What You Need to Know about Tick-Borne Illness

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1 What You Need to Know about Tick-Borne Illness Marie George, MD Keith Michl, MD, FACP Bradley Tompkins, MS, MPH Trey Dobson, MD, FACEP

3 Why we re here

4 What we ll cover Tick-Borne Illness Introduction and case presentation (Dr. Trey Dobson) Epidemiology (Bradley Tompkins) Prevention techniques (Dr. Keith Michl) What to do if bitten by a tick (Dr. Keith Michl) Diagnosis and treatment (Dr. Marie George) Future research (Dr. Trey Dobson) Questions from audience

5 Tick-Borne Illness Typical case presentation (2005) Chief complaint: I have a fever and a big red mark History of present illness: 34 year old female presents to her primary care physician with 2 days of intermittent fevers, joint pain, and an evolving, ovoid lesion on her arm. Describes herself as an avid hiker and dog lover. Frequently removes ticks from herself and family members. Resides in Shaftsbury, Vermont. Otherwise well. No significant past medical history. Physical exam: T 38.3 C (101 F) HR 90 BP 130/80 RR 16 General: Smiling, talking, no distress

7 Tick-Borne Illness Typical case presentation (2017) Chief complaint: My body hurts History of present illness: 60 year old male presents to his primary care physician with 4 days of intermittent fevers, headache, muscle aches, malaise. Describes himself as an office worker. Hobbies include clock restoration and carpentry. Resides in Bennington, Vermont. Past medical history includes chronic obstructive pulmonary disease, hypertension, sleep apnea. Physical exam: T 39.2 C (102.5 F) HR 110 BP 160/90 RR 22 General: Ill in appearance, moves slowly, prefers to lie down on the exam table

8 Tick-Borne Illness Tick-borne diseases present in Vermont 1. Lyme disease 2. Anaplasmosis 3. Babesiosis 4. Borrelia miyamotoi 5. Ehrlichiosis 6. Spotted fever group rickettsiosis 7. Tularemia 8. Powassan virus disease 9. Heartland virus disease (?) MOST COMMON LEAST COMMON

9 Tick-Borne Illness Tick-borne diseases are increasing in Vermont.

10 Tick-Borne Illness Increase is driven by Lyme disease (#1). 89% increase in cases

11 Increase is driven by anaplasmosis (#2). Tick-Borne Illness 36% of anaplasmosis cases in Vermont are hospitalized

12 Tick-Borne Illness Tick-borne Diseases in Vermont,

13 Tick-Borne Illness Bennington County remains TBD hotspot. Bennington County has highest incidence (per 100,000) of: Lyme disease Bennington: 300 Rest of VT: 110 Anaplasmosis Bennington: 245 Rest of VT: 19

14 Tick-Borne Illness Tick-borne diseases are a seasonal risk.

15 Tick-Borne Illness Different diseases, different seasonal trends

16 Tick-Borne Illness Different diseases, different Vermonters at risk Mental Health Services in the Bennington Vermont Department Health of Health Service Area

17 Other diseases caused by blacklegged tick Babesiosis Only tickborne disease caused by a parasite Tick-Borne Illness Half of all cases in Vermont live in Bennington & Rutland counties Borrelia miyamotoi First case in U.S. recorded in 2013 Fewer than 10 cases have been reported in Vermont Powassan Virus Disease Last reported case in Vermont was in 1999

18 Human habitat is tick habitat. Tick-Borne Illness

19 On the Horizon? Tick-Borne Illness The lone star tick is expanding its range northward 1. 1 doi: /gbe/evw080

Spotted fever group rickettsiosis 7. Tularemia 8. Powassan virus disease 9.

20 Tickborne Diseases Present in Tick-Borne Illness Vermont 1. Lyme disease 2. Anaplasmosis 3. Babesiosis 4. Borrelia miyamotoi 5. Ehrlichiosis 6. Spotted fever group rickettsiosis 7. Tularemia 8. Powassan virus disease 9. Heartland virus disease (?) Locations of lone star tickassociated cases in Vermont.

21 Tick-Borne Illness Be tick smart All ticks come in small, medium, and large sizes. Ticks can be active even in the winter. Ticks wait for small rodent hosts at the shoe level and crawl up. Ticks carry disease-causing microbes. Only deer ticks transmit Lyme disease bacteria. Look carefully. Deer tick nymphs look like a poppy seed on your skin. For most tick-borne diseases, you have at least 24 hours to find and remove a feeding tick before it transmits and infection.

