Resource Manual: Information and Risk of Tick-borne Diseases In the state of Maryland

THE DEPARTMENT OF HEALTH AND HUMAN SERVICES COMMUNICABLE DISEASE AND EPIDEMIOLOGY BY MEREDITH G. MORROW, MSPH (ABT ’09) UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES PRACTICUM MENTOR: CINDY A. EDWARDS, MSHCA ACTING NURSE ADMINISTRATOR DISEASE CONTROL PROGRAM

JULY 2008

Table of Contents Introduction History of Lyme Disease………………………………………………………..3 Signs and Symptoms of Lyme Disease………………………………...........5 Diagnosis and Treatment of Lyme Disease………………………………….8 2008 CDC Case Definition……….……………………………….…..10 Information on Ticks Life Cycle……………………………………………………………………….13 How to Remove a Tick………………………………………………………..16 Protecting yourself from Tick bites…………………………………………..18 Other Tick-Borne Diseases Babesiosis………………………………………………………………………20 Human Granulytic Anaplasmosis/Human Monocytic Ehrlichiosis.…..…...21 Rocky Mountain Spotted Fever………………………………………………22 Tick Paralysis…………………………………………………………………..23 Colorado Tick Fever…………………………………………………………...24 Tularemia……………………………………………………………………….25 Tick-borne Relapsing Fever…………………………………………………..26 Powassan Encephalitis………………………………………………………..27 Southern Tick-Associated Rash Illness (STARI)…………………………...28 Current/Future Research: Vaccines, Trials, and Challenges Function of Outer surface proteins…………………………………………..30 Outer Surface Protein A (OspA) …………………………………………….30 Outer Surface Protein C (OspC) …………………………………………….32 Immune Response…………………………………………………………….36 Current Vaccine Research……………………………………………………38 Future Perspectives…………………………………………………………...39 Appendix A: Laboratories for Tick testing…………………………………………...42 Appendix B: Documenting a Tick bite ………………………………………………44 Appendix C: DHHS: Preventing Lyme Disease in Montgomery County…………46 Appendix D: Trends of Lyme disease/Rocky Mountain Spotted Fever in MD (’90-’05)…..49 Appendix E: Local Agencies………………………………………………………….52 Appendix F: Educational Materials…………………………………………………..54 References Cited……………………………………………………………………..60 2

INTRODUCTION

History of Lyme Disease Most Lyme Disease literature erroneously reports that Lyme Disease was first documented in Lyme, Connecticut, in the late 1970s. However, record of the infection dates back to 1883 when a German physician named Alfred Buchwald observed a degenerative skin condition which is presently hypothesized to have been a Lyme-related ailment (Vanderhoof-Forschner, 1997). As early as 1920 in the United States, physicians began correlating what are now known to be Lyme Disease symptoms with tick bites (EM rash, joint and muscle pain, etc.). By 1950, doctors had already discovered that antibiotic therapy provided relief for the symptoms in question (Vanderhoof-Forschner, 1997). Although it was not until the 1970s that the disease received its common name. The first American case of Lyme disease was documented in 1970 in a cluster at a naval submarine base in Groton, Connecticut by Navy doctors who reported their findings in 1976 (Vanderhoof-Forschner, 1997). It became more widely known and received its common name when it struck a group of families in nearby Lyme, Connecticut. In 1975, the Connecticut State Health Department received complaints from Polly Murray, a mother living in the small town of Lyme, Connecticut (Vanderhoof-Forschner, 1997). Two of her children had been diagnosed with

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juvenile rheumatoid arthritis, but she knew of others in the area with similar symptoms. A senior official with the Health Department contacted Allen Steere, who was studying rheumatology at Yale University. Steere met with Ms. Murray, who gave him a list of children who shared a set of symptoms. Steere called each affected family, representing 39 children in all, and he found an additional twelve adults suffering from what was thought to be juvenile rheumatoid arthritis (Vanderhoof-Forschner, 1997). A quarter of the people Steere interviewed remembered getting a strange, spreading skin rash (erythema migrans) before experiencing any other symptoms. A European doctor happened to be visiting Yale at the time, and he pointed out that the rash was similar to one frequently encountered in northern Europe and known to be associated with tick bites. The recognition that the patients in the United States had erythema migrans led to the recognition that "Lyme arthritis" was one manifestation of the same tick-borne disease known in Europe. This clustering of a mysterious syndrome found in and around Lyme and Old Lyme, Connecticut came to be called "Lyme Arthritis" and later "Lyme Disease." In 1982 Willy Burgdorfer of the Rocky Mountain Laboratories in Hamilton, Montana, identified the spiral-shaped bacteria, Borrelia burgdorferi, that causes Lyme disease (Vanderhoof-Forschner, 1997). By 1987 physicians had detected the disease in the southern United States. Reported cases grew from 545 in 1989 to 8,000 in 1993 (Vanderhoof-Forschner, 1997). Symptoms seldom linger in

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victims who obtain early treatment with antibiotics, although as of 2001 doctors disagreed about how easy it is to diagnose the disease and about what to do for patients whose symptoms last beyond the typically effective four-week antibiotic treatment. Some fear that using additional antibiotics too readily will expose patients to uncomfortable side effects and, worse, engender resistant bacterial strains of the disease.

Signs and Symptoms of Lyme Disease The varied symptoms of Lyme disease are caused by the Borrelia burgdorferi (Bb) spirochete bacterium which is characterized by a thin, corkscrew structure. Bb is transferred to a host through the bite of an infected carrier, most commonly various species of ticks. Disease can also rarely be passed on by other biting insects (Luger, 1990; Sanogo et al, 2000). 300 different genospecies of Bb have been found worldwide so far; 100 of them are in the United States alone (Vanderhoof-Forschner, 1997). While some of these genospecies are quite similar, others are extremely heterogeneous (all of the strains are collectively called Bb sensu stricto). These differences drastically affect how transmission occurs and also the apparent virulence of the disease (Carrol et al., 2000). Therefore, treatment of patients depends on which particular strain they are infected with. However, at this time, there is still no definitive diagnostic test to confirm or deny a Lyme disease infection, let alone a test to inform healthcare providers with which strain(s) patients may be infected (Guttman et al., 1996).

