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Understanding

and Preventing

Lyme Disease─ Reducing

Occupational Risk

Elizabeth L. Maloney, MD

MSPS 64th Annual Meeting

n 

¨ Disease statistics

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¨ Tick basics

Conflicts of interest: nothing to disclose

© 2016 Elizabeth Maloney, MD

¨ Risk factors

¨  Illness

¨ Reducing exposure

¨ Preventing and managing bites

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n  Most common vector-borne illness in US n  Serious/chronic illness for some n  Risk higher than thought

CDC estimates incidence > 300,000

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http://www.cdc.gov/lyme/stats/graphs.html Accessed Jan 10, 2016

CDC surveillance Case Reports 1995 – 2014

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n  Concentrated ¨  Northeast ¨  Upper Midwest

n  Pockets ¨  Seattle ¨  San Francisco ¨  Gulf coast ¨  South coast

n  Scattered www.cdc.gov/ncidod/dvbid/LYME/ld_Incidence.htm

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Lyme/Anaplasmosis Risk

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n  MN “top 10” state; 12 -15,000* new cases/year

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n Avoid state’s known/likely tick locations n Many and varied

¨  Greater MN and metro ¨  Examples

n  Golf courses n  City parks n  Camp sites n  Backyards n  Undeveloped real estate

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Kirby Stafford, Ph.D.

n  Reservoir hosts proliferate ¨  Small mammals – white footed mice,

chipmunks, shrews

n  Humans, incidental hosts closer

EL Maloney 8

MM

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2008; 57:SS

1-10.

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MM

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2008; 57:SS

1-10.

Reported Cases by Age Group

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You, and most Minnesotans n  Individualized Risk factors

¨  Exposure to high-risk areas n  Home, work, vacations n  Outdoor activities

¨  Pet ownership ¨  Family members with tick-borne disease ¨  Lack of disease awareness ¨  Failure to use prevention measures

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n  Chronic in 20% or more

n  Significant disability ¨  Advanced cases: 65% cut back or quit school/work

25% received disability payments

n  Costs per patient vary

¨  All cases: $8400 ¨  Late disease: > $16,000*

n  Limited access to care for complicated cases ¨  Few doctors trained ¨  Patients leave MN

$$$

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n  Multiple stages - Early, Late, Post-treatment

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n  Transmitted by deer ticks

n  Bacterial infection

Zoonotic bacteria n  Infects multiple animal species

n  Adaptable ¨  Tolerates changing environment ¨  Multiple survival strategies

Wadsworth Center, N Y State Dept. of Health

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§ Not easy to kill

B. afzelii

B. burgdorferi senso stricto

B. garinii

>100 strains in US

B. spielmanii B. miyamotoi

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n  Distinctive appearance ¨  Black “cape” red-brown body

n  2 year life cycle ¨  4 stages

n  Eggs, larva, nymph, adult ¨  3 feedings – chance to become infected

CDC

CDC

n Feed on small mammals ¨ Mice, chipmunks, shrews

n Once infected, always infected ¨ Only nymphs, adults transmit

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Tick Habitat n  Moisture a must

¨  Dehydrate quickly

n  Locations: ¨  Non-residential

n  Long grasses, leaf litter, fallen logs, woods edge ¨  Home

n  Birdbaths, birdfeeders, wood piles

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n Don’t travel far on their own ¨  Don’t fall from trees or jump

n  Long-range transport - deer and birds

n  People and pets bring ticks inside

CDC/Emerging Infectious Diseases 1997;Vol 3(2)

n Passive search for meal

¨ Front legs grab what brushes by

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Dog Lone star

Deer

Dog CDC

CDC CDC Both photos: Maine Medical Center Research Institute, South Portland, ME

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n  Other diseases spread by black-legged ticks

