Early summer meningoencephalitis

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Classification according to ICD-10
A84 Viral encephalitis, transmitted by ticks
A84.1 Central European encephalitis, transmitted by ticks
ICD-10 online (WHO version 2019)

The tick-borne encephalitis ( TBE ; English tick-borne encephalitis , TBE ) is a by the TBE virus caused disease with flu-like symptoms, fever, and in a subset of patients with meningoencephalitis , runs, inflammation of the brain and meninges. However, the majority of infected people do not show any signs of disease.

The disease is transmitted by the bite (tick bite) of an infected tick , mainly by the common wood tick ( Ixodes ricinus ); less often through the consumption of raw milk from an infected animal. A causal treatment of TBE is not possible. In addition to general protective measures such as body-covering clothing and searching the body after a visit to the forest, active vaccination can be considered as a preventive measure. It is recommended by different authorities for all people who are in "risk" or endemic areas, which varies slightly from country to country . Proof of infection in a person with the TBE pathogen is notifiable in Germany (by the laboratory), Austria and Switzerland .

Pathogen and transmission

The cause of the early summer meningoencephalitis is the TBE virus , a human pathogenic virus from the Flaviviridae family and the genus Flavivirus . This virus is an enveloped single- stranded RNA virus [ss (+) RNA], of which three subtypes (Western, Siberian, Far Eastern subtype) are currently known.

tick

Mainly occurring in Europe Western subtype of TBE virus is through the sting of an infected tick transmitted. The main carriers of the disease in Central Europe are the species of the genus Ixodes with the most common native species, the common wood tick ( Ixodes ricinus ), as well as Ixodes persulcatus , as well as the alluvial forest tick ( Dermacentor reticulatus ), more rarely also other representatives of the genus Rhipicephalus and representatives of the genera Dermacentor , Haemaphysalis , Amblyomma and from the family of leather ticks the genera Argas and Ornithodorus .

The TBE virus is transmitted from the tick's salivary gland when it is bitten. The greatest risk of a tick bite is in the bushes, on the edges of forests or in tall grass in meadows, because small mammals (mice), birds and game live there as the main hosts (primary pathogen reservoir) of the ticks. There are no ticks infected with TBE at altitudes above 1000 meters, although the common wood tick in the Alps is now at heights of up to 2000 m. ü. M. has advanced. This difference is related to the specific survival conditions of the virus. In risk areas, the proportion of TBE-infected ticks is around 0.1% to 5%.

Transmission through virus-infected milk products ("biphasic milk fever") rarely occurs in Germany, Austria and Switzerland, as this is only possible through raw milk from goats , sheep or cows . In the Baltic countries, a higher prevalence of antibodies against the TBE virus is associated with frequent consumption of goat milk. Transmission from person to person is not possible. The virus is reliably inactivated by pasteurizing the milk.

Ticks can also transmit Lyme disease . Borreliosis is caused by bacteria ( Borrelia ) and is much more common than TBE (between 20 and 90 cases of Lyme disease are reported per 100,000 inhabitants in federal states with mandatory reporting, with TBE this number is only 1.3, see below). So far there is no vaccination against Lyme disease, but in contrast to TBE, the infection can be treated with antibiotics. While TBE only occurs in certain risk areas in Germany, borreliosis can be assumed to be at risk of infection in all parts of the country.

frequency

In Germany , early summer meningoencephalitis has been notifiable by the head of the diagnostic laboratory according to Section 7 (1) Infection Protection Act since 2001 . In 2004 a total of 274, in 2005 432 and 2006 546 cases were reported that corresponded to the case definitions of the Robert Koch Institute (RKI). In 2007, contrary to the forecasts of the RKI, a significant decrease was recorded with 238 cases, 195 cases were reported in 2012, 420 in 2013, 260 in 2014 and 223 cases in 2015. The number of cases rose to 344 in 2016, to 486 in 2017 and to 584 in 2018. In 2019 it fell to 440. A "case" is defined here if a person who:

  1. has flu-like symptoms or central nervous system symptoms
  2. laboratory diagnostic evidence ( serology or PCR ) of an underlying TBE is successful.

In Switzerland around 100 people develop TBE each year, with a sharp increase in 2005 (204 cases) and 2006 (249 cases). As a result, the number was 100 to 170 cases per year until 2013.

