Research Article|Articles in Press

Tick-borne encephalitis: Acute clinical manifestations and severity in 581 cases from Germany, 2018–2020

Published:February 14, 2023DOI:


      • Comprehensive description of clinical TBE manifestations and symptom persistence.
      • Evidence against the assumption that TBE is usually mild in children (50% of the pediatric cases were moderate/severe).
      • Uncovering underreporting of CNS symptoms in routine TBE data (>80% vs. ∼50%).
      • Novel factors associated with acute severity: hypertension, monophasic course.
      • Documenting current diagnostic and treatment practices and potential deficits.



      Tick-borne encephalitis (TBE) is a growing public health problem with an average of 361 cases notified annually to Germany’s passive surveillance system since 2001. We aimed to assess clinical manifestations and identify covariates associated with severity.


      We included cases notified 2018–2020 in a prospective cohort study and collected data with telephone interviews, questionnaires to general practitioners, and hospital discharge summaries. Covariates’ causal associations with severity were evaluated with multivariable logistic regression, adjusted for variables identified via directed acyclic graphs.


      Of 1220 eligible cases, 581 (48%) participated. Of these, 97.1% were not (fully) vaccinated. TBE was severe in 20.3% of cases (children: 9.1%, ≥70-year-olds: 48.6%). Routine surveillance data underreported the proportion of cases with central nervous system involvement (56% vs. 84%). Ninety percent required hospitalization, 13.8% intensive care, and 33.4% rehabilitation. Severity was most notably associated with age (odds ratio (OR): 1.04, 95% confidence interval (CI): 1.02–1.05), hypertension (OR: 2.27, 95%CI: 1.37–3.75), and monophasic disease course (OR: 1.67, 95%CI: 1.08–2.58).


      We observed substantial TBE burden and health service utilization, suggesting that awareness of TBE severity and vaccine preventability should be increased. Knowledge of severity-associated factors may help inform patients’ decision to get vaccinated.


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