Understanding Vector-Borne Diseases & Repellents: Key Messages for Prevention

1. The Who/What/When/Where and WHY of Vector-Borne Diseases and Repellents Dana Balchunas, BSN, M.Ed, RN April 19, 2019

2. Why Care about Repellents? • For many VBDs, prevention is the only option • VBDs are becoming more prevalent • TYPES of VBDs are increasing • Personal protection for those at home/traveling

3. Key Messages for Students, Parents and Others • Why personal protection is crucial to prevent bites from mosquitoes and ticks • Proper repellent choices and use • Efficacy • Safety • What to do if you’re bitten

4. Among the Goals… • Encourage parents, medical professionals to think VBD as a potential when they see flu-like symptoms • Train students/parents/others on proper repellent use • Help school families to be knowledgeable about VBDs and prevention wherever they are

5. Learning Outcomes • Regulation and use of EPA-registered repellents • Safety and efficacy information • Proper application • Urban legends • Messages that work • Dealing with special audiences • Anti-vaxxers • English as second language communities • Those afraid of chemicals

6. Ticks • “The Swiss Army knife of disease vectors” (National Academy of Sciences) • Deliver bacteria, protozoans, viruses • Around since the Jurassic era • Major factor in illnesses worldwide • Are opportunistic • They do not fall from trees…are in knee-high vegetation • Survive frigid climates

7. Tick Statistics • 700 hard tick species worldwide • Of these, 241 are Ixodes • 80 in USA, 4 exotic • 20 species of hard ticks in Oregon, but only four prey on humans • Western black-legged tick • Rocky Mountain wood tick, • American dog tick • Pacific Coast tick. • Multi-year life span—all phases can be infected Tick populations are expanding

8. Seasonality • Spring/Summer are peak seasons but there’s year-round activity • Illnesses in “off season” reported November to March 2018-2019

9. Areas of Concern in Oregon • West of the Cascades at lower elevations • Western Deer Ticks • Co-infected with Lyme, anaplasmosis, Ehrlichia Southern Oregon • Miyamotoi—causes relapsing fever • Western Deer ticks • Co-infected with Lyme (3.5%) • Jackson County 7% are infected • One human case confirmed • Eastern Oregon • American dog ticks vector Rocky Mountain Spotted Fever

10. Reported Cases of Lyme Disease Lyme: 95% of cases from 14 states Cases in OR have doubled

11. Only the Females Bite

12. Most Common Symptom • Onset 7-14 days after attachment • Bull’s eye • Painless, doesn’t itch • Identified in 60-80% of cases • Usually no associated symptoms

13. Atypical Erythema Migrans Smith RP et al. Ann Intern Med 2002

14. Babesiosis • Can occur in isolation or as a co-infection • Spread by Ixodes ticks (Deer ticks) • Transmission via blood transfusion Reported cases of Babesiosis, 2014

15. Human Ehrlichioses By County 2000–2013 Anaplasmosis (HGA) Ehrlichiosis (HME) MMWR Recommendations and Reports / May 13, 2016 / 65(2);1–44

16. Lone Star Ticks are Aggressive Biters Not in Oregon yet but already in Southern California http://www.cdc.gov/stari/geo/

17. Southern Tick Associated Rash Illness (STARI) • NOT bacterial • Pathogen as yet unknown • Same symptoms as Lyme • Also called Masters’ Disease

18. Spotted Fever Rickettsioses • Rocky Mountain Spotted Fever • R. parkeriPacific Coast tick fever • Rickettsial pox Incidence of SFR by County, 2000-2013

19. Cases of SFR, 1993-20176000 vs 30,000 annually for Lyme http://www.cdc.gov/rmsf/stats/

20. Rocky Mountain Spotted Fever • Primarily the American dog tick—found across the U.S. • Vertical transmission for 6 generations=130 quintillion infected ticks from birth • >50% recall prior tick encounter • Tick attachment >6 hours required for injection of bacteria

21. Rocky Mountain Spotted Fever • Symptom onset 7 days (range, 2-14 days) after tick bite • Reported throughout the lower 48 • FIVE states account for 60%+ of all cases • NC, OK, AR, TN, MO • PRESENT IN OREGON

22. RMSF RASHEarly (d2-4) Late (>day 4)

23. Case Fatality Rate, RMSF2008-2013 Children <10 years =6% of RMSF diagnoses, but 22%of RMSF deaths “If you don’t treat by Day 5, they are DEAD by Day 8”—CDC MD Before antibiotics, fatality rate was 80% for all cases

24. Colorado Tick Fever—Oregon Makes the News • Virus, no cure • Transmitted by Rocky Mountain Wood ticks • Found throughout western USA and Canada • HIGH ALTITUDES—4-10,000 ft (ASL) • Grassy areas near sage brush • Febrile illness, non-specific symptoms, leukopenia • 30% of patients require hospitalization • Usually 1 case annually—in 2018 there were 4 • Three suspected cases—2 were children • Pathogen circulating in central Oregon • May-June are active periods but likely year round

26. Co-Infections Compound the Risk • Deer Ticks • Anaplasmosis • Babesiosis • Borrelia Miyamotoi • Lyme • Powassan • Lone Star Tick • Ehrlichiosis • Heartland • STARI • Tularemia • Alpha-gal • American Dog Tick • RMSF • Tularemia • Gulf Coast Tick • Rickettsia Parkeri • Maybe others?

27. What’s Powassan All About? • Viral—so not treatable with antibiotics • Fatal in 10% of patients • 50% have chronic neurological issues afterwards (similar to WNV encephalitis) • TICK ATTACHMENT TIME FOR VIRAL TRANSMISSION IS 15 MINUTES • Most other tick-borne diseases have a 24-36 hour “window” before disease transmission • No vaccine, no cure • Rare, but now being studied

28. Powassan Virus Neuro-invasive Disease Powassan virus neuroinvasive disease cases reported by year, 2007-2016 http://www.cdc.gov/powassan/statistics.html.

