiaries stationed in Europe, piqued Department of Defense (DoD) interest for an updated review of both the magnitude of TBE disease and an approach toward management within the U.S. military population. However, it was quickly recognized that there are challenges in assessing TBE epidemiology in U.S. military populations, including lack of recognition of the disease among U.S. and host nation providers, incomplete reporting of recognized disease, and misclassification of vaccine administration as true disease in administrative medical records (Armed Forces Health Surveillance Branch, email communications, 23–24 September 2019). These issues resulted in a large amount of concern and uncertainty regarding the threat of TBE to U.S. personnel among not only medical and public health assets within the U.S. European Command (USEUCOM) but also among the supported operational forces.

The 2 articles on TBE in this issue of the MSMR constitute an effort to provide a more accurate and precise risk assessment for U.S. military personnel stationed or deployed in USEUCOM through high-quality data that are actionable and inform FHP posture. The first article presents surveillance data including trends in TBE disease from 2006 to 2018 in U.S. military populations in Europe and reports on the efforts to identify and validate cases through multiple data sources and records review. The second article describes an in-depth review of a series of TBE cases that occurred in 2017 and 2018 in the area supported by the U.S. Army Medical Department Activity-Bavaria. These articles highlight the value and power of the centralized Defense Medical Surveillance System (DMSS) in combination with in-depth review of medical records by medical and public health personnel. Together, the 2 articles provide objective evidence that the risk to U.S. service members and beneficiaries of contracting TBE disease in Europe is small but non-zero as well as some limited evidence of increasing risk in recent years.

The risk assessment presented in the first article is relevant to discussions of pursuing additional vaccine options to enhance FHP posture against TBE. DoD Instruction 6205.0220 establishes policy, assigns responsibilities, and provides procedures to establish a uniform DoD immunization program in accordance with the authority in DoD Directive 6200.0421 and DoD Instruction 1010.10.22 For infectious diseases identified within the U.S. or in areas with frequent U.S. travelers, the military (similar to the civilian population) relies on primary prevention tools, including FDA-approved immunizations, which are administered in accordance with recommendations from the Centers for Disease Control and Prevention (CDC) and its Advisory Committee on Immunization Practices (ACIP). However, given the worldwide assignments of DoD beneficiaries, there may be diseases, such as TBE, for which a host nation approved medical product may exist but for which the manufacturer has not submitted an application for U.S. FDA approval.

When there is no available FDA-approved medical product, under DoD Instruction 6200.02,23 a DoD component may request that the Assistant Secretary of Defense for Health Affairs (ASD-HA) authorize the voluntary use of an investigational medical product for FHP use. Such requests, approval, and implementation must comply with applicable laws and FDA regulations and would involve the provision of the non-FDA approved vaccine for FHP purposes on a voluntary basis under an Emergency Use Authorization or IND protocol. TBE vaccine is currently not an FHP requirement, but the host nation approved product is authorized for voluntary receipt through TRICARE for at-risk DoD beneficiaries in endemic areas of Europe and Asia when vaccine is received from TRICARE authorized providers.24

Both USEUCOM and the Defense Health Agency, through the Immunization Healthcare Branch, the Office of the ASDHA, and other key DoD stakeholders, are working together to reduce the barriers to vaccination and increase the availability of vaccines to U.S. military beneficiaries stationed in Europe. The challenges surrounding pursuing additional vaccination options and the considerations regarding associated resources to invest will continue to be guided by accurate, precise estimates of the disease burden like the ones provided in this issue of the MSMR. Additional seroepidemiologic studies are needed in areas where DoD beneficiaries reside to better define the distribution of TBE and to guide future TBE vaccination policies in areas with high TBE incidence.25 Furthermore, it cannot be overstated that protective measures against tick-borne diseases, such as TBE, remain grounded in primary prevention.


Author affiliations: Immunization Healthcare Branch, Public Health Division, Defense Health Agency, Falls Church, VA.

REFERENCES

1. Lindquist L, Vapalahti O. Tick-borne encephalitis. Lancet. 2008;371(9627):1861–1871. 

2. Beauté J, Spiteri G, Warns-Petit E, Zeller H. Tick-borne encephalitis in Europe, 2012 to 2016. Euro Surveill. 2018;23(45).

3. Kaiser R. The clinical and epidemiological profile of tick-borne encephalitis in southern Germany 1994–98: a prospective study of 656 patients. Brain. 1999;122:2067–2078.

4. Taba P, Schmutzhard E, Forsberg P, et al. EAN consensus review on prevention, diagnosis and management of tick-borne encephalitis. Eur J Neurol. 2017;24(10):1214–e1261.

