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Tick-Borne Diseases: Identification, Management and Prevention

Authors:
Abstract
Tick borne diseases have become a public health crisis in endemic areas of the world. It is important
for health care professionals to be aware of the clinical manifestations of tick borne diseases, and
recommended practices for their diagnosis and treatment. It is also important to educate the public on
signs of disease and how to mitigate exposure. An understanding about the life cycle of ticks and the
interplay of the environment is also crucial to reduce morbidity and mortality. is article presents the
most common tick borne diseases of hard bodied ticks in the United States which are transmitted by: deer
tick: Ixodes scapularis and pacicus, dog tick: Amblyomma americium and lone star tick: Dermacentor
variabilis. Diseases from infected ticks (bacterial, parasitic and viral) include Lyme disease, babesiosis,
anaplasmosis, ehrlichiosis, tularemia, Powassan virus (POW virus) and Southern Tick Associated Rash
Illness (STARI). ere is increasing concern with new and emerging strains of other tick borne diseases
such as Borrelia miyamotoi.
Tick-Borne Diseases: Identification, Management and Prevention
Publication History:
Received: May 06, 2017
Accepted: August 09, 2017
Published: August 11, 2017
Keywords:
Tick-borne diseases, Powassan
virus, Interventions
Review Article Open Access
Introduction
e incidence of tick borne diseases is on the rise. ese trends
result in larger numbers of persons requiring treatment, placing a
greater nancial impact on the healthcare system and individual
patients thus creating a greater burden on society. Prevention
measures, pharmacological treatment, possible vaccines, and non-
pharmacological interventions such as behavior changes or tick-
targeted strategies need to be evaluated and improved. Interventions
need to include emphasis on public health education [1].
Lyme disease is the most common vector borne disease in North
America and Europe with approximately 300,000 cases per year in
the U.S.[2] e spirochete infection is caused by the Borrelia species
(B. bourdorferi, a spirochete related to the syphilis pathogen) and is
transmitted by the bite of infected Ixodes ticks (Ixodes scapularis also
known as deer ticks or black legged ticks and Ixodes pacicusalso
known as western black legged ticks)[2]. Lyme disease can aect the
skin, joints, nervous system, and heart. In the U.S., the Ixodes ticks
can also transmit human granulocytic anaplasmosis, babesiosis,
and Powassan virus [2,3]. Infected Amblyomma americanum (Lone
star ticks) can transmit human monocytic ehrlichiosis and STARI
(Southern Tick Associated Rash Illness). Also, lone star larval tick
bites can cause an allergy to meat due an IgE immune response to
galactose-alpha-1,3-galactose also known as alpha gal [4]. e
Dermacentor variabilis tick can transmit Rocky Mounted Spotted
Fever (RMSF), tularemia and tick paralysis. Pathogenic organisms
normally cycle among small mammals and birds. e white-footed
deer mouse (Peromyscus leucopus) is the dominant mammalian
reservoir host for tick borne diseases, especially Borrelia burgdorferi.
It is estimated in some geographic regions (North Eastern U.S.) over
ninety percent of the white footed deer mouse are infected [5].
Ticks have three stages in their two-year life cycle: larva, nymph,
and adult. Lyme disease is most commonly transmitted by nymphal
ticks, which are most active during the late spring and early summer
in temperate regions. Nymphal ticks are smaller in size and not as
easily detected on skin. Larger adult ticks are most active in the fall.
(Figure 1) [6,7].
Individuals at highest risk for tick borne diseases including Lyme
disease are those who live in endemic regions. Individuals in endemic
areas who work outside and/or participate in recreational activities
*Corresponding Author: Dr. Anna-Marie Wellins, School of Nursing, Stony
Brook University, 100 Nicolls Rd, Stony Brook, NY 11794, USA; E-mail:
anna-marie.wellins@stonybrook.edu
Citation: Wellins AM (2017) Tick-Borne Diseases Identication, Management
and Prevention. Int J Nurs Clin Pract 4: 248. doi: https://doi.org/10.15344/2394-
4978/2017/248
Copyright: © 2017 Wellins. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author
and source are credited.
International Journal of
Nursing & Clinical Practices
Anna-Marie Wellins
School of Nursing, Stony Brook University, 100 Nicolls Rd, Stony Brook, NY 11794, USA
Int J Nurs Clin Pract IJNCP, an open access journal
ISSN: 2394-4978 Volume 4. 2017. 248
Wellins, Int J Nurs Clin Pract 2017, 4: 248
https://doi.org/10.15344/2394-4978/2017/248
are at even higher risk for tick borne diseases. Conrmation of tick
borne diseases may be based on laboratory testing; however, antibiotic
therapy should not be delayed in a patient with suggestive clinical
presentation [2].
