Sarah Rhea, DVM 1 Larry Glickman, VMD, DrPH 1 Seth Glickman, MD, MBA 1 Anna Waller, ScD 1 Amy Ising, MSIS 1 Jean-Marie Maillard, MD, MSc 2 Jeff Engel, MD 2 - PowerPoint PPT Presentation

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Canine Tick Infestation is a Sentinel for Environmental Tick Activity and Human Tick-Related Health Events 7th International Society for Disease Surveillance Conference Raleigh, NC Sarah Rhea, DVM 1 Larry Glickman, VMD, DrPH 1 Seth Glickman, MD, MBA 1 Anna Waller, ScD 1 Amy Ising, MSIS 1

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Canine Tick Infestation is a Sentinel for EnvironmentalTick Activity andHuman Tick-Related Health Events 7th International Society for Disease Surveillance ConferenceRaleigh, NC

Sarah Rhea, DVM1

Larry Glickman, VMD, DrPH1

Seth Glickman, MD, MBA1

Anna Waller, ScD1

Amy Ising, MSIS1

Jean-Marie Maillard, MD, MSc2

Jeff Engel, MD2

  • Department of Emergency Medicine, UNC Chapel Hill

  • North Carolina Division of Public Health


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Outline

  • Basic tick biology

  • Approaches to tick surveillance

  • Hypotheses and study methods

  • Results

  • Conclusions

  • Future studies

  • Potential uses and advantages of a novel tick surveillance system


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Ticks Indigenous to North Carolina*

  • Hard ticks: hard shell (scutum) covering body

  • Deer tick or blacklegged tick (Ixodes scapularis)

  • American dog tick (Dermacentor variabilis)

  • Lone star tick (Amblyomma americanum)

*Apperson, Engber, Waldvogel,

Ticks and Tick-Borne Diseases in

North Carolina, 2003


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Example 3-host Tick Life-Cycle


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Importance of Tick Surveillance in North Carolina

  • Tick-borne diseases are significant cause of morbidity & mortality in NC

    • Rocky Mountain Spotted Fever

      (Rickettsia rickettsii)

    • Ehrlichiosis, Anaplasmosis

      (Ehrlichia spp)

    • Lyme disease

      (Borrelia burgdorferi)

CDC


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Traditional Methods of Tick Surveillance

  • Environment

    • Field dragging

    • Small mammal trapping

  • People

    • Reportable tick-borne diseases

    • Calls to health departments or poison control centers


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Limitations to TraditionalSurveillance Methods

  • Environment

    • Samples small geographic areas only

    • Labor intensive

  • People

    • Reported tick-borne diseases are a gross underestimation

    • Paired titers infrequently available to support a diagnosis (3-5%)


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A Study to Evaluate Potential Sources of Human and Veterinary Medical Data for Tick Surveillance:

Canine tick activity is a sentinel for environmental tick activity and human tick-related health events


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Dog Tick Infestation & Human Lyme Disease in the US by Month, 2002-2004

Glickman et al, Vector-borne & Zoonotic Diseases, 2006


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Hypotheses

  • Canine tick infestation in NC is seasonal

    • Affected by topography and climate of NC

    • Precedes onset of human tick-related health events in NC

  • NC emergency department surveillance data is useful in monitoring human tick-borne infections in a community in a timely manner.

  • Doxycycline prescription rates and hospital inpatient data correlate well with ED chief complaints of tick exposure and ED diagnoses of tick-borne diseases


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Study Methods:Source of Canine Tick Data (2005-2007)

  • BanfieldR primary care veterinary hospital electronic medical records

    • >700 BanfieldR hospitals in 44 states

    • 33 NC hospitals

      • 2007: >240,000 dog visits & >1700 tick-infested dogs


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Sources of Human Tick-related Health Data (2005-2007)

  • ED surveillance data from NC DETECT (North Carolina Disease Event Tracking and Epidemiologic Collection Tool)

    • Chief complaint &/or Triage notes with keyword: “tick”*

    • Tick-related ICD-9-CM diagnosis code(s)

  • NC Division of Public Health notifiable tick-borne disease reports*

  • Doxycycline prescription data from the IMS Health informatics corporation

  • NC Hospital inpatient data from HCUP (Healthcare Cost and Utilization Project)

*Preliminary results presented today


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NC DETECT ED Data

  • Statewide early event detection

  • 110/112 EDs reporting

  • 2007: >3.7 million ED visits & nearly 1600 keyword “tick” ED visits


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Risk of Tick-Related Exposureby NC region

  • Number of dogs w/ tick infestation per 1,000 dog visits

  • Number of NC DPH reported human tick-borne disease per 1,000,000 people

  • Number of ED visits with tick-related chief complaints &/or triage notes per 10,000 ED visits


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2005

Sources: NC DPH reportable disease records, Banfield medical records


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2005

Sources: NC DPH reportable disease records, Banfield medical records


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Sources: NC DETECT ED data, Banfield medical records


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Conclusions

  • Canine and human tick activity in NC is seasonal

    • Patterns are slightly different among the 3 regions

  • Canine tick data and ED chief complaint surveillance data provide similar information.

