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Tick-borne disease surveillance.

Tick-borne diseases (TBDs) represent some of the world's most rapidly expanding arthropod-borne infectious diseases. (1) (p1) In the United States, ticks are responsible for more human disease than any other arthropod group. The incidence and the number of pathogens transmitted by ticks are increasing. For example, Lyme disease is now the most commonly reported arthropodborne illness in the United States. (2) Anaplasmosis, ehrlichioses, and rickettsioses are also on the rise. (1) (p1) In most parts of the world, TBDs are potentially serious health threats to troops, civilian employees, and residents at military installations. (2) (p6) Companion animals and military working dogs (MWD) are also at risk in areas where ticks and TBDs are endemic or emerging.

Risk of TBD increases with the introduction of exotic tick species into new areas and the expansion of historical tick ranges. One example of exotic ticks that effects the United States is Boophilus annulatus and B microplus, also known respectively as the cattle fever tick and the southern cattle tick, that were imported here by Spanish colonists who brought tick-infested cattle and horses with them. These ticks transmit a severe disease to cattle called Texas fever or cattle fever that caused enormous losses to the US cattle industry in the past. Present efforts to keep this tick out of the United States exist as the Cattle Fever Tick Eradication Program. (3) Nilgai antelopes, native to India, Nepal, and Pakistan, that were released into southern Texas are also hosts to the cattle fever ticks, posing a threat as maintenance hosts of cattle fever. (4) There are many other examples of exotic tick introductions from migratory birds, exotic and wildlife species, and domestic animals. (5)

Changes in climate may also alter the geographic distribution of tick vectors, and in turn, cause a change in the currently recognized demographic patterns, seasonality, and incidence of TBDs. (1) (p61) For example, the range of the Gulf Coast tick (Amblyomma maculatum) has historically been along the Gulf of Mexico and southern Atlantic coast as far north as South Carolina, and extending approximately 100-150 miles inland. However, resident populations of these ticks are now established in Arkansas, Oklahoma, and Kansas, (6) and they have been collected on the east coast as far north as Delaware and Maryland. (7) Another example is the lone star tick (A americanum) which has moved northward as far as Maine and westward into central Texas and Oklahoma. (8) Incidental introductions of these ticks, and the diseases they carry beyond endemic regions, occur with increasing frequency. This is likely due to the feeding of immature ticks on migrating birds, and the transportation of tick-infested livestock and wildlife into new areas. (6) These introductions may also come from pets belonging to people who move from one area to another.

In addition, suburbanization has contributed to the increase in TBD transmission in North America by bringing people and their pets close to ticks and by creating new tick habitat. (9) In the northeastern United States, the highest risk for Lyme disease occurs around the homes of those who have been infected. (10) As communities continue to expand into tick habitat, and people are encouraged to enjoy outdoor recreation and pursue activities such as urban farming, the risk for peridomestic exposure to ticks and TBDs may increase.

The National Notifiable Disease Surveillance System (NNDSS) of the Centers for Disease Control and Prevention (CDC) maintains a list of diseases that are considered to be of public interest by reason of their contagiousness, severity, or frequency. The 7 TBDs on the NNDSS list are shown in the Table.

Many of these diseases, which are caused by closely related tick-borne pathogens, can also be acquired internationally. There are also many TBDs that can be acquired abroad that do not occur in the continental United States. In addition to transmitting disease, ticks can cause irritation, pain, and swelling at attachment sites, otoacariasis (invasion of the auditory canal), paralysis, allergic reactions, and anaphylactic reactions. (11) Heavy infestations of ticks on animals can cause debilitation due to blood loss.