22 Tick-Borne Illness Types of ticks The Deer Tick or Black-legged Tick Ixodes scapularis (dammini) Nymph-Male-Female-Engorged Female The American Dog Tick Dermacentor variabilis

23 Tick-Borne Illness Nymphal Ixodes scapularis on the hand

24 Tick-Borne Illness Preventing tick bites Avoid contact. Ticks are in wooded and bushy areas, high grass, and leaf litter. Walk in center of trails. Use repellent that contains 20 percent or more DEET, picaridin, or IR3535 on exposed skin for protection that lasts several hours. Always follow product instructions. Parents should apply this product to their children, avoiding hands, eyes, and mouth.

25 Tick-Borne Illness EPA web tool Find the Repellant that is Right for You

26 Tick-Borne Illness Examples of permethrin

27 Tick-Borne Illness Clothing repellant: permethrin Treat clothing and gear, such as boots, pants, socks and tents with products containing 0.5% permethrin. Studies show that you re MUCH less likely to be bitten by a tick when your clothing is treated.

28 Tick-Borne Illness Clothing repellant: permethrin Odorless Won t stain clothing Very safe for children and adults Repels and kills ticks Treated clothing effective for up to six weeks or six washings Pre-treated clothing is available and may be protective longer

29 Tick-Borne Illness Clothing repellant: permethrin

30 Finding ticks before they attach Tick-Borne Illness Take clothes off quickly after coming inside. Tumble dry clothes in a dryer on high heat for 10 minutes to kill ticks on dry clothing after you come indoors. If the clothes are damp, additional time may be needed. If the clothes require washing first, hot water is recommended. Cold and medium temperature water will not kill ticks effectively. If the clothes cannot be washed in hot water, tumble dry on low heat for 90 minutes or high heat for 60 minutes. The clothes should be warm and completely dry.

31 Tick-Borne Illness Finding ticks before they attach Bathe or shower as soon as possible after coming indoors (preferably within 2 hours). Conduct a full-body tick check using a hand-held or full-length mirror to view all parts of your body upon return from tick-infested areas. Parents should check their children for ticks. Under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in their hair. Ticks can ride into the home on clothing. Examine pets, gear, coats, and day packs.

32 Tick-Borne Illness

33 Tick-Borne Illness Protecting your yard Clear tall grasses and brush around homes and at the edge of lawns. Place a 3-foot wide barrier of wood chips or gravel between lawns and wooded areas and around patios and play equipment. Mow the lawn frequently and keep leaves raked. Stack wood neatly and in a dry area, which discourages rodents that ticks feed on. Keep playground equipment, decks, and patios away from yard edges and trees and place them in a sunny location, if possible. Remove any old furniture, mattresses, or trash from the yard that may give ticks a place to hide.

34 Tick-Borne Illness Tick control tubes Tick Control tubes are stuffed with cotton nesting material impregnated with permethrin. Mice are attracted by this nesting material. Tubes are placed in areas harboring mice. Mice steal the treated nesting material and place it in their nests. Once mice have treated nests, they almost never are infested by ticks. Targeting the ticks that feed on mice can greatly reduce the number of infected ticks in your yard.

35 Tick-Borne Illness Dealing with tick bites Ixodes

36 Tick-Borne Illness Removal The easiest and safest way to remove a tick is with pointy tweezers. Don t use Vaseline, gasoline, or touch with a hot object. Grasp the tick as close to the skin as possible. Pull the tick straight upward with a steady even pressure. Squeezing the tick will not increase the risk of infection. The mouthparts of adult ticks are more difficult to remove intact. The remaining mouthparts will not increase the chance of getting Lyme disease. Save the tick to help identify. Disinfect with alcohol or other skin disinfectant.

Diagnosis of Lyme disease Clinical diagnosis is best and most accurate method Symptoms Flu in the summer Erythema migrans rash (<25%) Head, neck and joint aches Enlarged lymph nodes

37 Diagnosis of Lyme disease Clinical diagnosis is best and most accurate method Symptoms Flu in the summer Erythema migrans rash (<25%) Head, neck and joint aches Enlarged lymph nodes Fever Fatigue Sudden onset Trouble thinking Usually does not include sore throat, cough, diarrhea Bell s palsy Shooting nerve pains Joint effusion (fluid in the joint, mostly knees)

38 Bite reaction vs. Lyme rash Bite reaction usually starts right after bite or up to 24 hours later Bite reaction <5 cm (2 in.) in size Reasonable to watch site over a few days to see if it enlarges Bite reaction has usually no other symptoms of fever, headache, joint aches, flu-like Can have both reaction to bite and Lyme

39 Diagnosis of Lyme disease Antibody capture EIA (Eliza) Very sensitively detects antibodies your body makes against Lyme bacteria IgM-1 st antibody Detects at days after infection and remains detectable 6-24 months after infection following treatment IgA Early antibody, specific for Lyme, usually severe infection, rapid fall after treatment IgG Reliably detected 4-10 weeks after infection (sometimes earlier), may never be detected if treated early Combination of antibodies is most specific indication of early Mental infection Health Services in the Bennington Health Service Area

40 Western blot Series of small specific antibody reactions which accurately indicates Lyme infection. We only use IgG western blots to support a diagnosis of Lyme disease.

