Research article Open Access
Like 0


With an annual incidence between 8 and 15 per 100,000 population in the period from 2009 to 2013, Slovenia has one of the highest notified incidences of tick-borne encephalitis (TBE) in Europe. TBE vaccination coverage remains at about 7.3%. To inform vaccination policy, we used surveillance data from 2009 to 2013 to calculate the overall and age- and sex-specific mean annual TBE incidence. We estimated disability-adjusted life years (DALYs) with 95% uncertainty intervals (UI), using the Burden of Communicable Diseases in Europe approach from the European Centre for Disease Prevention and Control. The mean annual incidence was 11.6 per 100,000 population, peaking in older age groups (50–74 years: 18.5/100,000) while relatively lower among children (5–14 years: 10.2/100,000). We estimated an overall 10.95 DALYs per 100,000 population per year (95% UI: 10.25-11.65). In contrast to the TBE incidence, the disease burden in children aged 5–14 years was higher than in adults aged 50–74 years: 17.31 (95% UI: 14.58–20.08) and 11.58 (95% UI: 10.25–12.91) DALYs per 100,000 stratum-specific population, respectively. In a limited resource setting where prioritisation of TBE vaccination strategies is required, vaccination programmes targeting children may have a higher impact on disease burden.


Article metrics loading...

Loading full text...

Full text loading...



