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CM E Activity Online (See Page 18)
CM E Valid Until June 7, 2021
Ci t y Heal t h I n f or m at i on
Volume 39 (2020) | No 2; 12-18
New Yor k City Depar tm ent of Health and M ental Hygiene
PREVENTI NG, DI AGNOSI NG, AND M ANAGI NG TI CK-BORNE DI SEASES
- Tick-borne diseases among New Yorkers have been trending upward since 2000 with fluctuations from year to
year.
- Most New Yorkers are infected with a tick-borne disease during travel to endemic areas in upstate New York,
Long Island, and surrounding states.
- Locally acquired cases of Lyme disease and babesiosis continue to be reported from Staten Island, and smaller
numbers have been reported from the Bronx.
- Be aware of the types of ticks and tick-borne diseases present in and around NYC, how to diagnose tick-borne
diseases, and where to find guidance on treatment.
Tick-bor ne diseases am ong r esidents of New Yor k City W ith the exception of RM SF, m ost cases of tick-bor ne
(NYC) have been tr ending upw ar d since 2000, w ith diseases ar e associated w ith tr avel outside of NYC,
fluctuations fr om year to year.1,2 The m ost com m only com m only to upstate New Yor k, Long Island,
r epor ted tick-bor ne disease is Lym e disease, follow ed Pennsylvania, Connecticut, New Jer sey, and
by anaplasm osis and babesiosis. Ver y few cases of M assachusetts.2 Not all ar eas of NYC ar e suitable for all
ehr lichiosis and Rocky M ountain spotted fever (RM SF) ticks because of their com plex life cycle that r equir es
ar e r epor ted in NYC.2 desir able habitat and host anim als. How ever , the
blacklegged tick has becom e established on Staten
Island and in the nor ther n Br onx, w her e cases of Lym e
INSIDE THIS ISSUE (click t o access) disease and babesiosis w ithout associated tr avel have
been r epor ted for sever al year s (Box 12).
INTRODUCTION
Tick-borne diseases in New York City (box) The geogr aphic expansion of Lym e disease cases over
TICKS OF CONCERN
the past sever al decades is associated w ith incr eases in
subur ban developm ent and defor estation in the
EDUCATE PATIENTS ABOUT TICK-BORNE DISEASES
nor theaster n United States. The changing landscape
Tick prevention (box)
puts people in close contact w ith host species, such as
Insect repellent (box)
sm all r odents and deer , that enable the spr ead and
How to remove a tick (box) gr ow th of tick populations. Fur ther m or e, changing
DIAGNOSING TICK-BORNE DISEASES clim ate patter ns can alter the natur al envir onm ent and
Lyme disease rash: erythema migrans (figure) long-standing ecological r elationships causing expected
Testing for tick-borne diseases (box) changes in seasonality and location of tick-bor ne
LYM E DISEASE PROPHYLAXIS diseases.3
TREATM ENT OF TICK-BORNE DISEASE
REPORTING
RESOURCES FOR PROVIDERS
RESOURCES FOR PATIENTS
REFERENCES
CONTINUING EDUCATION ACTIVITY
BLACKLEGGED TICK LONE STAR TICK AM ERICAN DOG TICK
City Health Infor m ation Volum e 39 (2020)
TICKS OF CONCERN BOX 2. TICK PREVENTION 10,11
Thr ee m ain ticks of concer n in the nor theaster n Ou t door s
United States ar e the blacklegged tick (Ixodes
- Avoid going through areas with overgrown bushes, grasses,
scapularis), lone star tick (Amblyomma americanum), and lots of dead leaves
and Am er ican dog tick (Dermacentor variabilis).4
- Use insect repellent as directed (Box 3)
The bl ack l egged t i ck tr ansm its the bacter ia that can Clot h in g
cause Lym e disease (Borrelia burgdorferi) and
- Wear light-colored clothing to see ticks more easily
anaplasm osis (Anaplasma phagocytophilum), the
- Tuck pants into socks and shirts into pants
intr aer ythr ocytic par asite that causes babesiosis
- If desired, use products containing 0.5% permethrin on
(Babesia microti), and Pow assan vir us, w hich causes