Direct effects from TBDs include troop and MWD morbidity and mortality. There are also many indirect effects, such as illness of dependents or Department of Defense (DoD) civilian personnel, and related healthcare costs. Both types of effects can be mitigated through aggressive surveillance, public education, and prevention/control programs, together with prompt diagnosis and treatment. (2) (p6)

TICK BIOLOGY AND DISEASE TRANSMISSION

Ticks are grouped into 2 separate families. Family Ixodidae, also called hard ticks, have 4 developmental stages: egg, larva, nymph, and adult. The latter 3 each take one large blood meal and then molt to the next stage, or lay eggs in the case of the adult. Hard ticks have mouthparts with recurved teeth that allow them to firmly anchor themselves to hosts while feeding with the assistance of a cement-like substance secreted by the salivary glands. This allows them to feed for extended periods of time that can vary from 2 to 12 days or longer, depending on species, life stage, and gender. Family Argasidae, also called soft ticks, have the same 4 developmental stages, but most have multiple nymph stages. Soft ticks have mouthparts that allow them to hold fast to their host, as hard ticks do, but they do not secrete cement. Although some soft ticks can remain attached to the host for several days, (11) (p501) others can complete a meal within minutes to hours. (12) This is still much longer than other bloodsucking arthropods such as mosquitoes, and is one of the factors that contribute to their high vector potential because it increases the likelihood of pathogen ingestion and allows them to secrete large amounts of host-derived fluid and salivary secretions, which contain pathogens, back into the host.

Other factors that make ticks efficient disease vectors include a highly sclerotized body that protects them from environmental stresses, high reproductive potential, and a long life span (compared to other blood feeding arthropods). Although the majority of TBDs are transmitted during normal feeding activity, they can be transmitted by other routes as well, including through regurgitation and feces. Argasid ticks can also release pathogens through excess liquid excreted from the coxal glands located adjacent to the first segment (coxa) of the front legs. (11) (p512) Adding to their efficiency as vectors, the larvae and nymphs are very small. The presence of an immature tick on a host often goes unnoticed, enabling the tick to feed to repletion and drop off without detection, which increases the likelihood of pathogen transmission.

Ticks can also transmit more than one pathogen at a time. For example, Ixodes ticks can simultaneously or sequentially infect their hosts with Borrelia burgdorferi, Anaplasma phagocytophilum, and Babesia microti. (1) (p61) Co-infections with these pathogens have been reported from wild and domestic animals, including dogs, as well as humans. These infections can result in more severe and longer illnesses and can complicate diagnoses. (1) (p493) Ticks are also effective disease reservoirs. In some species, pathogens can be transmitted from the adult female to its offspring (transovarial transmission) and from one developmental stage to the next (transstadial transmission). Infected ticks can also transmit viruses to uninfected ticks while feeding simultaneously on an uninfected host. (11) (p512) Therefore, they can maintain and transmit infections even if they have not fed on an infected host.

SURVEILLANCE

Surveillance is the process of determining the presence of vectors and pests, estimating their general population levels, and determining if pathogens of concern are present in the population. It gives quantifiable data on which to base control and education programs and is the starting point in the prevention of any arthropod-borne disease. The analysis and interpretation of information gained from surveillance is the basis for developing quantitative and qualitative risk assessments that can be used to predict the occurrence of pest outbreaks or vector-borne diseases. (13) (p7) Various methods can be used to describe disease risk. One commonly used index is called the Entomologic Risk Index (ERI), an indicator of the number of infected ticks that a person might come into contact with over a set distance. The ERI is calculated as the number of infected ticks collected over a 1,000-meter drag (described below). Accurate ERIs are obtained by testing ticks for pathogens to determine tick infection rate. Public health officials can use indices like the ERI in public education efforts and to determine if, when, and what control measures should be implemented. (13) (p7)

Information on vector quantity, type, and infection rates obtained from environmental sampling can be combined with human case data to help predict risk of acquiring vector-borne diseases. Ticks are active year round in some of the warmer areas of the continental United States. In fact, 31% of the ticks received at US Army Public Health Command (USAPHC) Region-West between the years 1944 and 2013 were collected in the months of November, December, January, and February. Therefore, surveillance and pathogen testing should occur throughout the year.

