4Diagnostic Issues with CA Focus In CA, 70% do not recall tick bite97% of vector borne diseaseOnly 56.8% have EM41% exposed outside county of residence22% exposed outside of stateEM not seen on dark skinIn CA less than 60% of population is white, but ~ 90% of reported cases are whitePeople who work as gardeners, contractors, field workers, park rangers, fire fighters are at high risk
5Nymphal ticks transmit most LD Smaller than a poppy seedThree blood mealsBite is painlessIn CA nymphal tickshave the highest rate of infectionHumans incidental and end host
7How do we determine risk? Will the ecosystem support Lyme infected ticks?Are there ticks that can carry Lyme in the area?Are there ticks that do carry Lyme?Are people exposed to these ticks?Will the ecosystem support Lyme infected ticks? The question here is whether the known animal reservoirs that maintain Bb are in the environment? Here, we are talking about mice, rabbits, birds, squirrels, and deer. Actually, the deer are not believed to be a reservoir. However, the ticks do mate on deer.The next question is whether black legged ticks are in the area. Other ticks don’t seem to house Bb. If there are black-legged ticks, all that is required is that they feed on a reservoir animal to become infected.Then we ask if there actually are ticks in the area that are known to be infected? If so, we have a problem. This is why it is important to do tick testing. It is also important to recognize that there may be foci of infected ticks—which means that there tend to be pockets of ticks carrying Bb. This means that if you test a tick in one area and that pool is negative, a hundred yards over there may be infected ticks and if you don’t test them you won’t know. (In short, just because you don’t catch any fish doesn’t mean there aren’t any fish in the lake.)Finally, people have to be exposed to them. I know in my neighborhood, Los Feliz, its not uncommon to have deer, racoons, skunk, opossum, mice, rats all hanging out by the kitchen door.
8How does Lyme disease risk spread? Tick TransportsBirds are the long distance carriersPockets of fociTick testing in one area may not reflect other areas
11Lyme disease is throughout CA Many doctors unaware that Lymedisease is in CAMost of the public are unaware thatLyme disease exists in CAPublic is unaware that ticks aredangerousDo not take proper precautionsDo not do tick checksDo not remove ticks properlyDo not know that rash means they should go to the doctor
12W. LA Vector Control District Model websiteInformation on ticks, prevention & coinfections.Regular flagging activity.Use the best labs in the state to test ticksPlacer CountySonoma County
13Number of cases in California In one small rural community in Mendocino County 37% of the residents had definite or probable Lyme disease, while 24 % were seropositive.In 2001, estimates of the annual incidence of Lyme disease in California ranged from 920 (10 times the number of officially reported cases) to 1,500 cases (based on estimated lab reports) to 2,640 (based on physician estimates.
14LA County Wilderness Areas LA County: 13 million people (If state, the 9th most populated)30% of land = state parks, national parks and agricultureUrban areas next to wilderness areas (Hollywood Bowl, Rose Bowl, the Greek Theatre)Black-legged ticks found throughoutHollywood Bowl (Hollywood Hills), Griffith Park, Angles National Forest, Santa Monica Mountains, Los Padres National Forest, San Gabriel Mountains, Santa Monica Mountains, Whittier Hills, La Puente Hills, Palos Verdes
15Griffith Park Abundance of ticks Largest urban wilderness in United States10 million visitors a yearHumans, horses, and dogs use trails
16Los Angeles 6th out of 59 counties in Lyme cases from 1994-2003 Butte (9.7%)Sonoma (9.2%)Humboldt (8.6%)Mendocino (7.2%)San Diego (5.8%)Los Angeles (4.8%)
17Local parks with infected ticks Malibu (Tapia State Park,1998; Charmlee 2000)Pacific Palisades (Will Rogers State Park 2000)Topanga (Topanga State Park 2000)Palos Verdes (Bluff Cove 2000)Backbone trail connecting Will Rogers and Topanga State Park an unidentified Bb strainCrestview Hills Park (north of Brentwood)