Early cutaneous infection with B. burgdorferi can manifest with a
bull’s eye rash also known as erythema migrans (EM). Appearance
of rash may occur less than y percent in Lyme disease infections.
Ticks can transmit more than one disease to humans resulting in
coinfections such as Lyme disease and babesiosis or Lyme disease and
ehrlichiosis [2,3].
Life Cycle of Hard Ticks
Aer hatching from eggs, ticks go through three stages which
include larval, nymphal, and adult stages. Ticks must have a blood
meal at each of these three stages to survive and will die if they do not
nd a host for their next feeding. (Figure 2)[7,8].
Ticks nd their animal hosts by sensing their body heat, vibration
and/or carbon dioxide. Hosts consist of mammals such as deer, horses
or humans. Preferred hosts for larval ticks consist of rodents such as
mice, squirrels and chipmunks. Larval ticks also feed on birds. If the
rodents or birds are infected with a tick-borne disease such as Borrelia
burgdorferi, the tick then becomes infected during feeding. Nymphal
and adult ticks prefer larger hosts such as deer, horses, dogs or humans.
Larger mammals including deer and humans are considered dead end
hosts (infection cannot be transmitted to feeding ticks) [7,8].
Ticks that need a blood meal wait for their host by resting on tips of
grasses or shrubs. ey can also wait in leaf litter. Ticks do not jump or
y, but wait with hind legs attached to vegetation known as “questing”.
Int J Nurs Clin Pract IJNCP, an open access journal
ISSN: 2394-4978 Volume 4. 2017. 248
Citation: Wellins AM (2017) Tick-Borne Diseases Identication, Management and Prevention. Int J Nurs Clin Pract 4: 248. doi: https://doi.org/10.15344/2394-
4978/2017/248
Page 2 of 6
Figure 1: Tick Species and Size courtesy of CDC.
Figure 2: Life Cycle of Ticks Courtesy of CDC.
Citation: Wellins AM (2017) Tick-Borne Diseases Identication, Management and Prevention. Int J Nurs Clin Pract 4: 248. doi: https://doi.org/10.15344/2394-
4978/2017/248
Int J Nurs Clin Pract IJNCP, an open access journal
ISSN: 2394-4978 Volume 4. 2017. 248
Page 3 of 6
When a host brushes by the positioned tick it quickly attaches to
the skin of the host. e tick attaches into skin with their barbs that
anchor into the skin. Ticks also secrete cement like substance to
further secure their anchor along with an anesthetic chemical in their
saliva so their presence can go unnoticed by the host [6-8].
e longer an infected tick is attached and feeds the more likely the
transmission of disease, especially if the tick becomes engorged. Ticks
that feed on humans, especially nymphal ticks can become attached,
feed and then fall o without any awareness of the individual,
especially if ticks are attached in areas such as the groin, axillae, back
or behind the knees [ 7,8]. Ticks feed by sucking the host's blood for
several days. If the host reservoir such as a rodent or bird is infected,
the tick then becomes infected. e next time the tick feeds in its life
cycle, the tick then may infect an animal or human. It is estimated that
twenty percent of nymphal Ixodes scapularis and y percent of adult
Ixodes scalpularis are infected with Borrelia burgdorferi [7,8].
Tick eggs are not initially infected; however, when eggs molt into
larva and they feed on an infected rodent such as a mouse, then the
tick become infected. e larval tick then molts into a nymph; the
infected nymphs seek a blood meal which can be a deer or human and
then transmits the infection during the feeding process. e adult ticks
prefer to feed and mate on white tailed deer (Odocoileus virginianus),
with females then falling o to lay their eggs before they die. A single
female tick typically lays one to three thousand eggs. White-tailed
deer are the principal host for the adult ticks; an important means
of transport and tick abundance is closely linked to the abundance of
these animals. A frost does not kill ticks and adults may become active
as soon as it is above freezing [ 9].
One key success of I. scalpularis as a Borrelia vector relies on its
ability to limit proliferation of spirochetes. Certain gene expression
contributes to the innate ability of I. scapularis to control B. burgdorferi
levels aer its acquisition. is has potential ramications for Lyme
disease transmission, as spirochete load in the tick can inuence
transmission eciency [10].