  1. Chambers TJ, Hahn CS, Galler R, Rice CM. Flavivirus genome organization, expression, and replication. Annu Rev Microbiol. 1990;44(1):649-88.  https://doi.org/10.1146/annurev.mi.44.100190.003245  PMID: 2174669 
  2. Gubler JD, Kuno G, Markoff L. Flaviviruses. In: Knipe DM, Howley PM, editors. Fields Virology. 5th ed. London, New York, Tokyo: Lippincott Williams and Wilkins; 2007. pp. 1043-1125.
  3. Kiffner C, Zucchini W, Schomaker P, Vor T, Hagedorn P, Niedrig M, et al. Determinants of tick-borne encephalitis in counties of southern Germany, 2001-2008. Int J Health Geogr. 2010;9(1):42.  https://doi.org/10.1186/1476-072X-9-42  PMID: 20707897 
  4. Gustafson R, Svenungsson B, Forsgren M, Gardulf A, Granström M. Two-year survey of the incidence of Lyme borreliosis and tick-borne encephalitis in a high-risk population in Sweden. Eur J Clin Microbiol Infect Dis. 1992;11(10):894-900.  https://doi.org/10.1007/BF01962369  PMID: 1486884 
  5. Haglund M, Günther G. Tick-borne encephalitis--pathogenesis, clinical course and long-term follow-up. Vaccine. 2003;21(Suppl 1):S11-8.  https://doi.org/10.1016/S0264-410X(02)00811-3 
  6. European Centre for Disease Prevention and Control. Epidemiological situation of tick-borne encephalitis in the European Union and European Free Trade Association countries. Stockholm: ECDC; 2012. Available from: http://ecdc.europa.eu/en/publications/Publications/TBE-in-EU-EFTA.pdf
  7. Suss J. Tick-borne encephalitis in Europe and beyond--the epidemiological situation as of 2007. Euro Surveill. 2008;13(26):18916. PMID: 18761916 
  8. Süss J. Tick-borne encephalitis 2010: epidemiology, risk areas, and virus strains in Europe and Asia-an overview. Ticks Tick Borne Dis. 2011;2(1):2-15.  https://doi.org/10.1016/j.ttbdis.2010.10.007  PMID: 21771531 
  9. European Commision. Commission implementing decision of 8 August 2012 amending Decision 2002/253/EC laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council. Off J Eur Union 2012;55(L 262):1–57. http://dx.doi.org/ https://doi.org/10.3000/19770677.L_2012.262.eng 
  10. Grgič-Vitek M, Klavs I. High burden of tick-borne encephalitis in Slovenia--challenge for vaccination policy. Vaccine. 2011;29(32):5178-83.  https://doi.org/10.1016/j.vaccine.2011.05.033  PMID: 21620916 
  11. Vaccines against tick-borne encephalitis: WHO position paper. Wkly Epidemiol Rec. 2011;86(24):241-56. PMID: 21661276 
  12. Heinz FX, Holzmann H, Essl A, Kundi M. Field effectiveness of vaccination against tick-borne encephalitis. Vaccine. 2007;25(43):7559-67.  https://doi.org/10.1016/j.vaccine.2007.08.024  PMID: 17869389 
  13. Kunz C. TBE vaccination and the Austrian experience. Vaccine. 2003;21(Suppl 1):S50-5.  https://doi.org/10.1016/S0264-410X(02)00813-7  PMID: 12628814 
  14. Grgic-Vitek M, Klavs I. Low coverage and predictors of vaccination uptake against tick-borne encephalitis in Slovenia. Eur J Public Health. 2012;22(2):182-6.  https://doi.org/10.1093/eurpub/ckr018  PMID: 21398380 
  15. Košnik IG, Lah AK. A campaign to increase the vaccination rate in a highly endemic tick-borne encephalitis region of Slovenia. Vaccine. 2013;31(5):732-4.  https://doi.org/10.1016/j.vaccine.2012.12.005  PMID: 23246549 
  16. Rapola S. National immunization program in Finland. Int J Circumpolar Health. 2007;66(5):382-9.  https://doi.org/10.3402/ijch.v66i5.18310  PMID: 18274204 
  17. Lucenko I, Jansone I, Velicko I, Pujate E. Tickborne encephalitis in Latvia. Euro Surveill. 2004;8(26):2495.
  18. Mangen M-JJ, Plass D, Havelaar AH, Gibbons CL, Cassini A, Mühlberger N, et al. The pathogen- and incidence-based DALY approach: an appropriate [corrected] methodology for estimating the burden of infectious diseases. PLoS One. 2013;8(11):e79740.  https://doi.org/10.1371/journal.pone.0079740  PMID: 24278167 
  19. Kretzschmar M, Mangen M-JJ, Pinheiro P, Jahn B, Fèvre EM, Longhi S, et al. New methodology for estimating the burden of infectious diseases in Europe. PLoS Med. 2012;9(4):e1001205.  https://doi.org/10.1371/journal.pmed.1001205  PMID: 22529750 
  20. Colzani E, Cassini A, Lewandowski D, Mangen MJ, Plass D, McDonald SA, et al. A Software Tool for Estimation of Burden of Infectious Diseases in Europe Using Incidence-Based Disability Adjusted Life Years. PLoS One. 2017;12(1):e0170662.  https://doi.org/10.1371/journal.pone.0170662  PMID: 28107447 
  21. Murray CJ. Quantifying the burden of disease: the technical basis for disability-adjusted life years. Bull World Health Organ. 1994;72(3):429-45. PMID: 8062401 
  22. Murray CJL, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010: design, definitions, and metrics. Lancet. 2012;380(9859):2063-6.  https://doi.org/10.1016/S0140-6736(12)61899-6  PMID: 23245602 
  23. Haagsma JA, Maertens de Noordhout C, Polinder S, Vos T, Havelaar AH, Cassini A, et al. Assessing disability weights based on the responses of 30,660 people from four European countries. Popul Health Metr. 2015;13(1):10.  https://doi.org/10.1186/s12963-015-0042-4  PMID: 26778920 
  24. Salomon JA, Haagsma JA, Davis A, de Noordhout CM, Polinder S, Havelaar AH, et al. Disability weights for the Global Burden of Disease 2013 study. Lancet Glob Health. 2015;3(11):e712-23.  https://doi.org/10.1016/S2214-109X(15)00069-8 
  25. European Centre for Disease Prevention and Control (ECDC). Burden of communicable diseases in Europe Toolkit. Application to calculate DALYs. Version 1.1. Stockholm: ECDC; 2015. Available from: http://ecdc.europa.eu/en/healthtopics/burden_of_communicable_diseases/Pages/Tool.aspx
