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U.S. Army Public Health Command

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1 U.S. Army Public Health Command
DOD Efforts in Tick Surveillance and Preventing Tick-Borne Disease in the US U.S. Army Public Health Command Good morning, I’m Ellen Stromdahl. I‘m an entomologist at the US Army Public Health Command. Ellen Stromdahl Entomological Science Program UNCLASSIFIED

2 Tick-borne Disease is an
Occupational Health Risk for Military Personnel The DOD has always been concerned with ticks because tick-borne disease is an occupational health risk to soldiers training in the field, Tick-Borne Disease Laboratory UNCLASSIFIED 2

3 Deer on Military Installations
and to civilians and dependents who live & work on military installations. Tick-Borne Disease Laboratory UNCLASSIFIED 3

4 Tick Taxonomy / Imaging
Tick and Tick-Borne Disease Surveillance Tick Taxonomy / Imaging Tick Repellents DOD activities at present involving ticks in the US include: Tick and Tick-Borne Disease Surveillance Tick Taxonomy and Tick Imaging and work on Tick Repellents Tick-Borne Disease Laboratory UNCLASSIFIED 4

5 PHC Region-North Ticks are collected by a variety of methods
Tick Drag, CO2 trap Small, medium, large mammals Sample information Test Organism Coll’n method Sample type Bb #/D/%D Ec Ee Ap Babesia Rickettsia Drag A. americanum Non-vector 82/1/1% 82/4/5% 82/0/0% D. variabilis 33/0/0% I. scapularis 1/0/0% A. maculatum 2/1/50%1 Coyote I. affinis2 3/1/33% 3/0/0% 3/2/67%3 The work of the US Army PHC includes pathogen analysis of ticks field-collected or removed from animals on military installations. 1 Rickettsia parkerii positive causative agent of Tidewater Fever 2 5 collected 3 tested 2 submitted to US National Tick Collection as voucher 3 Babesia canis

6 Threatmap with Proposed Tick Control
This data is then used to create GIS maps of high-threat tick habitat. For example, at Ft. A.P. Hill, VA, for the National Scouting Jamboree (that is, 40,000 scouts in tick habitat), the PHC did tick surveillance and produced a threat map showing the probability of encountering lone star ticks. This information was then used to target tick control efforts including acaricide spraying and 4-poster deer feeders,

7 and the mapping was also used to produce educational materials, like this poster, for display during the event.

8 Scouts’ ticks tested at the Jamboree
PHC Region-North Laboratory identification and PCR analysis during the Jamboree to determine the infection rate of ticks TICK INFORMATION Test RESULTS TICK ID # TICKS TESTED HME #D (%D) EE Rr Ap LD Babesia A. americanum 1241 3 (2%) 7 (6%) Non-vector D. variabilis 1612 0 (0%) I. scapularis 3 TOTAL 288

9 DOD Human Tick Test Kit Program
Clinical support for health care providers and their tick-bite patients Tick I.D. and analysis Lyme disease Human granulocytic anaplasmosis Babesiosis Human monocytic ehrlichiosis Ewingii ehrlichiosis R. parkeri rickettsiosis Rocky Mountain spotted fever The PHC also offers this same service year round - the DOD Human Tick Test Kit Program - providing tick id and PCR testing to military personnel and DOD civilians. Tick-Borne Disease Laboratory UNCLASSIFIED 9

10 Locations of Tick Test Kit Program Participants
We test several thousand ticks every year from around 100 participating military installations. This map shows locations, the big dots indicate the installations that send us the most ticks. Tick-Borne Disease Laboratory UNCLASSIFIED 10

11 Results of id and testing are of course provided back to the tickbite victim and the healthcare provider, and also results are cumulated to provide overviews of tick abundance, distribution and infection prevalence on an installation or regional level. Tick-Borne Disease Laboratory UNCLASSIFIED 11