Environmental Factors
Factors that foster disease prevalence in ticks and risk of disease for
humans include environmental inuences which include precipitation,
abundance of acorn production in areas in the northeastern US. e
abundance of acorns inuences white-footed deer mouse and deer
populations [5].
Reshaping of landscapes caused by humans has set the change in
the ecology of Lyme disease and other tick borne diseases. By the
middle of the 20th century farming became predominant in the Mid-
Western United States which forced the farms to close in the northeast
allowing elds to become mixed hard wood forests. Encroachment
of suburban environments facilitated increase in white-tailed deer as
they were no longer sought aer for food [5,6].
ese peri-domestic changes have drastically reduced medium
sized predators that rely on rodents in the food chain, resulting in
increased numbers of the white-footed mouse population who are
competent reservoirs for tick borne diseases. [5]is paradigm can be
applied to other areas of North America and Europe.
White tailed deer are heavily covered with ticks in the late fall and
early spring. e use of roller applicators such as the “four posters”
which apply insecticides to the deer while they are eating corn placed
into bins. e pesticides then kill the adult ticks which then halt the
ticks from laying of eggs, therefore reducing tick populations [1].
Lyme Disease
Lyme disease early signs and symptoms can occur three to thirty
days aer a tick bite. Signs and symptoms may elusive. Predominant
in spring through summer, symptoms can include u like symptoms
such fever, chills, headache, myalgias, joint pain and swollen lymph
nodes. An erythema migrans (EM) rash (Figure 3) may appear at the
site of the tick bite three to thirty days (average of 7 days) this rash
may then expands over a period of days and can reach up to 30 cm in
size which may clear as it enlarges to appear as a target or a “bull’s eye
conguration.” If a rash does appear it may not always have a classic
EM appearance. A rash may not always be apparent in darker skinned
individuals, a rash may appear as a bruise-like. Although the CDC in
2015 reported a rash in 70% of Lyme cases, this is oen not the case.
Fever and generalized signs and symptoms may occur without a rash.
Presence of a rash makes the diagnosis of Lyme easier, but disease
cannot be ruled out if a rash is not present [2,3].
Later signs and symptoms, especially if Lyme disease is initially
missed, can occur days to months aer a tick bite. ese symptoms
can have overlap in early and late Lyme disease. Symptoms include
severe headaches, neck stiness, visual changes, mental cloudiness,
fatigue, arthritis with severe pain and swelling commonly of knees
and other large joints (Lyme arthritis), myalgia, bone and or tendon
pain, heart palpitations (Lyme carditis), facial palsy, nerve pain,
neuropathy, shortness of breath, malaise. Additional EM rashes may
appear on other parts of the body. Also, in addition to headache,
neck pain and fever, meningeal signs or meningitis (inammation of
meninges of the brain and spinal cord) symptoms can include changes
in mental status, dizziness and short term memory impairment [2,3].
In children, a sudden onset of symptoms may occur such as severe
fatigue unrelieved by rest, insomnia, joint pain, headaches, nausea,
abdominal pain, diculty with concentration and learning (oen
mis-diagnosed with attention decit disorder or other behavioral
problems) or even food aversions. Early symptoms may be missed or
even dismissed in children especially if a rash is not noticed or present.
Children are especially vulnerable to tick-borne diseases because they
are physically close to the ground during activities and play [7].
A small bump or redness at the site of a tick bite that occurs
immediately and resembles a mosquito bite is common. is
irritation generally goes away in 1-2 days and is not a sign of Lyme
Figure 3: Erythema Migrans Courtesy of CDC.
Citation: Wellins AM (2017) Tick-Borne Diseases Identication, Management and Prevention. Int J Nurs Clin Pract 4: 248. doi: https://doi.org/10.15344/2394-
4978/2017/248
Int J Nurs Clin Pract IJNCP, an open access journal
ISSN: 2394-4978 Volume 4. 2017. 248
Page 4 of 6
disease. A rash with a very similar appearance to EM occurs with
Southern Tick-associated Rash Illness (STARI), but is not Lyme
disease. Ticks can spread other organisms that may cause a dierent
type of rash [2].
Treatment
Treatment includes oral antibiotic of doxycycline course (100mg
twice daily) for 14-21-dayduration. Dosing can be extended for 28
days based on symptoms. Doxycycline should be taken with food
(nondairy) to prevent GI upset. Sun safety is important to prevent
photosensitivity. Adults who may be allergic to doxycycline or work
outside should be given amoxicillin. Long courses of doxycycline are
not indicated for children less eight years of age due to the potential of
teeth staining. Amoxicillin dose is weight based for children and the
usual duration of treatment in 21 days. It is important for completion
of antibiotic course to eectively eliminate the infection. Neurological
Lyme disease is diagnosed by spinal uid analysis and requires an
extended course of intravenous ceriaxone [2,3].