clothing or shoes (but not the skin) to repel ticks
Pow assan vir us disease.4 In NYC, the blacklegged tick is
Ret u r n in g in door s
pr evalent only in Staten Island and ar eas of the Br onx,
including Pelham Bay Par k and Hunter Island.2 The - Check for ticks
tick is pr evalent in Dutchess, Or ange, Putnam , - in the navel
Rockland, Sullivan, and Ulster counties in upstate New - behind the ears and knees
Yor k .5,6 B. miyamotoi, a spir al-shaped bacter ia distantly - between the legs
r elated to B. burgdorferi, has also been found in - around the waist
blacklegged ticks in the nor theaster n United States. At - in the hairline
this tim e, infection w ith B. miyamotoi is thought to be - in other skin folds
an uncom m on cause of illness, though it is not a
- Immediately remove any attached ticks (Box 4)
r epor table condition so national case counts ar e
- Shower within 2 hours of coming indoors to wash off and
unknow n.7
find any crawling ticks
The l on e st ar t i ck tr ansm its the bacter ia that can - Wash clothing in hot water to kill ticks (if hot water cannot
cause ehr lichiosis (Ehrlichia chaffeensis, E. ewingii).2 be used, tumble dry on low heat for 70 minutes or high
Ehr lichiosis cases in NYC ar e pr edom inantly heat for 40 minutes)
tr avel-associated. The lone star tick is pr evalent on - Place dry clothing in a dryer on high heat for 10 minutes to
kill ticks. Wet or damp clothing might need more time in the
dryer
BOX 1. TICK-BORNE DISEASES IN Pet s
NEW YORK CITY2 - Ask your veterinarian which tick prevention products are
- The number of tick-borne diseasea cases has been best for your pet
increasing over time - Check for ticks on your pet and immediately remove any
- Cases rose from 610 in 2012 to 922 in 2018? a 51% that are found
increase - If you think your pet may have been bitten by a tick and
- Most cases of tick-borne diseases are among residents of they become sick, speak with your veterinarian
Manhattan and Brooklyn, who were infected while traveling Yar d
to endemic areas surrounding New York City
- Trim shrubs and tree branches around your yard to let in
- Surveillance for local transmission of tick-borne diseases more sunlight
found in Staten Island:
- Use gravel or woodchips to define a tick-safe zone around
- Increasing proportion of locally acquired Lyme disease your yard
cases from 31% in 2012 to 64% in 2018b
- Keep playground equipment and outdoor furniture in a
- Increasing number of locally acquired babesiosis cases sunny location, away from yard edges and trees
from 3 in 2016 to 10 in 2018
- Don?t leave out food that attracts deer and other wildlife
a
- Consider hiring a pest management professional
Anaplasmosis, babesiosis, ehrlichiosis, Lyme disease, Rocky Mountain spotted
fever
b
Residents of outer boroughs diagnosed with erythema migrans (EM) April
1?October 31 were interviewed about travel during the 3- to 30-day incubation
period prior to onset. Manhattan residents were excluded as there is no
evidence of local transmission of Lyme disease in the borough; a previous See Resources for Patients for tick-prevention materials
study showed 97% of EM cases reported travel, and there are no established including tick identification and removal graphics
blacklegged ticks in the borough
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13
City Health Infor m ation Volum e 39 (2020)
Long Island and in upstate NY (par ticular ly the low er Ot h er t i ck s include the br ow n dog tick
Hudson Valley r egion), New Jer sey, Connecticut, (Rhipicephalus sanguineus) and the Asian longhor ned
M assachusetts, and Pennsylvania. In NYC, the tick is tick . The br ow n dog tick pr im ar ily feeds on dogs and
only pr evalent in Staten Island and focal ar eas of the can tr ansm it bacter ia that cause canine ehr lichiosis.
