Sep 01, 2023

Retrospective study of the epidemiological risk and serological diagnosis of human babesiosis in Asturias, Northwestern Spain

Parasites & Vectors volume 16, Article number: 195 (2023) Cite this article

1 Altmetric

Metrics details

Babesiosis is a globally growing tick-borne disease in humans. Severe babesiosis caused by Babesia divergens has been reported in two patients from Asturias (Northwestern Spain), suggesting an undetected risk for the disease. To analyze this risk, we retrospectively evaluated the seroprevalence of babesiosis in the Asturian population from 2015 through 2017, a period covering the intermediate years in which these two severe cases occurred.

Indirect fluorescent assay (IFA) and Western blot (WB) were performed to detect B. divergens IgG antibodies in 120 serum samples from Asturian patients infected with the tick-transmitted spirochete Borrelia burgdorferi sensu lato, a condition that indicates exposure to tick bites.

This retrospective study confirmed a B. divergens seroprevalence rate of 39.2% according to IFA results. B. divergens incidence was 7.14 cases/100,000 population, exceeding previously reported seroprevalence rates. No differences in epidemiology and risk factors were found between patients infected solely with B. burgdorferi s.l. and those infected with B. burgdorferi s.l. and with IgG antibodies against B. divergens. This last group of patients lived in Central Asturias, had a milder clinical course and, according to WB results, developed different humoral responses against B. divergens.

Babesia divergens parasites have circulated for several years in Asturias. Epidemiological evidence of babesiosis makes Asturias an emerging risk area for this zoonosis. Human babesiosis could also be relevant in other Spanish and European regions affected by borreliosis. Hence, the potential risk of babesiosis on human health in Asturias and other European forest regions needs to be addressed by the health authorities.

Babesiosis is an emerging tick-borne disease caused by apicomplexan parasites of the genus Babesia [1].

Babesia divergens is the primary agent responsible for babesiosis in humans and cattle in Europe [2, 3]. This intraerythrocytic parasite is transmitted primarily by Ixodes ricinus ticks and also has the characteristics necessary to be transmitted by blood transfusion [4, 5].

Symptomatic infection caused by B. divergens is relatively rare in humans. When occurring, it causes fever, anemia, jaundice, hemoglobinuria and renal failure. Sometimes it progresses to a fulminant disease with high mortality, mainly in immunocompromised and elderly patients, especially in those with asplenia [2].

In contrast to the low incidence of full-blown clinical babesiosis in Europe, the number of persons with Babesia antibodies that are asymptomatic or paucisymptomatic is significant. Babesia IgG prevalence ranges from 2% to 39.7% in different populations [6,7,8,9,10], suggesting that most of the Babesia infections remain undetected and may be more frequent than suspected [2, 11, 12]. These undetected infections could also represent a potential risk for blood donation safety in European regions with evidence of human babesiosis [2, 4, 5, 9, 13].

Human babesiosis is considered very uncommon in Spain, but recent works have demonstrated that its incidence in hospitalized patients has increased from 1997 through 2019 (0.28 cases per 10,000,000 population-year). In addition, it entails an elevated hospital cost per patient (6445.71 euros) and an associated mortality rate of around 6.9% (2 deaths/29 total cases of babesiosis, although both dead patients had significant comorbidities) [14, 15].

Asturias, which is located along the North Atlantic coast in Northwestern Spain, is the region where challenging human babesiosis cases have occurred in recent years [16, 17]. Asturias has a total area of 10,603.57 km2 divided into 78 councils. It is one of the largest forest areas in Spain and constitutes the perfect environment for tick-borne diseases, including endemic Lyme disease caused by Borrelia burgdorferi sensu lato and human babesiosis, whose incidence among hospitalized patients was 0.41 cases per 10,000,000 population-year from 1997 through 2019 [14, 18,19,20,21].

One of the human babesiosis cases reported in Asturias was an exceptionally severe infection caused by B. divergens in a immunocompetent, healthy, 46-year-old forest ranger [16], whose clinical manifestations did not match the "classic description" of European babesiosis [1]. This case and two other cases of young (35 and 37 years old), immunocompetent individuals with normal spleen sizes from France [22] suggest that they had an unknown susceptibility to this infection. Another severe case corresponded to an 87-year-old immunocompromised Asturian woman with intact spleen who died of babesiosis [17].

These two Asturian cases raised concerns that underlying human babesiosis might be occurring in Asturias. Therefore, we retrospectively evaluated the seroprevalence of human babesiosis in 74 Asturian councils from 2015 through 2017, a period covering the intermediate years in which these severe human babesiosis cases occurred.

