christina davey regional epidemiologist serving lawrence, pike, ross, and scioto counties tick-borne...

Christina DaveyRegional Epidemiologist

Serving Lawrence, Pike, Ross, and Scioto Counties

Tick-borne Diseases in Ohio

Overview

• Rocky Mountain Spotted Fever

• Lyme Disease

• Ehrlichiosis/Anaplasmosis

• Tick Submission

Rocky Mountain Spotted Fever (RMSF)

Agent/transmission• Rickettsia rickettsii• Maintained and amplified by hard

ticks, primarily American dog tick (D. variabilis) and Rocky Mountain wood tick (D. andersoni).

• Brown dog tick (Rhipicephalus sanguineus) and Cayenne tick (Amblyomma cajennense) also been implicated as vectors.


Agent/transmission (Continued)• In Ohio, the American dog tick (Dermacentor variabilis) is the vector.• Humans contract RMSF through the bite of dog tick, or by coming in

contact with tick secretions or body fluids through careless handling of ticks.

• Dogs can transport ticks into the household environment and may also become ill with spotted fever.

• Humans are dead-end hosts


Signs/Symptoms• Average incubation 1 week after bite• Fever (acute onset), possibly accompanied by

– Headache– Malaise– Myalgia– Nausea/vomiting– Neurologic signs

• Fatal in 5-10% of untreated cases• Severe fulminant disease possible


Signs/Symptoms (Continued)• Characteristic spotted rash• Macular or maculopapular rash in most (about 80% of) patients • 4-7 days post-onset,• Rash often present on palms and soles.


Occurrence

• 71/88 counties in Ohio

• Almost half of all cases from Clermont, Franklin and Lucas (from 1999-2007)

• 19 deaths since 1964

• April through July


Tick-Borne Diseases Reported in Ohio

2008

EpiData Analysis Graph

Reportable DiseaseLyme Disease Rocky Mountain Spotted Fever Ehrlichiosis

Num

ber

of R

eport

s

350

300

250

200

150

100

50

0

341

91

16


Tick-Borne Diseases Reported in Ohio in 2008, by Case Classification

0

50

100

150

200

250

300

350

Lyme Disease Rocky Mountain Spotted Fever Ehrlichiosis

Reportable Disease

Nu

mb

er

of

Ca

se

s R

ep

ort

ed

Not A Case

Confirmed

Probable

Suspected


Diagnosis (CDC Laboratory Criteria for Surveillance Purposes)

Laboratory Confirmed:• Serological evidence of a fourfold change in IgG-specific

antibody titer reactive with R. rickettsii antigen by indirect IFA between paired serum specimens*, or

• Detection of R. rickettsii DNA in clinical specimen via amplification of a specific target by PCR assay, or

• Demonstration of spotted fever group antigen in biopsy or autopsy specimen by IHC, or

• Isolation of R. rickettsii from clinical specimen in cell culture



Laboratory Supportive:• Serologic evidence of elevated IgG or IgM antibody

reactive with R. rickettsii antigen by IFA, ELISA, dot-ELISA, or latex agglutination*


Case Definitions for Surveillance• Confirmed: A clinically compatible case (meets

clinical evidence criteria*) that is laboratory confirmed.

• Probable: A clinically compatible case (meets clinical evidence criteria*) that has supportive laboratory results.

• Suspect: A case with laboratory evidence of past or present infection but no clinical information available (e.g. a laboratory report).


Treatment (need based on clinical and epidemiological information)

• Tetracycline antibiotics (usually doxycycline)

• Treat for at least 3 days after fever subsides and until evidence of clinical improvement

• Standard duration of treatment: 5-10 days


Prevention and Control• Avoid ticks in endemic areas• Tuck pants into socks• Use repellents (carefully following label

instructions)• Wear light-colored clothing• Regularly inspect for and remove ticks (on

humans and pets)• Keep grass and weeds mowed

Lyme Disease

Agent/transmission• Borrelia burgdorferi• Reservoir=mice, squirrels, other small

animals• Ixodes scapularis (black-legged tick,

also known as “deer tick”)=vector in eastern and midwestern states

• Ixodes pacificus=vector in western United States

• Other species of ticks not known to transmit Lyme Disease.