It is not uncommon for patients treated for Lyme disease with a
recommended 2 to 4-week course of antibiotics to have lingering
symptoms of fatigue, pain, or joint and myalgias at the time they
nish treatment. In a small percentage of cases, these symptoms can
last for more than 6 months. Although sometimes called “chronic
Lyme disease,” this condition is properly known as “Post-treatment
Lyme Disease Syndrome” (PTLDS). e exact cause of PTLDS is
not yet known. Most experts believe that the lingering symptoms
are the result of residual damage to tissues and the immune system
that occurred during the infection. Similar complications with
auto–immune like responses are known to occur following other
infections. B. burgdorferi does not remain in the blood so culturing
is problematic. More research needs to be done to determine if the
spirochetes are still present as the organism can wall o into cyst like
forms in collagen rich tissue [3].
For prevention aer a recognized I. scapularis tick bite a single
prophylactic dose of 200mg of doxycycline may be given to adults
and children greater than eight years or older based on the following
criteria: the nymphal or adult tick has been attached for greater or
equal to 36 hours and the tick is engorged [3].
Diagnostic testing
Laboratory diagnosis includes IgM or IgG antibodies in serum. A
two-tier testing protocol EIA or IFA is performed rst. If positive or
equivocal it is followed by a Western blot. Polymerase chain reaction
(PCR) may also be done. e two-tier test for antibodies is usually
negative in early Lyme disease. (Figure 4) It may take up to one
month for seroconversion to occur. If a patient is treated early with
appropriate antibiotics, antibodies may not be present. PCR may be
negative as the spirochete prefers to migrate into tissues or joints. In
suspected Lyme meningitis testing for intrathecal (requiring a spinal
tap) IgM or IgG is recommended [2,3].
Lyme vaccine
Currently there are no tick-borne disease vaccines for humans
in the United States. In 1998, the U.S. licensed a vaccine for Lyme
disease; however this vaccine was withdrawn from the market
in 2002. is vaccine was based on an outer surfacecell protein A
(Osp A) found on the pathogen which prevented transmission of
Borrelia burgdorferi from ticks to humans by killing spirochetes in
ticks. ree doses were needed to provide protection from infection
(only 80 percent protection). Unfortunately, the problem was that
antibody titers did not persist for long periods of time requiring
frequent boosters. Additionally, there were reported autoimmune
related side eects, including arthritis and neuropathology causing its
elimination. Research goals are to design an anti-tick saliva vaccine
aimed to reduce prolonged tick attachment [1].
Figure 4 : Courtesy of CDC.
Citation: Wellins AM (2017) Tick-Borne Diseases Identication, Management and Prevention. Int J Nurs Clin Pract 4: 248. doi: https://doi.org/10.15344/2394-
4978/2017/248
Int J Nurs Clin Pract IJNCP, an open access journal
ISSN: 2394-4978 Volume 4. 2017. 248
Page 5 of 6
Babesiosis
Babesiosis is most frequently reported from endemic areas of
the North Eastern and upper Mid-Western U.S. Like malaria, the
organism is a parasite: Babesia microti which infects red blood cells.
e incidence of babesiosis is approximately 1,700 cases reported
to the CDC from 2001-2014 and is on the rise. is organism can
also be transmitted from infected blood donors. Babesia infection
can range from anasymptomatic to a life threatening clinical course.
Increased risk factors for severe babesiosis include asplenia, impaired
immunity and advanced age. Severe cases can be associated with
marked thrombocytopenia, disseminated intravascular coagulation,
end organ failure and death [2,3].
e incubation period for babesiosis is one to nine weeks or longer.
Signs and symptoms can be like Lyme disease to include constitutional
symptoms such as fever, chills, diaphoresis, fatigue, malaise, joint pain
and myalgias. Gastrointestinal symptoms can include nausea and
anorexia. Splenomegaly and hepatomegaly can also occur [2,3].