Since Ixodes ricinus is the tick species that transmits babesiosis and Lyme disease, we examined serum samples from patients that were positive for B. burgdorferi s.l. IgG, a condition that indicates previous exposure to tick bites [8]. Next, we analyzed and compared the epidemiological and serological factors among patients infected solely with B. burgdorferi s.l. and those who also had serological evidence of B. divergens infection and discussed the epidemiological importance of human babesiosis in Asturias.

This study included 120 B. burgdorferi s.l. IgG-positive patients who resided, from 2015 through 2017, in 74 out of 78 councils of Asturias (Northwestern Spain). Patients from four Asturias coastal councils were excluded from the study because their Borrelia serology tests were done in their reference hospitals, different from the Hospital Universitario Central de Asturias (HUCA), Oviedo.

According to the Spanish National Statistical Office (, the 74 councils, which occupy a surface area of 9997 km2, were inhabited by 658,186 residents in 2017. The population density of these councils was 65.84 inhabitants/km2 and represented 66.3% of the total population and 94.3% of the total Asturian territory.

The patients in this study were admitted to or were externally followed at the Infectious Diseases, Neurology, Rheumatology or Dermatology Services of the HUCA or its regional affiliated hospitals.

Patients’ serum samples were collected, tested for Lyme disease and kept at – 80 °C at the Microbiology Service of the HUCA. Detection of B. burgdorferi s.l. IgG antibodies was done by using an automated qualitative test (Vidas, BioMerieux, Madrid, Spain). Results were confirmed by immunoblot (Borrelia IgG IgM EcoLine, Sekisui Diagnostics, Rüsselsheim, Germany) [21]. This study also included three positive serum controls as follows: from the Asturian elderly patient who died of B. divergens babesiosis [17], from a Spanish patient from outside Asturias co-infected with HIV and Babesia divergens, who suffered a severe babesiosis that was diagnosed by our group, and from a Finnish patient doubly infected with B. burgdorferi s.l. and B. divergens who died of babesiosis [23, 24]. A human sera pool positive for B. microti, a sera pool positive for malaria and a human sera pool negative for different infectious diseases, including toxoplasmosis, malaria and babesiosis, that have been tested in previous studies [16, 17, 23, 25, 26], were used as negative controls. To detect B. divergens IgG antibodies in the samples seropositive for B. burgdorferi s.l., we used our in-house indirect fluorescent assay (IFA) [16, 17, 23] with slight modifications. We developed a novel Western blot (WB) by using B. divergens (Rouen 87 strain) protein extracts as targets to evaluate the humoral antibody response in the patients infected with B. divergens. We also utilized our previous WB based on the use of a major surface protein of B. divergens (Bd37) as a target [23, 27] with slight modifications.

To carry out our in-house IFA, 1 × 107 cells/ml from B. divergens (Rouen 87 strain) infected human erythrocyte cultures (25%–30% parasitemia) [28, 29], were pipetted onto 16-wells slides (10 μl of culture per well) (Thermo Scientific, Portsmouth, NH, USA) and incubated at 37 °C for 30 min. Then, the slides were fixed in cold 50% acetone–50% methanol, washed three times in phosphate-buffered saline (PBS) and incubated at 37 °C for 1 h with B. burgdorferi s.l. seropositive samples and controls. All serum samples and controls were tested in triplicate. According to World Health Organization (WHO) guidelines, the cut-off titers used for discrimination between seronegative and seropositive reactions by IFA were set at 1:128 for B. divergens [6]. Bound antibody was detected by using fluorescein isothiocyanate-conjugated anti-human IgG diluted 1:200 in PBS (Invitrogen, Eugene, OR, USA). The preparations were counterstained with 5 μl (2.5 μg/ml in PBS) of DAPI (Pierce, Rockford, IL, USA) per well and examined by fluorescence microscopy (Leica DH 2000 LED, Wetzlar, Germany).

