2015 Tick and Lyme Disease Board of Health Report

Report to: Board of Health

Meeting Date: June 1, 2016

Report Number: BOH Report – BH.01.JUN0116.R11

Prepared by: Shawn Zentner, Manager Health Protection

Mike Coburn, Public Health Inspector

Sarah Croteau, Health Promotion Specialist

Approved by: Rob Thompson, Director Health Protection

Submitted by: Dr. Nicola Mercer, Medical Officer of Health & CEO

Recommendation(s)

(a) That the Board of Health receives this report for information.

Infographic discusses the Background, passive surveillance and reporting, active surveillance and education activities for 2015 Ticks and Lyme Disease Report. All information in infographic is in the body of the report.

EXECUTIVE SUMMARY

Lyme disease (LD) is a zoonotic, tick-borne disease caused by spiral-shaped bacteria called Borrelia burgdorferi. The bacteria is transmitted to humans through the bite of an infected blacklegged tick with Lyme being the most common vector-borne disease in North America. In 2015, there were 358 confirmed cases of Lyme disease reported in Ontario, which represents a sharp increase from previous years. This can be attributed to increased public awareness and reporting, the expanding range of the blacklegged tick, and the consequent increases in human-tick encounters.

WDGPH’s prevention and control program for Lyme disease focuses on public education and surveillance. Due to the expanding range of the blacklegged tick and the increasing number of Lyme disease cases reported in the province, surveillance and education efforts were intensified in 2015 from previous years.

Passive surveillance involved accepting ticks from the public for identification purposes. Positively identified blacklegged ticks were forwarded to Health Canada for bacterial testing. In 2015, over 80 ticks were submitted to WDGPH and one third of them were blacklegged ticks. Three of these ticks tested positive for Borrelia burgdorferi, however none of those that tested positive were acquired within the borders of Wellington or Dufferin counties.

An active surveillance initiative began in 2015, in partnership with the University of Guelph. Tick-dragging, an unsophisticated but effective method of collecting ticks, was carried out in areas with habitat that would be suitable for blacklegged ticks and the bacteria which causes Lyme disease. No blacklegged ticks were found.

Public education was also strengthened in 2015. Key messages focused on the cause and symptoms of Lyme disease, characteristics of blacklegged ticks, preventing tick bites and tick removal. These messages were communicated through the WDGPH website, social media, a blog post, print materials and the One Health newsletter. 

Continued passive and active surveillance will be instrumental in acquiring baseline data for the blacklegged tick within Wellington and Dufferin counties. Measuring and mapping the tick’s progress over time will allow WDGPH to better utilize resources and target education and awareness campaigns towards specific areas and populations in 2016 and beyond.

BACKGROUND

Lyme disease is a zoonotic, tick-borne disease caused by a species of bacteria belonging to the Borrelia genus. In Canada, the only species known to cause Lyme disease is Borrelia burgdorferi. The bacteria are transmitted to humans through the bite of infected blacklegged ticks (Ixodes scapularis), also known as deer ticks. Lyme disease is the most commonly transmitted vector-borne disease in North America, and appears to be on the rise.1

In Ontario, in the early 1990s only Long Point Provincial Park on the north shore of Lake Erie was considered to be endemic.2 Since that time the range of the blacklegged tick has expanded and there are currently seven known endemic Lyme disease areas, and several known high risk areas, in Ontario (Appendix A).2 Lyme disease endemic areas are those in which blacklegged ticks are established and where there is evidence that ticks are transmitting B. burgdorferi among reservoir hosts.3 Lyme disease risk areas are locations where blacklegged ticks have been identified, or are known to occur, and where humans have the potential to come into contact with infected ticks, but where the presence of B. burgdorferi has not been confirmed.4