5. LaSala PR, Holbrook M. Tick-borne flaviviruses. Clin Lab Med. 2010;30(1):221–235.

6. Rendi-Wagner P. Risk and prevention of tick-borne encephalitis in travelers. J Travel Med. 2004;11(5):307–312.

7. McNeil JG, Lednar WM, Stansfield SK, Prier RE, Miller RN. Central European tick-borne encephalitis: assessment of risk for persons in the armed services and vacationers. J Infect Dis. 1985;152(3):650–651.

8. Clement J, Leirs H, Armour V, et al. Serologic evidence for tick-borne encephalitis (TBE) in North-American military stationed in Germany. Acta Leiden. 1992;60(2):15–17.

9. Kunz C, Heinz FX, Hofmann H. Immunogenicity and reactogenicity of a highly purified vaccine against tick-borne encephalitis. J Med Virol. 1980;6(2):103–109.

10. Barrett PN, Dorner F, 1994. Tick-borne encephalitis vaccine. In: Plotkin SA, Mortimer EA, eds. Vaccines. 2nd ed. Philadelphia, PA: W. B. Saunders Company, 715–727.

11. Office of the Assistant Secretary of Defense. Health Affairs Policy Memorandum—Policy for Tick-Borne Encephalitis Preventive Measures for U.S. Forces Deployed During Operation Joint Endeavor. HA Policy 96-031. 20 February 1996.

12. Craig SC, Pittman PR, Lewis TE, et al. An accelerated schedule for tick-borne encephalitis vaccine: the American military experience in Bosnia. Am J Trop Med Hyg. 1999;61(6):874–878.

13. Kunze U, ISW-TBE. Tick-borne encephalitis—a notifiable disease: report of the 15th Annual Meeting of the International Scientific Working Group on Tick-Borne Encephalitis (ISW-TBE). Ticks Tick Borne Dis. 2013;4(5):363–365.

14. Sumilo D, Bormane A, Vasilenko V, et al. Upsurge of tick-borne encephalitis in the Baltic States at the time of political transition, independent of changes in public health practices. Clin Microbiol Infect. 2009;15(1):75–80.

15. Heinz FX, Stiasny K, Holzmann H, Grgic-Vitek M, Kriz B, Essl A, Kundi M. Vaccination and tick-borne encephalitis, central Europe. Emerg Infect Dis. 2013;19(1):69–76.

16. Kunz C. TBE vaccination and the Austrian experience. Vaccine. 2003;21(suppl 1):s50–s55.

17. Heinz FX, Stiasny K, Holzmann H, et al. Emergence of tick-borne encephalitis in new endemic areas in Austria: 42 years of surveillance. Euro Surveill. 2015;20(13):9–16.

18. World Health Organization. Vaccines against tick-borne encephalitis: WHO position paper. Wkly Epidemiol Rec. 2011;86(24):241–256.

19. European Centre for Disease Prevention and Control. Epidemiological situation of tick-borne encephalitis in the European Union and European Free Trade Association countries. https://ecdc.europa.eu/publications-data/epidemiological-situation-tick-borne-encephalitis-european-union-andeuropean. Accessed 17 October 2019.

20. Office of the Under Secretary of Defense for Personnel and Readiness. Department of Defense Instruction 6205.02. DoD Immunization Program. 23 July 2019.

21. Headquarters, U.S. Department of Defense. Directive 6200.04, Force Health Protection (FHP). 23 April 2007.

22. Office of the Under Secretary of Defense for Personnel and Readiness. Department of Defense Instruction 1010.10. Health Promotion and Disease Prevention. 12 January 2018.

23. Office of the Under Secretary of Defense for Personnel and Readiness. Department of Defense Instruction 6200.02. Application of Food and Drug Administration (FDA) Rules to Department of Defense Force Health Protection Programs. 27 February 2008.

24. Office of the Assistant Secretary of Defense Health Affairs. Chapter 12, Section 1.2. TRICARE Overseas Program (TOP) Medical Benefit Variations. In: TRICARE Policy Manual 6010.57-M. 1 February 2008.

25. Botelho-Nevers E, Gagneux-Brunon A, Velay A, et al. Tick-borne encephalitis in Auvergne-Rhône-Alpes region, France, 2017–2018. Emerg Infect Dis. 2019;25(10):1944–1948.

You also may be interested in...