Babesia divergens (Rouen 87 strain)-infected and non-infected human erythrocytes from in vitro cultures (30%–40% parasitemia) [28, 29] were solubilized into three volumes of saponin buffer (0.15% of saponin in PBS) and incubated at 37 °C for 20 min. Then, samples were washed by centrifugation with PBS. Pellets were resuspended in PBS with a protease inhibitor mixture (Sigma-Aldrich, St. Louis, MO, USA) and 2 × Laemmli sample buffer (National Diagnostics, Atlanta, GA, USA) before electrophoresis. To produce the Bd37 recombinant protein (GST-rBd37), B. divergens DNA encoding Asn28 to Phe341 of Bd37 [27] was amplified by PCR and cloned into the expression plasmid vector pGEX-4T1 (GE Healthcare, Uppsala, Sweden) according to the manufacturer's instructions. Escherichia coli strain BL21-gold (DE3) plysS (Agilent Technologies, Santa Clara, CA, USA) was transformed with the Bd37 expression plasmid. Then, super optimal broth (SOB) medium (250 ml) containing 100 μg/ml ampicillin (Sigma-Aldrich) was inoculated with 1 ml of fresh overnight transformed E. coli strain BL21-gold cultured and grown at 37 °C to A600 = 0.6 before induction with 0.5 mM isopropyl-β-d-thiogalactopyranoside (IPTG), (Sigma-Aldrich). After 3 h of induction to produce the GST-rBd37, cells were pelleted and resuspended in B-PER bacterial protein extraction reagent (Thermo Scientific) supplemented with a protease inhibitor mixture (Sigma-Aldrich) for 10 min. Then, the insoluble material was removed by centrifugation, and the soluble fraction was used to purify the GST-rBd37 by using glutathione-Sepharose 4B (GE Healthcare) as described by the manufacturer. The glutathione-S-transferase (GST) fusion partner (26 kDa) for Bd37 was also produced and purified following the same procedure.

Babesia divergens protein extracts and the GST-rBd37 were used as target substrates for WB. Non-parasitized human erythrocytes protein extracts and GST recombinant protein were also used as controls. Thirty μg of protein extracts and 150 ng of recombinant GST-rBd37 and GST proteins were loaded per well on 12.5% SDS-PAGE gel and transferred to Amersham Protran nitrocellulose membranes (GE Healthcare) at 80 mA for 1 h at room temperature. Membranes were blocked in a blocking solution made of PBS with 0.05% Tween-20 (PBS-T) and 3% (w/v) bovine serum albumin (Sigma-Aldrich) and incubated for 1 h at room temperature with patients’ serum samples and controls diluted 1:128 in the blocking solution. Then, membranes were treated with horseradish peroxidase-conjugated anti-human IgG (1:10,000 dilution) (Thermo Scientific) for 1 h at room temperature and washed with washing buffer (PBS + 0.05% Tween-20). Antigen detection was assessed by a colorimetric reaction (CN-DAB Substrate kit, Thermo Scientific).

Diverse epidemiological and risk factors were evaluated and compared in patients infected with B. burgdorferi s.l. and with IgG antibodies against B. divergens versus those infected only with B. burgdorferi s.l. The non-parametric Mann-Whitney U test was used to assess the differences in age, whereas the Chi-square test and Fisher's exact text, when appropriate, were used to compare proportions between the two study groups. Borrelia burgdorferi s.l.-B. divergens incidences during the study period were calculated for each council where B. divergens IgG antibodies were detected as well as for the 74 councils included in the study as a whole. The SPSS software v. 25 (IBM Corp., Armonk, NY, USA) was used for statistical calculations. The limit for statistical significance was established at the < 0.05 level for a two-sided test.

Babesia divergens IgG antibodies were detected by IFA in 39.2% (47/120) of the serum samples from patients infected with B. burgdorferi s.l. Similar result was observed by WB using B. divergens protein extracts, given that 40 serum samples of the total were positive by this technique (33.3%). Serum samples identified different Babesia divergens protein profiles ranging in size from 25 to 75 kDa. The most frequent IgG antibody response was against a ≈37-kDa protein that was recognized by 47.5% (n = 19) of the serum samples, followed by two larger proteins ranging between ≈48 and 63 kDa that were recognized by 45% (n = 18) of them (Table 1; Fig. 1).

Serological detection of specific anti-B. divergens IgG antibodies by Western blot (WB). Panel a: WB was prepared by using B. divergens (Rouen 87) and non-infected human erythrocyte protein extracts. Blots were incubated with sera of patients infected with B. burgdorferi s.l. and positive and negative controls. Lanes 1–40: different B. divergens proteins, ranging from 25 to 75 kDa, that were identified from serum patient samples. Protein bands differed in number, frequency, size and intensity between patients. Lanes 41–47: some of the serum samples from patients infected with B. burgdorferi s.l. that did not recognize B. divergens proteins. Lanes 48–53 and lines C1+, C2+ and C3+: Some of the serum samples and positive controls that did not recognize erythrocyte proteins. Serum samples that reacted against a native B. divergens protein with ~ 37 kDa (*). Serum samples that reacted against native B. divergens proteins of ~ 48–63 kDa (+). Panel b: WB was prepared by using the recombinant GST-rBd37 (Rouen 87) protein and the GST fusion partner for Bd37. Specificity from the patients’ sera against recombinant Bd37 from B. divergens was observed by WB. Lanes A and B: GST-rBd37 (59.5 kDa) and GST (26 kDa) recombinant proteins, respectively, subjected to SDS-PAGE. The number of the lanes indicates which serum sample from Panel a recognized the GST-rBd37 protein. Positive control 1 (C1+): serum sample from an Asturian patient [23]. Positive control 2 (C2+): serum sample from a non-Asturian Spanish patient co-infected with HIV and B. divergens [25]. Positive control 3 (C3+): serum sample from a Finnish patient doubly infected with B. burgdorferi s.l and B. divergens. Negative control (C−) consisted of a human sera pool negative for different infectious diseases, including toxoplasmosis, malaria and babesiosis. None of the sera reacted with the recombinant GST protein

