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Table 1.  

Country, y (reference) Total FB-TBE cases No. FB-TBE/TBE cases (%)†
Slovakia[5,14,15] 177  
   1993   7/NA
   2012   15/32 (46.88)
   2013   5/157 (3.18)
   2014   11/115 (9.57)
   2015   14/80 (17.50)
   2016   65/169 (38.46)
   2009–2016   60 additional cases not included in mentioned outbreaks‡
Czech Republic[3,16] 65  
   1994   1/617 (0.16)
   1997   2/415 (0.48)
   1998   1/422 (0.24)
   1999   28/489 (5.73)
   2002   5/647 (0.77)
   2003   6/606 (0.99)
   2004   2/507 (0.39)
   2005   8/643 (1.24)
   2007   8/546 (1.47)
   2008   4/631 (0.63)
Poland[17,18] 52  
   1995   48/NA
   2017   4/196 (2.04)
Hungary[10,19] 42  
   2007   31/69 (44.93)
   2011   11/43 (25.58)
Estonia[8,20] 28  
   2005   27/164 (16.46)
   2019   1/82 (1.22)
Germany[21,22] 16  
   2016   2/348 (0.57)
   2017   14/485 (2.89)
Croatia[23,24] 14  
   2015   9/26 (34.62)
   2019   5/13 (38.46)
Austria[9,25] 8  
   1989   2/NA
   2008   6/86 (6.98)
Russia[6] 5  
   1991   5/NA
Slovenia[26] 3  
   2012   3/164 (1.83)

Table 1. Foodborne and nonfoodborne TBE cases, Europe, 1980–2021*

*FB-TBE, foodborne tick-borne encephalitis; NA not available; TBE, tick-borne encephalitis.
†Number of TBE cases are from European Centre for Disease Prevention and Control annual report[2] and other reports[27,28].
‡From [14].

Table 2.  

Country (reference) No. confirmed cases No. CNS invasive disease CNS invasive disease type Blood serology CSF serology
Austria[9] 6 4 4 ME cases Positive IgG and IgM Borderline IgM, positive IgG; borderline IgM, borderline IgG; positive IgM, positive IgG; positive IgM, borderline IgG
Croatia[23] 7 6 proven, 7 symptomatic 5 meningitis cases, 1 ME case; 1 case with fever and headache but LP not performed Positive IgG and IgM 6 patients had CSF pleocytosis but negative IgG and IgM
Czech Republic[16] 1 1 ME, myelitis Positive IgM CSF pleocytosis
Estonia[20] 1 1 ME Positive IgM and IgG positive serology
Germany[22] 2 2 ME in both cases Positive IgG and IgM Positive IgG and IgM
Hungary[10] 25 2 confirmed; 25 with neurologic symptoms but LP only performed on 3   Positive IgG and IgM Positive IgG in 2 of 3 CSF samples
Hungary[19] 7 4 4 confirmed ME cases In all 7 confirmed cases, positive IgM in blood or CSF  
Poland[18] 35 15   Positive IgM and IgG Positive serology for 15 patients with neuroinfection
Poland[29] 4 4 4 meningitis cases 2 had elevated IgG and IgM. 1 had only elevated IgM. The fourth wasn't examined All 4 had elevated IgG and IgM
Slovakia[15] 2 1   Positive IgM Positive IgM
  43 12   Positive IgM and IgG 12 patients with IgM and IgG in CSF
Slovenia[26] 3 1 2 cases with symptoms of ME but LP only performed on 1 Positive IgG and IgM CSF pleocytosis

Table 2. Neuroinvasive disease reported in cases of foodborne tick-borne encephalitis, Europe, 1980–2021*

*CNS, central nervous system; CSF, cerebrospinal fluid; LP, lumbar puncture; ME, meningoencephalitis.

Table 3.  

Country (reference) Year No. persons exposed Clinical attack rate, % Source of dairy products
Slovakia[5] 1993 7 100 Goat
Poland[18] 1995 63 76.2 Goat
Hungary[10] 2007 154 20.1 Goat
Austria[9] 2008 7 57.1 Goat and cow
Hungary[19] 2011 103 10.7 Cow
Slovenia[26] 2012 4 75 Goat
Croatia[23] 2015 10 90 Goat
Germany[22] 2016 32 6.3 Goat
Slovakia[15] 2016 500 8.8 Sheep
Germany[21] 2017 27 51.9 Goat

Table 3. Attack rates for foodborne tick-borne encephalitis, Europe, 1980–2021

CME / ABIM MOC

Systematic Review and Meta-Analysis of Foodborne Tick-Borne Encephalitis, Europe, 1980–2021

  • Authors: Meital Elbaz, MD; Avi Gadoth, MD; Daniel Shepshelovich, MD; David Shasha, MD; Nir Rudoler, DVM, MPH, PhD; Yael Paran, MD
  • CME / ABIM MOC Released: 9/15/2022
  • Valid for credit through: 9/15/2023
Start Activity

  • Credits Available

    Physicians - maximum of 1.00 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 1.00 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for infectious disease clinicians, public health officials, internists, neurologists, and other clinicians caring for patients with or at risk for foodborne tick-borne encephalitis.