Diagnostic testing
Identication of intraerythrocytic babesia parasites by light-
microscopy of a peripheral blood smear typically has a “Maltese
cross” appearance seen on red blood cells. Other diagnostic tests
such as polymerase chain reaction (PCR) analysis for Babesia microti
and indirect uorescent antibody (IFA) for Babesia-specic antibody
titer may be routinely done. General laboratory ndings may
show decreased hematocrit, thrombocytopenia and elevated liver
transaminase values. [2,3] It is important to note that in endemic areas
babesia co-infection may occur with Lyme disease. It is important to
consider testing to rule out possible babesiosis as drug treatment is
dierent than in Lyme disease [3].
Treatment
Treatment of babesiosis requires a combination of oral atovaquone
(750 mg every 12 hours) and azithromycin (500-1000mg daily) for
seven to ten days. Also, a combination of intravenous clindamycin
and oral quinine can be given for seven to ten days in patients with
more severe symptoms. Occasionally, exchange transfusions may be
required for critically ill patients. [2,3]
Anaplasmosis
Anaplasmosis (Anaplasma phagocytophilum) which is transmitted
by the Ixodes Scapularis tick is most frequently reported in the
northeastern and upper Midwest areas of the U.S. that correspond
to the geographic areas endemic for Lyme disease. e incidence of
anaplasmosis reported by the CDC was approximately 1,700 in 2010.
[2,3].
e incubation period for anaplasmosis is one to two weeks.
Clinical signs and symptoms are like other tick borne diseases such
as ehrlichiosis such as fever, chills, malaise, myalgia, GI symptoms,
cough and rarely a rash [2,3].
Diagnostic testing
Antibodies to A. phagocytophilum are usually detected seven to ten
days aer illness onset. Positive laboratory results show a four-fold
change in IgG specic antibody titer by immunouorescence assay
(IFA) in paired serum samples (second sample taken two to four
weeks later). Also, positive detection of DNA polymerase chain
reaction (PCR) is most sensitive within the rst week of illness. Other
lab ndings associated with anaplasmosis are leukopenia, elevated
hepatic transaminases and anemia. Visualization of morulae in
the cytoplasm of granulocytes may be seen; however, blood smear
examination is insensitive and should not be relied on solely to rule
out anaplasmosis [2,3].
Treatment
Recommended treatment of anaplasmosis is Doxycycline 100mg
mg twice per day, orally or intravenously for a minimum of 5-7
days. Doxycycline is also recommended for children (weight based
dosing of 2.2mg/kg twice per day). (CDC, 2015) Use of antibiotics
other than doxycycline increases the risk of death. ere has been no
evidence shown causing tooth staining at the recommended dosing
and duration in children less than eight years of age [11].
Ehrlichiosis
e areas from which cases are reported correspond to the
known geographic distribution of the lone star tick (Amblyomma
americanum) which transmits both E. chaeensis and E. ewingii. e
incubation period is one to two weeks. Ehrlichiosis and anaplasmosis
have a similar clinical presentation such as fever, headache, malaise,
myalgia and GI upset. In children, a rash may occur [2,3].
Diagnostic testing
Antibodies to Ehrlichia are usually detected seven to ten days aer
illness onset. Positive laboratory results show a four-fold change
in IgG specic antibody titer by immunouorescence assay (IFA)
in paired serum samples (second sample taken two to four weeks
later). Also, positive detection of DNA polymerase chain reaction
(PCR) is most sensitive within the rst week of illness. Other lab
nding associated with ehrlichiosis are leukopenia, elevated hepatic
transaminases and anemia. During the acute stage of illness, morulae
(clusters of Ehrlichia multiple in monocyte vacuoles to form large
mulberry shaped aggregates) may be detected in in twenty percent of
E.chaeenis cases [2].
Treatment
Doxycycline 100mg mg twice per day, orally or intravenously
for a minimum of 5-7 days (usual oral dosing7-14 days) is the
recommended rst line of treatment for ehrlichosis. Doxycycline is
also recommended for children (weight based dosing of 2.2mg/kg
twice per day) [2]. Use of antibiotics other than doxycycline increases
the risk of death. ere has been no evidence shown causing tooth
staining at the recommended dosing and duration in children less
than eight years of age [11].
Lone star tick larvae are very active during the late summer and
early fall. ey are voracious feeders which feed multiple times.
Exposure to larval tick bites may cause a delayed allergic reaction to
meat due to antibodies to Galactose-alpha-1,3-galactoseor commonly
known as alpha gal [4].