Surveillance Types

Surveillance for ticks and TBDs can be accomplished both actively and passively. Public health personnel who go into the field to collect ticks directly from animals or brush, as described in the following paragraphs, are conducting active surveillance. Passive surveillance depends on the voluntary submission of ticks to public health entities for identification and pathogen analysis. Passive surveillance also includes the gathering of TBD data from sources such as the CDC Morbidity and Mortality Weekly Report, (a) the USAPHC Vector-borne Disease Report (b) or the Armed Forces Health Surveillance Center Medical Surveillance Monthly Report. (c) This type of passive surveillance is important as it can give military public health personnel a rough picture of tick and pathogen presence or activity in a broad area. No single surveillance method can give a complete picture of TBD risk; therefore, it is important to employ as many techniques as possible.

SURVEILLANCE METHODS

Tick Drags. Tick drags are typically constructed of a one meter square sheet of light colored, soft material, such as muslin or flannel. A 1.2 meter dowel is attached to the leading edge of the material to keep it spread apart as it is pulled through the tick habitat and a two meter cord attached at both ends of the dowel can be used to pull the drag. Tick drags are conducted by passing the cloth over likely tick habitat, with the goal of collecting ticks that are questing (seeking a host). This method collects representative samples of Ixodid ticks present, and generally mirrors the actual exposure that a person might experience in a given area.

Tick Flags. Tick flagging is similar to tick drags. A flag is made by attaching a one meter square piece of cloth to a stick or dowel so that it resembles a flag. The flag is then waved back and forth under, in, and over vegetation or leaf litter, taking advantage of those areas where ticks are most likely to quest for their preferred host.

Tick Walks. A tick walk is accomplished by walking in a sampling area and collecting ticks that cling to the walker. This is the best estimate of the tick threat to humans. Precautions must be taken when using this method to protect the walkers. Coveralls should be worn with tube socks pulled over the leg openings and wrist openings sealed with tape. Coveralls and socks should be white or some other light color in order to better see any ticks that may be crawling on the clothing.

Traps. Traps vary in design. Their basic construction consists of a collecting device that attracts ticks using carbon dioxide. Effectiveness of this method differs by species. For instance, A americanum may be collected effectively with this method. Ixodes scapularis, on the other hand, are slower moving and are not effectively collected using traps. (2) (p29)

Wildlife Trapping and Examination. Various methods are used to collect ticks from wildlife hosts. Ticks can be removed from harvested deer that are brought to check stations during hunting season. This method allows for the collection of both the tick for testing for pathogens, as well as blood and tissue from the deer. Small mammals, including mice, chipmunks, voles, and ground squirrels are primary hosts for immature stages of ticks and can be trapped and then examined for ticks. Small mammal trapping, while labor intensive, is the most sensitive method to detect immature stages of ticks and to detect pathogens in host populations. Small mammal host tissues or blood samples may be collected to determine if pathogens are circulating in wildlife reservoirs. Nesting material can also be placed in Berlese funnels (traps used for extracting arthropods from soil and litter samples) to extract ticks.

Ticks Collected at Veterinary Treatment Facilities. Ticks removed from pet dogs, stray animals, and MWDs can enhance public health surveillance because they can be tested for animal and human pathogens that may circulate in the area. Pets often frequent the edges of trails or wooded areas and may come in contact with tick-infested habitats more often than people. They may, therefore, play an important role in bringing disease-transmitting ticks into close proximity to their owners or handlers. Pets and MWDs are compliant and easily sampled. In addition to dogs, horses can be hosts to ticks that can transmit disease to humans. Clearly, surveillance of domestic animals may assist in determining whether TBD is present. Common commercial tests, such as TickChek (TickChek LLC, East Stroudsburg, PA), Lyme-Aid (Lyme-Aid, East Stroudsburg, PA), and ProTickMe (Mainely Ticks Inc, Sanford ME), can determine infection with several common TBDs. There is some evidence that canine tick infestation precedes the onset of human tick-related health events and could possibly be a useful sentinel for human diseases. (14) Moreover, owners are often motivated to have their animals tested. Most military bases have veterinary support that can coordinate on- and off-base surveillance. When dogs are brought in for examination, ticks should be collected and forwarded to public health entities for identification and pathogen testing. This type of surveillance can be facilitated through the use of preconstructed submission kits. The kits include instructions on how to submit a tick, a collection container (such as a plastic vial), a standardized submission form, and a preaddressed padded envelope for shipment.