Br onx.2 The bite of a lone star tick is associated in som e The Asian longhor ned tick is found in Staten Island and
people w ith the developm ent of an alpha-gal aller gy, the Br onx 2; it has not been show n to tr ansm it hum an
w hich is an aller gy to m am m alian m eat.8 pathogens in the United States to date.9
The Am er i can dog t i ck is found in all bor oughs,
though num ber s have been decr easing over tim e.2 It EDUCATE PATIENTS ABOUT TICK-BORNE
tr ansm its the bacter ium Rickettsia rickettsii, w hich DISEASE
causes RM SF, and the bacter ium Francisella tularensis, Educate patients w ho visit, live, w or k, or tr avel in
w hich causes tular em ia. endem ic ar eas on pr evention of tick bites and
tick-bor ne diseases (Box es 210,11 an d 312,13) and on
cor r ect r em oval of an em bedded tick (Box 410). Ticks
BOX 3. INSECT REPELLENT12,13 ar e m ost active in the w ar m er m onths, fr om M ar ch to
Abou t r epellen t s Novem ber. Advise patients to take pr ecautions against
Repellents last for different amounts of time depending on ticks dur ing these m onths and be aw ar e of signs and
the active ingredient. Generally, the higher the percentage of sym ptom s of tick-bor ne diseases in patients. M ost
the active ingredient, the longer the duration of protection.
infections r esult fr om an undetected tick; ear ly
However, products with more than 30% DEET do not offer
longer protection. Look for repellents with one of the
detection and pr om pt r em oval r educe the chance of
following active ingredients: disease.14 Er ythem a m igr ans (EM )? a r ed r ing-like or
- DEET
- Picaridin
- IR3535
BOX 4. HOW TO REM OVE A TICK10
- Dispose of a crawling tick or an embedded tick that has
- Oil of lemon eucalyptus (also known as PMD)
been removed by wrapping it tightly in tape and throwing it
Not all r epellen t s ar e r egist er ed by t h e En vir on m en t al out or flushing it down the toilet. To save a tick, you can put
Pr ot ect ion Agen cy (EPA). Products with active ingredients it in a container with alcohol or in a sealed bag/container
deemed to pose minimal risk have not been evaluated for
- To remove an embedded tick
effectiveness. Examples of ingredients used in unregistered
repellents include essential oils such as citronella, cedar, - Using pointed-tip tweezers, grab the tick at the point
geranium, peppermint, and soybean where it is closest to the skin (this is the head of the tick);
do not grab the body of the tick, as that can cause the
Repellen t t ips
mouth parts to break off and remain in the skin and
- Use a repellent that is registered with
increase the risk of an infection
the EPA (Resou r ces). Look for the
repellency awareness graphic - Gently pull up on the tick with slow, even pressure to
ease out the mouth parts. After removing the tick, wash
- Follow directions on the repellent?s label your hands and skin with soap and water or rubbing
- Permethrin can be applied to clothing alcohol
and shoes but not to skin - Do not
- Do not spray products directly to your - Handle the tick with bare hands
face; instead, spray your hands and then rub them carefully
- Squash or squeeze the tick
over the face, avoiding the eyes and mouth
- Use petroleum jelly (Vaseline® ), nail polish remover, or
- Ch ildr en heat to remove the tick. These methods can increase the
- Apply the repellent to children?s skin, avoiding eyes, risk of infection
mouth, and hands, and use sparingly on the ears - Advise patients to contact a health care provider
- DEET-based repellents are approved for use on children immediately if they develop fever, aches and pains, or a
- Apply repellent to children aged 2 months and older rash
- Don?t apply oil of lemon eucalyptus to children aged
younger than 3 years See the video ?Tick Prevention: Removal? on the Lyme
Disease and Other Diseases Carried by Ticks page for a
demonstration of correct tick removal
See Find the Repellent That Is Right for You
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City Health Infor m ation Volum e 39 (2020)
expanding r ash (Fi gu r e)? is diagnostic for Lym e for diagnosis of Lym e disease w ithout other signs or
disease and should pr om pt the patient to seek m edical sym ptom s.14 A r ash is som etim es seen w ith
attention. Advise patients to contact you or go ehr lichiosis, par ticular ly am ong childr en, but is r ar e
im m ediately to the em er gency depar tm ent if they w ith anaplasm osis (< 10%). No r ash is seen w ith
develop sym ptom s of fever , headache, confusion, babesiosis or Pow assan vir us disease.4 See Box 515 for
w eakness, vom iting, or difficulty br eathing in the days infor m ation on testing.
