LYME DISEASE IN MICHIGAN:

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1 Erik Foster AND Veronica Fialkowski LYME DISEASE IN MICHIGAN: what does the future hold?

2 Objectives Attendees will gain knowledge regarding tick ecology and its importance in understanding emerging tick-borne pathogens. Attendees will gain knowledge regarding Lyme disease emergence over time as it relates to a changing environment, human behavior, and improving diagnostics. Attendees will learn about nationally recognized guidelines for the prevention and control of Lyme disease, and how targeted outreach may improve healthcare provider practice.

3 Quick background LYME DISEASE: most common vector-borne disease in the US 1 VECTOR: ticks Ixodes scapularis (AKA blacklegged or deer tick) PAHTOGEN: Borrelia burgdorferi 1. (CDC MMWR, 2013; Steer et al. 2004) Copyright M. Plonsky. All rights reserved.

4 History of Lyme 1976 Several cases of arthritis in children were reported. The Department of Health and the Yale University School of Medicine planned a joint survey to detect additional cases in the area and describe the disease in detail. Douglas S. Lloyd, M.D., M.P.H. Health Commissioner

History of Lyme 1976 51 cases of apparently similar arthritis, characterized by recurrent attacks of pain and swelling in large joints.

5 History of Lyme cases of apparently similar arthritis, characterized by recurrent attacks of pain and swelling in large joints. Others had fever, headaches, weakness and a skin rash as well. One quarter of patients had an unusual skin lesion before the onset of joint symptoms. Image Michigan Department of Health and Human Services.

6 History of Lyme 1976 The seasonal and geographic distribution, and the associated skin lesion suggested a virus associated with a biting insect.

7 History of Lyme 1909 Swedish dermatologist Arvid Afzelius described an expanding, ring-like lesion following the bite of a sheep tick. He named the lesion erythema migrans (EM).

8 History of Lyme 1970 Wisconsin dermatologist, Rudolph Scrimenti, recognized an EM lesion in a patient after recalling description of the rash in European literature. This was the first documented case of EM in the United States.

Biological spirochetes Laboratory, collections in 60% of the of Deer ticks.

9 History of Lyme 1980 While NYS HD examining Epidemiologist the ticks Jorge for Benach Rickettsia, provided Willy noticed Willy poorly Burgdorfer, stained, researcher rather long, at Rocky irregularly Mountain coiled Biological spirochetes Laboratory, collections in 60% of the of Deer ticks. ticks He realized (Ixodes scapularis) that the spirochetes from a known might Lyme-endemic be the long-sought area. cause of EM and Lyme disease.

10 History of Lyme 1980 Coordinating with Alan Barbour of U-Texas, Willy was able to isolate the spirochetes from patients with Lyme disease. The spirochete was named Borrelia burgdorferi in his honor.

11 The one health approach HUMAN ANIMAL ENVIRONMENT

12 Lyme disease biogeography? National maps and statistics available at

13 Lyme disease surveillance trends CDC Estimate 1 : (approx. 10x underreporting) ~329,000 cases annually 1) Nelson CA, Saha S, Kugeler KJ, Delorey MJ, Shankar MB, Hinckley AP, et al. Incidence of clinician-diagnosed Lyme disease, United States, Emerg Infect Dis Aug [Sept.2015].

14 Losing our innocence (it was really just a matter of time)

15 First detection of ticks, pathogen, and cases: Michigan s UP late 80s, early 90s

16 Lyme disease has emerged in Michigan with the expansion of blacklegged tick populations.

17 Michigan Lyme disease risk map: 2015

18 How do we know? MDNR, MSU, & MDHHS Collaborative field surveillance for establishing tick populations and B. burgdorferi infection.

19 How do we know? MDARD & MDHHS Established tick identification and testing program for Michigan residents.

20 ANIMAL HEALTH

Tick basics A tick is related to a spider It must obtain blood from an animal host in order to live, develop, and reproduce Once contacting a host, it

21 Tick basics A tick is related to a spider It must obtain blood from an animal host in order to live, develop, and reproduce Once contacting a host, it will attach and feed for several days, depending on the stage Ticks feed on a variety of animals from small and medium sized mammals, to birds and lizards

22 Image: Erik Foster, MDCH Image: Kent Loeffeler, Cornell University Dermacentor variabilis (American dog tick or wood tick) Most common tick in Michigan Active from early-spring through the end of summer Vector: Rocky Mountain spotted fever, tularemia Ticks in Michigan