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Because of this lack of technology, and the fact that Bb is an intracellular parasite (thus explaining why blood tests for antibodies to Bb may be negative even when bacteria are present inside of cells) it is possible that some Lyme disease cases remain unreported. While some patients only exhibit the “typical” arthritic symptoms usually associated with Lyme disease, others may experience severe neurological and/or cardiological complications (Vanderhoof-Forschner, 1997).

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variations are thought to indicate the ways in which different genospecies of Bb can manifest themselves in addition to how different immune systems react to invasion of spirochetes (Vanderhoof-Forschner, 1997). Traditionally, Lyme disease has been associated with a "bull's-eye" or target-like rash, sometimes expanding to 5 cm or more, with concentric circles of redness and a central clearing, which is sometimes warm to the touch but not usually painful.

Image from: http://www.cdc.gov/ncidod/dvbid/ CDC (Division of Vector-Borne Infectious Diseases)

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As Harvard Medical School professor Dr. Jonathan Edlow reported in 2002, "Although much attention has been paid to the classic form – the target lesion or bull's eye – here are variations that are more common. These include uniform coloration, lesions with necrotic [oozing] or vesicular [blistered] centers, and lesions with shapes that are not circular or oval" (Edlow, 2002). In addition, multiple, smaller Lyme-related rashes, even bull’s-eyes, appearing all over the body have been documented (Cooke and Dattwyler 1992; Nadelman and Wormser 1995; Wormser et al. 2005). According to the Centers for Disease Control, the rash is noticed in 60 to 80 percent of persons who contract Lyme disease. However, other studies have suggested that this percentage may be as low as 50 percent or fewer (Donta 2002; Stricker and Lautin 2003), and as few as 14-32 percent recall a tick bite even if a rash or other symptoms later appear (Nadelman and Wormser 1995). Lyme-associated rashes may appear in a few days or several weeks after the bite. For all these reasons, a high level of suspicion should be maintained if a rash of any kind appears on any part of the body after a known tick exposure. Patients also experience symptoms of fatigue, chills, fever, headache, and muscle and joint aches, and swollen lymph nodes. In some cases, these may be the only symptoms of infection (CDC, 2008). Untreated, the infection may spread to other parts of the body within a few days to weeks, producing an array of discrete symptoms. These include loss of muscle tone on one or both sides of the face (called facial or "Bell's palsy), severe headaches and neck stiffness due to meningitis, shooting pains that may interfere with sleep, heart palpitations and

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dizziness due to changes in heartbeat, and pain that moves from joint to joint (CDC, 2008). Many of these symptoms will resolve, even without treatment (CDC, 2008). After several months, approximately 60% of patients with untreated infection will begin to have intermittent bouts of arthritis, with severe joint pain and swelling (CDC, 2008). Large joints are most often affected, particularly the knees. In addition, up to 5% of untreated patients may develop chronic neurological complaints months to years after infection (CDC, 2008). These include shooting pains, numbness or tingling in the hands or feet, and problems with concentration and short term memory (CDC, 2008).

Diagnosis and Treatment of Lyme Disease

While a diagnosis of Lyme disease may be based solely on clinical signs and symptoms (such as a patient presenting with an EM rash), laboratory tests are available to assist physicians in making a diagnosis. Laboratory confirmation of infection with Bb, is established when a laboratory isolates the spirochete from tissue or body fluid, detects diagnostic levels of IgM or IgG antibodies to the bacteria in serum or cerebrospinal fluid (CSF), or detects a significant change in antibody levels in paired acute and convalescent serum samples (CDC, 2008). Serological assays remain the most common and practical method of laboratory testing for Lyme disease. The Centers for Disease Control and Prevention (CDC) recommend that, initially, specimens be tested by a sensitive test such as an enzyme immunoassay (EIA) or immunofluorescent assay (IFA). Samples with

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positive or equivocal results from these tests should be re-tested using a standardized Western blot procedure. The two-step algorithm, as opposed to using a single test, increases the specificity of laboratory testing (CDC, 2008). Some laboratories offer Lyme disease testing using assays whose accuracy and clinical usefulness have not been adequately established (CDC, 2008). These tests include urine antigen tests, immunofluorescent staining for cell walldeficient forms of Bb, and lymphocyte transformation tests. In general, the CDC does not recommend these tests.

The National Institutes of Health (NIH) has funded several studies on the treatment of Lyme disease. These studies have shown that most patients can be cured with a few weeks of antibiotics taken by mouth (CDC, 2008; Wormser et al., 2006). Antibiotics commonly used for oral treatment include doxycycline, amoxicillin, or cefuroxime axetil (CDC, 2008; Wormser et al., 2006). Patients with certain neurological or cardiac forms of illness may require intravenous treatment with drugs such as ceftriaxone or penicillin (CDC, 2008; Wormser et al., 2006).

Patients treated with antibiotics in the early stages of the infection usually recover rapidly and completely. A few patients, particularly those diagnosed with later stages of disease, may have persistent or recurrent symptoms. These patients may benefit from a second 4-week course of therapy (CDC, 2008; Wormser et al., 2006). Longer courses of antibiotic treatment have not been shown to be beneficial and have been linked to serious complications, including death (CDC, 2008; Wormser et al., 2006).

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Studies of women infected during pregnancy have found that there are no negative effects on the fetus if the mother receives appropriate antibiotic treatment for her Lyme disease (CDC, 2008; Wormser et al., 2006). In general, treatment for pregnant women is similar to that for non-pregnant persons, although certain antibiotics are not used because they may affect the fetus.

2008 CDC Case Definition

The following CDC surveillance case definition (CDC, 2008) was developed for national reporting of Lyme disease; it is not intended to be used in clinical diagnosis.

Clinical presentation A systemic, tick-borne disease with protean manifestations, including dermatologic, rheumatologic, neurologic, and cardiac abnormalities. The best clinical marker for the disease is erythema migrans (EM), the initial skin lesion that occurs in 60%-80% of patients.