follow ing a tick bite. A histor y of a tick bite is not a pr er equisite for
consider ing tick-bor ne diseases for patients w ith
DIAGNOSING TICK-BORNE DISEASES com patible illness, since only a sm all pr opor tion of
Tick-bor ne diseases ar e associated w ith nonspecific patients diagnosed w ith these diseases r ecall being
and var iable signs and sym ptom s that m im ic vir al bitten by a tick .16 Recent tr avel dur ing w ar m er m onths
illness, such as chills, acute fever , headache, and to upstate New Yor k, Long Island, and other par ts of the
myalgias. Labor ator y findings include Nor theast, M id-Atlantic, and Upper M idw est should
thr om bocytopenia, anem ia, and elevated liver values.14 pr om pt consider ation of tick-bor ne diseases.17
W hile not com m on, coinfection w ith a second For m or e detailed guidance, see Tickborne Diseases of
tick-bor ne disease pathogen can occur fr om a single the United States: A Reference M anual for Healthcare
tick bite. Rashes occur in 70% to 80% of RM SF patients.4 Providers.
EM (Fi gu r e) is r epor ted am ong 60% to 80% of
patients w ith Lym e disease.4 An EM > 5 cm is sufficient
FIGURE. LYM E DISEASE RASH: ERYTHEM A M IGRANS
Sources: Top row, CDC Public Health Image Library; bottom row (left to right), Bernard Cohen, Robin Stevenson, Taryn
Holman
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15
City Health Infor m ation Volum e 39 (2020)
LYM E DISEASE PROPHYLAXIS TREATM ENT OF TICK-BORNE DISEASE
Antibiotic pr ophylaxis m ay be used for Lym e disease M ost tick-bor ne diseases ar e tr eatable w ith
but not for other tick-bor ne diseases. A single dose of antim icr obials. See Tickborne Diseases of the United
doxycycline (200 m g for adults or 4.4 m g/kg for States: A Reference M anual for Healthcare Providers for
childr en of any age w eighing less than 45 kg) m ay be guidance.
offer ed to patients to r educe the r isk of Lym e disease
w hen all of the follow ing cir cum stances exist 14: REPORTING
- the patient has spent tim e in a Lym e-endem ic Lym e disease, babesiosis, anaplasm osis, ehr lichiosis,
r egion, spotted fever gr oup r ickettsioses, tular em ia, and
- the tick has been attached for ? 36 hour s, based on Pow assan vir us disease ar e r epor table in NYC. Repor t
engor gem ent or histor y, confir m ed tick-bor ne diseases w ithin 24 hour s via
- pr ophylaxis can be star ted w ithin 72 hour s of tick NYCM ED.
r em oval, For m or e infor m ation, see Provider Reporting: How to
- the tick can be r eliably identified as I. scapularis, Report Diseases, Events, and Conditions to the NYC
- the patient does not have any contr aindications to Health Department.
tr eatm ent w ith doxycycline.
BOX 5. TESTING FOR TICK-BORNE DISEASES15
Optimal diagnostic tests depend on timing relative to symptom onset and disease
- Polymerase chain reaction (PCR) tests for anaplasmosis and ehrlichiosis are most sensitive during the first week of illness
- Serologic assays may lead to false-negative results when performed in the 1 to 2 weeks following illness onset due to a delayed
antibody response. Additionally, antibodies may persist for several years, and if detected, may not be indicative of current
illness
- With anaplasmosis, ehrlichiosis, and Rocky Mountain spotted fever (RMSF), repeat serologic testing on a convalescent specimen
after 2 to 4 weeks; a fourfold or greater rise in antibody titers confirms a diagnosis
- False-positive serologic results may occur with RMSF. Antibodies to spotted fever group rickettsioses (SFGR) other than RMSF
may reflect past exposures to a wide variety of SFGR species, including Rickettsia akari, and not reflect incident cases of RMSF.
R. akari is the causative agent of rickettsialpox, testing for which is available at the Centers for Disease Control and Prevention
(CDC)
- The CDC recommends a two-step test for Lyme disease. If the first antibody test is negative, no further testing is recommended.