23 Image: Erik Foster, MDCH Ixodes scapularis (blacklegged tick) Smaller size than D. variabilis Adults: April July, October November Nymphs: May August Vector: Lyme disease, anaplasmosis, babesiosis, deer tick virus, Ehrlichia muris-like Image: Kent Loeffeler, Cornell University Ticks in Michigan

24 Habitat suitability

26 Lyme disease transmission Lyme disease is maintained in nature through a cycle of infection between Blacklegged ticks and small mammals. Questing Tick Lyme bacteria

27 Lyme disease transmission People come into contact with ticks while working or recreating in wooded areas or areas with shade and vegetation, which is the preferred habitat for Blacklegged ticks.

Prompt removal of ticks is preventative for Lyme disease as studies

28 Lyme disease transmission Ticks will embed their mouthparts in the skin, and may be difficult to detect due to their small size. Prompt removal of ticks is preventative for Lyme disease as studies have shown it takes >36 hours for efficient B. burgdorferi transmission to occur.

Expansion of suburbia into wooded areas Increased exposure

29 Lyme disease re emergence Michigan circa 1890 s Detroit Publishing Company Reforestation Overabundant deer Increased numbers of ticks Expansion of suburbia into wooded areas Increased exposure opportunities Changes in diagnostic, surveillance, and reporting practices

30 HUMAN HEALTH

31 Lyme disease noun Lyme dis-ease \ˌ līm diˌzēz \ an inflammatory disease characterized at first by a rash, headache, fever, and chills, and later by possible arthritis and neurological and cardiac disorders, caused by bacteria that are transmitted by ticks.

32 Clinical Manifestations of Confirmed Lyme Disease Cases--US,

33 70% of infected persons have Erythema migrans (EM) rash Begins at the site of a tick bite after a delay of 3 to 30 days Expands gradually Bull s-eye appearance Photo: CDC/James Gathany

37 Other symptoms after 3 to 30 days after tick bite include: Fever Chills Headache Fatigue Muscle and joint aches Swollen lymph nodes

38 Weeks to months after infection Pain and swelling in the large joints Facial or Bell's palsy Shooting pains that may interfere with sleep Severe headaches and neck stiffness due to meningitis Heart palpitations and dizziness Early disseminated stage

39 If not appropriately treated: intermittent bouts of arthritis, with severe joint pain and swelling chronic neurological complaints: shooting pains numbness or tingling in the hands or feet problems with short-term memory Late disseminated stage

40 Some symptoms may persist even after treatment muscle and joint pains cognitive defects sleep disturbance fatigue called Post-treatment Lyme disease Syndrome

41 Lyme carditis

42 Diagnosis Lyme disease is diagnosed based on: Signs and symptoms A history of possible exposure to infected blacklegged ticks Laboratory blood tests Treated with antibiotics

43 Who is at most risk? ANYONE working or recreating in forested or forest-edge habitats: Man-made trail systems Trails used by animals Campgrounds Brushy or grassy areas near buildings or yards Wooded river banks

45 Case diagnosis peak during the summer months Reported Lyme Disease Cases, Michigan by Region of Exposure: 2014 Western MI Exposure UP MI Exposure Other MI Exposure Out of State Exposure Blacklegged tick activity Nymphs Adults Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Onset month E.Foster, MDHHS: April, 2015

46 No. Cases MI cases have increased over time Unknown Exposure Out-of-State Exposure In-State Exposure Year

47 Representative Rate (Statewide %) Lyme disease by age group, >/=71years years years years years years years 2-10 years </=1 year Age Groups

48 Lyme disease by gender

49 Race & ethnicity of Lyme disease cases White American Indian or Alaka Native Black or African American Asian 84% white Unknown

50 One health stakeholders Local Public Health Vector Control Michiganders Veterinarians Pet Owners MDNR MDHHS MDARD Tourists Businesses Healthcare Providers National Park Service Universities Local Parks Staff

51 Avoid tick habitats Ticks are most common along wooded or brushy manmade trails and animal trails, and along the edges of woodlots. Simply staying in the middle of a hiking or walking trail through the woods might prevent ticks from attaching. IMPORTANT FOR: Michiganders Pet Owners Tourists

Protect your body from ticks There are many safe and effective tick repellents labeled for skin including DEET, IR3535, Picaridin, and Oil of Lemon Eucalyptus.

