Ticks and tick-borne diseases in Belgium: recent updates

Ticks and tick-borne diseases in Belgium: recent updates Dr. Ir. Valérie Obsomer

Introduction: incidence in Europe? Reliable data Risk of being bitten by ticks High Medium Low Negligible Nul Erythema Migrant monitored in Austria, Belgium and the Netherlands Incidence per 100000 Methodology Define a level of incidence per level of risk 550 125 30 5 0 Use % of territory covered per risk level, to propose an estimate Europe= 65000 cases detected per year (Hubalek el al. 2009) but 22000 in NL? Incidence is largely underestimated

Other vector ticks Number: estimates of annual cases Number of cases per year: 1 175 825 Incidence per year: 201/100000 Number of seropositive: 39 029 579 (7% of European population) Risk level (estimated incidence) (Quartiles) Low (0-37/100000) Medium (38-120/100000) High (121-315/100000) Very high (316-605/100000) No info

Analysis and recording of existing data about 1. Ticksin Belgium en Belgique ( > 80000 ticks recorded on 1624 sites) http://www.parasitesandvectors.com/content/6/1/190 2. Pathogens 3. Incidence of tick-borne diseases Preliminary results from the public survey on bites and symptoms 1500 first answers: general statistics www.tekentiques.net Objectives Knowledge updates Demonstration of seriousness of the situation in our country Ideas for solutions In Belgium? Information source:

Table of contents 1. Ticks 2. Pathogens 3. Human vector contact 4. Human cases 5. Symptoms and diagnosis 6. Conclusion

1. 1 Ticks: which species? >14 species in Belgium 2 have an impact on human health: known vectors, infected, bite humans, frequent on cats and dogs, everywhere in Belgium I. ricinus Quest for host on the vegetation The most frequent on animals and human More than 90 microorganism found in that species Parasite most vertebrates: increase circulating pathogens between species I. hexagonus Present in nest or burrow Present in urban gardens – surface nest are a risk for gardening The other species contribute to circulating pathogens in the wildlife

Recording of existing data (Obsomer et al, 2013) Any region Locally very abundant Imperfect recording 1.2. I. ricinus distribution Public Health- Belgium Pffocial report EFSA EU : 2010 Rare? Only local?

Ticks have been present for years in the country but at low abondance 64% more ticks in 2013 in the Netherlands (tekentradar) Increase in Belgium identified by nature professionnals and the population Public survey: started around 1990, or only in 2013 in other regions More and more locations present abondant population of ticks Documented abroad If this increase is recorded in 2013 in some region: is this just happening now? The risk of being bitten depend from abundance Why an increase? Nothing certain Climate warming Land cover change More efficient tick subspecies Increase in cervid and wildboar population Disequilibrium in species- predator-hosts Invasive species: ticks or hosts 1.3. More ticks There is an increase in the number of ticksI. ricinus in nature

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Lyme, anaplasmose and rickettsies pathogenic for human are found all over Belgium in ticks collected on cats and dogs or the vegetation Babesiosis more locally around Rochefort (Claerebout et al, 2013) Pathogens found in Belgium – Public health: no systematic study Pathogens found in our species abroad – potentially present in Belgium 6 or 7 Borrelia species found in Belgium (Heylen et al, 2013) 95 micro-organisms found in I. ricinus of which at least 45 are pathogenic Borrelia myanmotoi found at the border in France and the Netherlands To improve Classical molecular technique to seach for pathogens in ticks (QPCR) will find only what is looked for New techniques exist (NGS) which analyse all DNA that is found in ticks and search to which pathogens it could belong: more systematic 2. Pathogen Introduction – Tiques –Pathogènes – Transmission/contact – Maladies – Conclusions 7/34

2.1 Pathogens – distribution and diversity (Claerebout et al, 2013)

2.2. Abondance of Borrelia b s.l. – agent of Lyme disease

2.3. Diversity of Borrelia b s.l. – agent of Lyme disease Toutes les borrélies pathogènes sont présentes dans les tiques trouvées sur les mésanges

11 out of 14 tick species carry Borrelia Ixodes ricinus bites all vertebrates and make pathogens circulate between species Bird 30% of bird specific ticks are infected by Borrelia Bétail 30% of Walloon cows are seropositive for Borrelia L’anaplasmose causes abortus in cows in the Flanders Babesia causes mortality in calves around Rochefort towards the German border Other animals that carry Borrelia in Belgium ( and ticks) Rabbit, squirrels, dog, horse, hedgehogs, blackbirds, Great tit, Some species influence presence of ticks and borrelia The lizard seems to reduce Borrelia presence in ticks Rabbits seem to reduce tick population Ants, chicken and birds seem to eat ticks Large mammals feed hundreds of adult ticks ready to lay eggs ( cervids, wild boar) 2.4. Pathogens are all around us in nature Ticks

3. Transmission and contact Engorged adult ticks ( which alread have fed) are easy to see. Because people see such large ticks on their dogs or cats, they do not think that tick and particularly nymphs are so small and don’t look proerly for tick bites on their body eggs Very small – 6 legs • Eat once on a host, then fall off and change into nymph • Infected only by pathogens received from the adult female: 4% borrelia (25% for Hexagonus), Babésia Host 1 Les nymphes sont petites ! The most dangereous because hard to see and very infected • Have many pathogens • taken on the first host (rodent, bird, cervid, ...) • Eat once on a host then fall off and change into adults Host 2 Quite easy to see on human • Carry even more pathogens Host 3 Ixodes ricinus: life cycle

Number of bites since birth: 1 to 750 times including 100 times/year (forest workers) 41% have been bitten 5 times or more, 31% 10 times or more and 28% once 37% of people ( out of 112 answers) do not know that ticks can wander around on the body before biting – they check only exposed parts Ticks might bite everywhere on the body but particularly hot places. 38% of tick bites are located in areas difficult to check: hair, rear neck, back, between the buttocks, on the genitals, the belly button, the back of the knee. 32% of the people are bitten in their garden or at school 5.6% of transmission route identified (1264 answers) are attributed to other than ticks including other undetermined insect (26 cases), deer flies (14 cases), from mother to child (12 cases), mosquitoes (5), flea (4), other (4), chiggers (aoutat) (2), blood transfusion (2), spider (1), sexual transmission (1) Results from the survey: Transmission by deer fly in Belgium is documented in the literature as well as transmission from mother to child in utero

4. Human cases in Belgium Anaplasma 7.4% of people positive for Borrelia also have anaplasma (Guillaume et al, 2002) 15% of patients negative for Borrelia and who have symptoms are positive for anaplasma (Heyman et al, 2003) Only 300 tests for anaplasma required – while it is very abondant in ticks Borrelia Example year 2010 INAMI Total tests : 229250 INAMI Number of persons ( because IgG/igM) tested First Line Test: 129000 INAMI Erythema migrans: 90 per 100000 *population*63% Lyme with EM = 15000 cases Vigie laboratory: 1116 cases Reference laboratory positive lab tests: 500 cases Other Only 10 tests for rickettsia required – while it is very abondant in ticks No recorded tests for Human Babesia Introduction – Tiques – Pathogènes – Transmission/contact – Maladies – Conclusions 21/34

4.1. Borrelia in the Netherlands: 22000 cases/ year • - Association have alerted the government • - A web site record tick bites and now also erythema migrans (www.tekenradar.nl) • Regular monitoring of the number of Erythema migrans and tick bites: a questionnaire every 4 years sent to 8000 general practitionners • A dedicated service at the governmental level on vector borne diseases ticks = Bites = Erythèmes Prevention measure: take rapidly ticks off the skin: NOT ENOUGH TO STOP THE INCREASE IN THE NUMBER OF CASES (Public Health Institute NL - Sprong et al. 2013) New research: treat all the tickbite by 1 day antibiotic Introduction – Tiques – Pathogènes – Transmission/contact – Maladies – Conclusions 18/34

The tests cannot detect all the Belgian Lyme species ( 2 to 5 according to the lab) Only positive second line tests (western blot) for some voluntary laboratories Very few doctors require a second test if the first test is positive ( elisa) Many people are still tested at the EM stages – which gives false positive 4.2. Official numbers in Belgium Inadequate monitoring = no data Number of cases per year: 500 or 1500 cases according to ISP, not the same distribution Labo vigies Reference labs ? Most cases are not accounted for Introduction – Tiques – Pathogènes – Transmission/contact – Maladies – Conclusions 19/34

0 to 25 per 100000 25 to 50 per 100000 50 to 100 per 100000 100 to 200 per 100000 >200 per 100000 Erythema migrants survey, questionnaire sent to 161 medical doctors: 15000 cases From 2004 to 2009: 8% increase in 4 years 2005 2009 2004 2009 1994 2001 2005 2009 2009 2009 2009 2009 Introduction – Tiques – Pathogènes – Transmission/contact – Diseases – Conclusions 20/34

2005 ( Hofhuis) 2009 ( Hofhuis) Erythema migrans from GP Network ( 8000 GPs) Erythema migrans from GP Network ( 8000 GPs) ELISA Blood test IgG ELISA Blood test IgG 2006 ( INAMI) 2009 ( INAMI) Introduction – Tiques – Pathogènes – Transmission/contact – Maladies – Conclusions 22/34

Table of contents 1. Ticks 2. Pathogens 3. Human vector contact 4. Human cases 5. Symptoms and diagnosis 6. Conclusion: actions to take

5. Diagnostic and Symptoms Because diagnostic tests are currently unreliable, the diagnostic should be based on symptoms But doctors do not agree about which symptoms is related to Lyme and co-infections Existing list of symptoms are built based on Borrelia species present in the USA or in Germany, the borrelia species found in Belgium influence the type of symptoms found in our country and this should be analysed locally ( per country) Many symptoms are not specific to Borrelia ( such as fatigue, back pain, head aches) and are thus difficult ot interpret. But sometimes those are the only symptoms and should thus be considered in diagnostic More than 80 symptoms are listed in the public survey. The frequency of those symptoms in the population with or without Lyme is calculated Introduction – Tiques – Pathogènes – Transmission/contact – Maladies – Conclusions 1/30

39% have been diagnosed for Lyme 65% of people diagnosed for Lyme had an erythèma migrans, which is similar to already available numbers for Belgium (63%- Bigaignon, et al. 1989)

Results available on www.tekentiques.net Introduction – Tiques – Pathogènes – Transmission/contact – Maladies – Conclusions 1/30

Misdiagnosis Participant listed 191 cases of diagnosed diseases which later revealed to be Lyme Borreliosis instead. They are most often related to the nervous system (132), the immune system and infectious diseases (20), the squeleton and skin (18). Fibromyalgia ( including also Tiestze disease, sciatic, cruralgia, nevralgia) and chronic fatigue syndrome ( including also 6 burn out) are two conditions which seems to hide the most misdiagnosis for Lyme disease reach each 18% of the cited misdiagnosis. Other conditions cited 5 or more times include thyroid problems ( including Ashimoto), back pain, multiple sclerosis and more general symptoms such as anxiety, stress and depression which are more difficult to interpret.

Chronic diseases 200 up to 1500 answers

For unclear reason ticks population (pathogens) have exploded to epidemic level Current surveillance systems are inadequate and failed to record the increase Prevention measures are poor and lead to many bites and undiagnosed EM Diagnostic tools are inadequate Doctors disagree about symptoms and treatment: many are left untreated 15000 new cases per year in underestimated Since 2009, the number increased of 50% in the Netherlands In the Netherlands, doctors are trained to identify EM and patients go to the doctors when they have EM. In Belgium most patients do not go to the doctor for a extending spot and many doctors still do not recognise EM According to Pr Zeke ( head of medicine faculty BE), When a mother is actively infected, this results in transmission to the child at 75%, including death of the fœtus, are health problems for the new-borne child including mental disorder ( including autistic problems, heart problems,…) The situation Ticks and Borrelia have been around us for a while

To minimise the problem is the worse option and lead to a catastrophic situation Stop the Ostrich way of handling tick-borne disease Check what’s happening in the Netherlands Good news? There are solutions Vector-borne diseases offer many opportunity for actions Reducing human-vector contact Reducing vectors Introduction – Tiques – Pathogènes – Transmission/contact – Maladies – Conclusions 3/34

Why? Current high level of abondance is not natural High number of tick bites is detrimental for wildlife too (pheasant, blackbird, robin) Transmission of many diseases to wildlife, cattle, domestic animals and humans Priority: reduce ticks presence in places of high contact with humans 37% of tick bites occur in gardens, schools, preschool, public playground 4 tick bites per month on children playing in some garden of Brabant wallon Land management can help reducing: Cut the grass very short Create a dry zone next to forests Impede access to large wildlife mammals Treat domestic animals for ticks Check presence of ticks by dragging a white cloth on the ground More difficult: reduce population in natural area Treat cervids and wildboar with acaricid ( on post ) Reduce population of cervids and wild boars Investigate the use of sheep as mop 6.1. Reducing tick population

Fedor Gassner - RIVM

Better inform the population about ticks Identify tick/ disease hot spot and give the information to the public Ticks – nymphs are very small c They are everywhere in the woods , particularly out of the path Ticks bite directly or wander several hours on clothes and body before biting Preparation before going in ticks area Put repelent if needed ( but unknown which ones are efficient) Put on clothes that makes it difficult for ticks to bite, particularly in places of the body difficult to search for ticks At least: Protect hairs (cap of pirate cap) and the area from the navel to the genital part ( thick underwear with tight elastics going up the navel) Put long sleeves and thick trousers inside socks Inside tick areas Avoid area of abundance an particularly ferns Be careful if you have to urinate in nature – for girls After Take your clothes off as quickly as possible preferably in the bath Wash dierectly your clothes at 60 degrees at least or put in drier Brush your dog before entering the house Check the all body, cumb your hair and take a shower 6.2. Reducing tick bites also in natural settings

Better information on how to take away the tick Do not press on the belly Do not put any product on the tick Better information on symptoms Go to the doctor if you have a extending spot to check if it is EM Go to the doctor if your health deteriorate or if you have some of the symptoms from the list Better diagnostic and treatment for the doctor If EM treat directly with 3 weeks antibiotics without requiring test If persisting symptoms but no EM, test for Borrelia, Anaplasma, Babesia and Rickettsia Keep in mind that tests are uncomplete and miss part of the species present in Belgium: concentrate on the symptoms and clinic Many patients are suffering from tick-borne diseases for sometimes a long period without knowing it – search for those patients to help them 6.3. Better handling of tick bites

6.4. Other Update tick distribution maps to underline risk and trigger better treatment of EM Map borrelia species precisely to help identify symptoms Check number of borrelia in ticks – high numbers can reduce transmission time to a few hours Test directly ticks who have biten the human Build up tests based on species found in Belgium Test prophylactic use of antibiotics such as the Netherlands ONE HEALTH approach: in this context, useful to study and manage tick borne diseases together with veterinarian who faces the same challenges and wildlife managers. Wildlife and environmental management could potentially help reduce number of tick and pathogens

Merci de votre attention Des questions? SVP Diffusez l’enquête ;-) www.tekentiques.net Journée d’info pour les médecins: Lyme sans frontières, le 6-8 juin à Strasbourg Contact: valerie.obsomer@uclouvain.be tekentiques@gmail.com

Ticks and tick-borne diseases in Belgium: recent updates