One Health: An Integrated

Approach to Lyme Disease

Management in Wisconsin

Diep (Zip) Hoang Johnson

Division of Public Health

Wisconsin Department of Health Services

03/12/2014

Protecting and promoting the health and safety of the people of Wisconsin

2 2

Overview

• Lyme disease and other tickborne

infections associated with I. scapularis in

Wisconsin.

• Tick vectors, reservoirs, and hosts.

• Lyme and other tickborne diseases data

and statistics.

• Lyme disease characteristics.

• Diagnosis and treatment.

• Control and prevention.

Courtesy of CDC

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Tickborne Diseases in Wisconsin

• Anaplasmosis - caused by the bacteria Anaplasma phagocytophilum.

• Babesiosis - typically Babesia microti parasite.

• Ehrlichiosis - bacteria Ehrlichia chaffeensis and E. muris-like.

• Lyme disease - bacteria Borrelia burgdorferi.

• Powassan virus - tickborne virus in the arbovirus group.

4 4

Surveillance in WI, 2002-2012

Total Cases (%)

Tickborne Infections 2012 2002-2011 Total (confirmed and probable) n= 2,552 n= 21,099

• Powassan 2 (0.78) 11 (0.05)

• Lyme disease 1,906 (75)** 18,189 (86)

• Anaplasmosis/Ehrlichiosis 586 (23) 2,665 (13)

• Babesiosis 44 (1.7) 204 (0.97)

• Spotted fever rickettsiosis (SPF)* 14 (0.55) 30 (0.14)

*Mostly acquired during travel to another endemic state.

**Change in reporting requirement in June 2012

• Ticks are found in woods, bushes, high grass, and leaf litter.

• Active outdoors in warm weather and need moisture to survive.

• They can detect heat and carbon dioxide from nearby host.

• Attach to host when there is physical contact.

• In US, there are 80 species (850 species worldwide).

• 12 species are of public health or veterinary concerns, only one is of concern in WI.

• Ixodes sp. commonly known as the “blacklegged” or “deer” tick, is an important vector for most of the tickborne diseases in Wisconsin.

Ticks

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I. scapularis (Blacklegged or

Deer Tick)

Adult

female deer

tick Adult

male

deer tick Nymph

Larva

Smaller than a

American dog/wood

tick, adult female

and nymph can

transmit infection

through a bite for a

blood meal.

Dermacentor

variabilis ,

commonly

known as

American dog

or wood tick.

One Inch 6

“Wood” Ticks

Dermacentor variabilis • Commonly known as “wood” ticks, American dog

ticks.

• Most common ticks found in eastern and central

United States.

• They do not transmit Lyme disease,

anaplasmosis, ehrlichiosis, and Powassan virus.

• Can transmit spotted fever group, but limited tick

testing have not identified this pathogen in

Wisconsin.

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Distribution of I. scapularis

• Found along the east coast of United States.

• Small mammals, primarily white-footed mice

(Peromyscus leucopus) are the most important

reservoir hosts.

• Adult ticks feed on large mammals, primarily the

white-tailed deer; therefore, deer can play an

important role in the tick-life cycle.

• However, deer blood can inactivate Borrelia

bacteria and are dead-end host.

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M o d e r a t e L o w M i n i m a l o r N o n e

H i g h

Lyme Disease High Risk Areas

Upper Midwest & Northeast

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Life Cycle of Blacklegged Tick

Courtesy of CDC

Larva activity peak

in August when they

feed on primarily

white-footed mice

(small mammals and

birds), first chance

for picking up the

bacteria .

During the 2-year life cycle,

total 3 blood meals.

Nymphs feed on

variety of hosts.

Based on EM case

onsets, nymphs

account for most

human transmission.

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Adult ticks

becomes

active in

October and

can remain

active in the

winter if

temperatures

are above

freezing.

Stages of blood engorgement in female adult Ixodes ticks depicted by

the durations of attachment (borrowed from IDSA, Dr. Richard Falco-

Fordham University).