Ticks Collected From People. Ticks removed from people can be sent to the USAPHC Army Institute of Public Health Entomological Sciences Program through the DoD Human Tick Test Kit Program, which is a free tick identification and testing service for DoD healthcare facilities. More information can be found at the Human Tick Test Kit Program web site. * Care should be taken to remove ticks promptly and properly to prevent infection with TBD, to ensure mouthparts are not left in the skin, and to allow for tick identification and testing. The proper methods to remove ticks are listed in the inset.

IMPORTANCE

The geographic ranges of many tick species are expanding, and the serious diseases transmitted by ticks are becoming more common. (15) Due to overlapping tick and host ranges, this expansion may also lead to more co-infections and areas with multiple pathogens and vectors. As previously discussed, co-infections are not unusual and can result in more severe illness than infection with a single pathogen. (1(p243)) In the United States alone, TBDs produce tens of thousands of illnesses every year, many of which are severe and result in hospitalization, longterm illness, disability, and death. (1(p155))

Tick surveillance is the starting point for effective TBD prevention. Surveillance establishes species and densities of tick populations present in a given area, and provides data for establishing the potential TBD risk. This data provides leaders, preventive medicine personnel, pest management professionals, and individuals the information they require to promote proactive measures, including behavior change such as using personal protective measures and avoiding tick habitat, and tick-targeted strategies (tick checks or tick population reduction measures) (1(p155)) to prevent TBDs.

Tick surveillance will be most effective when multiple entities are involved. The USAPHC personnel can visit installations and collect ticks. Given the limited scope of this method, it alone will not be sufficient to accurately assess the risk of TBDs. Limited budgets also make this a less than cost-effective way to address TBDs. Local entities, most notably from installation preventive medicine and veterinary personnel, should make efforts to augment the work currently performed by USAPHC personnel. For example, Public health Command Region-West (PHCR-W) personnel collected ticks from 8 installations during 2014 while only 2 installations collected and sent a significant number of ticks. If all of the installations within our 20-state region would collect and send ticks for analysis, the knowledge of TBD risk in the region would be greatly improved.

Analysis of TBDs should be expanded to include all tick species that are considered vectors as well as the pathogens they transmit because the epidemiology of newly emerging TBDs is not well known. For example, in 2008, the first human infection with Rickettsia 364D was confirmed in a patient from northern California. (16) Illness caused by this pathogen is now a reportable disease under the California Code of Regulations Title 17. (17) It is also listed on the CDC web site as a source of Rickettsial infections. (10) Because R rickettsii (the causative agent of Rocky Mountain spotted fever) is rarely identified in human-biting ticks in CA, it has been suggested that Rickettsia 364D, provisionally named Rickettsia phillipi, is responsible for many of the illnesses in this region that resemble and are misdiagnosed as Rocky Mountain spotted fever. (18) (p671) Dermacentor occidentalis, the Pacific Coast tick, is the vector of Rickettsia 346D and occurs throughout California and in parts of Oregon. Both immature and adult stages of this tick are relatively indiscriminant feeders and will readily bite humans. (19) Rickettsia 364D has been detected in up to 11% of D occidentalis from 8 California counties. (16) (p542) Without diligent surveillance and pathogen testing, changes in tick distributions and the risk of acquiring TBDs will remain unknown, especially for newly emerging TBDs.

Two other recent examples of newly described, emerging TBDs include Heartland virus (20) and Ehrlichia murislike infection. The Ehrlichia muris-like organism was isolated from I scapularis ticks during an outbreak investigation in Wisconsin in 2009. (21) Previously, only Ehrlichia chaffeensis and E ewingii were thought to cause tick-borne Ehrlichiosis in humans in the US, and neither is endemic in Wisconsin or Minnesota. When patients in these states, without travel to endemic areas of the United States, began to present to their healthcare providers with symptoms of Ehrlichiosis and were further investigated, blood samples submitted for polymerase chain reaction (PCR) screening identified the previously undescribed Ehrlichia species. Field surveys and retrospective testing of I scapularis ticks further established that Ehrlichia muris-like is present in tick and wildlife populations. (22,23)