These endemic and high risk areas are similar in that they are typically zones of deciduous or mixed forests, and are populated by large and small-sized mammals which act as reservoirs for the bacteria and hosts for the ticks. This flora and fauna, as well as similar climatic characteristics, are conducive to the proliferation and survival of both the tick species and the bacteria. These areas are also located on bodies of water and are known destinations for, or on the flight paths of, migrating birds which, together with deer, are considered to be important factors in the distribution of blacklegged ticks. With the increase in tick numbers and continued expansion of its range, due in part to climate change, there has been an increase in human cases of Lyme disease. The majority of these cases are contracted in endemic and high risk areas in Eastern Ontario.1

Blacklegged ticks are not infected when they hatch from their eggs and only acquire the bacteria after feeding on an infected animal, such as a white-footed mouse or fox. By the time a tick becomes an adult female it has had two feedings and is more likely to test positive for Borrelia bacteria than a nymph. However, it is the nymph that is responsible for more human cases of Lyme disease, as their small size makes them difficult to detect.5

Moreover, adult ticks are most active in the spring and fall, while larvae and nymphs are most active during the summer months. The majority of suspect human cases of Lyme disease are reported during June, July, and August. There is a strong relationship between the number of human cases reported, increased human outdoor activities, and the presence of infected nymphs in the environment during these warmer months. Feeding nymphs are more difficult to detect on the body than adults, which leads to the increased likelihood of longer attachment times and, therefore, greater potential for bacterial transmission. 

The disease is difficult to diagnose clinically, and is often mistaken for other ailments during the early stage of infection. Symptoms usually begin 3–30 days after being bitten by an infected blacklegged tick and can include fever, headache, fatigue and swollen lymph nodes. A “bulls-eye rash” (erythema migrans) may appear in some infected people at the site of the tick bite. Treatment typically involves the administration of antibiotics. Early detection and treatment are instrumental in eliminating the infection and its symptoms, however if the disease is diagnosed late and/or treatment is delayed, more serious symptoms may develop which could be very difficult to address. Untreated individuals may progress to the second stage of the disease and develop more severe symptoms such as skin rashes, heart palpitations, muscle and joint pain, arthritis and arthritis-like conditions, extreme fatigue and weakness, central and peripheral nervous system disorders. The third stage of the disease can last for months or years with recurring neurological problems.1

WDGPH’s prevention and control program for Lyme disease focuses on public education and surveillance. Due to the expanding range of the blacklegged tick and the increasing number of Lyme disease cases reported in the province, surveillance and education efforts were intensified in 2015 from previous years.

Passive Surveillance

WDGPH began recording the number and type of ticks that were submitted by the public in 2011. Before that time, tick inquiries were rare. During the years that followed, the number of ticks being submitted to the health unit has been increasing (Appendix B). In 2015, over 80 ticks were submitted by the public throughout the spring and summer months.  In order to help develop a baseline for tick activity in the health unit, and to assist with Health Canada’s ongoing surveillance efforts, WDGPH expanded passive surveillance to include ticks found on pets. Submitted ticks were identified by WDGPH staff, where possible, any positively identified blacklegged ticks were forwarded to Health Canada’s National Microbiology Laboratory (Field Studies―Zoonotic Diseases and Special Pathogens) in Winnipeg for bacterial testing. Ticks which could not be positively identified by WDGPH staff were forwarded to Health Canada or the Public Health Ontario Laboratory for identification.

In 2015, 68% of all blacklegged ticks submitted to the health unit came from within the WDGPH region, however none tested positive for B. burgdorferi.  A total of 3 adult female blacklegged ticks tested positive for B. burgdorferi and all originated from outside of health unit boundaries in Kingston, Ontario a known endemic area. Additionally, there was one adult female blacklegged tick that tested positive for Anaplasma phagocytophilum and one that tested positive for Babesia microti.