• No known human-human transmission (though transplacental transmission may occur)

Lyme Disease

Signs/Symptoms • Incubation period of up to 30 days after tick bite• Muscle aches• Fever• Swollen lymph nodes• Headache• Joint pain• Fatigue• Late manifestations

Lyme Disease

Signs/Symptoms (Continued)• Erythema migrans (“bull’s-eye”

rash)– Best clinical marker– Seen in 60-80% of cases– Develops at site of tick attachment

after a delay of 3-30 days– Usually appears 7-14 days after

exposure– Gradually expands over several

days

Lyme Disease

Occurrence• Since 1990, 932 cases reported from 83/88 Ohio

counties• 48 cases reported to CDC in 2008• Most commonly reported vector-borne disease

in U.S. with 20,000 cases each year• 80% of total U.S. cases from Mid-Atlantic and

New England (mostly New York, New Jersey and Pennsylvania)

• Black-legged tick rare in Ohio

Lyme Disease

Lyme DiseaseTick-Borne Diseases Reported in Ohio

2008



Num

ber

of R

epor

ts

350

300

250

200

150

100

50

0

341

91

16

Lyme DiseaseTick-Borne Diseases Reported in Ohio in 2008, by Case Classification

0

50

100

150

200

250

300

350


Reportable Disease

Nu

mb

er

of

Ca

se

s R

ep

ort

ed

Not A Case

Confirmed

Probable

Suspected

Lyme Disease


• Positive culture for B. burgdorferi, or• Demonstration of diagnostic IgM or IgG

antibodies to B. burgdorferi in serum or CSF*, or

• Single-tier IgG Western blot / immunoblot seropositivity interpreted using established criteria*

Lyme DiseaseCase Definitions for Surveillance• Confirmed: a) a case of EM with a known exposure,

or b) a case of EM with laboratory evidence of infection (by CDC lab criteria) and without a known exposure or c) a case with at least one late manifestation that has laboratory evidence of infection.

• Probable: any other case of physician-diagnosed Lyme disease that has laboratory evidence of infection (by CDC lab criteria).

• Suspected: a) a case of EM where there is no known exposure and no laboratory evidence of infection, or b) a case with laboratory evidence of infection but no clinical information available (e.g. a laboratory report).

Lyme Disease

Treatment

• Antibiotic therapy during acute phase

• Doxycycline, amoxicillin, or cefuroxime axetil

• IV ceftriaxone or penicillin for neurological or cardiac

• Second 4-week course if symptoms persist or recur

Lyme Disease

Prevention, and Control • Vaccine no longer available• Avoid of ticks in endemic areas• Tuck pants into socks• Wear light-colored clothing• Use repellents (carefully following label instructions)• Regularly inspect for and remove ticks (on humans and

pets)• Keep grass and weeds mowed• Reduce reservoir populations

Lyme Disease

Ehrlichiosis/Anaplasmosis

Agents/transmission

• Ehrlichia chaffeensis - formerly known as human monocytic ehrlichiosis (HME)

• Anaplasma phagocytophilum, (aka Ehrlichia equi or Ehrlichia phagocytophila) - formerly known as human granulocytic ehrlichiosis (HGA, HGE)

• Ehrlichia ewingii


Agents/transmission• E. chaffeensis is transmitted

principally by the Lone Star tick, Amblyomma americanum

• A. phagocytophilum appears to be transmitted by the blacklegged ticks, Ixodes scapularis and Ixodes pacificus.

• E. ewingii appears to be transmitted by the Lone Star tick, Amblyomma americanum.

• Reservoirs for vector ticks: deer, elk, wild rodents and dogs.


• Humans contract Ehrlichiosis/Anaplasmosis through the bite of vector tick, or by coming in contact with tick secretions or body fluids through careless handling of ticks.

• Humans are dead-end hosts.

Ehrlichiosis/AnaplasmosisSigns/symptoms• Incubation period: 5-14 days after tick bite for

Ehrlichia chaffeensis infection and E. ewingii infection; 5-21 days for Anaplasma phagocytophilum infection

• Fever (acute onset) and one or more of the following:

– Headache– Myalgia– Malaise– Anemia– Leuokpenia– Thrombocytopenia– Hepatic transaminase elevation– Nausea– Vomiting– Rash (uncommon for HME, rare for HGE)

• Case fatality rate of 2-3% for E. chaffeensis, less than 1% for A. phagocytophilum, and not documented for E. ewingii


Occurrence• Found primarily in the South and Mid-Atlantic,

North/South Central United States, and isolated areas of New England, E. chaffeensis is transmitted principally by the Lone Star tick, Amblyomma americanum.

• A. phagocytophilum is more likely to be found in the New England, North Central and Pacific States, and appears to be transmitted by the blacklegged ticks, Ixodes scapularis and Ixodes pacificus.

• Found primarily in the South Atlantic and South Central United States with isolated areas of New England, E. ewingii appears to be transmitted by the Lone Star tick, Amblyomma americanum.