12 Publications – ticks and tick-borne pathogens
Sardelis MR, Neidhardt K, Perich MJ, Milstrey EG, Harlan HJ, Boobar LR. Reduction of the Amblyomma americanum (acari:Ixodidae) population at Fort A.P. Hill, Virginia by aerial application of diazinon granules: correlation of percentage control with received dose. J Med Entomol :494. Evans SR, Korch GW Jr, Lawson MA. Comparative field evaluation of permethrin and deet-treated military uniforms for personal protection against ticks (Acari). J Med Entomol : Kardatzke, JT, Neidhardt, K, Dzuban, DP Sanchez, JL,et al. Cluster of tick-borne infections at Fort Chaffee, AR: rickettsiae and Borrelia burgdorferi in Ixodid ticks. J Med Entomol 1992; 29:669–72. Amerasinghe FP, Breisch NL, Azad AF, Gimpel WF, Greco M, Neidhardt K, Pagac B, Piesman J, Sandt J, Scott TW, et al. Distribution, density, and Lyme disease spirochete infection in Ixodes dammini (Acari:Ixodidae) on white-tailed deer in Maryland. J Med Entomol :54-61. Solberg VB, Neidhardt K, Sardelis MR, Hildebrandt C, Hoffmann FJ, Boobar LR. Quantitative evaluation of sampling methods for Ixodes dammini and Amblyomma americanum (Acari:Ixodidae) . J Med Entomol :451-6. Solberg VB, Neidhardt K, Sardelis MR, Hoffmann FJ, Stevenson R, Boobar LR, Harlan HJ. Field evaluation of two formulations of cyfluthrin for control of Ixodes dammini and Amblyomma americanum (Acari: Ixodidae). J Med Entomol :634-8. Amerasinghe FP, Breisch NL, Neidhardt K, Pagac B, Scott TW. Increasing density and Borrelia burgdorferi infection of deer-infesting Ixodes dammini (Acari: Ixodidae) in Maryland. J Med Entomol : Stromdahl, EY, Randolph, MP, O'Brien, JJ, Gutierrez, AG.. Ehrlichia chaffeensis (Rickettsiales: Ehrlichieae) infection in Amblyomma americanum (Acari: Ixodidae) at Aberdeen Proving Ground, Maryland. J Med Entomol : Stromdahl, EY, Evans, SR, O'Brien, JJ, Gutierrez, AG. Prevalence of infection in ticks submitted to the human tick test kit program of the U.S. Army Center for Health Promotion and Preventive Medicine. J Med Entomol 2001; 38:67-74.  Stromdahl, EY, Williamson, PC, Kollars, TM Jr, Evans, SR, et al. Evidence of Borrelia lonestari DNA in Amblyomma americanum (Acari: Ixodidae) removed from humans. J Clin Microbiol 2003; 41:  Sumner, JW, Durden, LA, Goddard, J, Stromdahl, EY, Clark, KL, Reeves, WK and Paddock, CD. A survey of gulf coast ticks (Amblyomma maculatum) for Rickettsia parkeri in the United States. Emerg Infect Dis :751-3  Loftis, AD, Mixson, TR, Stromdahl , EY, Yabsley, M J, Garrison, LE, Williamson, PC, Fitak, R R, Fuerst, PA and Blount K.B. Geographic distribution and genetic diversity of the Ehrlichia sp. from Panola Mountain. BMC Infect Dis 2008; 8:54  Stromdahl, EY, Vince, MA, Billingsley, PM, Dobbs, NA, et al.  Rickettsia amblyommii infecting Amblyomma americanum larvae.  Vector Borne Zoonotic Dis 2008; 8:   Jiang, J, Yarina, T Melissa K. Miller, Ellen Y. Stromdahl, Allen L. Richards. Molecular detection of Rickettsia amblyommii in Amblyomma americanum parasitizing humans. Vector Borne Zoonotic Dis : Ellen Y. Stromdahl, Ju Jiang, Mary Vince and Allen L. Richards. Infrequency of Rickettsia rickettsii in Dermacentor variabilis Removed from Humans. Vector Borne Zoonotic Dis 2010 (Epub ahead of print) Eremeeva, ME, Stromdahl, EY. New spotted fever group Rickettsia in a Rhipicephalus turanicus tick removed from a child in eastern Sicily, Italy. Am J Trop Med Hyg :99-101 We also publish results of surveillance - here are over 20 years worth of titles.

13 Field-portable macro imaging device for arthropod identification
The PHC also has capabilities to create marvelous images of ticks. We‘ve developed a camera that creates sequential images with overlapping depth of field. Then software combines this “stack” of images to produce an ultra high resolution image that remains focused even as you zoom in on key taxonomical characters – like the goblets in the spiracular plate. The images are available for public use and are on line.

14 TickMap Downloadable collection form
>50,000 records New website (requires Silverlight): The Walter Reed Biosystematics Unit is developing TickMap, an online, interactive tool for mapping worldwide tick abundance, distribution and pathogen prevalence.

15 Relate vector distribution to collection records
Like WRBU’s MosquitoMap, you can pan and zoom in on any part of the world to see the tick species there, and it has modeling capabilities to predict the range of a given species,

16 and a tick Mal-Area calculator is being included, which will combine human distribution with vector and pathogen distribution.

17 How to contribute collection records
Excel Mapper Collection forms Contributions of tick records are solicited and encouraged – you can upload your collection records and use TickMap to manipulate them in combination with other collection data.