  26. Vose D. Risk Analysis: A Quantitative Guide. 2nd ed. Chichester: John Wiley and Sons, Ltd; 2001.
  27. Eurostat database. Brussels: European Commission. [Accessed 1 Sep 2015]. Available from: http://ec.europa.eu/eurostat/data/database
  28. Stefanoff P, Polkowska A, Giambi C, Levy-Bruhl D, O’Flanagan D, Dematte L, et al. Reliable surveillance of tick-borne encephalitis in European countries is necessary to improve the quality of vaccine recommendations. Vaccine. 2011;29(6):1283-8.  https://doi.org/10.1016/j.vaccine.2010.11.077  PMID: 21145914 
  29. Colzani E. Results from the 2015 Burden of Communicable Diseases in Europe (BCoDE) study. Milan: European Public Health Conference, 14-18 October; 2015.
  30. Cassini A, Plachouras D, Eckmanns T, Abu Sin M, Blank HP, Ducomble T, et al. Burden of Six Healthcare-Associated Infections on European Population Health: Estimating Incidence-Based Disability-Adjusted Life Years through a Population Prevalence-Based Modelling Study. PLoS Med. 2016;13(10):e1002150.  https://doi.org/10.1371/journal.pone.0144988  PMID: 26672751 
  31. National Institute of Public Health (NIJZ). Epidemiološko spremljanje nalezljivih bolezni v sloveniji v letu 2013. [Epidemiological surveillance of communicable disease in Slovenia in 2013]. Ljubljana: NIJZ; 2014. Slovenian. Available from: http://www.nijz.si/sites/www.nijz.si/files/publikacije-datoteke/epidemilosko_spremljanje_nalezljivih_bolezni_2013.pdf
  32. Šmit R, Postma MJ. The Burden of Tick-Borne Encephalitis in Disability-Adjusted Life Years (DALYs) for Slovenia. PLoS One. 2015;10(12):e0144988.  https://doi.org/10.1371/journal.pone.0144988  PMID: 26672751 
  33. Askling HH, Insulander M, Hergens M-P, Leval A. Tick borne encephalitis (TBE)-vaccination coverage and analysis of variables associated with vaccination, Sweden. Vaccine. 2015;33(38):4962-8.  https://doi.org/10.1016/j.vaccine.2015.07.030  PMID: 26207593 
  34. Slunge D. The Willingness to Pay for Vaccination against Tick-Borne Encephalitis and Implications for Public Health Policy: Evidence from Sweden. PLoS One. 2015;10(12):e0143875.  https://doi.org/10.1371/journal.pone.0143875  PMID: 26641491 
  35. Loew-Baselli A, Poellabauer EM, Pavlova BG, Fritsch S, Firth C, Petermann R, et al. Prevention of tick-borne encephalitis by FSME-IMMUN vaccines: review of a clinical development programme. Vaccine. 2011;29(43):7307-19.  https://doi.org/10.1016/j.vaccine.2011.07.089  PMID: 21843576 
  36. Beran J, Xie F, Zent O. Five year follow-up after a first booster vaccination against tick-borne encephalitis following different primary vaccination schedules demonstrates long-term antibody persistence and safety. Vaccine. 2014;32(34):4275-80.  https://doi.org/10.1016/j.vaccine.2014.06.028  PMID: 24950352 
  37. Cizman M, Rakar R, Zakotnik B, Pokorn M, Arnez M. Severe forms of tick-borne encephalitis in children. Wien Klin Wochenschr. 1999;111(12):484-7. PMID: 10420507 
  38. Fröding I, Hjertqvist M. [Severe TBE with sequelae can also affect young children. Vaccination advice to children should be individualized, degree of exposure essential]. Lakartidningen. 2013;110(42):1861-4. PMID: 24294655 
  39. Sundin M, Hansson MEA, Engman M-L, Orvell C, Lindquist L, Wide K, et al. Pediatric tick-borne infections of the central nervous system in an endemic region of Sweden: a prospective evaluation of clinical manifestations. Eur J Pediatr. 2012;171(2):347-52.  https://doi.org/10.1007/s00431-011-1542-2  PMID: 21842178 
  40. Schmolck H, Maritz E, Kletzin I, Korinthenberg R. Neurologic, neuropsychologic, and electroencephalographic findings after European tick-borne encephalitis in children. J Child Neurol. 2005;20(6):500-8.  https://doi.org/10.1177/088307380502000606  PMID: 15996399 
  41. Engman M-L, Lindström K, Sallamba M, Hertz C, Sundberg B, Hansson MEA, et al. One-year follow-up of tick-borne central nervous system infections in childhood. Pediatr Infect Dis J. 2012;31(6):570-4.  https://doi.org/10.1097/INF.0b013e31824f23c0  PMID: 22333696 
  42. Hansson MEA, Orvell C, Engman M-L, Wide K, Lindquist L, Lidefelt K-J, et al. Tick-borne encephalitis in childhood: rare or missed? Pediatr Infect Dis J. 2011;30(4):355-7.  https://doi.org/10.1097/INF.0b013e3181fe3b5a  PMID: 21412206 
  43. Lidefelt K-J, Lindquist L, Engman M-L, Sundin M. [TBE (tick-borne encephalitis) in childhood--is it dangerous?]. Lakartidningen. 2013;110(9-10):452-3. PMID: 23540023 
  44. Leistner C, Dahlem P. Tick-borne meningoencephalitis in a 4.5-month-old infant. Klin Padiatr. 2011;223(4):242-3.  https://doi.org/10.1055/s-0030-1263193  PMID: 20814849 
  45. Fowler Å, Forsman L, Eriksson M, Wickström R. Tick-borne encephalitis carries a high risk of incomplete recovery in children. J Pediatr. 2013;163(2):555-60.  https://doi.org/10.1016/j.jpeds.2013.01.037  PMID: 23452585 
  46. Fritsch P, Gruber-Sedlmayr U, Pansi H, Zöhrer B, Mutz I, Spork D, et al. Tick-borne encephalitis in Styrian children from 1981 to 2005: a retrospective study and a review of the literature. Acta Paediatr. 2008;97(5):535-8.  https://doi.org/10.1111/j.1651-2227.2008.00763.x  PMID: 18394095 
  47. Gibbons CL, Mangen M-JJ, Plass D, Havelaar AH, Brooke RJ, Kramarz P, et al. Measuring underreporting and under-ascertainment in infectious disease datasets: a comparison of methods. BMC Public Health. 2014;14(1):147.  https://doi.org/10.1186/1471-2458-14-147  PMID: 24517715 

Data & Media loading...

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error