For purposes of surveillance, EM is defined as a skin lesion that typically begins as a red macule or papule and expands over a period of days to weeks to form a large round lesion, often with partial central clearing. A single primary lesion must reach greater than or equal to 5 cm in size across its largest diameter. Secondary lesions also may occur. Annular erythematous lesions occurring within several hours of a tick bite represent hypersensitivity reactions and do not qualify as EM. For most patients, the expanding EM lesion is 10

accompanied by other acute symptoms, particularly fatigue, fever, headache, mildly stiff neck, arthralgia, or myalgia. These symptoms are typically intermittent. The diagnosis of EM must be made by a physician. Laboratory confirmation is recommended for persons with no known exposure.

For purposes of surveillance, late manifestations include any of the following when an alternate explanation is not found:

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Musculoskeletal system. Recurrent, brief attacks (weeks or months) of objective joint swelling in one or a few joints, sometimes followed by chronic arthritis in one or a few joints. Manifestations not considered as criteria for diagnosis include chronic progressive arthritis not preceded by brief attacks and chronic symmetrical polyarthritis. Additionally, arthralgia, myalgia, or fibromyalgia syndromes alone are not criteria for musculoskeletal involvement.

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Nervous system. Any of the following, alone or in combination: lymphocytic meningitis; cranial neuritis, particularly facial palsy (may be bilateral); radiculoneuropathy; or, rarely, encephalomyelitis. Encephalomyelitis must be confirmed by demonstration of antibody production against Borrelia burgdorferi in the cerebrospinal fluid (CSF), evidenced by a higher titer of antibody in CSF than in serum. Headache, fatigue, paresthesia, or mildly stiff neck alone, are not criteria for neurologic involvement.

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Cardiovascular system. Acute onset of high-grade (2nd-degree or 3rddegree) atrioventricular conduction defects that resolve in days to weeks and are sometimes associated with myocarditis. Palpitations, bradycardia, bundle branch block, or myocarditis alone are not criteria for cardiovascular involvement.

Laboratory evidence

For the purposes of surveillance, the definition of a qualified laboratory assay is (1) a positive culture for B. burgdorferi, (2) two-tier testing interpreted using established criteria (MMWR, 1995), or (3) single-tier IgG immunoblot seropositivity interpreted using established criteria (MMWR, 1995; Dressler et al., 1993; Engstrom et al., 1995; MMWR2, 2005).

Exposure

Exposure is defined as having been (less than or equal to 30 days before onset of EM) in wooded, brushy, or grassy areas (i.e., potential tick habitats) in a county in which Lyme disease is endemic. A history of tick bite is not required.

Disease endemic to county

A county in which Lyme disease is endemic is one in which at least two confirmed cases have been acquired in the county or in which established populations of a known tick vector are infected with B. burgdorferi.

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Case classification

Confirmed: a) a case of EM with a known exposure (as defined above), or b) a case of EM with laboratory evidence of infection (as defined above) and without a known exposure or c) a case with at least one late manifestation that has laboratory evidence of infection.

Probable: any other case of physician-diagnosed Lyme disease that has laboratory evidence of infection (as defined above).

Suspected: a) a case of EM where there is no known exposure (as defined above) and no laboratory evidence of infection (as defined above), or b) a case with laboratory evidence of infection but no clinical information available (e.g. a laboratory report).

Lyme disease reports will not be considered cases if the medical provider specifically states this is not a case of Lyme disease, or the only symptom listed is "tick bite" or "insect bite."

INFORMATION ON TICKS Life Cycle

Each stage in the tick's life cycle must have a blood meal for the tick to mature into an adult and lay eggs for the next generation. The adult female is

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ferlized by the male while she is engorged with blood on her last host. She will then drop off the host and, in about 3-10 days, will begin laying 4,000-6,000 eggs in a mass (Sparks, 2002). The eggs will hatch within 2 weeks up to several months, depending on the environment, into six legged larvae or "seed ticks." A person may get a large number of seed ticks on their body due to their concentration in an area where the eggs were laid (Sparks, 2002). After again engorging with blood, the larval tick will drop off the host, shed its skin and change in an eight legged nymph. The nymph will seek another house, engorge with blood, drop off, shed its skin, and develop into the adult stage. The feeding is usually done without pain and may take several days for completion. Ticks survive best in high grass or brush areas that are also attractive to their hosts -these are the areas where you are most likely to encounter a tick. The American dog tick feeds on humans only in the adult stage. All three stages of the lone star and black legged ticks will feed on humans. Risk of human infection (of Lyme disease) is greatest in late spring and summer when nymphs are abundant (CDC, 2008; Sparks, 2002).

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Image from: Napa County Mosquito Abatement District

Image from: http://www.cdc.gov/ncidod/dvbid/ CDC (Division of Vector-Borne Infectious Diseases)

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Image from: http://www.cdc.gov/ncidod/dvbid/ CDC (Division of Vector-Borne Infectious Diseases)

How to Remove a Tick It is important to remove a tick from your skin as soon as you notice it. Using fine-tipped tweezers, firmly grasp the tick as close to your skin as possible. With a steady motion, pull the tick’s body away from your skin (CDC, 2008; (Sparks, 2002). Then clean your skin with soap and warm water. If you choose to discard the dead tick, you may do so in regular household trash.

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Avoid crushing the tick’s body and do not be alarmed if the tick’s mouthparts remain in the skin. Once the mouthparts are removed from the rest of the tick, it can no longer transmit the Lyme disease bacteria. If you accidentally crush the tick, clean your skin with soap and warm water or alcohol. If you choose to send the tick away for identification and laboratory analysis, you need to keep the tick alive (Vanderhoof-Forschner, 1997). Obtain a plastic or glass container/vial and add a moistened tissue. This should provide the tick with the appropriate moisture it requires for up to several days. (Please see Appendix A for Laboratories that will test ticks for possible infection). You may document the tick bite by writing down the name of the person bitten, date of bite, location where bite occurred (city, state), location of bite on body, estimated length of time the tick was attached, type of tick (if known), and how the tick was removed (Appendix B). Keep note of any rashes or symptoms that may occur in the 6 weeks following the bite and call your physician for an appointment if you do notice a rash or have any physical complaints.