Alpha-gal is not naturally present in humans (or apes), but is
present in all other mammals. Lone star eggs contain alpha-gal
carbohydrate. Lone star larval ticks can then inject the alpha-gal
Citation: Wellins AM (2017) Tick-Borne Diseases Identication, Management and Prevention. Int J Nurs Clin Pract 4: 248. doi: https://doi.org/10.15344/2394-
4978/2017/248
Int J Nurs Clin Pract IJNCP, an open access journal
ISSN: 2394-4978 Volume 4. 2017. 248
Page 6 of 6
into a person's skin, which in turn will cause the immune system to
release a ood of IgE antibodies to ght o the foreign carbohydrate
[4].
Treatment
An aected individual with alpha gal allergy typically experiences
an allergic reaction three to six hours aer ingesting mammalian meat
such as beef, pork or lamb. Allergic reaction symptoms may be worse
with consumption of fattier meats. Symptoms range from pruritus, GI
upset to angioedema [4].
ere is a diagnostic test for antibodies to alpha gal. Patients with
this allergy need to be under the care of an allergist, avoid meat, meat
products and gelatin. An epinephrine auto injector is also needed for
possible anaphylactic reactions. is allergy can wane over time if
there is no re-exposure to Lone star larval tick bites [4].
Rocky Mounted Spotted Fever
Rocky Mounted spotted fever (RMSF) has been reported in all
continuous U.S. states. However, sixty percent of cases have been
reported from North Carolina, Arkansas, Tennessee, Oklahoma and
Missouri and more recently in Arizona. e incidence of RMSF has
increased to 8.4 cases per million persons from 1.9 cases per million
in 2000. RMSF can be rapidly fatal if not treated within the rst ve
days of symptoms. RMSF is caused by Rickettsia rickettsii transmitted
by an infected Dog Tick (Dermacentor variabilis)[2].
e incubation period for RMSF is one to two weeks. Clinical
symptoms consist of fever, chills, severe headache, malaise, myalgias,
GI upset, cough, photophobia, focal motor nerve paralysis or sudden
transient deafness. A maculopapular rash typically appears two to ve
days aer the onset of fever. Rash typically is non-pruritic, appears
initially on the wrists, forearms, and ankles which then spreads to
the trunk and occasionally to the palms and soles. Approximately ten
percent of all RMSF never develop a rash or a rash may develop later
in disease [2].
Diagnostic testing
Antibodies to R. rickettsii are usually detected seven to ten days
aer illness onset. Positive laboratory results show a four-fold change
in IgG specic antibody titer by immunouorescence assay (IFA) in
paired serum samples (second sample taken two to four weeks later).
Detection of Rickettsia rickettsii DNA in a skin biopsy of the rash by
Polymerase Chain Reaction assay (PCR) conrms the diagnosis. PCR
of blood is generally unreliable. Other lab ndings associated with
RMSF are thrombocytopenia, elevated hepatic transaminases and
hyponatremia [2].
Treatment
Doxycycline 100mg mg twice per day, orally or intravenously for
a minimum of 5-7 days is the recommended rst line of treatment.
Doxycycline is also recommended for children (weight based
dosing of 2.2 mg/kg twice per day)[2]. Use of antibiotics other than
doxycycline increases the risk of death. ere have been no evidence
shown causing teeth staining at the recommended dosing and
duration in children less than eight years of age [11].
Tularemia
Tularemia (Francisella tularensis) can be transmitted by the dog
tick (Dermacentor variabilis), wood tick (Dermacentor andersoni) and
the lone star tick (Amblyomma americanum). Tularemia can also be
transmitted from contact or in the handling of infected animals such
as rabbits [2].
Incubation period for Tularemia is usually three to ve days. Clinical
symptoms may include fever, chills, headache, malaise, anorexia,
vomiting, diarrhea, abdominal pain, myalgia, chest discomfort,
cough, sore throat, photophobia, excessive lacrimation, conjunctivitis,
lymphadenopathy. ere may a cutaneous ulcer at infection site (not
always present) with localized lymphadenopathy [2].
Diagnostic Testing
Positive laboratory results show a four-fold change in IgG specic
antibody titer by immunouorescence assay (IFA) in paired serum
samples or a single antibody titer. General laboratory ndings include
elevated sedimentation rate and leukocyte count, thrombocytopenia,
hyponatremia, elevated hepatic transaminases, elevated creatine
phosphokinase, myoglobinuria or sterile pyuria [2].
Treatment
Treatment for tularemia includes regimen of streptomycin
(intramuscular), gentamycin (intramuscular or intravenously),
oral ciprooxacin or doxycycline. Regimens range from 10-21 days
based on severity of disease. Children are treated by weight based
doses of streptomycin, gentamycin or ciprooxacin. (Gentamycin
or streptomycin is preferred for treatment of severe tularemia which
needs to be adjusted for renal insuciency). Chloramphenicol may be
added to streptomycin to treat meningitis [2].