Update: Routine Screening for Antibodies to Human Immunodeficiency Virus, Civilian Applicants for U.S. Military Service and U.S. Armed Forces, Active and Reserve Components, January 2016–June 2021

Article
9/1/2021
HIV awareness graphic is created on Adobe Photoshop at Fort Carson, Colorado, July 16, 2021. Measures taken to reduce the risk of contracting HIV is abstinence, using condoms while having sex, taking preventative medications, getting tested for HIV or other STDs regularly, and talking to your sexual partners about HIV and STDs. (U.S. Army graphic by Spc. Woodlyne Escarne)

Recommended Content:

Medical Surveillance Monthly Report

Cross-Sectional Analysis of the Association between Perceived Barriers to Behavioral Health Care and Intentions to Leave the U.S. Army

Article
9/1/2021
U.S. Army Central Reserve component Soldiers swear the oath of enlistment during a mass reenlistment ceremony in celebration of the U.S. Army Reserve 113th birthday at Camp Arifjan, Kuwait, April 23, 2021. This ceremony reaffirms their commitment to the U.S. Army Reserve and the people of the United States. (U.S. Army photo by Sgt. Robert Torres, 203rd Public Affairs Detachment)

Recommended Content:

Medical Surveillance Monthly Report

Is Suicide a Social Phenomenon during the COVID-19 Pandemic? Differences by Birth Cohort on Suicide Among Active Component Army Soldiers, Jan.1, 2000–June 4, 2021

Article
9/1/2021
Spc. Brittney VerBerkmoes speaks among fellow Soldiers in a group centered on finding a way for the Army to mitigate the amount of suicides that occurs among Soldiers. The Solarium was held to help junior service members to communicate with the Army’s senior leaders about finding solutions to important issues occurring in the Army. (U.S. Army photo by Sgt. Elizabeth Rundell)

Is Suicide a Social Phenomenon during the COVID-19 Pandemic? Differences by Birth Cohort on Suicide Among Active Component Army Soldiers, 1 January 2000–4 June 2021

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Snapshot: A Simple Model Estimating the Impact of COVID-19 on Lost Duty Days Among U.S. Service Members

Article
9/1/2021
U.S. Navy Hospital Corpsman 2nd Class Julian Gordon, left, a preventative medicine technician with Marine Rotational Force - Darwin, administers a COVID-19 test to a U.S. Marine with MRF-D, at Royal Australian Air Force Base, Darwin, NT, Australia, March 22, 2021. Marines and Sailors with MRF-D are required to conduct strict COVID-19 mitigation procedures prior to arrival in Darwin, in compliance with Northern Territory Health Authorities. All service members must provide three documented negative COVID-19 swab tests throughout their travel and prior to being released from a 14-day quarantine period. (U.S. Marine Corps photo by Sgt. Micha Pierce)

Recommended Content:

Medical Surveillance Monthly Report

Mental Health Disorders, Behavioral Health Problems, Fatigue and Sleep Outcomes in Remotely Piloted Aircraft/Manned Aircraft Pilots, and Remotely Piloted Aircraft Crew, U.S. Air Force, 1 October 2003–30 June 2019

Article
8/1/2021
U.S. Air Force Capt. Danielle ‘Dani’ Pavone, an MQ-9 pilot with the 110th Wing, speaks during a training scenario through a plexiglass barrier to Staff Sgt. Justin Brandt, an MQ-9 sensor operator at the Battle Creek Air National Guard Base, Battle Creek, Michigan. The plexiglass mitigates risk of coronavirus transmission during the pandemic. (U.S. Air National Guard photo by Staff Sgt. Bethany Rizor)

Recommended Content:

Medical Surveillance Monthly Report

Surveillance of Mental and Behavioral Health Care Utilization and Use of Telehealth, Active Component, U.S. Armed Forces, 1 January 2019–30 September 2020

Article
8/1/2021

Recommended Content:

Medical Surveillance Monthly Report

Update: Mental Health Disorders and Mental Health Problems, Active Component, U.S. Armed Forces, 2016–2020

Article
8/1/2021
 Capt. Elrico Hernandez, battalion physician assistant for 2nd Battalion, 3rd Infantry Regiment, 3rd Stryker Brigade Combat Team, 2nd Infantry Division, discusses a training scenario that is part of the first Primary Care Behavioral Health seminar. The new program is being undertaken by medical care providers throughout United States Division-North in order to provide better mental health screening for Soldiers

Update: Mental Health Disorders and Mental Health Problems, Active Component, U.S. Armed Forces, 2016–2020

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Prevalence of Screening Positive for Post-Traumatic Stress Disorder Among Service Members Following Combat-Related Injury