18 The Armed Forces Health Surveillance Center publishes MSMR, the Medical Surveillance Monthly Report, which includes cases of tick-borne disease among military patients. It is available free on-line. This issue, July, 2009, featured an article on Lyme disease cases.

19 Defense Medical Epidemiology Database:
The Armed Forces Health Surveillance Center also offers on-line the Defense Medical Epidemiology Database. Users may access data and perform queries regarding disease rates - including vector-borne disease - in military populations.

20 Here’s a sample of an Excel table created from DMED data.

Researchers at the Naval Medical Research Center make tremendously important contributions to the study of Rickettsia, many of which are tick-borne. More than 16 newly recognized spotted fever rickettsiae have been identified since 1984, and many of these agents were catapulted into the realm of human recognition by extraordinary advances in molecular technology.

22 Quantitative real-time PCR(qPCR) assays
qPCR assays for detection of Rickettsia in ticks Rickettsia genus assay-Rick17b tick-borne spotted fever group assay-Trick species specific assays: R. rickettsii-Rrick R.parkeri-Rpark Candidatus R. andeanae-Rande R.felis-Rfelis R. montanensis -Rmont R.amblyommii-Rambl R.conorii-Rcono R.raoultii-Rraou R.slovaca-Rslov R.aeschlimannii-Raesc qPCR assays avalible for detection of other tick-borne pathogens Borrelia lonestari Borrelia burgdorferi Ehrlichia chaffeensis E. canis Anaplasma phagocytophilum Coxiella burnetii qPCR assays avalible for identification of tick species Amblyomma americanum Dermacentor variabilis Ixodes scapularis Ixodes pacificus Molecular biologists at NMRC have designed and developed elegant assays that are assisting us in sorting out these rickettsia. Notice that the lab has also developed qPCRs for other tick-borne pathogens – and primers for molecular identification of ticks. Multilocus Sequencing Typing (MLST) Primers are designed to amplify the well known genes for characterization of Rickettsia : 16s rRNA gene, 17 kDa antigen gene, gltA, ompA,ompB, and sca4

23 Publications - detection of tick-borne pathogens
Stromdahl EY, Jiang J, Vince M, Richards AL. Infrequency of Rickettsia rickettsii in Dermacentor variabilis removed from humans, with comments on the role of other human-biting ticks associated with spotted fever group rickettsiae in the United States. Vector Borne Zoonotic Dis 2010 (Epub ahead of print) Smith MP, Ponnusamy L, Jiang J, Ayyash LA, Richards AL, Apperson CS. Bacterial pathogens in ixodid ticks from a Piedmont County in North Carolina: prevalence of rickettsial organisms. Vector Borne Zoonotic Dis Dec;10(10):939-52 Jiang J, Yarina T, Miller MK, Stromdahl EY, Richards AL. Molecular Detection of Rickettsia amblyommii in Amblyomma americanum Parasitizing Humans. Vector Borne Zoonotic Dis 2010 May;10(4): Whitman TJ, Richards AL, Paddock CD, Tamminga CL, Sniezek PJ, Jiang J, Byers DK, Sanders JW. Rickettsia parkeri infection after tick bite, Virginia. Emerg Infect Dis 2007;13(2):334-6. Wright CL, Nadolny RM, Jiang J, Richards AL, Sonenshine DE, Gaff HD, Hynes WL. R. parkeri found in A. maculatum from VA. Emerg Infect Dis 2011 Jiang J, Stromdahl EY, Richards AL. Detection of Rickettsia parkeri and Candidatus Rickettsia andeanae in Amblyomma maculatum Gulf Coast Ticks Collected from Humans in the United States. Vector Borne Zoonotic Dis (submitted) Rozmajzl PJ, Flyer JG, Jiang J, Stromdahl EY, and Richards AL. Development of a Quantitative Real-time Polymerase Chain Reaction (qPCR) Assay for the Detection of Rickettsia montanensis Validated with Dermacentor variabilis Collected from Humans. Am J Trop Med Hyg (submitted) Truong M, Jiang J; Yarina T, Evans H, Turner J, Miller M, Christensen TP, Richards AL. Rickettsia parkeri and Ehrlichia chaffeensis Detected in Ixodidae Ticks from Fort Eustis, Virginia. Am J Trop Med Hyg (submitted) These assays are validated and results of testing large numbers of ticks have been published. The assays perform reliably and are easy to use. They have been adopted by military PCR labs, helping to standardize our procedures.