Powassan Virus Disease
Powassan virus (POW virus) infections have been recognized in
the U.S., Canada and Russia. In the U.S. cases are primarily from
the northeastern and great lake regions. Powassan virus which is a
avivirus, can be transmitted by the deer tick (Ixodes scapularis).
Approximately 75 cases of POW virus cases reported in the U.S. over
the past ten years [2,12].
e incubation period is one to four weeks. Clinical symptoms
include fever, headache, vomiting and generalized weakness.
Symptoms usually progress to encephalitis and/or meningitis with
altered mental status, seizures, aphasia, paresis, movement disorders
or cranial nerve palsies. Approximately have of survivors have
permanent neurologic sequelae with ten percent of POW virus
encephalitis cases are fatal. Individuals with POW are oen in the
Intensive Care Unit requiring ventilator and hemodynamic support
[2,12].
Diagnostic testing
ere are no commercially available tests. Testing is available at
the CDC and in selected state health departments. IgM antibodies
can be detected in serum or cerebrospinal uid (CSF). However,
cross reactivity can occur with other avivirses such as West Nile, or
dengue fever [2].
Citation: Wellins AM (2017) Tick-Borne Diseases Identication, Management and Prevention. Int J Nurs Clin Pract 4: 248. doi: https://doi.org/10.15344/2394-
4978/2017/248
Int J Nurs Clin Pract IJNCP, an open access journal
ISSN: 2394-4978 Volume 4. 2017. 248
Page 6 of 6
Treatment
ere is no specic antiviral treatment. Patients oen require
supportive care in the Intensive Care Unit especially if ill with
complications of encephalitis or meningitis [2].
Southern Tick Associated Rash Illness (STARI)
Since the 1980s, in the south central and southeastern US, patients
have been observed to have Lyme disease-like rashes on patients aer
exposure to tick bites. However, the tick vector associated with these
lesions is the Lone Star tick (Amblyomma americanum), rather than
either of Ixodes tick species – I. scapularis or I. pacicus which are
known to transmit Lyme disease in the United States. It is unclear
if Borrelia burgdorferi, is associated with these rashes. is clinical
entity has been dierentiated from Lyme disease and is called
Southern Tick-Associated Rash Illness, or STARI. [13]
e hallmark of Southern Tick-Associated Rash Illness is the
Lyme-like lesion. e rash usually appears within seven days of a Lone
Star tick bite, and similar to the Lyme lesion, expands in a circular
or elliptical fashion. Patients with STARI can also have constitutional
symptoms, such as fever, headache, sti neck, myalgia’s and joint pain,
but these are less frequent and generally less severe in STARI patients
than in patients with Lyme disease [13].
Diagnostic testing
e causative agent of STARI has never been cultured and is not
currently known. However, some evidence exists that a recently
discovered spirochete, Borrelia lonestari, may be responsible: B.
lonestari has been detected by polymerase chain reaction (PCR) in
Lone Star ticks removed from humans, as well as in Lone Star ticks
collected during general epidemiological studies [13].
Treatment
Tick Removal needs to be done as soon as a tick is noticed. Tick
removal techniques from adults and children would be the same for
domestic animals such as cat, dogs and horses (gure 5) [2].
Education for proper tick removal should include:
• Use of ne-tipped tweezers to grasp the tick as close to the skin's
surface as soon as possible.
• Pull tick upward with steady, even pressure.
• Don't twist or jerk the tick; this can cause the mouth-parts to
break o and remain in the skin. If this happens, remove the
mouth-parts with tweezers.
• If unable to remove the head easily with clean tweezers, area can
be le alone to let/or the skin heal. Transmissions of pathogens
do not occur if head of tick remains in skin, however this can
result in skin irritation and inammation.
• Aer removing the tick, thoroughly clean the bite area and hands
with rubbing alcohol, an iodine scrub, or soap and water.
• Avoid following folklore remedies such as the use of hot matches;
petroleum jelly or nail polish remover. ese interventions are
not eective can cause injury or infection.
• Dispose of a live tick by submersing it in alcohol, placing it in a
sealed bag/container, wrapping it tightly in tape, or ushing it
down the toilet [2].
Prevention of tick exposure
It is important for the public to be educated in taking preventive
measures against ticks year-round and to be especially vigilant in
warmer months (April-September) when ticks are most active.
