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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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slide1
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
outline
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
ticks indigenous to north carolina
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

importance of tick surveillance in north carolina
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

traditional methods of tick surveillance
Traditional Methods of Tick Surveillance
  • Environment
    • Field dragging
    • Small mammal trapping
  • People
    • Reportable tick-borne diseases
    • Calls to health departments or poison control centers
limitations to traditional surveillance methods
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%)
a study to evaluate potential sources of human and veterinary medical data for tick surveillance
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

dog tick infestation human lyme disease in the us by month 2002 2004
Dog Tick Infestation & Human Lyme Disease in the US by Month, 2002-2004

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

hypotheses
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
study methods source of canine tick data 2005 2007
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
sources of human tick related health data 2005 2007
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

nc detect ed data
NC DETECT ED Data
  • Statewide early event detection
  • 110/112 EDs reporting
  • 2007: >3.7 million ED visits & nearly 1600 keyword “tick” ED visits
risk of tick related exposure by nc region
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
slide16
2005

Sources: NC DPH reportable disease records, Banfield medical records

slide17
2005

Sources: NC DPH reportable disease records, Banfield medical records

conclusions
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.
study limitations
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
planned studies
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
potential uses advantages
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
acknowledgements
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

brown dog tick rhipicephalus sanguineous
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
rmsf erlichiosis case classification
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

lyme disease case classification
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

slide37
Dog Tick Infestation and NC DPH Reportable Human Tick-borne Disease, 2005

NC Piedmont Region

NC Coastal Region

slide38
Dog Tick Infestation and NC DPH Reportable Human Tick-borne Disease, 2006

NC Piedmont Region

NC Coastal Region

slide39
Coastal

Dog & DPH reports, 2007

Piedmont

Mountain

animals as sentinels for human disease
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
events for surveillance
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
importance of tick surveillance in north carolina43
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

study methods source of canine tick data 2005 200744
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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