Up until 2016, with the exception of 113 infected people in 2011, there were less than 100 infections per year in Austria ; in 2012 the number fell to 52. In 2013, an increase to 99 cases was recorded, 80 cases were registered in 2014 and 64 cases in 2015. In contrast, 95 cases were reported in 2016 and 116 cases were recorded in 2017. At least 84 cases had already been confirmed by the end of July 2018.

Due to the flu-like, often unspecific symptoms, a high number of unreported illnesses is possible (which are then harmless).

risk areas

Distribution area of ​​TBE transmitted by ticks
TBE risk areas in Germany according to the statistics of the Robert Koch Institute (as of January 17, 2019, 5090 cases in the years 2002 to 2018)

In Germany, up until 2006, rural or urban districts were considered TBE risk areas in which in one year at least two or in five years at least five diseases occurred - due to an infection in the same area. As high-risk areas were to 2006, those risk areas where in five years at least 25 cases of the disease occurred. These were the Black Forest in southern Baden, the Odenwald in southern Hesse , the Bergstrasse and the region around Passau . A tick hot spot is often no bigger than a soccer field or only half the size - and spatially stable for years.

Since 2007, a (rural) district in Germany has been considered a risk area if the number of TBE diseases transmitted in five consecutive years in the district or in the district region (in the district and all neighboring districts) is significantly higher than that of a five-year incidence of one disease expected number of cases per 100,000 inhabitants (the Germany-wide incidence of TBE is 1.3 patients per 100,000 inhabitants annually). As a result of the new definitions, 33 new districts in Germany were declared a TBE risk area, an increase of 34% (see maps under web links). In addition, despite the large spread of the incidences (up to over 30 per 100,000 inhabitants), there was no differentiation between high-risk and high-risk areas. The increase in new urban and rural districts was not caused by more TBE infections, but because these districts are surrounded by risk areas. In 80 districts, a five-year incidence was calculated that was significantly higher than one disease per 100,000 inhabitants; in a further 51 districts it was lower. The increased demand for vaccines caused by this expansion led - and still leads today - to delivery bottlenecks again and again .

The Standing Vaccination Commission recommends a regular TBE vaccination only for the districts of the TBE card issued by the Robert Koch Institute (RKI). The RKI criticizes maps from other authors, some of which cover risk areas.

Due to the sharp increase in the number of cases in Switzerland, the Federal Office of Public Health (FOPH) issued a vaccination recommendation for all of Switzerland with the exception of the cantons of Geneva and Ticino in February 2019. TBE vaccinations are paid for by health insurance companies. Above 1500  m above sea level M. ticks do not occur and above 1000  m above sea level. M. is (as of 2012) no TBE area known in Switzerland either. Both of these can change due to increasing global warming .

Austria is considered a heartland of the TBE virus spread in Europe. The entire federal territory is endemic to ticks. No cases of TBE from tick bites are known from altitudes above 1000 meters (as of 2007). Most illnesses occurred in 2005 in Styria , Upper Austria and Tyrol , but there were TBE cases in all federal states. The high-risk areas are along the Danube in Vienna , in the Wachau , in the St. Pölten area and between Passau and Linz. Large parts of Burgenland , Carinthia and Styria as well as the Tyrolean Inn Valley are also areas with high risk; There are also risk areas in between. In Austria, relatively few people fell ill with TBE in 2004, despite its widespread distribution, because around 90% of them were vaccinated.

Table of TBE cases in Austria
Years Age group
1 - 20 years		 Age group
21 - 50 years		 Age group
> 50 years		 total
1971-1981 779 1077 522 2378
1986-1994 158 607 523 1288
1994-2002 043 278 466 0787

What is striking is the sharp decline in the total numbers, especially among people under 50 years of age. The decline in the number of diseases is considered to be a result of the high vaccination coverage . The TBE vaccination has existed in Austria since 1981. The vaccination has also been officially recommended to travelers and holidaymakers since 2010.

There is a high risk of disease in Russia and the Czech Republic . It is highest in Europe in Lithuania , Estonia and Latvia . In addition to Germany, Austria and Switzerland, TBE is of considerable importance in Poland , Hungary , Slovenia , Croatia , Sweden , Finland and Slovakia . It is rarely seen in France , Italy , Denmark and Greece , and none at all in the United Kingdom , the Benelux countries and the Iberian Peninsula .

