Back to Top Skip to main content

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...

Case Report: Hansen’s Disease in an Active Duty Soldier Presenting with Type 1 Reversal Reaction

Article
12/1/2019
Ulcer along the interspace between the patient’s right index and middle fingers. Photograph courtesy of Brooke Army Medical Center Medical Photography.

Recommended Content:

Medical Surveillance Monthly Report

Prevalence of Glucose-6-Phosphate Dehydrogenase Deficiency, U.S. Armed Forces, May 2004–September 2018

Article
12/1/2019
Staff Sgt. Cory Gage, 23d Medical Support Squadron medical laboratory technician, places a blood specimen in an automated hematology analyzer, Aug. 29, 2017, at Moody Air Force Base, Ga. Moody’s lab technicians process blood to check for a variety of cell abnormalities from infections to cancer. (U.S. Air Force photo by Airman 1st Class Erick Requadt)

Recommended Content:

Medical Surveillance Monthly Report

Positive Predictive Value of an Algorithm Used for Cancer Surveillance in the U.S. Armed Forces

Article
12/1/2019
Naval Hospital Jacksonville physicians Lt. Catherine Perrault, right, and Lt. Joseph Sapoval review patient charts at the hospital’s labor and delivery unit. Perrault, from Orlando, Florida, rendered aid at the scene of an accident involving a train and a school bus on Sept. 27, 2018. Perrault recently returned from a deployment to the Middle East where she served as the general medical officer aboard the amphibious assault ship USS Iwo Jima (LPH 2). During the deployment, she provided routine, acute, and critical care. (U.S. Navy photo by Jacob Sippel/Released)

Recommended Content:

Medical Surveillance Monthly Report

Update: Gallbladder Disease and Cholecystectomies, Active Component, U.S. Armed Forces, 2014–2018

Article
12/1/2019
Hansen's disease nerve

Recommended Content:

Medical Surveillance Monthly Report

Tick-borne encephalitis surveillance in U.S. military service members and beneficiaries, 2006–2018

Article
11/1/2019
©ECDC/Photo by Guy Hendrickx

Recommended Content:

Medical Surveillance Monthly Report

Case Report: Tick-borne Encephalitis Virus Infection in Beneficiaries of the U.S. Military Healthcare System in Southern Germany

Article
11/1/2019
A paratrooper with 1st Squadron, 91st Cavalry Regiment, 173rd Airborne Brigade lies concealed in a forest and observes his target during a combined sniper exercise with the British Army's 1st Battalion, Royal Irish Regiment as part of Exercise Wessex Storm at the 7th Army Joint Multinational Training Command's Grafenwoehr Training Area, Germany, July 30, 2015. Wessex Storm is an annual maneuver exercise for British forces, integrating NATO allies and partners. (U.S. Army photo by Visual Information Specialist Gertrud Zach/released)

Recommended Content:

Medical Surveillance Monthly Report

Update: Cold Weather Injuries, Active and Reserve Components, U.S. Armed Forces, July 2014–June 2019

Article
11/1/2019
A U.S. Marine with Marine Rotational Force-Europe (MRF-E) 19.1 maintains a defensive security position during Exercise Winter Warrior in Haltdalen, Norway, Dec. 5, 2018. The three-week exercise tested the Marines' abilities to adapt to harsh weather conditions, move across long distances in the snow and push themselves to complete the mission despite austere situations. (U.S. Marine Corps photo by Cpl. Elijah Abernathy/Released)

Recommended Content:

Medical Surveillance Monthly Report

Animal Bites and Rabies Post-exposure Prophylaxis, Active and Reserve Components, U.S. Armed Forces, 2011–2018

Article
10/1/2019
Big Brown Bat stock photo (iStock.com)

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Snapshot: Influenza Immunization Among U.S. Armed Forces Healthcare Workers, August 2014–April 2019