29. B. miyamotoi hard tick relapsing fever (OREGON!) Heartland virus Ehrlichia.muris-like organism Babesia MO-1 R. parkeri and other spotted fever group Rickettsioses Bourbon virus AND THE LONGHORN TICK is capable of vectoring diseases in other parts of the world…stay tuned—9 states, Other Emerging Tick-borne Infections

30. Tick Messages • ALWAYS USE REPELLENT • Let clothing be a barrier • Use permethrin on clothing • When coming inside, put clothing into the dryer on high for 20 minutes • Do a tick-check when you’re in the shower • Check all nooks and crannies • Look for moving freckles • Nymphs emerge in early Spring…they’re one of the most dangerous life-forms—hard to spot, can be infected vertically (from mother)

31. Tick Removal What NOT to do… • Burn it (gasoline, kerosene) • Smother it (petroleum jelly) • Poison it (fingernail polish) • Annihilate it (hot match tip) • Crush it • Use Dove soap What TO DO REMOVE the tick ASAP Time is of the essence Clean wound area with soap and water, antiseptic Put the tick in alcohol to kill it

32. TESTING FOR TICK-BORNE DISEASES • Blood testing not accurate for 45+ days • Results are often confounded by PREVIOUS bites • Physicians should treat on presumption of a tick-borne disease when there are symptoms • Many ID experts tell us this treatment with antibiotics is a good diagnostic tool • If symptoms persist after antibiotics, they look for another diagnosis • Some issues with Western blot test interpretation lead to erroneous diagnoses • of Lyme

33. MD and Parent Messages:Treatment For Tick-borne Diseases • If the child is symptomatic, DO NOT wait for test results • Doxycycline is AAP’s and CDC’s recommendation • National survey 2012 • 35% of providers would not give to patients younger than 8 years old due to concern for dental coloration KEY MESSAGE: FOLLOW AAP/CDC GUIDELINES AND GIVE DOXYCYCLINE REGARDLESS OF THE PATIENT’S AGE

34. Not all Tick-borne Disease is Infectious….

35. Tick-Associated Red Meat AllergyLone Star Ticks are the Culprits • Galactose-alpha 1,3-galactose (alpha gal) present in tick saliva and red meat • Reaction to meat consumption • Symptoms: • Hives or skin rash • Nausea, stomach cramps, indigestion, vomiting, diarrhea • Stuffy/runny nose, sneezing • Bronchospasm • Headaches • Anaphylaxis

36. Treatment Alpha-Gal Allergy

37. Comments about Ticks from Medical Professionals • “We never thought about tick-bites for this patient”—Grand Rounds, KC hospital • Patient age 17 died of Ehrlichiosis • “The patient did not have a rash”—RMSF patient • “We did not ask where the family had been…” • Indiana medical team…toddler died after camping, was undiagnosed until it was too late. • NJ—Medical professionals don’t realize there’s more than Lyme disease to worry about • There should be 1 case of Ehrlichiosis for every 2 Lyme cases • NJ healthcare providers in Monmouth found 2 vs. 439 Lyme cases diagnosed

38. Message Summary • Lyme is most common, but regional Co-infections occur • Consider Ehrlichioses and Rickettsioses • Nonspecific febrile illness • Spring/summer/fall • Potential tick exposure • Rash may be a clue (but often absent) • Don’t wait for lab confirmation • Early treatment may be LIFE saving • Doxycycline for ALL ages

39. Landscaping Recommendations • Kirby Stafford, PHD, CT tick expert • Recommends “borders” at edge of the woods with gravel/wood chips/mulch to deter ticks from moving into your yard/school property • Keep grass low • Avoid having knee-high vegetation on the edge of yard, playgrounds, athletic fields (ticks use it for “questing”)

40. Landscaping Ideas to Help Deter Ticks

41. Yard Design

42. Mosquitoes • 174 species in the U.S. • Texas has 85 • WVA has 24 • NYC has more than 50 • NJ has 63 • Oregon has 50

43. Oregon Mosquitoes Vector Important Illnesses • WNV in eastern Oregon • Farming area, lots of irrigation and breeding spots • St. Louis Encephalitis • Cache Valley virus—rare in humans, see in animals where it causes abortion and stillbirth • Western Equine Encephalitis in Southern Oregon

44. West Nile Virus in Oregon • Oregon began surveillance programs in 2001 • WNV first identified in humans, birds and horses in 2004 • 2006 was the peak year for human WNV human cases with 73

45. History of WNV in Oregon • From 1999 – 2017 178 human cases • 38 were neuroinvasive • Incidence of human WNV disease was low in Oregon in 2018

46. West Nile Virus Testing and Surveillance • The Oregon State Public Health Laboratory performs confirmatory testing of WNV human infection • 13 vector control districts (VCDs) in Oregon collect, identify, and test mosquitoes and dead birds for WNV

48. Mosquitoes • Behaviors and biting differ by species • WNV night time biters (Culex pipiens and others) • The 4 D’s: dress, dawn/dusk, defend (with repellent), and drain standing water

49. West Nile Fever

50. West Nile in Children--US • 34% of cases reported to CDC in kids are neuroinvasive (N=2397 1999-2016) • Same incidence as in all other age groups • Adults present with encephalitis, kids with meningitis in the more severe cases • Fatality rate in older adults is 14%...1% in children • More cases WNV in kids than for all ages for SLE, LAC, EEE, and WEE combined! • Pediatric WNV-Associated Neuroinvasive Disease: A Review of the Literature. Herring et al. Pediatric Neurology 2018.07.019