¨  Single bite may transmit many diseases

Black-legged tick

American dog (wood) tick

Lone star tick

Lyme Babesiosis Ehrlichia muris-like disease Borrelia miyamotoi disease

Anaplasmosis Bartonellosis Powassan encephalitis

Rocky Mountain spotted fever

Tularemia

Tularemia

Ehrlichiosis

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n Diagnosis ¨ Symptoms of co-infections overlap with Lyme

n Treatment ¨ May need combinations of antibiotics ¨ Unrecognized co-infections mistaken for Lyme

“treatment failures”

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n  2-30 days after bite

n  Bacteria in skin

n  Multiple presentations ¨  Asymptomatic ¨  “Flu-like” illness

n  Blood tests not recommended ¨  Too many false negative results

¨  Erythema migrans rash (EM) ¨  Rash + “flu”

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n  Expands/clears over weeks; ≥ 5 cm in diameter

n 

M. Patmas KB Liegner, MD Bernard Cohen; http://www.DermAtlas.org

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Paul Auerbach, MD

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©2013 Elizabeth L Maloney, MD 24

n  Bacteria spreads to other body areas

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n Days to weeks after bite:

¨ Multiple EM ¨  Joint pain ¨ Headache ¨ Stiff neck ¨ Bell’s palsy ¨  Light sensitivity ¨ Emotional swings ¨ PAIN

¨  Constitutional symptoms ¨  Swollen lymph glands ¨  Cranial nerve symptoms ¨  Heart problems ¨  Memory difficulties ¨  Concentration problems ¨  FATIGUE

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n  Multiple EM

¨  Return of bacteria to skin ¨  Individual EMs often < 5cm

n  Facial nerve palsy ¨  25-50% cases in kids ¨  Bilateral FN palsy = Lyme ¨  Lyme likely if

n  Onset June-Oct and n  Fever, HA, no shingles/cold sore lesions

Bernard C

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CDC

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n  Meningitis ¨  Smoldering symptoms

n  Headaches > 7days; stiff neck, fever, n  +/= cranial nerve problems

¨  Often misdiagnosed as viral meningitis

n  Carditis – inflammation of heart ¨  Electrical system malfunctions ¨  Heart muscle weakness ¨  Inflammation of heart’s covering

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n Arthritis

CDC

¨ Months – years after bite ¨  60% of untreated cases

¨ Multiple brief episodes

¨ Knee most common n  Small joints occasionally n  Mistaken for rheumatoid arthritis

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n Late Neurologic ¨ Months – years after bite ¨ True incidence unknown ¨ Any part of nervous system

n Peripheral nerves ¨  Sensory changes, neuropathic pain ¨  Muscle weakness, twitching

n Autonomic nervous system n Brain/spinal cord

¨  Trouble thinking ¨  Dementia ¨  MS, ALS, Parkinson-like ¨  Movement disorders

¨  Psychiatric conditions §  Depression §  Anxiety

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n  Symptoms are variable

n  No specific “look” ¨  Hard for doctors to recognize disease patterns

n  Lyme mimics other diseases

n  Blood tests not always reliable ¨  Find certain types of cases but not all cases ¨  Positive results confirm diagnosis

n 

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Fibromylagia Chronic fatigue syndrome RA Diabetes Degenerative arthritis MS Vasculitis Hypothyroidism ALS Sarcoidosis Psychiatric disorders Sleep Apnea B12 deficiency Heavy metal toxicity

Anaplasmosis Babesiosis Bartonellosis Ehrlichiosis Epstein-Barr virus Mycoplasma Parvovirus West Nile virus Syphilis Relapsing fever B. miyamotoi

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n  Most effective in early disease ¨ 4 weeks of doxycycline, amoxicillin, Ceftin

n  Treatment failures not rare ¨  Treatment failure = Post-treatment disease

n  Post-treatment disease controversial ¨  Causes uncertain

n  Persistent infection documented

¨  Treatment options not worked out n  Antibiotic retreatment benefits some

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People

Property

Pets

Focused strategies

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Avoid blacklegged tick bites Habitat awareness, smart clothing choices

insecticide/repellant use

Prompt tick removal Tick checks, post-exposure showers

Selective antibiotic prophylaxis Risk assessment required

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Antibiotics during tick season

n Avoid tick habitat ¨  Wooded areas, brush, long grasses ¨  Rough of golf courses, ¨  Unmowed playing fields

n While in tick habitat - ¨  Stay away from leaf litter, fallen logs ¨  Stay in center of trails