Avoidance of wooded and brushy areas with high grass and leaf litter
will reduce exposure risk [2].
Education should include
• Walking in the center of trails, avoiding brushing against tall
grass and shrubs.
• Use of repellents that contain 20 to 30% DEET (N, N-diethyl-m-
toluamide) on exposed skin for protection that lasts up to several
hours. Always follow product instructions. Parents should apply
this product to their children, avoiding hands, eyes, and mouth.
• Use products that contain permethrin on clothing. Treat
clothing and gear, such as boots, sneakers, pants, socks and tents
with products containing 0.5% permethrin. It remains protective
through several washings. Pre-treated clothing is available and
may provide longer-lasting protection.
• Bathing or showering soon aer returning indoors (preferably
within 2 hours) to wash o and more easily nd ticks.
• Conduct a full-body tick check using a hand-held or full-length
mirror to view all parts of body upon returning from tick-
infested areas.
• Parents should check their children for ticks under the arms,
in and around the ears, inside the umbilicus, behind the knees,
between the legs, around the waist, and especially in their hair.
• Examine gear and pets. Ticks can ride into the home on clothing
and pets, then attach to a person later, so carefully examine pets,
coats, and day packs.
• Tumble dry clothes in a dryer on high heat for 10-20 minutes to
kill ticks on dry clothing aer returning indoors. If the clothes
are damp, additional time may be needed. If the clothes require
washing rst, hot water is recommended. Cold and medium
temperature water will not kill ticks eectively. If the clothes
cannot be washed in hot water, tumble dry on low heat for 90
minutes or high heat for 60 minutes [2].
Figure 5: Tick Removal Courtesy of CDC.
Citation: Wellins AM (2017) Tick-Borne Diseases Identication, Management and Prevention. Int J Nurs Clin Pract 4: 248. doi: https://doi.org/10.15344/2394-
4978/2017/248
Int J Nurs Clin Pract IJNCP, an open access journal
ISSN: 2394-4978 Volume 4. 2017. 248
Page 6 of 6
To reduce tick exposure near home environments, it is helpful to:
• Clear tall grasses and brush around home and at the edge of
lawns.
• Maintain a three-foot barrier of wood chips or gravel between
lawns and wooded areas and around patios and play equipment.
is will restrict tick migration into recreational areas.
• Frequent moving of lawns: grass should be kept at three inches
or less in height.
• Remove leaf litter (ticks do not survive in dry, hot, low humid
conditions; they prefer to stay in shaded, damp areas such as in
leaf litter).
• Keep wood neatly stacked in a dry area as this discourages
rodents that ticks feed on.
• Keep playground equipment, decks, and patios away from yard
edges and trees and place them in a sunny location, if possible.
Remove trash from the yard that may give ticks a place to hide.
• e use of acaricides (tick pesticides) can reduce the number of
ticks in treated areas of outdoor living spaces and yards.
• e Environmental Protection Agency (EPA) and state (US)
determine the availability of pesticides. ere are professional
pesticide companies that can apply appropriate pesticides [2].
Conclusion
Tick-borne diseases should be focused on preventative measures
similar to other infections of public health signicance. Environmental
interventions to reduce mouse and other animal reservoir populations,
reduction in deer and tick populations need to be implemented and
expanded. Research with increased funding is essential for improved
and timely diagnostic tests. Research is also needed for a safe vaccine,
especially for Lyme disease. Continued evidenced based practices
need to be on the forefront. Tick analysis for prevalence of infection in
endemic areas needs to be expanded, to include identication of new
emerging pathogens. Prevention measures to limit exposure oers the
best strategy over the long term to reduce the burden and impact of
tick-borne infections [1].
Competing Interests
e author declares that she has no competing interests.
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Committee on Lyme Disease and other Tick-Borne Disease: The State of the Science. Critical Needs and Gaps, Amelioration, and Resolution of Lyme and Other Tick-Borne Diseases: The Short-Term and Long-Term Outcomes
Institute of Medicine, US (2011) Committee on Lyme Disease and other Tick-Borne Disease: The State of the Science. Critical Needs and Gaps, Amelioration, and Resolution of Lyme and Other Tick-Borne Diseases: The Short-Term and Long-Term Outcomes. Washington (DC) National Academics Press (US).
Powassan virus encephalitis
  • J Birge
  • S Sonneyn
Birge J, Sonneyn S (2012) Powassan virus encephalitis, Minnesota, USA. Emerging Infectious Disease 18: 1669-1671.