In 2012, Heartland virus became the first phlebovirus associated with human infection described in the United States. (24) Two hospitalized patients with a history of exposure to lone star ticks, A americanum, presented to hospitals in northwestern Missouri in June 2009. Both patients, males over 55 years-old, presented with fever, fatigue, anorexia, nausea, low white-blood-cell count, low platelet count, and elevated liver enzymes. The patients were thought to have Ehrlichiosis, but failed to improve upon treatment with antibiotics. Further blood tests including PCR, sequencing, and electron microscopy eventually identified the causative virus as Heartland, which is classified as a distinct virus, but phylogenetically similar to the severe fever with thrombocytopenia syndrome virus. In 2012, ticks were collected from 12 sites including both patients' farms, and infection rates in A americanum nymphs were found to range from 0.47 to 3.91 infected ticks per 1,000 throughout the tick season. These examples highlight the importance of TBD surveillance as the collaboration between the medical, laboratory, and public health entomology communities led to the discovery early in the course of disease emergence of both of these pathogens.

Public Health Command Region-West conducts surveillance and testing for military installations in the western region of the United States including Missouri, Minnesota, Iowa, and parts of Texas and was the first governmental agency to detect Lyme disease from ticks or rodent biopsies in Santa Barbara and San Louis Obispo County, California. Once the detection techniques for Lyme disease were perfected, PHCR-W expanded its capabilities to test ticks and rodent tissue for other TBDs to include Ehrlichia chaffeensis, Anaplasma phagocytophilum, and Spotted Fever group Rickettsias.

We have since detected Ehrlichia from 4 installations in Missouri and A phagocytophilum in Minnesota and California. Several Rickettsia rickettsia and Ehrlichia chaffeensis tick pools were detected among ticks from dogs at Fort Leonard Wood, Missouri, in 2011. These surveillance activities have led to installation awareness and TBD risk assessments at numerous installations. Several installations have mandated briefings to field sanitation teams, environmental science officers, medics, and leaders prior to training operations in tick habitat to increase awareness and personal protective measures needed to minimize the transmission of TBDs.

The surveillance activities initiated by PHCR-W have also detected ticks transported on pets from other areas of the world, including German ticks on MWDs arriving at Joint Base Lewis-McCord (JBLM) and Beale Air force Base, an African tick off a tortoise in Washington state, a Missouri tick off of a MWD to JBLM, and a tick from the state of Georgia transported to Arizona during a PCS move. These examples highlight the importance of maintaining active surveillance and expanding tick testing capabilities for newly emerging TBD pathogens.

Equally important to increasing laboratory capabilities for the detection of TBDs is the assurance of reasonable but quick turnaround times for laboratory results. The public health value of any information gained from laboratory tests diminishes quickly over time. Further, customers who receive reports weeks or months after submitting specimens will be less likely to continue to make the effort to collect and send ticks to public health entities. Promptly detecting pathogens in submitted ticks is important in making determinations of the risk of TBD in military personnel, dependents, companion animals, and MWDs. It is also crucial in the planning and timing of disease control efforts, including vector control and educational activities. Public Health Command Region-West provides TBD laboratory analysis results in pathogen-specific reports that include tick collection data (species, site, collection date), laboratory analysis findings (positive or not detected), and recommendations on continued surveillance.

The prevention of TBDs is based on personal protective measures, landscape and environmental measures, and preventive treatments to ensure that infected ticks do not bite people or animals. The determination of disease risk and the employment of environmentally and economically sound tick control methods effectively result from TBD surveillance. Possibly of even greater importance, information acquired through tick surveillance can bolster public education and improve the awareness and health literacy of the military community regarding TBDs. Properly informed and aware personnel make more intelligent decisions about activities that put them at risk of TBD exposure and the personal protective measures that can be taken to reduce that risk. Clinical, preventive medicine, veterinary, pest management, and Army Public Health Command personnel must work cooperatively to improve the knowledge of tick species distributions and the incidence of the diseases they transmit. Liaisons with these entities and with state and local public health departments should also be established.