The goal of this activity is for learners to be better able to describe cases of alimentary-transmitted TBE in Europe in the last 4 decades, including estimated attack rate, epidemiological and clinical characteristics, and clinical and public health implications, based on a systematic review and meta-analysis of 410 cases.

Upon completion of this activity, participants will:

  1. Evaluate the epidemiological characteristics of foodborne tick-borne encephalitis in Europe in the last 4 decades, based on a systematic review and meta-analysis
  2. Assess the clinical characteristics and estimated attack rate of foodborne tick-borne encephalitis in Europe in the last 4 decades, based on a systematic review and meta-analysis
  3. Determine the clinical and public health implications of foodborne tick-borne encephalitis in Europe in the last 4 decades, based on a systematic review and meta-analysis


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


Faculty

  • Meital Elbaz, MD

    Infectious disease Unit
    Tel Aviv Sourasky Medical Center
    Tel Aviv, Israel

  • Avi Gadoth, MD

    Department of Neurology and Encephalitis Center
    Tel-Aviv Sourasky Medical Center
    Tel Aviv, Israel
    The Sackler Faculty of Medicine
    Tel-Aviv University
    Tel Aviv, Israel

  • Daniel Shepshelovich, MD

    Medicine D
    Tel Aviv Sourasky Medical Center
    Tel Aviv, Israel
    The Sackler Faculty of Medicine
    Tel-Aviv University
    Ramat Aviv, Tel Aviv, Israel

  • David Shasha, MD

    Infectious disease Unit
    Tel Aviv Sourasky Medical Center
    Tel Aviv, Israel
    The Sackler Faculty of Medicine
    Tel-Aviv University
    Tel Aviv, Israel

  • Nir Rudoler, DVM, MPH, PhD

    Koret School of Veterinary Medicine
    Hebrew University, Israel
    The Veterinary Unit
    Ministry of Health, Tel Aviv, Israel

  • Yael Paran, MD

    Infectious Disease Unit
    Tel Aviv Sourasky Medical Center
    Tel Aviv, Israel
    Encephalitis Center
    Tel-Aviv Sourasky Medical Venter
    The Sackler Faculty of Medicine
    Tel-Aviv University, Ramat Aviv, Tel Aviv, Israel

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie Inc.

Editor

  • Amy J. Guinn, BA, MA

    Copyeditor 
    Emerging Infectious Diseases

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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    For Physicians

  • Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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CME / ABIM MOC

Systematic Review and Meta-Analysis of Foodborne Tick-Borne Encephalitis, Europe, 1980–2021

Authors: Meital Elbaz, MD; Avi Gadoth, MD; Daniel Shepshelovich, MD; David Shasha, MD; Nir Rudoler, DVM, MPH, PhD; Yael Paran, MDFaculty and Disclosures

CME / ABIM MOC Released: 9/15/2022

Valid for credit through: 9/15/2023

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Abstract and Introduction

Abstract

Tick-borne encephalitis (TBE) is a viral infection of the central nervous system that occurs in many parts of Europe and Asia. Humans mainly acquire TBE through tick bites, but TBE occasionally is contracted through consuming unpasteurized milk products from viremic livestock. We describe cases of TBE acquired through alimentary transmission in Europe during the past 4 decades. We conducted a systematic review and meta-analysis of 410 foodborne TBE cases, mostly from a region in central and eastern Europe. Most cases were reported during the warmer months (April–August) and were associated with ingesting unpasteurized dairy products from goats. The median incubation period was short, 3.5 days, and neuroinvasive disease was common (38.9%). The clinical attack rate was 14% (95% CI 12%–16%), and we noted major heterogeneity. Vaccination programs and public awareness campaigns could reduce the number of persons affected by this potentially severe disease.

Introduction

Tick-borne encephalitis (TBE) is a viral infection of the central nervous system (CNS) caused by tick-borne encephalitis virus (TBEV). TBE occurs mainly in eastern, central, and northern Europe and in northern China, Mongolia, and Russia[1]. Although vaccination can effectively prevent TBE, >3,000 cases were reported in Europe in 2019, and case-fatality was 0.7%[2]. However, many mild and subclinical infections probably remain undiagnosed.

Humans acquire TBE mainly via tick bites, but TBEV can occasionally be transmitted through consumption of unpasteurized milk products from viremic livestock. The largest known outbreak of foodborne TBE (FB-TBE) occurred in 1954 in what was then Czechoslovakia, when TBE developed in >600 persons infected via TBEV-contaminated milk from cows and goats[3]. During that period, the disease was termed biphasic milk fever. During the past 4 decades, repeated smaller outbreaks have been reported in association with TBEV transmission via contaminated milk in various countries in Europe and in Russia[3–10].

Despite the role of food as a transmission route, FB-TBE has not been systematically described until recently. Two recent published reviews summarized published reports[11,12], but those studies did not include meta-analysis of published data. We systematically describe cases of alimentary TBEV transmission in Europe during the past 4 decades, estimate the attack rate of FB-TBE, and describe the epidemiologic and clinical characteristics of FB-TBE.