The B. divergens ≈37 kDa protein could correspond in size with the major surface protein of B. divergens, Bd37, which is also 37 kDa [27]. To assess this hypothesis we used the corresponding recombinant GST-rBd37 protein as a substrate to detect specific Bd37 IgG antibodies in the positive serum samples by WB.

Of the 40 serum samples tested, 12 samples recognized both the ≈37 kDa protein present in parasite protein extracts and also the GST-rBd37 protein. Moreover, three serum samples that did not initially show a ≈37 kDa protein in their protein profile latterly responded against the GST-rBd37 protein (Table 1; Fig. 1). Antibodies against the ≈37 kDa and GST-rBd37 proteins were also present in two of the three positive control sera [17, 23], while the third one, from a patient infected with both B. burgdorferi s.l and B. divergens [24], recognized one of the ≈48–63-kDa proteins (Fig. 1). Cross-reactivity with negative controls or against erythrocyte protein extracts and GST was not observed.

Western blot confirmed 85.1% of the positive serum samples detected by IFA. Moreover, 32% of the serum samples presented specific antibodies against the Bd37 protein.

According to IFA, the incidence of babesiosis in patients who were attended at the HUCA and regional affiliated hospitals during the study period was 7.14 per 100,000 population. There were no significant differences between monoinfected patients with B. burgdorferi s.l. and patients infected with B. burgdorferi s.l. and with B. divergens IgG antibodies in the diverse epidemiological and risk factors studied (Table 2). The median age of the patients with B. burgdorferi s.l. infection and detectable B. divergens antibodies was 56.4 years (IQ range 45.5–71.8). These patients had a mild clinical course, including two patients who had a known immunodepression. Most (82.9%, n = 34) developed tick-bite risky outdoor activities and some had non-professional contact with animals (39.0%, n = 16). However, only nine of these patients worked in agricultural, livestock or fishery sectors (Table 2). All patients infected with B. burgdorferi s.l. and with B. divergens IgG antibodies lived in 22 of the 74 Asturian councils under study. A third of the total population studied resided in Oviedo, an urban council inhabited by 220.300 people where 11 patients had B. divergens IgG antibodies. The rest resided in rural councils surrounded by Nature Reserves.

Of note, 66% of the patients with babesiosis were centripetally grouped in 20 contiguous councils of Central Asturias, a large area that also includes the councils where the two severe human babesiosis cases were reported [16, 17] (Fig. 2).

Geographical distribution of patients who had antibodies against B. divergens. Map shows the location of Asturias in Spain and the Asturian councils where B. divergens infected patients lived from 2015 through 2017. The number of infected patients appears associated to each council. The map also shows the councils where severe (*) and fatal (+) human babesiosis cases occurred in Asturias [16, 17]. The color blocks represent the range of incidence of babesiosis per 100,000 population in each council

From 2015 through 2017, at least 47 Asturian patients had serological evidence of both B. burgdorferi s.l. and B. divergens infections, although our study cannot determine whether both infections were simultaneous or sequential.

The seroprevalence of B. divergens antibodies in our patients infected with B. burgdorferi s.l. (39.2%) was similar to the 33.2% reported in 199 Belgian patients with history of tick bites and tick-borne disease symptoms [7] but higher than the 16.3% seroprevalence rate of B. microti-B. divergens antibodies reported in 86 Swedish individuals infected with B. burgdorferi s.l. [8].

Despite differences in local seroprevalence rates, all reports point out that persons with Babesia-positive antibodies exceed the number of clinically diagnosed human babesiosis cases from these, and even from other European geographical areas [1, 2]. However, as shown in this retrospective study, human babesiosis passes unnoticed by health systems, local blood transfusion services and surveillance plans. A low index of suspicion, asymptomatic babesiosis and confusion with common viral-like illnesses or with Lyme disease could mask babesiosis and might explain discrepancies between high seroprevalence and low clinical incidence.