Conclusion

Ticks are one of the major vectors of disease that threatens military personnel, families, and civilian employees on US military installations. (25) The presence of tickborne disease in military personnel, including our military working animals, may result in the loss of training days, decreased force strength, and may adversely affect unit readiness and effectiveness. Tick-borne disease also affects DoD civilians and the families of our troops. Soldier and unit readiness may be affected when family members and companion animals are sickened by TBDs. The information gained from tick surveillance regarding tick vectors, disease incidence, and pathogen prevalence is invaluable. It allows medical personnel to educate personnel regarding tick-bite and TBD recognition and prevention. Tick surveillance information also enables leaders to make decisions regarding the application of safety and control measures during training and operations to prevent TBDs. As with any disease, prevention of TBDs is highly preferable to treating the short- and long-term consequences once they occur. (1(p155))

Proper Tick Removal

Do:

Use fine-tipped tweezers to grasp the tick as close to the skin as possible, then pull straight out with a slow, steady motion. This will ensure the mouthparts do not break off in the skin.

Wash the wound after removal and apply antiseptic.

Do Not:

Squeeze or smash the tick.

Burn the tick.

Cover the tick with petroleum jelly, sport creams, alcohol, nail polish, or any other substance.

REFERENCES

(1.) Institute of Medicine. Critical Needs and Gaps in Understanding Prevention, Amelioration, and Resolution of Lyme and Other Tick-Borne Diseases: The Short-Term and Long-Term Outcomes: Workshop Report. Washington, DC: Washington, DC: The National Academies Press; 2011. Available at: http://www.nap.edu/catalog/13134/critical-needsand-gaps-in-understanding-prevention-ameliora tion-and-resolution-of-lyme-and-other-tickbornediseases. Accessed December 1, 2014.

(2.) Armed Forces Pest Management Board Technical Guide No. 26. Tick-borne Diseases: Vector Surveillance and Control. Silver Spring, MD: Armed Forces Pest Management Board Information Services Division; 2012. Available at: http://www.af pmb.org/sites/default/files/pubs/techguides/tg26. pdf. Accessed December 1, 2014.

(3.) Animal and Plant Health Inspection Service; Veterinary Services. Controlling Cattle Fever Ticks Factsheet. Washington, DC: US Department of Agriculture; August 2010. Available at: http://www. aphis.usda.gov/publications/animal_health/con tent/printable_version/cattle_fever_ticks.pdf. Accessed December 1, 2014.

(4.) Moczygemba J, Hewitt D, Campbell T, et al. Home ranges of the Nilgai antelope (Boselaphus tragocamelus) in Texas. Southwest Nat. 2012; 57(1):26-30.

(5.) Madder M, Pascucci I. Factors Influencing the spread and distribution of ticks. In: Salman M, Tarres-Call J, eds. Ticks and Tick-borne Diseases: Geographical Distribution and Control Strategies in the Euro-Asia Region. Boston, MA: CABI Publishing; 2013; 27-32.

(6.) The TickApp for Texas & the Southern Region: Gulf Coast tick [internet]. The Texas A&M University System Web site; 2011. Available at: http://tick app.tamu.edu/ticks/gulfcoasttick.php. Accessed

August 29, 2014.

(7.) Florin D, Brinkerhoff R, Gaff H, et al. Additional US collections of the Gulf Coast tick, Amblyomma maculatum (Acari: Ixodidae), from the State of Delaware, the first reported field collections of adult specimens from the State of Maryland, and data regarding this tick from surveillance of migratory songbirds in Maryland. Syst Appl Acarol. 2014; 19(3):257-262.

(8.) Centers for Disease Control and Prevention. Lone star tick a concern, but not for Lyme disease [internet]. October 21, 2011. Available at: http://www.cdc. gov/stari/disease/. Accessed September 17, 2014.

(9.) Ginsberg H, Faulde M. Ticks. In: Bonnefoy X, Kampen H, Sweeney K, eds. Public Health Significance of Urban Pests. Copenhagen, Denmark: WHO Regional Office for Europe; 2008:304-346.