Active Surveillance

Considering the blacklegged tick’s expanding range and population numbers, and the corresponding increase in tick-human encounters, WDGPH began active surveillance in 2015 in partnership with the University of Guelph. Active surveillance was initiated in the form of “tick dragging” in areas with habitat that would be suitable for the blacklegged tick and bacteria. Standard operating procedures based on Public Health Ontario guidelines were adopted.6

Tick–dragging (also known as tick–flagging) involves “dragging” a 1m x 1m square of white flannel fabric attached to a wooden pole through a potential tick habitat in the hopes that “questing” ticks will attach to the material. Areas for dragging were selected based on known tick habitats as well as areas deemed suitable for potential tick habitats. Each of the following areas was dragged twice in 2015, once in spring/early summer, and once in late summer/early fall:

  • Luther Marsh Conservation Area, Grand Valley
  • Island Lake Conservation Area, Orangeville
  • Fletcher Creek Ecological Preserve, Puslinch Township
  • Preservation Park, Guelph
  • Speed River Trail, Guelph
  • Watson Road Trail, Guelph  

Several American dog ticks (also known as wood ticks) were collected during the tick–dragging sessions, however, no blacklegged ticks were found.

Education

In 2015, several initiatives were undertaken to raise awareness among the community regarding Lyme disease and the prevention of tick bites:

A webpage was created on the WDGPH website. The webpage had 43 page views from 29 unique individuals throughout 2015. Average time spent on this page was five minutes and nine seconds.
A tick identification card was designed, printed and distributed to some local veterinary clinics, low-cost rabies vaccination clinics, and WDGPH office waiting areas (Appendix C). Approximately 400 were distributed throughout the fall of 2015. The tick ID card was very well received and feedback from partners indicate that it is popular among clients.
A blog post on ticks and Lyme disease was posted in October 2015.
In August 2015, ticks and Lyme disease were the focus of the WDGPH One Health newsletter that circulates to animal care professionals. This included information about local initiatives, tick submissions, and results of tick testing.
Key messages were tweeted in late summer and fall of 2015.                                                                                                                                                       

Key messages focused on the cause and symptoms of Lyme disease, characteristics of blacklegged ticks, preventing tick bites and tick removal.

ANALYSIS/RATIONALE

Lyme disease is the most commonly transmitted vector–borne disease in North America. In 2015, there were 358 confirmed cases of Lyme disease reported in Ontario, with the majority being acquired in the endemic and high risk areas of Eastern Ontario. This represents a sharp increase in the number of reported cases compared with previous years (Appendix D). This can be attributed to increased public awareness and reporting, the tick’s expanding range, and increases in human–tick encounters.1

Historically, Wellington, Dufferin and Guelph have had few reported human cases of Lyme disease (Appendix E). Only one case was reported in 2015 and it was likely acquired outside the health unit boundaries in Short Hills Provincial Park (Niagara region). Although WDGPH is not an endemic region, blacklegged ticks have been found in the area, with only one that has tested positive for Borrelia burgdorferi. Considering the expanding range of the blacklegged tick and the favourable flora and fauna that exist within Wellington and Dufferin counties, it is not unreasonable to expect that areas within the health unit could become endemic for the blacklegged tick and Borrelia burgdorferi in the future.

Continued passive and active surveillance will be instrumental in acquiring baseline data for the blacklegged tick within Wellington and Dufferin counties. Measuring and mapping the tick’s progress over time will allow WDGPH to better utilize resources and target education and awareness campaigns towards specific areas and populations in 2016 and beyond.

Ontario Public Health Standards

Health Hazard Prevention and Management Program Standard

Goal: To prevent or reduce the burden of illness from health hazards in the physical environment.

The board of health shall develop a local vector-borne management strategy based on surveillance data and emerging trends in accordance with the Infectious Diseases Protocol, 2015.

WDGPH Strategic Commitment

Strategic Directions
DIRECTION APPLIES? (YES/NO)
Health Equity: We will provide programs and services that integrate health equity principles to reduce or eliminate health differences between population groups.       NO
Organizational Capacity: We will improve our capacity to effectively deliver public health programs and services.        NO
Service Centred Approach: We are committed to providing excellent service to anyone interacting with Public Health.      YES
Building Healthy Communities: We will work with communities to support the health and well-being of everyone.      YES

Health Equity

There is no current research that points to a health equity issue relating to Lyme disease. However, anecdotally, a large number of tick submissions are from people who have recently spent time at their cottages and therefore this population is more likely to be exposed to blacklegged ticks. Hikers and campers, particularly those frequenting provincial parks, are at higher risk for tick bites as they spend time in areas where blacklegged ticks are endemic.