Symptoms and course of the disease

Only about 10–30% of those infected show symptoms; the rest of the disease is asymptomatic. In the so-called biphasic course, flu-like symptoms with fever and headache and body aches occur two to 20 days after infection , which regress after a few days. These symptoms may be absent in the monophasic course caused by the two other TBE strains.

In 70% of symptomatic patients there is a defever of fever after about a week and a second fever peak a few days later with a body temperature of up to 40 ° C. Signs of involvement of the brain and meninges also appear at this stage: headache, vomiting and meningeal signs ( meningeal irritation signs ). The symptoms can last for several months, and even after severe courses they can heal completely. In this second phase of the disease, around 50% develop meningitis . 40% of the patients develop meningoencephalitis with severe disturbances of consciousness and paralysis up to and including respiratory paralysis. In 10% of cases there is an myelitis with flaccid arm and leg paralysis, often with a brain stem encephalitis, often within hours, with involvement of motor cranial nerve nuclei and the anterior horn of the spinal cord. These severe forms rarely heal and usually only incompletely. Overall, children and adolescents have a better prognosis than adults.

Diagnosis

A memory tick bite in the medical history and the neurological examination provide clues to a disease. If a lumbar puncture is performed, cells multiply ( pleocytosis ) and an increase in protein in the cerebrospinal fluid ( cerebrospinal fluid ) from the second fever peak.

Evidence of TBE is the detection of IgM and IgG antibodies against the virus in serum or liquor using an ELISA test. This proof is only possible at the beginning of the second fever phase. It should be noted that a TBE vaccination leads to positive antibody titers . Special procedures for direct virus detection are RT-PCR and Western blot .

The Bundeswehr Institute for Microbiology has the world's largest collection of virus strains . When it comes to rickettsia research, the laboratory is one of the world's leading. A special program is intended to research possible health risks posed by African ticks.

Treatment and prognosis

There are no options for causal therapy, specific antiviral drugs do not exist. Once the disease has broken out, only symptomatic therapy focused on alleviating individual symptoms is possible. The therapeutic spectrum includes bed rest and pain relievers ( analgesics ). The avoidable use of antipyretic agents ( antipyretics ) and glucocorticoids is not recommended. In severe cases, intensive medical treatment with parenteral nutrition and fluid replacement, possibly also intubation and controlled ventilation, is necessary.

Methods such as physiotherapy , speech therapy and neurophysiological training are used as part of rehabilitation after the acute phase of the disease .

The prognosis for severe courses is unfavorable, better in children and adolescents than in adults. Almost 60% of those over the age of 15 show protracted, sometimes permanent, functional disorders after a serious course. Neurasthenic syndrome with emotional instability and stress intolerance can last for months . According to one study, only 20% of the patients recovered completely, over 50% retained neurological dysfunction and 30% died within a period of up to ten years as a result of TBE . After surviving an infection, there is long-term immunity, also against the other types of the TBE virus. The Robert Koch Institute recommends that the immune protection be refreshed after three to five years with a dose of a TBE vaccine.

prevention

General preventive protective measures (exposure prophylaxis) are the basis of prevention. In contrast to Lyme disease , early summer meningoencephalitis can often be prevented by an active vaccination ("tick vaccination"). The active ingredient for a passive vaccination after a tick bite (post-exposure immunoprophylaxis) is no longer sold in Germany.

General preventive measures

In order to prevent TBE and Lyme disease, tick bites should be avoided if possible. Clothing that covers as much of the body surface as possible (e.g. long trousers, long-sleeved shirts and sturdy shoes) significantly reduce the risk of tick infestation. Repellents are also effective against ticks to a certain extent; however, their effect wears off after about two hours. After staying close to nature in tick-prone areas, you should carefully search your body and clothing. Any ticks found should be carefully removed and stored, the site of the bite disinfected and the time and place of infestation noted. If possible, the tick should not be turned and under no circumstances should it be drizzled with oil or glue before removing it, as this could unnecessarily irritate the animal and cause it to give off its saliva and thus possible infectious agents.

vaccination

The TBE vaccine contains inactivated, non-reproductive TBE viruses for active immunization, and aluminum hydroxide as an adjuvant , which increases the effectiveness of the vaccine. The vaccine is injected intramuscularly . There are several vaccine manufacturers who offer different dosages of their products for adults and children. The TBE vaccine is very effective. Based on information on vaccination coverage and the frequency of diseases in vaccinated people, a study in Austria estimated the effectiveness after three doses to be 96–99%. The risk of the disease is reduced from about 1: 18,000 in non-vaccinated people to 1: 840,000. In Austria, between 1995 and 2004, only two vaccinated people fell ill with clear signs of the disease.