18Incidence in LA ≠ Disconnect CDC(2004 & cumulative)LA Support Group(Current)Physician EstimatesLab Estimates(2004)LA: 5 annualSo. Cal.: 200 (cum )262 ~ cum.260 ~ cum.(2004) ??AwarenessDiagnosisReportingStaffing10 or 40 X~ Annual?~2,000-8,000 cumChronic~15% total(~1,744?)Joiners(~1,730?)2 polledMay be more than one test per year
19Coinfections: Can be more common than Lyme? BabesiaMicroti & WA-1EhrlichiaHGE & HMEBartonellaSpirocheteMalaria like protozoaGram neg. bacteriaGram. Neg. bacteriaAverage for nymphs 12%N. CA community study1100 residentsMicroti: 0WA-1: ~18%N. CA community study2230 residentsHGE: 0.4%HME: 4.6 %19.2% *Santa Claratick study3(Chang 2001)1. Lane RS, et al Risk factors for Lyme disease in a small rural community in northern California. Am J Epidemiol 136:2. Fritz et al. 1997, Seroepidemiology of Emerging Tickborne Infectious Diseases in a Northern California Community. J Inf Dis 175:1432-9, 1997.3. C. C. Chang et al. Molecular Evidence of Bartonella spp. in Questing Adult Ixodes pacificus Ticks in California J. of Clin. Microbiology, April 2001, 39(4):
20What can be done? Alert public to Lyme risks, symptoms & precautions Newsletter to physiciansin LAOnly ~68% with EMEM alone diagnosticClinical diagnosisSurveillance definition not for diagnosisMake sure all physicians and labs aware of new mandatory lab reportinglab resultsPhysician form verifying CDC criteriaCompile data already being collected & add question to form re clinical diagnosis that does not meet CDC surveillance definition
21California Lyme Disease Association Vision StatementEvery person who contracts Lyme receives a prompt diagnosis and ideal treatment to prevent the development of persistent Lyme disease.Every person with persistent Lyme disease receives readily accessible and sufficient medical treatment to preserve health by either curing or controlling the disease to improve the individual’s current quality of life, prevent the progression of disease, or extend life span.Every physician in the state receives adequate education regarding tick-borne diseases and is able to accurately diagnose and treat tick-borne diseases.
22Lyme disease is now lab reportable ….Lyme disease has been made laboratory reportable, which means that a positive laboratory test for Lyme disease must be forwarded to the local health department,which will then follow up with the physician ordering the test to evaluate if the patient fits the surveillance case definition.Reportable Disease List to be Updated New Legislation Allows for Timely ChangesDepartment of Health Services, Division of Communicable Diseases, Medical Board of California, Action Alert Report, July :8.
23LA Has 5 Vector Control District—Only one is doing its job The Greater LA District prevents and controls three vectors: mosquitoes, black flies, and midges. Covers Los Feliz area.The Antelope Valley Mosquito & Vector Control District concentrates on mosquitoes and Africanized Honey Bees only.San Gabrial Valley: Vectors of concern in the San Gabriel Valley include mosquitoes, black flies, midges, rodents, …Africanized honey bees and other stinging insects. May test ticks? Website has no public information on ticks.Long Beach Health Dept – LBHDVCP No mention of ticks
242000 Vector Report for West LA “These positive results represents an unusually high infection rates of Lyme spirochete in southern California ticks, occupying a wide area from Pacific Palisades to the west of Malibu close to Ventura county and as far south as Palos Verdes.”
25New relapsing fever type strains found in California Bissett identified a new strain in California similar to reported European strains with antigenic variation similar to that seen in the Borrelia spp. that causes relapsing fever Bissett, ML and W. Hill, Characterization of Borrelia burgdorferi Strains Isolated from Ixodes pacificus Ticks in California. J Clin. Microbiology, Dec. 1987, 25 (12):Novel relapsing fever group spirochete also detected in Ixodes pacificus ticks in CA. Detected in Sonoma, Placer, Monterey, San Luis Obispo, Riverside,?? .Quintana, U.S. Army Center for Health Promotion & Prevention Medicine West.