Indeed, the babesiosis incidence that we observed (7.14 cases per 100,000 population) does not represent the true incidence of the infection. It is expected to be much higher, but it was biased low because we studied B. divergens infection incidence only in those symptomatic patients with Lyme disease who searched for care at the HUCA and HUCA-affiliated secondary hospitals.

Contrarily, it is very unlikely that other undiagnosed symptomatic babesiosis cases were overlooked for several reasons. First, the territory studied represented almost 95% of the total surface of Asturias. This area is sanitarily covered by the HUCA and its affiliated regional hospitals and all serological determinations are centralized in the microbiology laboratory of the HUCA. Second, the HUCA is the tertiary referral hospital of Asturias. Thus, complicated and unusual cases such as those of severe babesiosis are transferred to the HUCA for hospital care.

This study failed to find significant differences in the diverse epidemiological and risk factors analyzed between patients infected with B. burgdorferi s.l. and those infected with B. burgdorferi s.l. who also had B. divergens IgG antibodies. Our work suggests that the epidemiology of babesiosis is equally shared by the two infections. However, the relatively small sample size of this study and its retrospective nature may have overlooked minor differences between the two groups.

At this time, 40 doubly infected patients showed different patterns of antibody response against B. divergens by WB, the recognition of Bd37 present in B. divergens (Rouen 87) protein extracts prevailing, and in the form of recombinant protein (GST-rBd37 Rouen 87). Babesia divergens 48–63-kDa antigens were also dominant.

Notably, not all WB-positive serum samples had specific antibodies against the Bd37 major surface antigen. Discrepancies in the recognition of Bd37 in B. divergens protein extracts, but not of recombinant protein, were also observed in seven patients. The large genetic diversity of the B. divergens strains infecting humans [2], the polymorphism within the Bd37 protein between strains [30] and even the individual humoral immune response of each patient could at least partly explain these discrepancies, especially as only the B. divergens Rouen 87 strain was used for WB.

Interesting, three serum samples that did not recognized Bd37 in B. divergens protein extracts were able to recognize the recombinant GST-rBd37 protein. The quantity, quality and purity of the recombinant GST-rBd37 protein used in the WB compared to Babesia divergens protein extracts may favor the detection of specific IgG antibodies against Bd37, especially when antibody levels in patients’ sera are low.

The WB system was also unable to determine the humoral response in seven of the IFA-positive patients. As discussed above, the genetic diversity of B. divergens strains may explain the negative WB results and suggests that it may be convenient to use different B. divergens strains whenever possible to improve serological results in terms of sensitivity and specificity.

Although B lymphocytes and their production of antibodies are particularly important for the eradication of the babesiosis infection [31], there is still little information about the humoral immune responses elicited in patients with different grades of babesiosis severity.

To our knowledge, the humoral response against B. divergens has been analyzed in few patients. The chronological humoral response of two patients consisted in a constant response against a 36-kDa antigen from the first days post-hospitalization onwards and progressive response against other antigens, including a protein of 37 kDa, in the following days to months after the B. divergens diagnosis [28]. Babesia divergens proteins of 33 and 37 kDa were also detected by WB using serum samples from two breeders with a history of tick bite [32]. A study on the humoral response to B. divergens also revealed B. divergens IgG antibodies against the recombinant Bd37 protein in the serum of our HIV-infected patient [23].

However, it is still unclear whether these specific antibody repertories are similar or different among patients and whether they could modulate the efficacy of the humoral protective immune response and the disease outcome in patients monoinfected with B. divergens and in those concomitantly or serially infected with B. burgdorferi s.l.

As for infections caused by other Babesia species [33, 34], additional studies are needed to evaluate the humoral immune response during mono- and double infections with B. divergens and B. burgdorferi s.l. and to identify antigens that elicit the production of protective antibodies or to determine whether a supposedly healthy blood donor has an asymptomatic infection or a patient has an acute, chronic or past babesiosis.

Limitations of this study include those related to retrospective studies, including the gathering of data from old medical records. To our knowledge, the sample size of our study was the largest published so far for B. burgdorferi s.l. and B. divergens double infections. However, it may not have been large enough to detect subtle statistical differences between the two comparison groups resulting in a type II error. Also, the true incidence of the infection was surely underestimated in our study because not all babesiosis asymptomatic or paucisymptomatic persons do seek medical care. However, the centralization of the serological studies in a single laboratory ensures that no patient in which these infections were suspected was overlooked.

