Trends in Parasitology
ReviewCoinfection by Ixodes Tick-Borne Pathogens: Ecological, Epidemiological, and Clinical Consequences
Section snippets
Ixodes-Borne Pathogens as a Model System to Study Vector-Borne Coinfection
Wildlife and humans are frequently infected by multiple pathogens or several genotypes of a single pathogen 1, 2. Coinfecting pathogens can interact among themselves and with host symbionts for utilization of host resources or through modulation of host immunity 3, 4. Positive interactions (facilitation) may favor the emergence (see Glossary) of an invading pathogen or increase the prevalence of an established pathogen. Negative interactions (competition) may prevent the establishment of an
Coinfection with Ixodes-Borne Pathogens is Prevalent Worldwide
Ticks in the I. ricinus species complex have a Holartic distribution but are restricted to the regions with temperate climates 5, 10. Four species within this complex account for most of the transmission of human Ixodes-borne pathogens: Ixodes pacificus is primarily found along the Pacific coast of the USA; Ixodes scapularis in the Northeast, upper Midwest and South of the USA; I. ricinus across Europe, in parts of northern Africa, Turkey, and the Caucasus; and Ixodes persulcatus from
The emergence of babesiosis occurs within Lyme disease-endemic areas
The first case of babesiosis caused by B. microti in the USA was identified in 1969 in an immunocompetent individual who had summered on Nantucket Island, MA [8]. Shortly thereafter, the disease was recognized on other islands off the coast of southern New England and on the mainland, particularly in coastal counties ranging from MA to NJ. Another endemic area was identified in the upper Midwest. Over the following two decades, the number of cases reported to local public health departments
Coinfection facilitates maintenance of B. burgdorferi and B. microti in the enzootic cycle
Single and concurrent B. burgdorferi and B. microti infections have been well documented in I. scapularis ticks and enzootic reservoir hosts (Table 1). Single infections with Borrelia burgdorferi are consistently more prevalent than single infections with B. microti in both ticks and reservoir hosts. Among ticks, the prevalence of B. burgdorferi and B. microti coinfection ranges from 0% to 19% in nymphs and from 0% to 17% in adults 17, 22, 50, 56, 57, 58, 59, 60, 61, 62, 63. The prevalence of
Concurrent babesiosis exacerbates and prolongs the symptoms of Lyme disease
Initial case reports suggested that concurrent Lyme disease and babesiosis are associated with severe illness. Each of the first three reported cases of Lyme disease and babesiosis coinfection was admitted to the hospital 74, 75, 76. One patient required blood transfusion and multiple joint aspirations for a recurrent swollen knee, another developed pulmonary edema despite appropriate antibiotic therapy, and a third died of fatal pancarditis. The first prospective study of Lyme disease and
Future Directions
Lyme disease and babesiosis are expected to remain serious health threats and other tick-borne diseases are likely to emerge. Predicting the enzootic emergence of tick-borne pathogens will help anticipate the increase in incidence of tick-borne human diseases and may help develop ecological and public health measures to manage these health threats.
Concluding Remarks
The geographic expansion of I. scapularis has greatly contributed to increase the incidence of tick-borne diseases in the USA. Of the six human pathogens that I. scapularis transmits separately or in combination 8, 11, 14, 28, 30, 31, 44, 97, we focused on B. burgdorferi and B. microti because coinfection with these two pathogens is frequent in the enzootic cycle and can cause severe disease in humans. The emergence of babesiosis on the heels of Lyme disease is explained, in part, by the effect
Acknowledgments
The authors thank Kiersten Kugeler and Elizabeth Gray for providing surveillance data on Lyme disease and babesiosis; Stephen Davis, Aurelie Kern, and Max McClure for helpful discussions; and Sarah States for help with figure production. The authors acknowledge support by the Gordon and Llura Gund Foundation (to P.J.K. and E.V.) and the National Institutes of Health (R01 GM105246 to M.A.D-W. and R44HL127698 to P.J.K.).
Glossary
- Basic reproductive number (R0)
- a standard measure of pathogen transmissibility. R0 measures the average number of secondary cases caused by a pathogen in a completely susceptible population. It is also considered a measure of population fitness and can be interpreted as the likelihood that a pathogen will become established (R0 >1) or extinct (R0 <1) when introduced into a population of naive, fully susceptible hosts.
- Coinfection
- simultaneous infection of a host by two or more pathogen species or
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Co-first authors