42 Stored blood at laboratory Compares prior lab results with new specimens from the same patient. Can differentiate new infections from past infections.

44 Diagnosis of other tick-borne illnesses Anaplasmosis Babesiosis Borrellia Miyamotoi Real-Time PCR in Acute Infection Antibody response (serology) after infection Occasionally can see evidence of babesiosis or anaplasmosis on blood smear. Powassan virus specialized testing at CDC

45 Can a person get more than one tick-borne illness from one tick bite? Lyme-Anaplasma Anaplasma-Babesiosis Lyme-Borrelia Miyamotoi

46 Treatment of tick-borne illnesses Anaplasma Doxycycline Rifampin? Lyme Doxycycline Amoxicillin Cefuroxine-axetil (Ceftin) B. Miyamotoi Doxycycline Amoxicillin Babesiosis Atovaquone, plus azithromycin Clindamycin, plus quinine

47 Treatment of tick-borne illnesses Doxycycline for individuals > 8 years old for Lyme (14 21 days) Doxycycline for anaplasma in any age (7 10 days) Amoxicillin or ceftin alternatives for Lyme and B. miyamotoi Babesiosis Only infection with completely different treatment Think of this if fever persists after starting doxycycline Powassan virus No prescription options (Prevention, prevention, prevention!) After prescription and infection are gone, you are not immune. You can get tick-borne illness again if bitten by another tick.

48 Treatment of Lyme disease Prolonged antibiotics do not result in better outcomes 180 patients treated for early Lyme for 10 or 20 days; at 30 months the same positive outcome 607 patients, 99% well after 2 years of follow-up receiving 10 or >14 days of therapy After standard treatment and additional amoxicillin for 100 days, no better outcome than placebo Feeling better when receiving prolonged antibiotics can be due to the anti-inflammation effects of the antibiotic.

49 What if I still don t feel well after tickborne illness treatment? Lyme disease is completely curable with antibiotics in a vast majority of cases. It is not secretly hidden, persistent, or flaring. Many people (0-50% depending on study) have symptoms after treatment Fatigue Pain in muscles, joints, and bones Feeling dizzy, low energy, or unable to focus Data points to an immune response in the body, causing symptoms.

50 Risk factors for prolonged symptoms after treatment for Lyme disease More severe symptoms on presentation Multiple erythema migrans rash lesions Longer duration of symptoms before treatment

51 Important considerations when continuing to have symptoms after treating Lyme Is there a co-infection present that is not yet treated? i.e. babesiosis Is there another non tick-borne process? Is tick illness exacerbating underlying illness like rheumatoid arthritis or degenerative arthritis?

52 Steps to improvement Graded exercise Time and knowledge Medications for nerve pain, depression

53 Post Treatment Lyme Disease Syndrome (PTLDS) Symptoms after treatment lasting > 6 months 10-20% of patients who have been treated may have PTLDS

54 Post Treatment Lyme Disease Syndrome (PTLDS) immune mechanism Elevated inflammatory proteins in a mouse model Elevated interleukin 23 Elevated antibody level to nerve and bacterial proteins Patients with certain autoimmune diseases have increased risk

$Antibiotic refractory late Lyme arthritis Patients may have fluid in joints after 2-3 courses of antibiotics No$

55 Antibiotic refractory late Lyme arthritis Patients may have fluid in joints after 2-3 courses of antibiotics No bacteria found in synovial tissue Probably autoimmune arthritis and responds to medications for autoimmune conditions.

56 Future research Tick-Borne Illness Most research directed at prevention and treatment of Lyme disease Drug trials Multiple academic centers and research labs (Stanford, John s Hopkins) Creating new drugs from soil bacteria Improved testing of drugs for susceptibility (SYBR Green I/PI assay John s Hopkins) Antibiotic combinations Vaccines (LYMErix, VLA15-101) Monoclonal antibodies (Lyme PReP - UMass) Controlling of deer and mouse populations

57 Tick-Borne Illness Questions?

Keeping ticks away from your door (and body)

Keeping ticks away from your door (and body) by Joan Eliyesil Friday, May 16, 2014 Ticks. What was Mother Nature thinking? TICK-BORNE DISEASES REPORTED IN THE NORTHEASTERN U. S. Carried by blacklegged