PLEASE NOTE: o Do not “twist” the tick as you pull it out of your body, only pull the tick away in a steady motion. o Do not use petroleum jelly, a hot match, nail polish, or other products to remove a tick. All that is necessary is fine-tipped tweezers to remove the tick and its mouthparts from your skin. o Do not wait for the tick to back out after feeding. o Do not use your fingers to remove or crush the tick.

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Image from: http://www.cdc.gov/ncidod/dvbid/ CDC (Division of Vector-Borne Infectious Diseases)

Protecting yourself from Tick bites The best way to avoid tick bites when on wooded trails, in high grass or brush areas is to take some personal precautions:

o Wear long pants. Tuck the pant leg into your socks and tuck your shirt in (Sparks, 2002). The tick will move up toward the head where detection is easier. You don't want the tick to get under your clothing where detection is more difficult.

o Use a repellent. A repellent containing "deet" or "permethrin" is available in many brands (Sparks, 2002). The bottled repellent can be rubbed on the skin and will normally last several hours. Aerosols and sprays can usually be sprayed on clothing as well as skin for added protection.

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o Check yourself for ticks at least twice per day. There is evidence that the longer an infected tick feeds, the greater the chance it has of transmitting a disease (Sparks, 2002). Early removal is good prevention.

Around your house, you can treat your pets with an approved pesticide for ticks, keep the grass cut short, fence the yard to keep out other animals that may bring ticks in, and use a pesticide in the yard as needed to reduce tick populations (Sparks, 2002). Observe all directions, restrictions and precautions on pesticide labels. It is dangerous, wasteful and illegal to do otherwise.

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OTHER TICK-BORNE DISEASES

BABESIOSIS FACT SHEET What is Babesiosis? Babesiosis is a disease caused by a microscopic protozoan parasite, Babesia spp. (similar to those that cause malaria) that infects red blood cells. When was Babesiosis discovered? Babesiosis was discovered by Victor Babes in Romania in 1888 is an important cattle disease that affects all cattle and domestic animals such as cats and dogs. Occasionally humans are infected as well. The first U.S. case of Babesiosis was reported on Nantucket Island in 1966. How prevalent is Babesiosis? An increasing trend over the past 30 years may be the result of restocking of the deer population, curtailment of hunting, and an increase in outdoor recreational activities. Between 1968 and 1993, more than 450 cases of Babesia infections were confirmed in the United States. However, the actual prevalence of this disease is unknown because most infected patients are asymptomatic. How does a person get Babesiosis? You can get Babesiosis if you are bitten by a tick that is infected with the protozoan parasite. Babesiosis can occur during any time of the year. Can all ticks transmit Babesiosis? No. Babesiosis is spread by the bite of an infected deer tick (Ixodes scapularis), the same vector of Lyme disease. The longer a tick remains attached and feeding, the higher likelihood that it may spread the parasite. Deer ticks are capable of spreading more than one type of infection in a single bite. Young ticks (nymphs) are most active during late spring and summer. Adult ticks are most active during the fall and spring, but may also search for a host when winter temperatures are above freezing. How serious is Babesiosis? The elderly, people without a healthy spleen, and people with weakened immune systems are more likely to develop potentially life-threatening symptoms. 25% percent of adults and 50% of children infected with Babesiosis are asymptomatic and/or improve spontaneously without treatment. Less than 10% of patients with Babesiosis have died in the United States, mostly composed of elderly or asplenic patients. Approximately 20% of patients with Babesiosis are co-infected with Lyme disease. These patients experience more severe symptoms for a longer duration than those with either disease alone. What are the symptoms of Babesiosis? Symptoms of Babesiosis usually being to appear from 1-8 weeks after being bitten by an infected tick. Most people who are infected will show very mild signs of illness or no signs at all. If symptoms occur, they may include fever, chills, headache, achy joints and muscles, fatigue, nausea and vomiting, abdominal pain and dark urine. Symptoms can last for up to several months. How is Babesiosis diagnosed? Babesiosis is diagnosed by examining blood under a microscope. When present, the Babesia parasite can be seen inside red blood cells. What is the treatment for Babesiosis? Babesiosis can be treated with a combination of anti-parasite/antibiotic medications; however, serious complications requiring a blood transfusion and/or kidney dialysis can occur if the disease is not recnognized and treated early.

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HUMAN GRANULOCYTIC ANAPLASMOSIS & HUMAN MONOCYTIC EHRLICHIOSIS FACT SHEET What is HGA and HME?

Human Granulytic Anaplasmosis (HGA) is a tick-borne rickettsial infection of neutrophils caused by Anaplasma phagocytophilum. (Human granulocytic ehrlichiosis (HGE) was renamed as human granulytic anaplasmosis in 2003.) There is also a human monocytic ehrlichiosis (HME) that is caused by Ehrlichia chaffeensis and is found throughout much of southeastern and southcentral United States. In the past HGA and HME were lumped together to form a generic diagnosis of Human Ehrlichiosis. When were HGA and HME discovered? HGA was first identified in 1990 in a Wisconsin patient who died with a severe febrile illness 2 weeks after a tick bite. However, the pathogen was defined as a veterinary agent in 1932. In 1990, E. chaffeensis which causes HME was first isolated from the blood of a U.S. Army reservist at Fort Chaffee, Arkansas. How prevalent is HGA and HME?

Since 1990, US cases of HGA have markedly increased, and infections are now recognized in Europe. A high international seroprevalence suggests infection is widespread, but unrecognized. Cases of HME are mostly found in the southeastern and southcentral United States. How does a person get HGA and HME? A person can get HGA and HME from the bite of an infected tick. Both HGA and HME are caused by separate pathogens, but have similar symptoms. Can all ticks transmit HGA and HME? No. HGA is transmitted to humans by Ixodes scapularis (deer tick or blacklegged tick), the same tick that transmits Lyme disease. HME is carried and transmitted by certain ticks, such as the Lone Star tick (Amblyomma americanum) and the American dog tick (Dermacentor variabilis). How serious is HGA and HME? Although people of any age can get HGA and HME, it tends to be most severe in the aging or immunecompromised. The HME mortality rate is reported to be 2-5%, while that for HGA is 7-10%. It is important to obtain a prompt diagnosis and treatment. What are the symptoms of HGA and HME? The signs and symptoms of both HGA and HME are similar and may include: Fever (over 102°), Severe headache, Muscle aches and Chills. Less frequent symptoms of human anaplasmosis include nausea, vomiting, loss of appetite, weight loss, abdominal pain, cough, diarrhea, aching joints and change in mental status. How is HGA and HME diagnosed? A diagnosis of HGA or HME is confirmed by testing blood samples for antibody titers to the different bacterial species, and by observing the bacteria in different types of blood cells. What is the treatment for HGA and HME? The antibiotic doxycycline is very effective for treating both HGA and HME. No vaccine is available.