(10.) Connally NP, Durante AJ, Yousey-Hindes KM, Meek JI, Nelson RS, Heimer R. Peridomestic Lyme disease prevention: results of a population-based case-control study. Am J Prev Med. 2009; 37(3)201-206.

(11.) Nicholson WL, Sonenshine DE, Lane RS, Uilenberg G. Ticks (Ixodidae). In: Mullen G, Durden L, eds. Medical and Veterinary Entomology. 2nd ed. London, UK: Academic Press; 2009:483-532.

(12.) Sonenshine DE, Anderson JM. Mouthparts and digestive system: anatomy and molecular biology of feeding and digestion. In: Sonenshine DE, Roe RM, eds. Biology of Ticks. 2nd ed. New York, NY: Oxford University Press; 2014; 122-162.

(13.) United States Air Force Guide to Operational Surveillance of Medically Important Vectors and Pests-Operational Entomology. Ver 2.1. Washington, DC: Dept of the Air Force; August 15, 2006. Ver. 2.1. Available at: http://www.afpmb.org/sites/ default/files/pubs/guides/operational_surveillance_ guide.pdf. Accessed December 2, 2014.

(14.) Glickman L, Rhea S, Glickman S, Waller A, Ising A, Engel J. Canine tick diagnoses are a sentinel for tick-borne diseases in people. Adv Dis Surveill. 2008; 5:176.

(15.) McKenna M. The advance of ticks: new areas, new diseases, and a weird allergy to meat [internet]. Wired Science Blogs. December 28, 2012. Available at: http://www.wired.com/wiredscience/2012/12/ ticks-new-meat/. Accessed August 30, 2014.

(16.) Shapiro M, Fritz C, Tait K, et al. Rickettsia 364D: a newly recognized cause of eschar-associated illness in California. Clin Infect Dis. 2010; 50(4):541-548.

(17.) California Department of Public Health. Laboratory testing for spotted fever rickettsiosis. Richmond, CA: Viral and Rickettsial Disease Laboratory Branch/Division of Communicable Disease Control. July 2012. Available at: http://www.cdph. ca.gov/programs/vrdl/Documents/VRDLTesting forSpottedFeverGroupRickettsia_FINAL.pdf. Accessed December 1, 2014.

(18.) Parola P, Paddock CD, Socolovschi C, et al. Update on tick-borne rickettsioses around the world: a geographic approach. Clin Microbiol Rev. 2013; 26(4):657-702.

(19.) Mediannikov O, Paddock CD, Parola P. Other rickettsiae of possible undetermined pathogenicity. In: Raoult D, Parola P, eds. Rickettsial Diseases. 1st ed. New York, NY: Informa Healthcare; 2007:163-177.

(20.) Savage HM, Godsey MS Jr, Lambert A, et al. First detection of heartland virus (Bunyaviridae: Phlebovirus) from field collected arthropods. Am J TropMedHyg. 2013; 89(3):445-452.

(21.) Pritt BS, Sloan LM, Johnson DK, et al. Emergence of a new pathogenic Ehrlichia species, Wisconsin and Minnesota, 2009. N Engl J Med. 2011; 365(5):422-429.

(22.) Stromdahl E, Hamer S, Jenkins S, et al. Comparison of phenology and pathogen prevalence, including infection with the Ehrlichia muris-like (EML) agent, of Ixodes scapularis removed from soldiers in the midwestern and the northeastern United States over a 15 year period (1997-2012). Parasit Vectors. 2014; 7(1):553 (Epub ahead of print).

(23.) Castillo CG, Eremeeva ME, Paskewitz SM, et al. Detection of human pathogenic Ehrlichia murislike agent in Peromyscus leucopus. Ticks Tick Borne Dis. In press.

(24.) McMullan LK, Folk SM, Kelly AJ, et al. A new phlebovirus associated with severe febrile illness in Missouri. N Engl J Med. 2012; 367(9):834-841.