Similar scenarios could be occurring in other areas of Spain [14] and in other European regions that are also affected by human babesiosis [2] and where seroprevalence studies would be desirable.

This study evaluated the seroprevalence, epidemiology and risk factors of human babesiosis in patients seropositive for Lyme disease and determined the location of B. divergens in a specific period in Asturias.

The high babesiosis seroprevalence detected in patients infected with B. burgdorferi s.l. reveals that B. divergens could have circulated for several years in Asturias and may pose a threat to human health.

No differences were observed among the diverse epidemiological and risk factors analyzed between patients monoinfected with B. burgdorferi s.l. and those who also had serological evidence of infection with B. divergens.

However, patients showed different antibody response patterns against B. divergens. This result could be relevant to the host defense and lays the bases for future studies directed towards characterizing the individual humoral response against specific B. divergens antigens.

Since Asturias meets the natural conditions for the transmission of Babesia, the appearance of new babesiosis cases ranging from asymptomatic to severe infections are expected in the coming years. Moreover, there is clear evidence that the Asturian population has been exposed to B. divergens, which could entail some risks for the community health and for transfusion-transmitted babesiosis.

This local epidemiological evidence of babesiosis makes Asturias an emerging risk area for this zoonosis. Human babesiosis could also be relevant in other Spanish and European regions. Therefore, health surveillance plans might be desirable to evaluate tick-borne diseases seroprevalence, early diagnosis and blood screening and to develop control strategies in the future.

All data generated or analyzed during this study are included in this published article.

Major surface protein of B. divergens



Chi-square test

Degrees of freedom


Bd37 recombinant protein

Human immunodeficiency virus


Hospital Universitario Central de Asturias

Indirect fluorescent assay

Immunoglobulin G



Square kilometer




Phosphate-buffered saline

PBS with 0.05% Tween-20

Super optimal broth

Sodium dodecyl sulfate-polyacrylamide gel electrophoresis

Mann–Whitney U test

Western blot

World Health Organization

Kumar A, O’Bryan J, Krause PJ. The global emergence of human babesiosis. Pathogens. 2021;10:1447.

Article CAS PubMed PubMed Central Google Scholar

Hildebrandt A, Zintl A, Montero E, Hunfeld K-P, Gray J. Human babesiosis in Europe. Pathogens. 2021;10:1165.

Article PubMed PubMed Central Google Scholar

Zintl A, Mulcahy G, Skerrett HE, Taylor SM, Gray JS. Babesia divergens, a bovine blood parasite of veterinary and zoonotic importance. Clin Microbiol Rev. 2003;16:622–36.

Article PubMed PubMed Central Google Scholar

Castro E, González LM, Rubio JM, Ramiro R, Gironés N, Montero E. The efficacy of the ultraviolet C pathogen inactivation system in the reduction of Babesia divergens in pooled buffy coat platelets: UVC Inactivation of B. divergens in PLTs. Transfusion (Paris). 2014;54:2207–16.

Cursino-Santos JR, Alhassan A, Singh M, Lobo CA. Babesia : impact of cold storage on the survival and the viability of parasites in blood bags: Viability of Babesia after refrigeration. Transfusion (Paris). 2014;54:585–91.

Article Google Scholar

Hunfeld K-P, Lambert A, Kampen H, Albert S, Epe C, Brade V, et al. Seroprevalence of Babesia infections in humans exposed to ticks in midwestern Germany. J Clin Microbiol. 2002;40:2431–6.

Article PubMed PubMed Central Google Scholar

Lempereur L, Shiels B, Heyman P, Moreau E, Saegerman C, Losson B, et al. A retrospective serological survey on human babesiosis in Belgium. Clin Microbiol Infect. 2015;21:96.e1-96.e7.

Article CAS PubMed Google Scholar

Svensson J, Hunfeld K-P, Persson KEM. High seroprevalence of Babesia antibodies among Borrelia burgdorferi-infected humans in Sweden. Ticks Tick-Borne Dis. 2019;10:186–90.

Article PubMed Google Scholar

Sonnleitner ST, Fritz J, Bednarska M, Baumgartner R, Simeoni J, Zelger R, et al. Risk assessment of transfusion-associated babesiosis in Tyrol: appraisal by seroepidemiology and polymerase chain reaction. Transfusion (Paris). 2014;54:1725–32.

Article Google Scholar

Rigaud E, Jaulhac B, Garcia-Bonnet N, Hunfeld KP. Féménia F, Huet D,et al. Seroprevalence of Babesia divergens infection among forestry workers in Slovenia. Int J Med Microbiol. 2008;298:347–50.