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ROCKY MOUNTAIN SPOTTED FEVER FACT SHEET What is Rocky Mountain Spotted Fever? RMSF is a disease that is caused by Rickettsia rickettsii, a species of bacteria that is spread to humans by ixodid (hard) ticks. When was Rocky Mountain Spotted Fever discovered? Although RMSF was first discovered and recognized in the Rocky Mountain area, relatively few cases are reported from that area today. How prevalent is Rocky Mountain Spotted Fever? RMSF is one of the most severe and most frequently reported rickettsial illness in the United States. It also occurs in Mexico and in Central and South America. RMSF is a seasonal disease and occurs throughout the United States during the months of April through September. Over half of the cases occur in the southAtlantic region of the United States (Delaware, Maryland, Washington D.C., Virginia, West Virginia, North Carolina, South Carolina, Georgia, and Florida). The highest incidence rates have been found in North Carolina and Oklahoma. How does a person get Rocky Mountain Spotted Fever? The organism that causes Rocky Mountain spotted fever is transmitted by the bite of an infected tick. Can all ticks transmit Rocky Mountain Spotted Fever? No. The American dog tick (Dermacentor variabilis) and Rocky Mountain wood tick (Dermacentor andersoni) are the primary athropods (vectors) which transmit Rocky Mountain spotted fever bacteria in the United States. The brown dog tick Rhipicephalus sanguineus has also been implicated as a vector as well as the tick Amblyomma cajennense in countries south of the United States. How serious is Rocky Mountain Spotted Fever? Rocky Mountain spotted fever can be a severe illness, and the majority of patients are hospitalized. The disease can be difficult to diagnose in the early stages, and without prompt and appropriate treatment it can be fatal. What are the symptoms of Rocky Mountain Spotted Fever? Initial signs and symptoms of RMSF include sudden onset of fever, headache, and muscle pain, followed by development of rash. (The incubation period is usually approximately 5-10 days after a tick bite.) How is Rocky Mountain Spotted Fever diagnosed? A diagnosis of RMSF is based on a combination of clinical signs and symptoms and specialized confirmatory laboratory tests. Other common laboratory findings suggestive of RMSF include thrombocytopenia, hyponatremia, and elevated liver enzyme levels. What is the treatment for Rocky Mountain Spotted Fever? RMSF is best treated by using a tetracycline antibiotic, usually doxycycline. This medication should be given in doses of 100 mg every 12 hours for adults or 4 mg/kg body weight per day in two divided doses for children under 45 kg (100 lbs). Patients are treated for at least 3 days after the fever subsides and until there is unequivocal evidence of clinical improvement. Standard duration of treatment is 5 to 10 days. Because laboratory confirmation is generally not available during acute illness, treatment is initiated based on clinical and epidemiological information.

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TICK PARALYSIS FACT SHEET What is Tick Paralysis? Tick paralysis -one of the eight most common tick-borne diseases in the United States- is an acute, ascending, flaccid motor paralysis that can be confused with Guillain-Barre syndrome, botulism, and myasthenia gravis. When was Tick Paralysis discovered? Tick paralysis was first recorded in Australia in 1824, in the explorer Hovell's travel diary of his journey with Hume to Port Philip Bay (Melbourne). How prevalent is Tick Paralysis? In North America, tick paralysis occurs most commonly in the Rocky Mountain and northwestern regions of the United States and in western Canada. Most cases have been reported among girls aged less than 10 years during April-June, when nymphs and mature wood ticks are most prevalent How does a person get Tick Paralysis? Tick Paralysis occurs worldwide and is caused by the introduction of a neurotoxin elaborated into humans during attachment of and feeding by an infected tick of several tick species. Can all ticks transmit Tick Paralysis? No. In the United States, this disease is associated with Dermacentor andersoni (Rocky Mountain wood tick), D. variabilis (American dog tick), Amblyomma americanum (Lone Star tick), A. maculatum, Ixodes scapularis (black-legged tick), and I. pacificus (western black-legged tick). How serious is Tick Paralysis? If unrecognized, tick paralysis can progress to respiratory failure and may be fatal in approximately 10% of cases. Prompt removal of the feeding tick usually is followed by complete recovery. What are the symptoms of Tick Paralysis? Onset of symptoms usually occurs after a tick has fed for several days. The pathogenesis of tick paralysis has not been fully elucidated, and pathologic and clinical effects vary depending on the tick species. However, motor neurons probably are affected by the toxin, which diminishes release of acetylcholine. In addition, experimental studies indicate that the toxin may produce a substantial decrease in maximal motornerve conduction velocities while simultaneously increasing the stimulating current potential necessary to elicit a response. How is Tick Paralysis diagnosed? There are no laboratory tests to diagnosed tick paralysis. Health-care providers should consider tick paralysis in persons who reside or have recently visited tick-endemic areas during the spring or early summer and who present with symmetrical paralysis. What is the treatment for Tick Paralysis? Prompt removal of the feeding tick usually is followed by complete recovery. If exposure to ticks is a possibility, it is crucial to check the body carefully and thoroughly for an attached tick. Ticks are often attached to the head and neck where they may be concealed by hair. If breathing is impaired, oxygen therapy or mechanical ventilation may be necessary.