Opinions on the tolerability of the vaccines are divided. In 2004–2005, almost 10% of all suspected vaccination complications reported to the Paul Ehrlich Institute in Germany related to TBE vaccines (a total of 224 suspected cases). As a side effect, local skin reactions occur in up to a third of those vaccinated. Fever as a systemic side effect of the approved vaccines is rare in adults (<1%), but occurs somewhat more frequently in children (6–24%), but almost exclusively in a mild form (below 40 ° C body temperature). Other side effects can be headache, tiredness, nausea, visual disturbances, chills, hives , inflammation of the nerves, inflammatory reactions of the brain as well as muscle and joint pain (10–20% of those vaccinated). However, allergic reactions only occurred after 1–2 in 1,000,000 vaccinations.

The vaccination is often wrongly called "tick vaccination". Since the vaccination only protects against TBE, but not against other diseases that can be transmitted by ticks, this term is misleading. Even after a TBE vaccination, further preventive measures are necessary to reduce the likelihood of other tick-borne diseases - e. B. Lyme borreliosis , which occurs much more frequently than TBE , can be reduced. These include wearing light-colored, closed clothing, using repellents , avoiding rough terrain and undergrowth, promptly searching the body for ticks and removing them immediately. The television magazine Report Mainz broadcast a TV report on May 4, 2009, in which the advertising methods of vaccine-producing pharmaceutical companies and the sometimes inadequate education by vaccinating doctors were discussed.

execution

Basic immunization consisting of three vaccinations is necessary for long-term protection . After the first vaccination, it is vaccinated again four weeks later (from here the vaccination is effective), and it is completed with a third vaccination nine to twelve months after the second vaccination.

A booster vaccination is recommended after three to five years. In Austria, the first booster vaccination is carried out after three years, the others are given every five years. Various recent publications with determination of the antibody titre show, however, that there is probably a much longer vaccination protection. For example, the Swiss Federal Office of Public Health only recommends a booster vaccination every ten years.

If needed at short notice, the vaccinations can be administered in a rapid schedule. Three doses are given within three weeks (second and third dose on the 7th and 21st day). For long-term protection, a single revaccination is necessary after one year.

A vaccination after a tick bite can no longer protect unvaccinated persons from TBE infection from the tick that has just been removed. In order not to delay the diagnosis of TBE, basic immunization should be given no earlier than four weeks after the bite. Passive immunization by administration of antibodies against TBE is no longer recommended.

Vaccination recommendations

Germany : According to the vaccination recommendations of the Standing Vaccination Commission ( STIKO ) at the Robert Koch Institute, there is an indication for active vaccination for people "who are exposed to ticks in TBE risk areas, or people who are at risk from TBE (exposed laboratory staff as well as in Risk areas e.g. forest workers and those exposed in agriculture) ”. It should be noted that the main tick season is limited to the months of April to November, but ticks, especially in mild winters, can be active all year round and there is a corresponding risk of infection.

In children of preschool age, due to the mild course of the disease (in children under six years of age, defect healing occurs in only 2% and this only in children who have been treated with dexamethasone or passive immunization after tick bites) and the significantly increased vaccination side effect rates at this age ( see linked technical information of the vaccines below) the vaccination should be carried out more cautiously. In a survey by the Paul Ehrlich Institute (PEI), no case of severe TBE disease in children and adolescents up to 16 years of age could be identified in the period 1997/98.

Switzerland : The Federal Commission for Vaccination Questions in Switzerland recommends vaccinations for all people in endemic areas, but only from the age of six.

Austria : The Supreme Sanitary Council, an advisory body to the Federal Ministry of Health , recommends TBE vaccinations for children from the age of two in the 2014 vaccination plan.