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Ticks Hunting 2008

Diep (Zip) Hoang Johnson from the Wisconsin Division of Public Health

checked a hunter-registered deer for ticks. 12

UW-Madison, Entomology- Tick

Surveys 1981

1994

2008-2009

Dark color of the pie= % deer

infested with Ixodes ticks 13

Veterinary Medical Clinic(s)

Humane Society

Wildlife Rehab Center

No contributors

Douglas

Bayfield

Ashland

Sawyer

Washburn

Polk Barron Rusk

Price

Iron

Vilas

Oneida

Taylor Chippewa St. Croix

Pierce

Dunn

Pepin

Eau Claire

Buffalo

Trempealeau

Jackson

Monroe

Clark

Wood Portage

Juneau

Adams

Sauk

La Crosse

Vernon

Crawford

Richland

Grant

LaFayette Green

Dane Iowa

Columbia

Dodge

Jefferson Waukesha

Racine

Ozaukee

Sheboygan Fond du Lac Green Lake

Marquette

Waushara Winnebago

Calumet

Manitowoc

Kewaunee

Brown

Outagamie

Waupaca

Shawano

Menominee

Oconto

Langlade

Forest Marinette

Florence

Door

Milwaukee

Washington

Lincoln

Marathon

Wisconsin River Rock

Walworth

Wisconsin Tick Surveillance of Small Mammals,

2011-2012

Burnett

Veterinary Medical Clinic & Humane Society

All three

Other

Kenosha

Humane Society & Wildlife Rehab

Ticks collected

from different

agencies in

Wisconsin.

UW-Madison, Dept.

Entomology and

Wisconsin Division of

Public Health.

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I. scapularis found on

animals from counties.

Douglas

Bayfield

Ashland Sawyer Washburn

Polk Barron Rusk

Price

Iron

Vilas

Oneida

Taylor Chippewa St. Croix

Pierce

Dunn

Pepin

Eau Claire

Buffalo

Trempealeau

Jackson

Monroe

Clark

Wood Portage

Juneau

Adams

Sauk

La Crosse

Vernon

Crawford

Richland

Grant

LaFayette Green

Dane

Iowa

Columbia Dodge

Jefferson Waukesha

Racine

Ozaukee

Sheboygan Fond du Lac Green Lake

Marquette

Waushara Winnebago

Calumet

Manitowoc

Kewaunee

Brown

Outagamie

Waupaca

Shawano

Menominee

Oconto

Langlade

Forest Marinette

Florence

Door

Milwaukee

Washington

Lincoln

Marathon

Wisconsin River Rock

Walworth

Ticks Found On Animal Species, 2011-2012

Burnett

Kenosh

a

n= 853

No submissions from

participating counties.

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Tick Infectivity

Tick surveillance in Wisconsin performed by the

UW-Madison, Department of Entomology:

• Average state infectivity rate for Borrelia in nymphs is

22% (20-24%). Adult tick infectivity rate is twice that of

the nymphs.

• Other tickborne diseases infectivity rate is much lower

than Borrelia sp.

• Co-infectivity rate for tickborne diseases are unknown.

Lyme Disease

Bacteria- Borrelia burgdorferi

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Reported Lyme Disease, WI,1990-2011

(n=25,313)

32

9

43

7

47

0

38

4

39

9

37

0

40

7

48

6

60

7

51

6

65

8

65

3 11

03

76

7 11

91

14

79

14

87

18

38

14

96 19

48 25

11

23

76

12

33

98

7

63

6

54

5

0

400

800

1200

1600

2000

2400

2800

3200

3600

4000

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

*

20

09

20

10

20

11

Year of Illness Onset

No

. o

f C

ases

0

10

20

30

40

50

60

70

Incid

en

ce

Probable Cases

Confirmed Cases

Incidence per 100,000

* Prior to 2008 only confirmed cases were reported

* Previous to 2008 only confirmed cases were reported. Beginning 2008, the total

number of cases includes confirmed and probable cases. 18

Lyme Disease Average Annual Incidence

Wisconsin, 1990-2007, by County of Residence

1990-1992 1993-1995 1996-1998

1999-2001 2002-2004 2005-2007

19

Statewide Incidence

34.9 cases/100,000 20

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Early Localized Stage - Erythema

Migrans (EM)

• Ticks must be attached for at

least 24-48 hours to transmit

bacteria

• The EM rash expands in size

over time (70% people)

• Occurs within 30 days of tick bite

• Since Lyme disease is endemic in

WI, EM rash (>/=5cm) is

considered as a confirmed case

with or without laboratory testing

and should be reported to health

departments.