Article
8/1/2021
U.S. Army Sgt. Arne F. Eastlund of the California Army National Guard’s 49th Military Police Brigade was nearly killed in 2005 in Baghdad, Iraq, during Operation Iraqi Freedom. An improvised explosive device destroyed his military vehicle and killed comrade Sgt. 1st Class Isaac S. Lawson. Eastlund survived and has continued serving Cal Guard even as a retired war veteran. (U.S. Army National Guard photo provided by Arne Eastlund)

Recommended Content:

Medical Surveillance Monthly Report

Long-Acting Reversible Contraceptive Use, Active Component Service Women, U.S. Armed Forces, 2016–2020

Article
7/1/2021
Lt. Col. Paula Neemann, 15th Healthcare Operations Squadron clinical medicine flight commander, demonstrates several birth options, such as an intrauterine device, at the 15th MDG's contraceptive clinic at Joint Base Pearl Harbor-Hickam, Hawaii, May 6, 2021. The contraceptive clinic opened June 7 to service beneficiaries and provide same-day procedures without a referral. (U.S. Air Force photo by 2nd Lt. Benjamin Aronson)

Long-Acting Reversible Contraceptive Use, Active Component Service Women, U.S. Armed Forces, 2016–2020

Recommended Content:

Medical Surveillance Monthly Report

Oral Cavity and Pharynx Cancers, Active Component, U.S. Armed Forces, 2007–2019

Article
7/1/2021
Moist snuff, chewing tobacco is placed between cheek and gum. All varieties of smokeless tobacco can cause harmful effects on the oral cavity.

Oral Cavity and Pharynx Cancers, Active Component, U.S. Armed Forces, 2007–2019

Recommended Content:

Medical Surveillance Monthly Report

The Evolution of Military Health Surveillance Reporting: A Historical Review

Article
7/1/2021
The inaugural issue of the Medical Surveillance Monthly Report

The Evolution of Military Health Surveillance Reporting: A Historical Review

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Medical Encounters for Snakebite Envenomation, Active and Reserve Components, U.S. Armed Forces, 2016–2020

Article
6/1/2021
Masters of camouflage, the Sidewinder Rattlesnakes are out and about aboard Marine Corps Logistics Base Barstow, California, May 11. Watch where you put your hands and feet, and observe children and pets at all times, as this is the natural habitat for these venomous snakes and a bite can cause serious medical problems. Notice the sharp arrow-shaped head with pronounced jaws, and the raised eye sockets, as well as the telltale rattles. Keep in mind, however, that rattles can be broken or lost, so you may or may not hear a rattle before they strike to protect themselves.

Brief Report: Medical Encounters for Snakebite Envenomation, Active and Reserve Components, U.S. Armed Forces, 2016–2020

Recommended Content:

Medical Surveillance Monthly Report

The Cost of Lower Extremity Fractures Among Active Duty U.S. Army Soldiers, 2017

Article
6/1/2021
X-ray image of a fractured tibia.

Recommended Content:

Medical Surveillance Monthly Report

Department of Defense Mid-Season Vaccine Effectiveness Estimates for the 2019– 2020 Influenza Season

Article
6/1/2021
201019-N-PC065-1062 NORFOLK (Oct. 19, 2020) Hospital Corpsman 2nd Class Sashee Robinson, assigned to amphibious transport dock ship USS Arlington (LPD 24), administers an influenza vaccine to Machinery Repairman 2nd Class Hannah Swearingen in medical aboard the Arlington. Influenza vaccines are an annual medical readiness requirement throughout the Department of Defense. (U.S. Navy photo by Mass Communication Specialist 2nd Class John Bellino/Released)

Department of Defense Mid-Season Vaccine Effectiveness Estimates for the 2019– 2020 Influenza Season

Recommended Content:

Medical Surveillance Monthly Report

Early Identification of SARS-CoV-2 Emergence in the Department of Defense via Retrospective Analysis of 2019–2020 Upper Respiratory Illness Samples

Article
6/1/2021
Army Maj. Raymond Nagley, S-3 officer assigned to the 50th Regional Support Group (RSG), receives a nasal swab to screen for COVID-19 at Fort Hood, Texas, on Feb. 5, 2021, from Spc. Yoali Muniz, a lab tech assigned to the 7406th Troop Medical Clinic, based in Columbia, Missouri. The 50th RSG, a Florida Guard unit based in Homestead, Florida, is preparing for deployment to Poland. (U.S. Army Guard photo by Sgt. 1st Class Shane Klestinski)

Early Identification of SARS-CoV-2 Emergence in the Department of Defense via Retrospective Analysis of 2019–2020 Upper Respiratory Illness Samples

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 14

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.