Contraindications to vaccination are general vaccination obstacles such as febrile illnesses (over 38 ° C), allergies to vaccine components and upcoming major physical exertion. Chronic illnesses, however, are not an obstacle to vaccination; on the contrary, this group of people particularly benefits from vaccinations. Even common infections with a slight fever (up to 38 ° C) do not constitute an obstacle to vaccination. During pregnancy , the risks and benefits must be carefully weighed up. There is no experience of vaccinating pregnant women.

Vaccine manufacturing

The TBE vaccine is produced on so-called CEC ( chick embryo cells ) cells. This is a primary cell line made from embryonated chicken eggs . To do this, the ten to twelve day old eggs are opened, the embryo removed, crushed and subjected to a trypsin treatment. The CEC cells are inoculated with the TBE virus in small fermenters . After the virus has multiplied, the CEC cells die, the supernatant is harvested, and the virus is inactivated with formaldehyde . Subsequently, a is Antigen purification by means of a precipitation step, ultrafiltration and a continuous sucrose - gradient performed.

Development history

After the first description of the disease in 1931 and the isolation of the TBE virus in 1956 by the two Austrians Hans Moritsch and Josef Krausler succeeded in 1973 Christian Kunz from the Institute of Virology at the University of Vienna , the vaccine TBE immune produce. Industrial production began in 1976 by the Immuno company in Orth an der Donau , which was vaccinated from then on, initially only forest workers. In the late 1990s, Baxter International , an American pharmaceutical company, took over Immuno. Baxter brought its own vaccine called TicoVac , but it was noticed by common side effects (fever and febrile seizures in children) and was therefore withdrawn from the market in 2001, after which the vaccine was temporarily unavailable . Since 2002, improved TBE vaccines from Baxter (TBE-Immun) and Novartis (Encepur) have been available in children's and adult formulations.

Reporting requirement

In Germany, direct or indirect evidence of the TBE virus is notifiable by name in accordance with Section 7 of the Infection Protection Act (IfSG), if the evidence indicates an acute infection. The laboratories etc. are obliged to report ( § 8 IfSG).

In Austria, virus- related meningoencephalitis are notifiable diseases in accordance with Section 1 (1) of the 1950 Epidemic Act (including FMSE). The reporting obligation relates to cases of illness and death. Doctors and laboratories, among others, are obliged to report this ( Section 3 Epidemics Act).

In Switzerland, the positive laboratory analytical finding the disease early summer meningo-encephalitis (TBE) for doctors, hospitals, etc. notifiable and that after the Epidemics Act (EpG) in connection with the epidemic Regulation and Annex 1 of the Regulation of EDI on the reporting of observations communicable diseases in humans .

TBE in animals

Red deer and roe deer show high antibody titers (measure of the concentration of antibodies) in endemic areas , but do not become clinically ill. In domestic dogs individual cases with fever, decreased consciousness, paralysis and failure of the cranial nerves are described, but overall they seem very receptive, and even experimental infections in puppies did not lead to clinical symptoms.

Origin of name

The term early summer comes from the Russian taiga tick, which is only active in spring and early summer. In Central Europe, ticks are active all year round (except in cold winters).

literature

  • Peter Kimmig, Dieter Hassler, Rüdiger Braun: ticks. Trias, 2001, ISBN 3-431-04018-7 .
  • Patrick Oschmann, Peter Kraiczy: Lyme borreliosis and early summer meningoencephalitis. UNI-MED, Bremen 1998, ISBN 3-89599-408-1 .
  • Hans-Peter Wirtz: Ticks as a disease carrier: what to do if you get a bite? In: Biology in Our Time. 31 (4), 2001, ISSN  0045-205X , pp. 229-238.
  • Jochen Süss: Ticks - What you need to know about TBE and Lyme disease. Irisiana-Hugendubel, 2006, ISBN 3-7205-5006-0 .
  • Ralph Peters: Ticks and tick diseases. Borreliosis and TBE Association of Germany V., 2006, www.borreliose-bund.de

Web links

General links

Wiktionary: early summer meningoencephalitis  - explanations of meanings, word origins, synonyms, translations