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COLORADO TICK FEVER FACT SHEET What is Colorado Tick Fever? Colorado tick fever (CTF) is a tick-borne viral illness (Coltivirus) of humans in the United States. In the past, it has been named Mountain fever or American mountain fever. Infection with CTF virus is thought to provide long lasting immunity against reinfection. However, prior illness with CTF should not deter persons from practicing good tick-preventive measures or visiting a physician if signs and symptoms consistent with CTF occur, especially following a tick bite. When was Colorado Tick Fever discovered? CTF virus was first isolated from human blood in 1944. How prevalent is Colorado Tick Fever? CTF is a seasonal disease, and occurs in mountain forest habitats at altitudes from 4,000 to 10,000 feet in the Rocky Mountain region of the United States during the months of February through October. Approximately 90% of cases occur between April and July. Half of all cases are reported from Colorado and Idaho. An assessment of reported cases 1980 and 1988 revealed that of the 1,432 cases reported, the highest number (256) was from Colorado. How does a person get Colorado Tick Fever? The organism that causes CTF is transmitted by the bite of an infected tick. Some cases have been associated with exposures to the virus in laboratory settings and one case followed transfusion of blood from a person infected with CTF virus within 4 months of donation. Can all ticks transmit Colorado Tick Fever? No. The Rocky Mountain wood tick (Dermacentor andersoni) is the principal carrier of CTF in the United States. How serious is Colorado Tick Fever? CTF can be a severe illness, especially in children under 10 and older adults. Hospitalization may occur in 20% of CTF cases. What are the symptoms of Colorado Tick Fever? Patients infected with CTF virus often develop a two-staged fever and illness following an average incubation period of 4 days (range of 1-19 days) after a tick bite. The early signs of CTF are often nonspecific and may resemble many other infectious and non-infectious diseases. Initial symptoms may include sudden onset of fever, chills, headache, pain behind the eyes, light sensitivity, muscle pain, and generalized malaise. Abdominal pain, nausea and vomiting may occur during the course of the illness in addition to a rash. How is Colorado Tick Fever diagnosed? A diagnosis of CTF is based on a combination of clinical signs and symptoms and specialized confirmatory laboratory tests, including antibody assays and cell culture. Other common laboratory findings suggestive of CTF fever include leukopenia, thrombocytopenia and mildly elevated liver enzyme levels. What is the treatment for Colorado Tick Fever? There is no specific treatment for CTF. Symptomatic relief includes treatment of fever and pain with acetominophen and analgesics. Salicylates should not be used because of thrombocytopenia and the rare occurrence of bleeding disorders following CTF virus infection.

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TULAREMIA FACT SHEET What is Tularemia? Tularemia is a potentially serious illness that occurs naturally in the United States. It is caused by the bacterium Francisella tularensis found in animals (especially rodents, rabbits, and hares). It is also commonly referred to as “Hunter’s Disease” since hunter’s who deal with infected animal carcasses are also at risk of developing inhalation tularemia. When was Tularemia discovered? In 1911, George McCoy and Charles Chapin of the US Public Health Service were studying rats and ground squirrels they believed to have been infected with plague. They discovered an entirely separate disease and isolated the bacteria that caused the disease in California ground squirrels. McCoy and Chapin named the bacteria Bacterium tularense after the location, Tulare County, California, where their investigation took place. In 1928, Dr. Edward Francis of the US Health Service linked the causal bacteria agent of deer-fly fever to the bacteria discovered by McCoy and Chapin. The bacteria was renamed Francisella tularensis in Dr. Francis’ honor. Further, Francis described seven types of the disease and examined different cases including meningeal, oropharyngeal, and pulmonary forms of tularemia. In addition to insect vectors that facilitated transmission, large waterborne outbreaks occurred in the 1930s and 1940s. How prevalent is Tularemia? Tularemia is listed as a "rare disease" by the Office of Rare Diseases (ORD) of the National Institutes of Health (NIH). This means that Tularemia, or a subtype of Tularemia, affects less than 200,000 people in the US population. How does a person get Tularemia? People can get tularemia through the bite of an infected tick, deerfly or other insect, handling infected animal carcasses, eating or drinking contaminated food or water, or breathing in the bacteria, F. tularensis Tularemia is not known to be spread from person to person. Can all ticks transmit Tularemia? No, the most common species of ticks in the United States that can transmit tularemia are the American Dog Tick (Dermacentor variabilis) and the Lone Star Tick (Amblyomma americanum). How serious is Tularemia? People who have tularemia do not need to be isolated. People who have been exposed to the tularemia bacteria should be treated as soon as possible. The disease can be fatal if it is not treated with the right antibiotics. What are the symptoms of Tularemia? Symptoms of tularemia could include: sudden fever, chills, headache, diarrhea, muscle aches, joint pain, dry cough and progressive weakness. People can also catch pneumonia and develop chest pain, bloody sputum and can have trouble breathing and even sometimes stop breathing. Other symptoms of tularemia depend on how a person was exposed to the tularemia bacteria. These symptoms can include ulcers on the skin or mouth, swollen and painful lymph glands, swollen and painful eyes, and a sore throat. Symptoms usually appear 3 to 5 days after exposure to the bacteria, but can take as long as 14 days. In general, tularemia would be expected to have a slower progression of illness and a lower case-fatality rate than either inhalational plague or anthrax. How is Tularemia diagnosed? Rapid diagnostic testing for tularemia is not widely available. Physicians who suspect inhalational tularemia in patients presenting with atypical pneumonia, pleuritis, and hilar lymphadenopathy should promptly collect specimens of respiratory secretions and blood and alert the laboratory to the need for special diagnostic and safety procedures. F. tularensis may be identified through direct examination of secretions, exudates, or biopsy specimens using Gram stain, direct fluorescent antibody, or immunohistochemical stains. Growth of F. tularensis in culture is the definitive means of confirming the diagnosis of tularemia. What is the treatment for Tularemia? Tularemia can be successfully treated with antibiotics. A vaccine for tularemia is under review by the Food and Drug Administration and is not currently available in the United States.