Article
10/1/2019
181129-N-GR847-3000 ARABIAN GULF (Nov. 29, 2018) Hospitalman Jay Meadows, from Weaver, Ala., administers an influenza vaccine to a Sailor during a regularly scheduled deployment of the Essex Amphibious Ready Group (ARG) and 13th Marine Expeditionary Unit (MEU). The Essex ARG/13th MEU is flexible and persistent Navy-Marine Corps team deployed to the U.S. 5th Fleet area of operations in support of naval operations to ensure maritime stability and security in the Central Region, connecting to the Mediterranean and the Pacific through the western Indian Ocean and three strategic choke points. (U.S. Navy photo by Mass Communication Specialist 3rd Class Reymundo A. Villegas III)

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Snapshot: Trends in Opioid Prescription Fills Among U.S. Military Service Members During Fiscal Years 2007–2017

Article
10/1/2019
U.S. Air Force Tech Sgt. Ryan Marr, 18th Medical Group pharmacy craftsman, processes prescriptions, June 8, 2018, at Kadena Air Base, Japan. The pharmacy processes and fills prescriptions for hundreds of different medical needs. (U.S. Air Force photo by Staff Sergeant Jessica H. Smith) Merriam/Released)

Recommended Content:

Medical Surveillance Monthly Report

Measles, Mumps, Rubella, and Varicella Among Service Members and Other Beneficiaries of the Military Health System, 1 January 2016–30 June 2019

Article
10/1/2019
U.S. Air Force Airmen of the 163d Attack Wing line up to  receive a flu vaccine at March Air Reserve Base, California, Nov. 4, 2018. The flu vaccine is an annual requirement for military members to help curb the spread of the flu and limit its impact within the unit. (U.S. Air National Guard photo by Tech. Sgt. Julianne M. Showalter)

Recommended Content:

Medical Surveillance Monthly Report

Incidence and Temporal Presentation of Visual Dysfunction Following Diagnosis of Traumatic Brain Injury, Active Component, U.S. Armed Forces, 2006–2017

Article
9/1/2019
SAN DIEGO (April 6, 2017) Cmdr. John Cason, program director Navy Refractive Surgery, performs the second Small Incision Lenticular Extraction (SMILE) procedure at Naval Medical Center San Diego. The SMILE procedure is the latest advancement in refractive surgery for correcting myopia or nearsightedness. (U.S. Navy photo by Mass Communication Specialist 1st Class Elizabeth Merriam/Released)

Recommended Content:

Medical Surveillance Monthly Report

Editorial: The Department of Defense/Veterans Affairs Vision Center of Excellence

Article
9/1/2019
U.S. Army Spc. Angel Gomez, right, assigned to Charlie Company, 173rd Brigade Support Battalion, wraps the eye of a fellow Soldier with a simulated injury, for a training exercise as part of exercise Saber Junction 16 at the U.S. Army’s Joint Multinational Readiness Center in Hohenfels, Germany, April 5, 2016. Saber Junction is a U.S. Army Europe-led exercise designed to prepare U.S., NATO and international partner forces for unified land operations. The exercise was conducted March 31-April 24. (U.S. Army photo by Pfc. Joshua Morris)

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Ocular and Vision-Related Conditions, Active Component, U.S. Armed Forces, 2018

Article
9/1/2019
Senior Airman Breanna Daniels, 559th Medical Group optometry technician, takes images of Tech. Sgt. Stephanie Edmiston, 559th MDG trainee health flight chief, during an eye exam Oct. 19 at the Reid Clinic on Joint Base San Antonio-Lackland, Texas. The 559th MDG is home to the largest optometry and public health flight in the Department of Defense; the DOD's first military training consultation service. (U.S. Air Force photo/Staff Sgt. Kevin Iinuma)

Recommended Content:

Medical Surveillance Monthly Report

Incident and Recurrent Cases of Central Serous Chorioretinopathy, Active Component, U.S. Armed Forces, 2001–2018

Article
9/1/2019
A phoropter is an instrument used to determine an individual’s eyeglass prescription by measuring the eye’s refractive error and switching through various lens until the persons vision is normal. (U.S. Air Force photo by Airman Dennis Spain)

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 9

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.