CDC

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n Pretreat work area with insecticide

n  Maximal skin coverage ¨  Light-colored ¨  Pants tucked into socks;

n  +/- tick gaiters ¨  Hats/ponytails

n  Pretreated with permethrin

n  After exposure, into dryer ¨  High heat for 60 min

A. Mears

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n  Insecticide - kills ticks on contact

n  Long-lasting protection ¨  Apply to clothes, gear; NOT skin

n  Bonds to fabrics; no transfer to skin n  Lasts 2 – 6 weeks; multiple washings

¨  Multiple product types/manufacturers n  Online demos on application

¨  Permethrin embedded clothing n  ~ 70 washings

n  Safety well-established ¨  Passed EPA safety tests, extensive US military use

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DEET Picaridin Bio UD

For use on: Skin; some fabrics: wool, cotton

Skin; all fabrics, materials

Skin; all fabrics, materials

Product types:

Spray, lotion, wipes Spray, lotion, wipes Spray, lotions

Concentration: 30 – 40% 10 – 20% 7.75%

Human Safety:

US EPA: kids > 2 mo; Health Canada: no kids

US EPA/Health and Canada: no age limits

US EPA: no use limits

Years of use: 60 years ~ 10 years ~ 5 years

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n Body-wide ¨  Post-shower ¨  Thorough ¨ After each exposure

EL Maloney

IgeneX, Inc., Reference Laboratory, Palo Alto, CA

n Small targets

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n  Grasp tick close to the skin

n  Avoid squeezing body

n  Pull tick straight out

n  Don’t try ¨  Burning ¨  Covering with substances

n  Save tick for inspection California Dept. of Health Services

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n  Clean bite site

n  Contact medical provider ASAP ¨  Discuss antibiotics for prevention ¨  Don’t base care on test results

n  Watch for rashes, “flu-like” symptoms ¨  Immediate rash: think allergy to tick saliva

¨  EM rash or “Flu”:

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Options

n  “Wait and see” approach ¨  Risky; 30% never get a rash to “see”

n  Doxycycline for 10 - 20 days ¨  Wisconsin Medical Journal 2011; 110(2): 78-81. ¨  Expert Review of Anti-infective Therapy Sept 2014

n  Doxycycline, single 200 mg dose ¨  Most popular but decline it

n  Not very effective n  May throw off tests

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n  Avoid roaming ¨  Control dogs’ outdoor range ¨  Cats indoors only

n  Tick checks ¨  Pets bring ticks inside

EL Maloney

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n  Vaccine: dogs only

n  Tick collars: dogs and cats

n  Monthly topical agents: dogs and cats n  Some dog products cannot be used on cats

n  Frequently applied topical gels ¨  Every 3 days or so ¨  Dogs, cats, horses

n  Sprays, powders, dips

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n  People-friendly but tick, mouse, deer-hostile

n  Clean-up ¨  Leaf litter, woodpiles, birdbaths

n  Increase sunlight ¨  Place play structures/furniture in sunlit areas

n  Landscape appropriately ¨  Reduce plants that attract deer, protect ticks ¨  Move birdfeeders to edge of property ¨  Keep grass short ¨  Peripheral buffer zone ¨  Insecticides

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Kirby Stafford, Ph.D

Kirby Stafford, Ph.D.

Kirby Stafford, Ph.D.

EL Maloney

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n Lyme is a complex and significant illness ¨ Costly and disabling ¨ Diagnosis/treatment tricky

n Risk in MN significant and growing

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n Prevention works when used ¨ Multi-layered; strategies for people, pets, property

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n  Tick Management Handbook

n  Columbia University Lyme Research Center

n  Lyme Disease Association

n  Minnesota Lyme Association

n  Tick Encounter Resource Center ¨ 

n  Partnership for Tick-borne Diseases Education ¨ 

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