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TICKTICK-BORNE RELAPSING RELAPSING FEVER FACT SHEET PLEASE NOTE- There are two forms of relapsing fever: Tick-borne relapsing fever (TBRF) and Louse-borne relapsing fever (LBRF)- we will be focusing on TBRF. What is TBRF? Tick-borne Relapsing Fever (TBRF) is a disease characterized by relapsing or recurring episodes of fever, caused by several species of spirochete bacteria (most commonly Borrelia hermsii) that are transmitted to human through the bite of infected soft ticks. When was TBRF discovered? In 1927, TBRF was diagnosed in a 33-year-old man in Walla Walla, Washington, although his possible site of exposure was Montana. A specific location was not given, however, and spirochetes causing the illness were not identified. How prevalent is TBRF? Most cases occur in the summer months and are associated in particular with sleeping in rustic cabins in mountainous areas of the Western United States and Southern British Columbia, Canada. There are approximately 25 cases of TBRF in the United States each year. How does a person get TBRF? TBRF is transmitted through the bite of infected soft tick species. If the patient has donated blood, tissues or organ during the recent past, you must contact the blood or tissue bank immediately and warn of the potential exposure. Can all ticks transmit TBRF? No. In the United States, the soft ticks Ornithodoros hermsii and O. turicata most commonly transmit the infection. Soft ticks become infected by feeding on wild rodents that serve as reservoirs and then remain infective for their lifespan, passing the infection to their progeny. How serious is TBRF? With treatment, the mortality rate is very low. The mortality rate without treatment is estimated at 5-10%. What are the symptoms of TBRF? The illness has an incubation period of 4 to >18 days and is characterized by recurring episodes of fever accompanied by a variety of other manifestations, including headache, myalgia, arthralgia, chills, vomiting, and abdominal pain. How is TBRF diagnosed? TBRF is diagnosed and confirmed by the microscopic detection of spirochetes in the patient’s blood. What is the treatment for TBRF? TBRF is treated with appropriate antibiotic therapy. Patients should be monitored closely, particularly during the first 4 hours after antibiotics are administered.

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POWASSAN ENCEPHALITIS FACT SHEET What is Powassan Encephalitis? Powassan Encephalitis is a serious, though rare North American tick-borne illness caused by the Powassan (POW) virus. POW virus is classified as a flavavirus. When was Powassan Encephalitis discovered? POW virus was first isolated from a patient with encephalitis in 1958 in the town of Powassan, Ontario, Canada. The first recognized case of POW Encephalitis in the United States occurred in New Jersey in 1970. How prevalent is Powassan Encephalitis? From 1958 through 1998, 27 cases of human POW Encephalitis were reported from Canada and northeastern United States (Massachusetts, New Jersey, New York). The last case in the U.S. occurred in Massachusetts in 1994. However, during September 1999 to July 2001, 4 new cases were identified in Maine and Vermont after testing for suspected West Nile Virus was negative. As surveillance for arthropodborne viruses continues, the recognized incidence of POW Encephalitis may increase. How does a person get Powassan Encephalitis? You can get Powassan Encephalitis if you are bitten by a tick that is infected with the POW virus. Can all ticks transmit Powassan virus? No. In North America, POW virus has been isolated from four tick species: Ixodes cookei, Ixodes marxi, Ixodes spinipalpus, and Dermacentor andersoni. Evidence of POW virus infection has been found in 38 mammal species, primarily groundhogs. Ixodes cookei commonly infests groundhogs and is suspected to be the primary vector of POW virus. Unlike Ixodes scapularis, the major vector for the bacteria that causes Lyme disease, I. cookei rarely search for hosts on vegetation. Instead, they are most often found in or near the nests or burrows of medium-sized mammals and, therefore, rarely contact and bit humans. How serious is Powassan Encephalitis? Like most other arthropod-borne viruses, POW virus may cause no symptoms, or only mild illness, in some individuals. However, when the virus penetrates the central nervous system (CNS), it can cause encephalitis. POW Encephalitis is often associated with significant long-term illness and it has a fatality rate of 10-15%. Of those patients who survive, many suffer permanent brain damage. There is no vaccine or specific therapy. What are the symptoms of Powassan Encephalitis? When POW virus attacks the CNS, it causes cell death, inflammation and swelling within the brain (encephalitis). The membranous coverings (meninges) of the brain and spinal cord may also become inflamed (meningitis). Symptoms usually being 7-14 days following infection, and include headache, fever, nausea and vomiting, stiff neck, and sleepiness. As the disease progresses, more severe symptoms develop, such as breathing distress, tremors, confusion, seizures, coma, paralysis, and sometimes death. How is Powassan Encephalitis diagnosed? Symptoms of different arboviral infections are difficult to distinguish. Therefore, laboratory tests are necessary to confirm diagnosis. These tests are not commercially available, but testing can be performed at the CDC when requested through the state public health laboratories. Blood tests that detect antibodies to POW virus are most often used. Occasionally, POW virus may also be isolated from cerebrospinal fluid or other tissue. What is the treatment for Powassan Encephalitis? There are no specific treatments or medications for Powassan Encephalitis. Therapy is supportive only, directed at relieving the symptoms. This includes good nursing care, administration of intravenous fluids, respiratory support (ventilator), and prevention of secondary infections (pneumonia, urinary tract, etc.). Steroids may sometimes be used to reduce swelling in the brain.