Meredith S, Oakley M, Kumar S. Technologies for detection of Babesia microti: advances and challenges. Pathog Basel Switz. 2021;10.

Tomassone L, Berriatua E, De Sousa R, Duscher GG, Mihalca AD, Silaghi C, et al. Neglected vector-borne zoonoses in Europe: into the wild. Vet Parasitol. 2018;251:17–26.

Article PubMed Google Scholar

Hildebrandt A, Hunfeld K-P, Baier M, Krumbholz A, Sachse S, Lorenzen T, et al. First confirmed autochthonous case of human Babesia microti infection in Europe. Eur J Clin Microbiol Infect Dis. 2007;26:595–601.

Article CAS PubMed Google Scholar

Almeida H, López-Bernús A, Rodríguez-Alonso B, Alonso-Sardón M, Romero-Alegría Á, Velasco-Tirado V, et al. Is babesiosis a rare zoonosis in Spain? Its impact on the Spanish Health System over 23 years. PloS One. 2023;18:e0280154.

Guerrero Espejo A, Muñoz Parada C, Tomás DS. Incidencia de la babesiosis humana en España basada en los diagnósticos al alta hospitalaria. Med Clín. 2017;149:84–5.

Article Google Scholar

Gonzalez LM, Rojo S, Gonzalez-Camacho F, Luque D, Lobo CA, Montero E. Severe babesiosis in immunocompetent man, Spain, 2011. Emerg Infect Dis. 2014;20:724–6.

Article PubMed PubMed Central Google Scholar

Asensi V, González LM, Fernández-Suárez J, Sevilla E, Navascués RÁ, Suárez ML, et al. A fatal case of Babesia divergens infection in Northwestern Spain. Ticks Tick-Borne Dis. 2018;9:730–4.

Article PubMed Google Scholar

Asensi JM, Martínez AM, Guerrero A, Asensi V, Escudero R, de la Iglesia P, et al. Epidemiologic study of Lyme disease in Asturias. Enferm Infecc Microbiol Clin. 1993;11:420–3.

CAS PubMed Google Scholar

Espí A, Del Cerro A, Somoano A, García V, M. Prieto J, Barandika JF, et al. Borrelia burgdorferi sensu lato prevalence and diversity in ticks and small mammals in a Lyme borreliosis endemic Nature Reserve in North-Western Spain. Incidence in surrounding human populations. Enfermedades Infecc Microbiol Clín. 2017;35:5638.

Espí A, del Cerro A, Oleaga Á, Rodríguez-Pérez M, López CM, Hurtado A, et al. One health approach: an overview of Q fever in livestock, wildlife and humans in Asturias (Northwestern Spain). Animals. 2021;11:1395.

Article PubMed PubMed Central Google Scholar

Barreiro-Hurlé L, Melón-García S, Seco-Bernal C, Muñoz-Turrillas C, Rodríguez-Pérez M. Seroprevalence of Lyme disease in southwest Asturias. Enfermedades Infecc Microbiol Clin Engl Ed. 2020;38:155–8.

Article Google Scholar

Martinot M, Zadeh MM, Hansmann Y, Grawey I, Christmann D, Aguillon S, et al. Babesiosis in immunocompetent patients. Europe Emerg Infect Dis. 2011;17:114–6.

Article PubMed Google Scholar

González LM, Castro E, Lobo CA, Richart A, Ramiro R, González-Camacho F, et al. First report of Babesia divergens infection in an HIV patient. Int J Infect Dis. 2015;33:202–4.

Article PubMed Google Scholar

Haapasalo K, Suomalainen P, Sukura A, Siikamäki H, Jokiranta TS. Fatal babesiosis in man, Finland, 2004. Emerg Infect Dis. 2010;16:1116–8.

Arsuaga M, González LM, Padial ES, Dinkessa AW, Sevilla E, Trigo E, et al. Misdiagnosis of babesiosis as malaria, Equatorial Guinea, 2014. Emerg Infect Dis. 2018;24:1588–9.

Article PubMed PubMed Central Google Scholar

Arsuaga M, Gonzalez LM, Lobo CA, de la Calle F, Bautista JM, Azcárate IG, et al. First report of Babesia microti -caused babesiosis in Spain. Vector-Borne Zoonotic Dis. 2016;16:677–9.

Article PubMed PubMed Central Google Scholar

Delbecq S, Precigout E, Vallet A, Carcy B, Schetters TPM, Gorenflot A. Babesia divergens: cloning and biochemical characterization of Bd37. Parasitology. 2002;125:305–12.