24 Naval Medical Research Center
  Prevalence and Clinical Characteristics of Infection Caused by the Newly Emerging Pathogen, Rickettsia parkeri, in Adults and Children Presenting to Clinics and Emergency Departments with Acute Febrile Illness. And the NMRC is going to use these qPCR assays in an effort to tease out the incidence of Rickettsia parkeri infection – Tidewater spotted fever – from illness previously diagnosed as “fevers and rashes of unknown etiology”. First at Navy clinics in Portsmouth, VA, and Jacksonville, FL, 100 patients suspected of having rickettsial disease symptoms will be enrolled and tested. Subsequently other Military Medical Treatment Facilities will be included in the survey, and hopefully diagnostics will be expanded to include qPCR for other tick-borne pathogens. Todd Myers, PhD Naval Medical Research Center Silver Spring MD

And eventually, the plan is to include a form for submitting human samples to NMRC in the DOD Tick Test Kit, so that tick and tick-bite victim infection status could be married up to provide a convenience for Military medical practitioners, and more complete picture for diagnostic and epidemiological purposes. Due to today’s extraordinary advances in molecular technology, it seems like it is easier to discover a new pathogen than to associated it with a human disease and establish accurate surveillance for that disease. This program could assist in improving the accuracy of incidence determinations for tick-borne diseases. TICK TESTING & HUMAN DIAGNOSTICS

ARMED FORCES PEST MANAGEMENT BOARD LITERATURE RETRIEVAL SYSTEM The Armed Forces Pest Management Board has a website full of information. The Literature Retrieval System has all the papers on tick-borne disease you’ve been wanting to find – obscure papers from the first half of the 20th century, brand new papers in some expensive journal you don’t have a subscription to, all there available at a mouse-click. On the website you can also request a free tutorial DVD on tick morphology and identification, assembled by Dr. Richard Robbins, one of the foremost tick taxonomists in the world, who is on staff there. DVD ON TICK IDENTIFICATION

There’s also an image library, with photos of ticks, and this one of Dr. Harry Hoogstraal, the preeminent tick taxonomist of the 20th century, who was – a DOD civilian! Dr. Henry Hoogstraal

28 DoD Insect Repellent System
= Besides surveillance and testing, the DOD is trying to attack the problem of tick-borne disease at the root – preventing tickbite! Use of the DOD repellent system has long been required of military personnel, but compliance is never complete, especially in the case of the System’s most effective component against ticks –the permethrin-treated uniform.

29 0.5% PERMETHRIN Aerosol Spray Can
NSN Military Commercial In the past, you had to treat your uniform with spray, Tick-Borne Disease Laboratory UNCLASSIFIED 29

30 PERMETHRIN Impregnation (IDA) Kit
NSN Or the IDA or “Shake & Bake” Kit,

31 PERMETHRIN Application using 2-Gallon Sprayer
Or use a 2- gallon sprayer. All these methods were time-consuming, took advanced planning – the ordering of repellent & supplies – so permethrin treatment was too often overlooked.

32 Now, with the cooperation of a Galaxy of Agencies, a Constellation of Acronyms, uniforms are factory-treated with permethrin. Eventually, their use will be Universal. The DOD started working with the USDA in WWII to develop repellents. About 1980, permethrin was identified as an effective clothing repellent. Since then, fabric impregnation methods have been developed, tested and improved to produce an effective, long-lasting, and safe arthropod repellent.

33 Deployed War-Fighter Protection (DWFP) is a DOD-sponsored research program administered by the Armed Forces Pest Management Board (AFPMB). USDA ARS CMAVE has developed a test procedure to ensure military uniforms are correctly treated to protect troops from arthropod bites. There now is in place a Quality Assurance process to ensure the safety and efficacy of the factory treatment. USDA CMAVE in Gainesville, FL does biological monitoring to make sure the treatment is effective against arthropod vectors,

34 And Natick, or the US Army Natick Soldier Research, Development & Engineering Center, does the textile technology. A number of commercial vendors treat the uniforms, and they are constantly monitored to make sure the permethrin is applied correctly. Also, as new fabrics and uniform configurations are developed, permethrin treatment methods must be modified and results assessed.

35 Permethrin Factory-Treated Flame Resistant Army Combat Uniforms (FRACU-P)
And products and methods of treatment must be EPA registered. Here are labels in the Army uniforms.

36 Permethrin Factory-Treated Flame Resistant MultiCam Uniforms (Afghanistan)
This is the new MultiCam uniform and designed for the Afghanistan area of operation. This uniform is pretreated with permethrin. The Army Surgeon General considers permethrin-treated uniforms one of the most important protective measures for Soldiers, and fully endorses permethrin factory treatment.

37 U.S. Army Public Health Command Ellen Stromdahl Tick-Borne Disease Laboratory
The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense or the U.S. Government. UNCLASSIFIED 37

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