22

39

30 38 7

2

233

821

699

239

131

133

44

32

0

100

200

300

400

500

600

700

800

900

1000

Jan

Feb

Mar

April

May

June

July

Aug

Sept

Oct

Nov

Dec

Month of Illness Onset

No. of C

onfirm

ed C

ases

Confirmed Lyme Disease Cases Reported by Month – WI 2010 (n=2,511)

Rev – 05/09/2011

23

0

10

20

30

40

50

60

70

80

90

100

0-4

5-9

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+

Age Group (yrs)

Rate

* Confirmed cases per 100,000 population

Rate* of Confirmed Lyme Disease Reported by Age Group – WI 2010 (n=2,511)

Rev – 05/10/2011

24

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Lyme Disease- Testing Methods

• Serologic assays are the most common tests to

detect antibodies to Borrelia burgdorferi.

• Diagnostic testing should include 2-step testing on

the same sample.

1st step test:

– Enzyme immunoassay (EIA) tests, or

– Immunofluorescent assays (IFA)

2nd step test:

– Western Blot test.

Lyme Disease- Treatment

CDC follows the Infectious Diseases Society of America (IDSA) guidelines.

• Antibiotics- very effective if treated early. - children>/=8yrs and adult= doxycycline100mg 2x/day for 14days.

- children <8yrs= amoxicillin 50mg/kg/day in 3 divided doses.

• Usually oral but may be given intravenously in more severe cases.

• Recurrent symptoms may require a second course of antibiotics.

• Long-term intravenous courses (months to years) have not been shown to be beneficial but may cause more complications (gallstones, catheter associated bloodstream infections).

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Prophylaxis to Prevent Lyme

Disease

Prophylaxis (follow the Infectious Diseases Society of America guidelines).

– Tick had to be attached for at least 36hrs.

– At least 20% tick infectivity, Wisconsin meets this criteria because the average nymphal tick infectivity rate is about 22% (range from 20-24%).

– Given within 72 hours after tick removal.

One single dose of doxycycline (200mg) for adults and children >/=8yrs.

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Proper Tick Removal

• Tweezers or a tissue.

• Grasp the tick as close to skin’s surface

as possible.

• Slowly pull the tick straight out, not at an angle.

• Clean the bite area on the skin with rubbing alcohol or soap and water.

• Take note of the tick bite area, look for rash that is spreading over time and increasing in size.

• See a physician if a rash or tickborne illness-like symptoms develop after tick removal.

Courtesy of CDC

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Tick Prevention and Control

Integrated tick management:

• Avoidance of tick habitats.

• Personal protection.

• Vector management. – decrease reproduction and migration

– increase mortality.

• Reduction of tick habitats.

• Anti-tick vaccines for reservoir hosts and humans.

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Tick Prevention

Avoidance of tick habitats. • When in wooded areas, walk on cleared pathways and trails to

reduce the chance of coming in contact with ticks.

Personal protection. • Wear protective clothing, long pants and sleeves.

• Tuck shirts into pants and pants into socks or boots to prevent ticks from crawling under clothing and attaching to skin.

• Use repellents per label instructions (20% DEET and other products).

• Permethrin spray for clothing.

• Check for ticks for people and pets after being outdoors.

• Take showers to wash off crawling ticks.

• Use repellent products or acaricides on pets.

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Tick Control (continued)

• Restrict movement of infested hosts into an area to reduce immigration of ticks.

• Reduce the population of rodents habitats near homes by reduce stack wood and food sources.

• Use fences, deer repellents, and plants that will discourage large mammals including deer.

• Eliminate ticks on host by using nesting material, boxes with pesticides, or bait stations with acaracide (ivermectin).

• Wildlife vaccination delivered to hosts as oral bait.

Resources

• http://www.dhs.wisconsin.gov/communica

ble/Tickborne/Index.htm

• http://www.cdc.gov/ticks/index.html

• http://www.cdc.gov/lyme/

• http://cfpub.epa.gov/oppref/insect/

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Additional Questions

Feel free to contact DPH:

Diep (Zip) Hoang Johnson,

Epidemiologist Phone: (608) 267-0249

diep.hoangjohnson@dhs.wisconsin.gov