Maps of the risk areas

Individual evidence

  1. ↑ Notifiable diseases and pathogens. Robert Koch Institute, accessed January 12, 2013 . .
  2. ^ Illnesses subject to notification in Austria by the Federal Ministry for Social Affairs, Health, Care and Consumer Protection, as of January 2020 (PDF, 4 pages, tabular representation).
  3. ↑ Notifiable communicable diseases and pathogens. (PDF, 4 MB) Guidelines for the 2020 notification requirement. Federal Office of Public Health FOPH, Communicable Diseases Department, February 23, 2020, accessed on March 8, 2020 (detailed brochure).
  4. ↑ U. Dumpis, D. Crook, J. Oksi: Tick-borne encephalitis (review). In: Clin Inf Dis. 1999; 28, pp. 882-890 PMID 10825054
  5. ↑ New sources of TBE infection , In: Dt. TAB. Volume 65, Issue 5 2017, p. 592.
  6. ↑ a b c d Robert Koch Institute: Early Summer Meningoencephalitis (TBE). RKI Guide to Infectious Diseases - Leaflets for Doctors. Updated version 2011.
  7. ^ Heidemarie Holzmann, Franz X. Heinz: TBE outbreak through consumption of cream cheese made from non-pasteurized goat's milk. ImpfDialog 3/2008 (full text) ( Memento from March 10, 2012 in the Internet Archive )
  8. ↑ R. Herzig et al: An uncommon severe clinical course of European tick-borne encephalitis. In: Biomed. Pap. Med. Fac. Univ. Palacky. Olomouc. Czech. Repub. (2002) 146 (2), pp. 63-67 PMID 12572899 .
  9. ↑ A. Juceviciene et al: Prevalence of tick-borne-encephalitis virus antibodies in Lithuania. In: J. Clin. Virol. (2002) 25 (1), pp. 23-27 PMID 12126718
  10. ^ Robert Koch Institute: Epidemiological Bulletin . No. 38 of September 21, 2007 , pp. 351-355. (PDF, 1MB).
  11. ↑ It should be noted , however, that flu-like symptoms after a tick bite (which must be reported as a TBE case) can also be triggered by a Borrelia infection (in which wandering redness only occurs in about 50% of cases)!
  12. ↑ rki.de RKI, Infection Epidemiological Yearbook of Notifiable Diseases for 2012, accessed on February 25, 2014.
  13. ↑ RKI epidemiological bulletin , January 19, 2015
  14. ↑ Swiss Federal Office of Public Health ( Memento of the original dated February 9, 2017 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Early summer meningoencephalitis (TBE) / tick encephalitis, as of April 2017, accessed on June 9, 2017. @1@ 2Template: Webachiv / IABot / www.bag.admin.ch
  15. ↑ TBE vaccination "saves" 400 diseases annually. In: The Standard . March 14, 2013.
  16. ↑ Ticks: What You Should Know. www.news.at, April 26, 2016
  17. ↑ TBE cases in Austria 2016
  18. ↑ Increased cases of early summer meningoencephalitis.
  19. ↑ TBE: Risk areas in Germany (as of January 2019). Assessment of the local disease risk . In: Epidemiological Bulletin. No. 7/2019 of February 14, 2019. Robert Koch Institute, accessed on February 22, 2019 .
  20. ↑ TBE: On the current occurrence in Germany. Assessment of the local disease risk - map of the risk areas . Epidemiological Bulletin December 9, 2004, No. 21, pp. 171-172.
  21. ↑ Florian Klebs: Ticks: New species & TBE hot spots could increase the risk of disease. In: idw-online.de. March 6, 2018, accessed March 10, 2018.
  22. ↑ a b TBE: Risk areas in Germany. Assessment of the local disease risk . In: Epidemiological Bulletin. No. 18 of May 29, 2012. Robert Koch Institute, accessed on January 12, 2013 .
  23. ↑ Robert Koch Institute: Five-year incidence of early summer meningoencephalitis in districts and district regions , Germany, 2002–2010 , Annex to Epidemiological Bulletin 17/2011 of May 2, 2011, accessed on May 3, 2012 (PDF, 167 KB).
  24. ^ Robert Koch Institute: TBE: Risk areas in Germany, Current Changes in Epidemiological Bulletin No. 15 of April 13, 2007, p. 131, accessed on May 3, 2012.