  • Both canine tick data and ED chief complaint surveillance data may provide earlier warnings of tick activity than reportable disease data.


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Study Limitations

  • Currently, small number of Banfield pet hospitals in coastal and mountain regions of NC

  • Reliance on text documentation and ICD-9 coding for NC DETECT ED data

  • Doxycycline is indicated for conditions other than tick-borne disease (eg. STIs, acne, respiratory disease)

  • ED surveillance data cannot be linked to HCUP inpatient data


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Planned Studies

  • Complete the evaluation of human data

    • NC DETECT ED ICD-9-CM codes

    • Doxycycline prescriptions

    • HCUP inpatient data

  • Determination of the specificity of ED chief complaints and doxycycline prescribing for symptoms & diagnosis of tick-borne disease

  • Tick collection, identification, & PCR for tick-borne pathogens from pet dogs across NC

  • Develop statistical models for yearly prediction of the start of tick season


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Potential Uses & Advantages

  • Education and increased awareness of tick-borne disease

    • Physicians: Consider in differential diagnosis

    • Veterinarians: Alert pet owners to potential risk for tick exposure in environment, provide topical tick preventatives for pets

    • Public health practitioners: Alert the public and provide information about tick prevention

  • Readily available human and dog data

    • NC DETECT ED data

    • Banfield veterinary records


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Acknowledgements

UNC-CH Dept of Emergency Medicine

Nita Glickman

Charles Cairns

NC Division of Public Health

Carl Williams

UNC-CH Depts of Medicine & Pediatrics

David Weber


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Questions?


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Back-up Slides


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Brown dog tick (Rhipicephalus sanguineous)

  • Rarely takes blood meals from humans, feeds almost exclusively on dogs

  • Typically lives indoors & is active all year

    • does not likely experience the seasonal changes in activity seen with other NC ticks


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RMSF & ErlichiosisCase Classification

  • Confirmed: A clinically compatible case (meets clinical evidence criteria) that is laboratory confirmed.

  • Probable: A clinically compatible case that has supportive laboratory results.

  • Suspect: A case with laboratory evidence of past or present infection but no clinical information available.

CDC 2008


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Lyme DiseaseCase Classification

  • Confirmed: a) EM with a known exposure, or b) EM with lab evidence of infection & without a known exposure, or c) a case with at least one late manifestation & lab evidence.

  • Probable: any other case of physician-diagnosed Lyme disease that has lab evidence.

  • Suspected: a) EM with no known exposure and no lab evidence, or b) a case with lab evidence but no clinical information available.

CDC 2008


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NC Banfield Veterinary Hospitals


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NC Banfield Veterinary Hospitals


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Location of 110 EDs in North Carolina Participating in NC DETECT


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Sources: NC DETECT ED data, Banfield medical records


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Sources: NC DETECT ED data, Banfield medical records


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Dog Tick Infestation and NC DPH Reportable Human Tick-borne Disease, 2005

NC Piedmont Region

NC Coastal Region


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Dog Tick Infestation and NC DPH Reportable Human Tick-borne Disease, 2006

NC Piedmont Region

NC Coastal Region


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Coastal

Dog & DPH reports, 2007

Piedmont

Mountain


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Animals as Sentinels for Human Disease

  • Early coal miners used canaries to detect deadly methane gas in coal mines

  • Veterinary pathologists discovered WNV as cause for area bird deaths immediately prior to human WNV outbreak, NYC, 1999

  • Bioterrorism events


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Events for Surveillance

  • Tick density and biological activity in nature

  • Tick-related infections & diseases in people

    • Reportable

    • Not-reportable

  • Tick infestation of dogs

  • Tick-related infections & diseases in dogs


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Importance of Tick Surveillance in North Carolina

  • Tick-borne diseases are significant cause of morbidity & mortality in NC

    • Rocky Mountain Spotted Fever

      (Rickettsia rickettsii)

    • Ehrlichiosis, Anaplasmosis

      (Ehrlichia spp)

    • Lyme disease

      (Borrelia burgdorferi)

CDC


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Study Methods:Source of Canine Tick Data (2005-2007)

  • BanfieldR primary care veterinary hospital electronic medical records

    • >700 BanfieldR hospitals in 44 states

    • 33 NC hospitals

      • 2007: >240,000 dog visits & >1700 tick-infested dogs


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