If positive or indeterminate (or equivocal), perform the second Western blot test. The overall result is positive only when the
first and second tests are positive (or equivocal)
Tick t est in g
Testing ticks for diseases is generally not recommended because
- Results may be unreliable; laboratories that test ticks are not required to meet the same quality standards as clinical
laboratories
- A positive test does not mean that the tick was attached long enough to transmit the pathogen
- A negative test might provide a false sense of security as a patient might have unknowingly been bitten by a different tick
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City Health Infor m ation Volum e 39 (2020)
RESOURCES FOR PROVIDERS
Tick -bor n e diseases Disease r epor t in g
- Tickborne Diseases of the United States: A Reference Manual for - Provider Reporting: How to Report Diseases, Events, and
Healthcare Providers Conditions to the NYC Health Department
RESOURCES FOR PATIENTS
In sect r epellen t Addit ion al r esou r ces
- Find the repellent that is right for you: https://www.epa.gov/ - Centers for Disease Control and Prevention. Ticks:
insect-repellents/find-repellent-right-you https://www.cdc.gov/ticks/index.html
- Insect repellent safety: https://www1.nyc.gov/site/doh/ - Tick bite: what to do
health/health-topics/insect-repellent-safety.page - What you need to know about Asian longhorned ticks? a
NYC Healt h Depar t m en t new tick in the United States
- Ticks: https://www1.nyc.gov/site/doh/health/health-topics/ - Tick Encounter Resource Center: https://tickencounter.org/
ticks.page - The Northeast Regional Center for Excellence in Vector-
- New York City tick ID and removal wallet card (with tick Borne Diseases: https://www.neregionalvectorcenter.com
identification and removal illustrations) - New York State Department of Health. Tick prevention:
- Ticks taking over? Take back your yard removal (video): https://www.health.ny.gov/diseases/
- All about ticks: a workbook for kids and their parents communicable/lyme
REFERENCES
1. Rosenberg R, Lindsey NP, Fischer M, et al. Vital signs: trends in reported 8. CDC. Alpha-gal allergy. https://www.cdc.gov/ticks/alpha-gal/index.html.
vectorborne disease cases? United States and territories, 2004?2016. MMWR Accessed April 21, 2020.
Morb Mortal Wkly Rep. 2018;67(17):496-501. https://www.cdc.gov/mmwr/ 9. CDC. What you need to know about Asian longhorned ticks? a new tick in the
volumes/67/wr/mm6717e1.htm. Accessed April 16, 2020. United States. https://www.cdc.gov/ticks/longhorned-tick/index.html.
2. New York City Department of Health and Mental Hygiene (NYC DOHMH). Accessed April 21, 2020.
Advisory #12: Tick-borne disease. June 3, 2019. https://www1.nyc.gov/assets/ 10. NYC DOHMH. Ticks. https://www1.nyc.gov/site/doh/health/health-topics/
doh/downloads/pdf/han/advisory/2019/tick-borne-disease.pdf. Accessed ticks.page. Accessed April 21, 2020.
April 16, 2020.
11. CDC. Ticks. https://www.cdc.gov/ticks/index.html. Accessed April 21, 2020.
3. Centers for Disease Control and Prevention (CDC). Lyme and other tickborne
12. NYC DOHMH. Insect repellent safety. https://www1.nyc.gov/site/doh/health/
diseases increasing. https://www.cdc.gov/media/dpk/diseases-and-
health-topics/insect-repellent-safety.page. Accessed April 21, 2020.
conditions/lyme-disease/index.html. Accessed April 21, 2020.
13. United States Environmental Protection Agency. Regulation of skin-applied
4. CDC. Tickborne Diseases of the United States: A Reference Manual for Healthcare
repellents. https://www.epa.gov/insect-repellents/regulation-skin-applied-
Providers. 5th ed, 2018. https://www.cdc.gov/ticks/tickbornediseases/
repellents. Accessed April 21, 2020.
TickborneDiseases-P.pdf. Accessed April 21, 2020.
14. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment,
5. New York State Department of Health (NYS DOH). Deer tick surveillance:
treatment, and prevention of Lyme disease, human granulocytic
adults (Oct to Dec) excluding Powassan virus: beginning 2008.
anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious
https://health.data.ny.gov/Health/Deer-Tick-Surveillance-Adults-Oct-to-
Diseases Society of America. Clin Infect Dis. 2006;43(9):1089-1134.
Dec-excluding/vzbp-i2d4. Accessed April 16, 2020.
15. CDC. Information for health care providers. https://www.cdc.gov/
6. NYS DOH. Deer tick surveillance: nymphs (May to Sept) excluding Powassan
otherspottedfever/healthcare-providers/index.html. Accessed April 21, 2020.
virus: beginning 2008. https://health.data.ny.gov/Health/Deer-Tick-
Surveillance-Nymphs-May-to-Sept-excludin/kibp-u2ip. Accessed April 16, 16. NYC DOHMH. Preventing and managing Lyme and other tick-borne diseases.
2020. City Health Information. 2012;31(3):17-24. www1.nyc.gov/assets/doh/
downloads/pdf/chi/chi31-3.pdf. Accessed April 21, 2020.
7. CDC. B. miyamotoi. https://www.cdc.gov/relapsing-fever/miyamotoi. Accessed
April 21, 2020. 17. CDC. Regions where ticks live. https://www.cdc.gov/ticks/geographic_
distribution.html. Accessed April 21, 2020.
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City Health Information nyc.gov/health
42-09 28th Str eet, Long Island City, NY 11101 (347) 396-2914
Bi l l de Bl asi o
M ayor
Ox i r i s Bar bot , M D
Com m issioner of Health and M ental Hygiene
Di v i si on of Di sease Con t r ol
Dem etr e Daskalakis, M D, M PH, Deputy Com m issioner
Bu r eau of Com m u n i cabl e Di sease
M ar celle Layton, M D, Assistant Com m issioner
Scott Har per , M D, M PH, M edical Dir ector , Zoonotic, Influenza, and Vector -bor ne
ASK CHI
Disease Unit
Sally Slavinski, DVM , M PH, Dipl ACVPM , Assistant Dir ector , Zoonotic, Influenza, Have questions or comments
and Vector -bor ne Disease Unit
Asha Abdool, M PH, City Resear ch Scientist about ticks?
Jennifer Reich, M PH, CHES, City Resear ch Scientist
Em ail
Di v i si on of Epi dem i ol ogy
R. Char on Gw ynn, PhD, Deputy Com m issioner AskCHI@health.nyc.gov
Bu r eau of Pu bl i c Heal t h Tr ai n i n g an d I n f or m at i on Di ssem i n at i on
Calaine Hem ans-Henr y, M PH, CHES, Assistant Com m issioner
Joanna Osolnik, M PH, CHES, Senior Dir ector , Office of Infor m ation Dissem ination
Peggy M illstone, Dir ector , Scientific Education Unit
Sandhya Geor ge, M edical Editor
Liz Selkow e, M edical Editor
M elissa Donze, M PH, Pr ogr am M anager
Copyr ight © 2020 The New Yor k City Depar tm ent of Health and M ental Hygiene
E-m ail City Health Information at nycdohr p@health.nyc.gov
New Yor k City Depar tm ent of Health and M ental Hygiene.
Pr eventing, diagnosing, and m anaging tick-bor ne diseases.
City Health Information. 2020;39(2):12-18.
CONTINUING EDUCATION ACTIVITY
This issue of City Health Information, including the continuing education activity, can be viewed h er e.
In st r u ct ion s
Read this issue of City Health Information for the correct answers to the questions. To receive continuing education credit, you must answer 80% of
questions correctly. Visit h t t ps:/ / w w w.su r veym on k ey.com / r / 38ZF9JZ to complete this activity online.
CM E Accr edit at ion St at em en t f or Join t Pr ovider sh ip
NYC Health + Hospitals is accredited by The Medical Society of the State of New York (MSSNY) to provide continuing medical education for
physicians. This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the MSSNY through
the joint providership of NYC Health + Hospitals and the New York City Department of Health and Mental Hygiene. NYC Health + Hospitals
designates this continuing medical education activity for a maximum of 1 AMA PRA Category 1 CreditTM . Physicians should claim only credit
commensurate with the extent of their participation in the activity.
Fin an cial Disclosu r e an d Con f lict of In t er est St at em en t
Participating faculty members and planners have no relevant financial relationships to disclose:
- Asha Abdool, MPH
- Alexander Davidson, MPH
- Joseph Real, MPH
- Jennifer Reich, MPH, CHES
- Sally Slavinski, DVM, MPH, Dipl ACVPM
Tim e t o Com plet e
This activity will take approximately 60 minutes to complete.
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