• Lone Star ticks becoming more common in Ohio, especially Southern Ohio.

Ehrlichiosis/AnaplasmosisTick-Borne Diseases Reported in Ohio

2008



Num

ber

of R

epor

ts

350

300

250

200

150

100

50

0

341

91

16

Ehrlichiosis/AnaplasmosisTick-Borne Diseases Reported in Ohio in 2008, by Case Classification

0

50

100

150

200

250

300

350


Reportable Disease

Nu

mb

er

of

Ca

se

s R

ep

ort

ed

Not A Case

Confirmed

Probable

Suspected


Diagnosis (CDC Laboratory Criteria for Surveillance Purposes) – E. chaffeensis (HME)

Laboratory Confirmed:• Serological evidence of fourfold change in IgG-specific

antibody titer to E. chaffeensis antigen by indirect IFA between paired serum samples*, or

• Detection of E. chaffeensis DNA in clinical specimen via amplification of specific target by PCR assay, or

• Demonstration of ehrlichial antigen in biopsy or autopsy sample by immunohistochemical methods, or

• Isolation of E. chaffeensis from clinical specimen in cell culture


Diagnosis (CDC Laboratory Criteria for Surveillance Purposes) – E. chaffeensis (HME)

Laboratory Supportive:• Serological evidence of elevated IgG or IgM

antibody reactive with E. chaffeensis antigen by IFA, ELISA, dot-ELISA, or assays in other formats*, or

• Identification of morulae in the cytoplasm of monocytes or macrophages by microscopic examination


Diagnosis (CDC Laboratory Criteria for Surveillance Purposes) – E. ewingii

Laboratory Confirmed:

• E. ewingii DNA detected in clinical specimen via amplification of a specific target by PCR assay


Diagnosis (CDC Laboratory Criteria for Surveillance Purposes) – A. phagocytophilum (HGE)

Laboratory Confirmed:• Serological evidence of fourfold change in IgG-specific

antibody titer to A. phagocytophilum antigen by indirect IFA in paired serum samples*, or

• Detection of A. phagocytophilum DNA in clinical specimen via amplification of a specific target by PCR assay, or

• Demonstration of anaplasmal antigen in biopsy/autopsy sample by immunohistochemical methods, or

• Isolation of A. phagocytophilum from clinical specimen in cell culture


Diagnosis (CDC Laboratory Criteria for Surveillance Purposes) – A. phagocytophilum (HGE)

Laboratory Supportive:• Serological evidence of elevated IgG or IgM

antibody reactive with A. phagocytophilum antigen by IFA, ELISA, dot-ELISA, or assays in other formats*, or

• Identification of morulae in the cytoplasm of neutrophils or eosinophils by microscopic examination


Case Definitions for Surveillance• Confirmed: A clinically compatible case (meets

clinical evidence criteria) that is laboratory confirmed.

• Probable: A clinically compatible case (meets clinical evidence criteria) that has supportive laboratory results.

• Suspect: A case with laboratory evidence of past or present infection but no clinical information available (e.g. a laboratory report).


Treatment • Begin immediately upon strong suspicion of

ehrlichiosis through clinical and epidemiological findings

• Doxycycline or other tetracyclines (fever generally subsides within 24-72 hours)

• Minimal course of 5-7 days• Patients with anaplasmosis should be treated

with doxycycline for 10-14 days because of possible Lyme disease coinfection


Prevention and Control• Avoid ticks in endemic areas• Tuck pants into socks• Use repellents (carefully following label

instructions)• Wear light-colored clothing• Regularly inspect for and remove ticks (on

humans and pets)• Keep grass and weeds mowed

Tick Identification

• Free service through ODH Zoonotic Disease Program

• Proper tick identification essential in determining potential risk of infection with tick-borne disease

Tick Identification

Instructions for Submitting Ticks

• Keep ticks alive. Live ticks are easier to identify

• Moisten paper strip with one or two drops of water, place tick and paper strip in vial and close tightly.

• Complete form and submit with tick.

Tick Identification

Questions

Christina DaveyRegional EpidemiologistServing Lawrence, Pike, Ross and Scioto Counties, Ironton and Portsmouth CitiesPike County General Health District (Home Office)14050 US 23 NWaverly, OH 45690Office Phone: 740-947-7721Cell (24/7 Contact #): 740-222-2292Email: [email protected]

christina davey regional epidemiologist serving lawrence, pike, ross, and scioto counties tick-borne...

Documents

rocky mountain wood

tick secretions

bite of dog tick

hard ticks

careless handling of

maculopapular rash

bitefever acute onset

humans contract rmsf