(25.) Beard CB, Strickman D, eds. Federal Initiative: Tick-borne Disease Integrated Pest Management White Paper. Washington, DC: Federal Tick-Borne Disease Integrated Pest Management Workgroup; 2014. Available at: http://www.epa.gov/pestwise/ ticks/tick-ipm-whitepaper.pdf. Accessed December 1, 2014.

Authors

MAJ Petersen is Officer-in-Charge, Laboratory Sciences Division, US Army Public Health Command RegionWest, Joint Base Lewis-McChord, Washington.

CPT Foster is assigned to the Entomological Sciences Program, US Army Public Health Command RegionSouth, Joint Base San Antonio Fort Sam Houston, Texas.

1LT McWilliams is Officer-in-Charge, Entomological Sciences Program, US Army Public Health Command Region-West, Joint Base Lewis-McChord, Washington.

Mr Irwin is assigned to the Entomological Sciences Program, US Army Public Health Command Region-West, Joint Base Lewis-McChord, Washington.

(a) http://www.cdc.gov/mmwr/

(b) http://phc.amedd.army.mil/whatsnew/Pages/Periodic Publications.aspx

(c) http://www.afhsc.mil/

* http://phc.amedd.army.mil/topics/envirohealth/epm/Pages/ HumanTickTestKitProgram.aspx

MAJ Wade H. Petersen, MS, USA CPT Erik Foster, MS, USAR 1LT Beven McWilliams, MS, USA William Irwin
Tick-borne Diseases Listed in the National Notifiable Disease
Surveillance System.

Disease                     Agent               Vector

Anaplasmosis        Anaplasma                Ixodes
                      phagocytophilum          scapularis,
                                             I pacificus

Babesiosis          Babesia microti,         Ixodes spp
                    B. divergens,
                    B. duncani

Lyme Disease        Borrelia                 Ixodes
                      burgdorferi              scapularis,
                                             I pacificus

Ehrlichiosis        Ehrlichia chaffeensis,   Amblyomma
                    E. ewingii,                americanum
                    E. muris-like

Spotted Fever       Rickettsia rickettsii,   Dermacentor
Rickettsiosis       R. parkeri,                andersoni,
                    R. philippi              D variabilis

Tularemia           Francisella              Dermacentor
                      tularensis               andersoni,
                                             D variabilis,
                                             Amblyomma
                                               americanum

Powassan            Powassan virus           Ixodes spp
  Disease             lineage I & II
(Deer tick virus)

Disease                           Symptoms

Anaplasmosis        Fever, headache, muscle pain, chills,
                      malaise, nausea/abdominal pain,
                      cough, confusion, rash (rare)

Babesiosis          Fever, fatigue, headache, body ache,
                      chills, nausea, loss of appetite

Lyme Disease        Fever, fatigue, headache, chills,
                      muscle and joint aches, swollen
                      lymph nodes, erythema migrans
                      (red, expanding rash)

Ehrlichiosis        Fever, fatigue, headache, muscle
                      aches

Spotted Fever       Fever, fatigue, headache, muscle
Rickettsiosis         aches, eschar at bite site, rash

Tularemia           Fever, fatigue, headache, swollen and
                      painful lymph glands, ulcer, chills

Powassan            Fever, headache, vomiting, weakness,
  Disease             confusion, loss of coordination,
(Deer tick virus)     speech difficulties, seizures

Disease                            US Region

Anaplasmosis        Northeastern and upper midwestern
                      states, northern California

Babesiosis          Northeast and upper midwest

Lyme Disease        Northeast and upper midwest

Ehrlichiosis        Southeast and south-central US from
                      the eastern seaboard extending west-
                      ward to Texas.

Spotted Fever       Throughout the US but primarily in
Rickettsiosis         North Carolina, Oklahoma, Arkansas,
                      Tennessee, and Missouri

Tularemia           Tularemia has been reported from all
                      states except Hawaii, but is most
                      common in south-central states,
                      the Pacific northwest, and parts of
                      Massachusetts

Powassan            Northeastern states and the Great Lakes
  Disease             region
(Deer tick virus)
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Author:Petersen, Wade H.; Foster, Erik; McWilliams, Beven; Irwin, William
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:1U9CA
Date:Jan 1, 2015
Words:5393
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