Article CAS PubMed Google Scholar

Gorenflot A, Brasseur P, Precigout E, L’Hostis M, Marchand A, Schrevel J. Cytological and immunological responses to Babesia divergens in different hosts: Ox, gerbil, man. Parasitol Res. 1991;77:3–12.

Article CAS PubMed Google Scholar

del Carmen TM, González-Camacho F, González LM, Luque D, Montero E. Ultrastructure of the Babesia divergens free merozoite. Ticks Tick-Borne Dis. 2016;7:1274–9.

Article Google Scholar

Hadj-Kaddour K, Carcy B, Vallet A, Randazzo S, Delbecq S, Kleuskens J, et al. Recombinant protein Bd37 protected gerbils against heterologous challenges with isolates of Babesia divergens polymorphic for the bd37 gene. Parasitology. 2007;134:187–96.

Article CAS PubMed Google Scholar

Waked R, Krause PJ. Human babesiosis. Infect Dis Clin North Am. 2022;36:655–70.

Article PubMed Google Scholar

Gabrielli S, Galuppi R, Marcer F, Marini C, Tampieri M.P, Moretti A, et al. Development of culture-based serological assays to diagnose Babesia divergens infections. Vector Borne Zoonotic Dis. 2012;12:106.

Bastos RG, Laughery JM, Ozubek S, Alzan HF, Taus NS, Ueti MW, et al. Identification of novel immune correlates of protection against acute bovine babesiosis by superinfecting cattle with in vitro culture attenuated and virulent Babesia bovis strains. Front Immunol. 2022;13.

Djokic V, Akoolo L, Primus S, Schlachter S, Kelly K, Bhanot P, et al. Protozoan parasite Babesia microti subverts adaptive immunity and enhances Lyme disease severity. Front Microbiol [Internet]. 2019;10.

Download references

We thank the Centro de Transfusiones de la Comunidad de Madrid, which provided the human A+ blood from healthy volunteer donors. We also gratefully acknowledge Dr. Daniel Luque for formatting figures.

Funding was provided by a grant (PI20CIII-00037 to E.M. and L.G.M.) from the Health Institute Carlos III, Spain.

Parasitology Reference and Research Laboratory, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, 28220, Madrid, Spain

Estrella Montero, Belén Revuelta & Luis Miguel Gonzalez

Infectious Diseases Unit, Hospital Universitario Central de Asturias, Oviedo University School of Medicine, Oviedo, Spain

María Folgueras

Microbiology Service, Hospital Universitario Central de Asturias, Oviedo University School of Medicine, Oviedo, Spain

Mercedes Rodriguez-Pérez

Researcher, Group of Translational Research in Infectious Diseases, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain

Laura Pérez-ls & Javier Díaz-Arias

Internal Medicine, Hospital Alvarez-Buylla, Mieres, Asturias, Spain

Maria Meana

Department of Bacteriology and Immunology, Medicum, University of Helsinki, 00014, Helsinki, Finland

Karita Haapasalo

Infectious Diseases Unit, Hospital de Galdácano, Vizcaya, Spain

Julio Collazos

Infectious Diseases Unit, Hospital Universitario Central de Asturias and Group of Translational Research in Infectious Diseases, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain

Víctor Asensi

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

Conceptualization, E.M., V.A. and L.M.G. Investigation, E.M., M.F., M.R.P.,, J.D.A., M.M., B.R., K.H., J.C., V.A. and L.M.G.; Writing original draft preparation, E.M., J.C., V.A. and L.M.G.; Figures preparation, E.M. and L.M.G.; Writing review and editing, E.M., M.R.P., J.C., V.A. and L.M.G; Funding, L.M.G., E.M. All authors have read and agreed to the published version of the manuscript.

Estrella Montero is a senior research scientist at the National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Spain. Her primary research interest includes molecular, clinical and epidemiological aspects of Babesia and human babesiosis.

Correspondence to Estrella Montero.

This retrospective study was ethically approved by the Research Ethics Committee of Instituto de Salud Carlos III, Madrid, Spain (reference CEI PI 59_2022), which also granted a formal waiver of requiring the consent from patients. Human A+ blood from healthy donors was used to maintain cultures of B. divergens (Rouen 87). The blood and its protocol were approved for use by the Blood Transfusion Center, Madrid, Spain.

The authors declare no competing interests.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

Montero, E., Folgueras, M., Rodriguez-Pérez, M. et al. Retrospective study of the epidemiological risk and serological diagnosis of human babesiosis in Asturias, Northwestern Spain. Parasites Vectors 16, 195 (2023).

Download citation

Received: 20 February 2023

Accepted: 21 May 2023

Published: 09 June 2023


Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative