Ticks and Lyme Disease Know the Bug Know the Bite Know What To Do Dr. Paula Stewart Medical Officer of Health Leeds, Grenville Lanark District Health Unit June 5, 2015

Know the Bug Black-legged tick (Ixodes scapularis) • Likes sandy soil, bushy wooded area, hardwood trees, rivers, boggy areas • May carry bacteria that causes Lyme disease American dog tick • Likes long grassy areas • May carry organisms that causes Rocky Mountain spotted fever and Tularemia

Ixodes scapularis Black Legged Tick

Tick Activity in Ontario • Ixodes tick established along the northeastern seaboard of the United States, and New York State • Long Point and Point Pelee areas of Ontario (since the early 1990s) • Identified in the 1000 Islands region of Eastern Ontario in 2006 • Expansion in Eastern Ontario – All phases of life cycle

Surveillance of Ticks 2009 - 2013 About 20% test positive

Tick submissions by home address. The red dots are ticks that tested positive for Borrelia and the yellow were negative. A total of 102 tested positive out of 448 submissions (22.8%), 2013.

Red dot positive tick Yellow dot negative tick

Know the Bug: Migration

Know the Bug Lyme Disease Transmission Cycle • Larvae and nymphs become infected with the bacteria that causes Lyme Disease when they feed on infected small animals (reservoir for bacteria) • The bacteria remain in the tick as it develops from larva to nymph or from nymph to adult • Infected nymphs and adult ticks then bite and transmit the bacteria to small rodents, animals, and humans

Lyme Disease Transmission Cycle

Know the Bug • Ticks cannot fly, they do not jump and do not move large distances along the ground • Typically seek a host by climbing vegetation (such as grass, bushes or shrubs along forest edges), and wait for a suitable host to come in contact with them – Most ticks require from 3 to 7 days to feed fully – Once engorged, they drop from the host (animal/person)

Know The Bite • Ticks attach to a host via their mouthparts and slowly feed upon their blood for several days – When ticks bite, they may secrete or regurgitate small amounts of saliva that contain neurotoxins (anesthesia)

• Bacteria in gut changes so it can survive the tick’s saliva – Takes at least 24 hours – Bacteria cannot be passed to host until this occurs through saliva regurgitation

Fed vs. Unfed

Health Unit Prevention Strategies • Public Education • Communication with area Doctors and Hospitals • Press releases • Posters • Advertising (print & radio) • Tick ID cards

Know What to Do Protect yourself from tick bites • Stay on paths in brushy, wooded areas • In areas that are known to have ticks:  wear light-coloured clothing –easier to see ticks  wear long pants,  a long-sleeved shirt,  high socks (with pants tucked tightly under the socks)  wear boots/shoes, not sandals  Use a repellent Icaridin or DEET no more than 30% for adults and 10% for children around your pant legs and shoes, and re-apply every 2 hours (avoid your face and any cuts)

Know what to Do Protect Yourself from tick bites Tick check Take a quick shower which may help to remove a tick that hasn’t attached itself Put clothes in hot dryer Check and remove ticks from pets

Reduce Ticks Around Your Home • Ticks prefer to live in humid, wooded areas. • Keep the grass in your yard mowed. • Remove brush and fallen leaves from the edges of your property, especially if your yard is bordered by woods or fields of tall grass. • A border of gravel or wood chips that creates a physical separation between lawns and wooded areas will help reduce the movement of ticks from their natural habitat into your yard.

Reduce Ticks Around Your Home • Clean up areas under and around bird feeders, to reduce the attraction of small critters such as mice and voles. These mammals help to transport ticks and are necessary hosts for ticks to complete their life cycle. • Place children’s play structures away from wooded areas to avoid exposure to ticks

Know What To Do If You Spot a Tick • Don’t squeeze the tick or try to burn it off or put anything on it • Grasp the tick by the head as close to your skin as possible. • Pull it straight out, gently but firmly. • Use tweezers or tick twister if possible • Clean and disinfect the bite area

Know What to Do Complete Removal of Tick

Incomplete Removal of Tick

Ensure you remove the tick completely

Know What to Do • Consult health care provider if the tick has been on for > 24 hours and is engorged – may recommend prophylaxis • Mark the date when tick removed and monitor for symptoms within three days to a month or so after the tick bite

Know What to Do Reduce your risk of contracting Lyme Disease • Not all tick bites will result in disease • It is not the bite of the tick, but the bacteria (Borrelia burgdorferi) in the tick's saliva that causes Lyme disease • The tick must attach and feed on a human for 24-36 hours before the organism is transmitted (this amount of time is needed for the bacteria to travel from the tick’s gut to its salivary glands). Consult your health care provider if the tick has been attached for 24 hours or longer • Checking yourself when you come in from the outdoors and prompt removal of ticks will reduce your chances of contracting Lyme Disease

Lyme Disease • Early localized disease – (less than 30 days from exposure)

• Early disseminated disease – (weeks to months after exposure)

• Late disseminated disease – (weeks to years after exposure)

Lyme Disease • Suspect and confirmed cases of Lyme borreliosis must be reported as soon as possible on the appropriate form which can be faxed to LGL Public Health. • See the notification form on the Reportable Disease Toolkit (Health Professional/ToolkitLyme Disease)

Prophylaxis • One dose of doxycycline 4mg/kg to 200 mg. age 8+ • Recommended in LGL with > 20% prevalence of bacteria in ticks • Tick engorged, attached for >24 hours • Within 72 hours of tick bite

Early Localized Lyme Disease • Three to 30 days, usually 1 to 2 weeks, from exposure • Erythema migrans (EM) greater/equal to 5 cm in diameter, fever, Malaise, Headache, Myalgia, Neck stiffness, Fatigue, Arthralgia • Differentiate from early redness at bite site < 5 cm • Treatment – see RD Toolkit

Early Disseminated Lyme Disease • Weeks to months after exposure • Multiple EM, cranial nerve palsies (Bells’ Palsy), lymphocytic meningitis, conjunctivitis, arthralgia, myalgia, headache, fatigue, carditis (heart block) • Treatment – see RD Toolkit

Late Disseminated Lyme Disease • Weeks to years after exposure • Arrhythmias, heart block, myopericarditis, peripheral neuropathy, meningitis, encephalopathy (i.e., behavior changes, sleep disturbance, headaches), recurrent arthritis affecting large joints (i.e., knees), fatigue • Treatment – see RD Toolkit

Diagnosis and Testing • Diagnosis of localized Lyme Disease based on clinical symptoms, and the likely hood of exposure to risk factors i.e., ticks • Laboratory testing of a persons blood plays a role in supporting the diagnosis – highly sensitive if arthritis present – Antibodies appear 2-4 weeks after the bulls- eye rash • Blood tests performed by the Public Health Lab include ELISA test then Western Blot if ELISA positive

• No benefit to testing tick

Statistics for Reported Lyme Disease Reported Human cases of Lyme Disease in LGL 2013

23 confirmed and 24 probable

Update on Immunization of School Pupils Act

Requirements Children/youth attending primary and secondary school in Ontario must have either proof of immunization or exemptions against the following diseases: – – – – – – – – –

diphtheria tetanus polio measles mumps rubella meningococcal disease -- on or after 1 yr of age & again in grade 7 pertussis (whooping cough) varicella (chicken pox) – for children born 2010 or later (the last three new for the 2014/15 school year)

Vaccine timing • If vaccines are given outside of recommended intervals, parents will receive notice from HU requesting re-immunization • The first dose of MMR must be on or after 1st birthday. – An MMR given before the first birthday will not count as one of the two required doses.

• 4-6 yr Tdap-IPV booster on or after 4th birthday. • MenC-C on or after the first birthday

Medical exemptions • A medical reason why a child/teen should not be immunized

– Statement of medical exemption must be completed by a physician or nurse practitioner for the parent to provide to the public health unit. – Part of an insured service and cannot be billed to a client. – Based on any reason determined by the health care provider. – Permanent or limited to a specified period of time.

• The statement of medical exemption form is available at: www.forms.ssb.gov.on.ca

Medical Exemptions • Evidence of immunity against measles, mumps, or rubella requires laboratory confirmation of immunity or infection. • Evidence of immunity against varicella (chickenpox) requires either:

– diagnosis – verification of a history of varicella or herpes zoster infection > 12 months of age by a health care provider using clinical judgment • If varicella disease occurred before 12 months of age should be immunized with two doses of varicella-containing vaccine after 12 months of age.

– laboratory confirmation of immunity or infection.

Meningococcal Vaccine • Infant dose on or after one year of age – Men-C-C (monovalent C) – Assessed at school entry

• Menactra (quadrivalent ACYW)

– Required to be immunized for school attendance. – Students Grade 7 given at Public Health school clinics – Students grade 8 to 12 at Public Health community clinics by appointment. • Brockville, Gananoque, Kemptville, Smiths Falls, Perth, Almonte

Panorama • New provincial immunization database • Centralized student immunization records – Helps assessing immunization of transferred students • Exploring Public Immunization Portal for parents to enter immunization information for review by Public Health. • For more immunization information, go to: http://www.healthunit.org/immunization/

QUESTIONS?