Appendices

Appendix A –  List of Endemic Areas for Lyme Disease in Ontario

Appendix B –  Number and Type of Ticks Submitted to WDGPH for Analysis

Appendix C –  Tick Identification Card Designed, Printed, and Distributed by WDGPH

Appendix D –  Number of Probable and Confirmed Cases of Lyme Disease in Ontario, 2005–2015

Appendix E –  Number of Confirmed and Probable Cases of Lyme Disease and the Number of Positively Identified Ticks with Borrelia burgdorferi, in the WDG region, 2005–2015

References

  1. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Vector-borne diseases 2014 summary report. Toronto, ON: Queen’s Printer for Ontario; 2015. Available from: https://www.publichealthontario.ca/en/eRepository/Vector_Borne_Diseases_Summary_Report_2014.pdf
  2. Ontario Agency for Health Protection and Promotion (Public Health Ontario). PHO Technical Report: Update on Lyme Disease Prevention and Control (Feb 2012). Available from: https://www.publichealthontario.ca/en/eRepository/PHO%20Technical%20Report%20-%20Update%20on%20Lyme%20Disease%20Prevention%20and%20Control%20Final%20030212.pdf
  3. Canada Communicable Disease Report CCDR. Assessment of a screening test to identify Lyme disease risk. Volume 40-5; March 6, 2014. Available from: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/14vol40/dr-rm40-05/dr-rm40-05-2-eng.php
  4. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Map of Lyme Disease Risk Areas. Toronto, ON: Queen’s Printer for Ontario; 2015. Available from: https://www.publichealthontario.ca/en/eRepository/Lyme_Disease_Risk_Areas_Map_2015.pdf
  5. Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). Division of Vector–Borne Diseases (DVBD). Accessed at http://www.cdc.gov/lyme/transmission/index.html on May 1, 2016.
  6. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Tick dragging: Standard operating procedure. Toronto, ON: Queen’s Printer for Ontario; 2015.  Available from:  http://www.publichealthontario.ca/en/eRepository/Active_tick_dragging_SOP.pdf

APPENDIX A. 

List of Endemic Areas for Lyme Disease in Ontario:2

  • Long Point Provincial Park
  • Turkey Point Provincial Park
  • Rondeau Provincial Park
  • Point Pelee National Park
  • Prince Edward Point National Wildlife Area
  • Wainfleet Bog Conservation Area
  • St. Lawrence Islands National Park

Figure A: Map of Risk Areas for Lyme Disease in Ontario4

Lyme Disease Risk Areas

APPENDIX B.

Figure B1: Number and Type of Ticks submitted to WDGPH for Analysis in 2015

 

Number and Type of Ticks submitted to WDGPH for Analysis in 2015

Figure B2: Number and Type of Ticks Submitted to WDGPH for analysis 2011-2015

Number and Type of Ticks Submitted to WDGPH for analysis 2011 - 2015

 

APPENDIX C.

Figure C: Tick Identification Card designed, printed, and distributed by WDGPH.

Tick Identification Card designed, printed, and distributed by WDGPH.

APPENDIX D.

Figure D:  Number of Probable and Confirmed Cases of Lyme Disease in Ontario,
2005–2015

Number of Probable and Confirmed Cases of Lyme Disease in Ontario.

APPENDIX E.

Figure E:   Number of Confirmed and Probable Cases of Lyme Disease and the Number of Positively Identified Ticks with Borrelia burgdorferi, in the WDG region, 2005–2015

 

Number of Confirmed and Probable Cases of Lyme Disease and the Number of Postively Identified Ticks with Borrelia burgdorferi, in the WDG region. 2005 - 2015