  25. ↑ TBE card 2019 , RKI. Retrieved May 8, 2019.
  26. ↑ TBE: Expansion of risk areas (PDF)
  27. ↑ NZZ.ch May 2, 2019: Beware, ticks!
  28. ↑ Tick-borne diseases. (No longer available online.) Swiss Federal Office of Public Health, archived from the original on March 13, 2013 ; Retrieved January 12, 2013 .
  29. ↑ The Standard : How Dangerous Are Ticks Really? April 12, 2007.
  30. ^ Austrian Chamber of Pharmacists / FX Heinz: Balance of the FSME 2005: Epidemiological situation in Austria and an international comparison , February 22, 2006.
  31. ↑ a b On TBE in Europe . Epidemiological Bulletin 16/2005 of the RKI ( Memento of May 3, 2008 in the Internet Archive )
  32. ↑ reisemed.at
  33. ↑ www.zecken.at (accessed on May 7, 2019)
  34. ↑ Guideline for early summer meningoencephalitis (TBE) ( Memento from December 22, 2015 in the Internet Archive )
  35. ↑ a b Gleixner, Müller, Wirth: Neurology and Psychiatry. 4th edition. 2004/5, ISBN 3-929851-53-9 , p. 116.
  36. ↑ a b R. Kaiser: Early summer meningoencephalitis. In: Munich Medical Weekly Magazine. Volume 156, February 2014.
  37. ^ "The tick clearer" on the homepage of the medical service of the Bundeswehr
  38. ^ C. Kunz: TBE vaccination and the Austrian experience. In: Vaccine. 2003 Apr 1; ​​21 Suppl 1, pp. S50-S55. PMID 12628814
  39. ↑ K. Weißer et al .: Suspected cases of vaccination complications according to the Infection Protection Act and suspected cases of side effects (of vaccines) according to the Medicines Act from January 1, 2004 to December 31, 2005 . ( Memento from December 22, 2015 in the Internet Archive ) Published online on the Paul Ehrlich Institute website.
  40. ↑ a b c Federal Commission for Vaccination Issues : Recommendations for vaccination against tick encephalitis . Swiss Federal Office of Public Health (Ed.) URL: Archive link ( Memento from March 9, 2016 in the Internet Archive ) (accessed May 5, 2009)
  41. ↑ Scare tactics with tick vaccinations - The irresponsible campaigns of the pharmaceutical industry
  42. ↑ P. Rendi-Wagner et al .: Immunogenicity and safety of a booster vaccination against tick-borne encephalitis more than 3 years following the last immunization. In: Vaccine. 2004 PMID 15530690
  43. ↑ P. Rendi-Wagner et al .: Persistence of protective immunity following vaccination against tick-borne encephalitis - longer than expected? In: Vaccine. 2004 Jul 29; 22 (21-22), pp. 2743-2749. PMID 15246606
  44. ^ Robert Koch Institute: Recommendations of the Standing Vaccination Commission
  45. ^ PEI, Information for Doctors and Pharmacists from March 28, 2001.
  46. ↑ aerztezeitung.at: vaccination plan 2014 for infants and toddlers.
  47. ^ H. Schneider: On epidemic acute meningitis serosa. Wr. Clinical weekly. 1931, 44, pp. 350-352.
  48. ↑ H. Moritsch, J. Krausler: The endemic early summer menigoencephalitis in the Vienna basin (Schneider's disease). In: Wr. Clinical weekly journal. 1957, 69, pp. 921-926.
  49. ↑ C. Kunz, H. Hofmann, A. Stary: Field studies with a new tick-borne encephalitis (TBE) vaccine. In: Zentralbl Bakteriol. 1976 Jan; 234 (1), pp. 141-144. PMID 1258565
  50. ↑ How dangerous are ticks really. Contribution in the online standard
  51. ↑ TBE disease (early summer meningoencephalitis). In: Gesundheit.gv.at. Federal Ministry for Social Affairs, Health, Care and Consumer Protection (BMSGPK), May 10, 2019, accessed on March 26, 2020 .
  52. ↑ Bärbel Reiner, Andrea Fischer: Early Summer Meningoencephalitis (TBE) in Dogs in Germany: Two Case Reports. In: Small Animal Practice. 43 (1998), pp. 255-268.
  53. ↑ zeckenwetter.de
This version was added to the list of articles worth reading on June 3, 2006 .