52 Protect your body from ticks There are many safe and effective tick repellents labeled for skin including DEET, IR3535, Picaridin, and Oil of Lemon Eucalyptus. Permethrin treated clothing is also very effective at repelling ticks and other insects, especially for individuals that work in wooded environments. CDC.gov IMPORTANT FOR: Michiganders Pet Owners Tourists Parks Staff Anyone working or recreating in forested or brushy habitat!

Find & remove ticks promptly Periodic tick checks and showering promptly after recreating or working in tick habitats can identify and remove ticks before they attach, and/or allow for prompt removal.

53 Find & remove ticks promptly Periodic tick checks and showering promptly after recreating or working in tick habitats can identify and remove ticks before they attach, and/or allow for prompt removal. Grasp the head of the tick as close to the skin as possible, and pull straight out from the point of attachment without twisting. IMPORTANT FOR: Michiganders Pet Owners Tourists Parks Staff Anyone working or recreating in forested or brushy habitat!

Protect pets from ticks Tick prevention on pets not only protects the animal, but may prevent ticks from coming into the home and attaching to family members.

54 Protect pets from ticks Tick prevention on pets not only protects the animal, but may prevent ticks from coming into the home and attaching to family members. There are many available options for preventing ticks on pets, patients should consult with their veterinarian to choose the appropriate product. IMPORTANT FOR: Michiganders Pet Owners Tourists Veterinarians

55 Make your home less tick friendly Wood chip or gravel borders Trimmed vegetation More sunlight Recreation areas away from wooded edge habitat Acaricide treatment Host animal exclusion and treatment

56 LYME DISEASE EDUCATION

60 Healthcare Provider Education: Lyme Disease Toolkit

61 2% 7% Where has the vector of Lyme disease been found in Michigan? 48% 43% 57% INCORRECT

62 37% INCORRECT Which diagnostic test would you order for a patient with disseminated Lyme disease symptoms? 63% CORRECT

63 62% of providers correctly answered which treatment is recommended for Lyme disease.

64 Websites are an excellent way to communicate to practitioners.

65 Lyme Disease Toolkit Available Resources for Healthcare Providers Website Up-to-date information regarding Lyme disease & a one-page tip sheet Printed Resources Posters, brochures & tick ID cards Order Ticks and Your Health Brochure Order posters for your clinic Pocket-sized card to ID common ticks in MI Webinar & Free CME Credit Free on-demand webinar with 0.50 CME credits Tick Submission Kit Submit ticks for identification & testing

67 Lyme Disease Toolkit Available Resources for Healthcare Providers Website Up-to-date information regarding Lyme disease & a one-page tip sheet Printed Resources Posters, brochures & tick ID cards Order Ticks and Your Health Brochure Order posters for your clinic Pocket-sized card to ID common ticks in MI Webinar & Free CME Credit Free on-demand webinar with 0.50 CME credits Tick Submission Kit Submit ticks for identification & testing

69 Lyme Disease Toolkit Available Resources for Healthcare Providers Website Up-to-date information regarding Lyme disease & a one-page tip sheet Printed Resources Posters, brochures & tick ID cards Order Ticks and Your Health Brochure Order posters for your clinic Pocket-sized card to ID common ticks in MI Webinar & Free CME Credit Free on-demand webinar with 0.50 CME credits Tick Submission Kit Submit ticks for identification & testing

Resources Posters, brochures & tick ID cards Order Ticks

Pocket-sized card to ID common ticks in MI Webinar & Free

71 Lyme Disease Toolkit Available Resources for Healthcare Providers Website Up-to-date information regarding Lyme disease & a one-page tip sheet Printed Resources Posters, brochures & tick ID cards Order Ticks and Your Health Brochure Order posters for your clinic Pocket-sized card to ID common ticks in MI Webinar & Free CME Credit Free on-demand webinar with 0.50 CME credits Tick Submission Kit Submit ticks for identification & testing

72 QUESTIONS?

REPORT TO THE BOARDS OF HEALTH Jennifer Morse, M.D., Medical Director

Ticks and Tick-borne illness REPORT TO THE BOARDS OF HEALTH Jennifer Morse, M.D., Medical Director District Health Department #10, Friday, May 19, 2017 Mid-Michigan District Health Department, Wednesday,