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SOUTHERN TICKTICK-ASSOCIATED RASH ILLNESS (STARI) FACT SHEET **The Centers for Disease Control and Prevention is interested in obtaining samples from STARI patients under an Institutional Review Board-approved investigational protocol. Physicians seeing patients with a recent lone star tick bite and an expanding rash at least 5 centimeters in diameter are encouraged to contact CDC at 970-221-6400 for more information. Patients must be at least 4 years old to participate.** What is STARI? The cause of STARI is unknown. Studies have shown that is not caused by Borrelia burgdorferi, the bacterium that causes Lyme disease. Another spirochete, Borrelia lonestari, was detected in the skin of one patient and the lone star tick that bit him. However, subsequent study of over two dozen STARI patients has found no evidence of B. lonestari infection. When was STARI discovered? STARI was first recognized around the early 1990s when people began to show symptoms similar to Lyme disease. Unlike Lyme disease, these people did not have long-term problems, nor were they bitten by the same kind of tick (Ixodes scapularis or the black-legged tick). Studies have shown that the bacteria that causes Lyme disease, Borrelia burgdorferi, does not cause STARI. STARI may also be called "Masters disease" after the doctor who first identified the illness. How prevalent is STARI? The vector can be found from central Texas and Oklahoma eastward across the southern states and along the Atlantic coast as far north as Maine. How does a person get STARI? From the bite of an infected lone star tick, Amblyomma americanum. Can all ticks transmit STARI? No. STARI is specifically associated with bites of Amblyomma americanum, known commonly as the lone star tick. How serious is STARI? Unlike Lyme disease, STARI has not been linked to any arthritic, neurological, or chronic symptoms and is mainly associated with a rash and general flu-like symptoms. What are the symptoms of STARI? A rash similar to the bulls eye rash of Lyme disease has been described in humans who are eventually diagnosed with STARI. The rash may be accompanied by fatigue, fever, headache, muscle and joint pains. How is STARI diagnosed? STARI is diagnosed once Lyme disease has been ruled out, taking a medical history of the patient, and seeing if treatment with antibiotics resolves the rash and associated symptoms. What is the treatment for STARI? In the cases of STARI studied to date, the rash and accompanying symptoms have resolved promptly following treatment with oral antibiotics.

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CURRENT/FUTURE RESEARCH: VACCINES, TRIALS & CHALLENGES

Lyme disease is currently the fastest growing infectious disease in the world (Vanderhoof-Forschner, 1997): between 1991 and 2000, the incidence of Lyme Disease in the United States nearly doubled and the 17,730 cases reported for the year 2000 was higher than any other previous year (Schwan, 2003). Lyme disease even surpasses AIDS as one of our nation’s fastest growing epidemics (Lang, 1997). In order to control this new national health crisis, better diagnostic techniques and/or treatment options are necessary. In 1998 LYMErix® (a vaccine released by GlaxoSmithKline) was put on the market to alleviate the growing numbers of Lyme disease cases in the United States. However, in 2002 there was a recall on LYMErix due to complicated side effects in a small percentage of the population. The vaccine worked by stimulating specific antibodies directed against a specific Outer Surface Protein (Osp) on the outer membrane of Borrelia burgdorferi (Bb), thus enabling the immune system to fight off infection. At present, researchers are studying several other Osps on Bb for use in a possible new, safer vaccine. Two major Osps they are considering are OspA and OspC. Whether or not a new vaccine will be used in the future depends on how much we learn about candidate Osps and if we can determine when and why these proteins are produced during the spirochete life cycle.

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Function of Outer Surface Proteins In 1981, Borrelia burgdorferi was first discovered in ticks; since then much interest has been focused on the possible biological roles of certain outer surface proteins of Bb in the alternating life cycle that includes ticks and vertebrate hosts (Schwan, 2003). Two major proteins, OspA and OspC, are regulated by the spirochete during the several days when ticks feed. The decrease in OspA and the simultaneous up-regulation of OspC by the spirochetes when ticks are feeding, suggests that OspA aids in spirochete adhesion (in the tick) while OspC assists in the dispersal of spirochetes to the vertebrate host (Grimm et al., 2004; Carrol et al., 2003; Schwan, 2003; Fingerle et al., 2000; LYMErix, 1998; Revel et al., 2002; de Silva et al., 1996). Researchers have been working with mutant spirochetes that lack these proteins in order to provide evidence to these hypotheses. However, up until 2004, researchers have been unable to generate an OspA/OspC deficient mutant from a virulent strain of Bb. Yang et al. were the first to do this with OspA and proved that this outer surface protein was not required for Bb infection of mice. They also confirmed that OspA function was essential for Bb colonization and survival within the tick midgut (Yang et al., 2004). This finding has prompted more research into the biological roles of other outer surface proteins and the possible use of Osps for a new vaccine against Lyme disease.

Outer Surface Protein A The first Osp identified (OspA) in culture-derived Bb was approximately 31 kDa (Schwan, 2003). The OspA monomer has an elongated fold composed of 21

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anti-parallel beta-strands followed by a single short alpha helix (Kumaran, 2001). Indirect immunofluorescence with a monoclonal antibody that was produced against OspA, allowed researchers to visualize spirochetes from an infected tick for the first time. This specific antibody-protein binding became the main method for identifying Bb and also for analyzing tick tissues to look for spirochete infection (Schwan, 2003).

Simpson et al. (1991) studied antibody responses in animals that were experimentally infected with Bb and found that they differed from animals infected with Bb from a tick bite (as reviewed in Schwan, 2003). Rodents infected with Bb from a tick bite rarely stimulate an antibody response to OspA, whereas those inoculated with cultured Bb do (Schwan, 2003). In 1995, for the first time there was evidence for spirochetes altering their phenotypes in vitro. Schwan et al. demonstrated that Bb altered its Osps in ticks during feeding and with temperature changes during in vitro growth. Spirochetes in unfed ticks had OspA (and lacked OspC) yet after the ticks fed, spirochetes stained positive for OspC (Schwan, 2003). These were the first results to demonstrate that Bb spirochetes changed phenotypically during tick feeding since OspA is down-regulated while ticks feed. Most spirochetes in the midgut of unfed ticks produce OspA, but after 3-4 days of feeding, only 30-40% of the spirochetes contain this protein (de Silva et al., 1996). The fact that there are a high number of OspA positive spirochetes in the midgut of unfed ticks, and only OspA negative spirochetes are likely to persist in mammals during infection, led to the hypothesis that OspA acts as a tick midgut adhesion molecule to prevent the spirochetes from being eliminated

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in tick feces (Yang et al., 2004; Schwan, 2003; Fingerle et al., 2000; Pal et al., 2000; LYMErix, 1998; de Silva et al., 1996). As mentioned earlier, in February 2004, Yang et al. lent support to prove this hypothesis by creating an OspA deficient mutant of an infectious strain of Bb (strain 297).

Outer Surface Protein C One year after identifying OspA, researchers described a 22 kDa protein found in ticks and patients in Europe; this protein was eventually named OspC (Schwan, 2003). The OspC monomer is almost all helical, with four long helices plus a short fifth helix (Kumaran, 2001). Originally, researchers believed that OspC was found only in sprirochetes from Eurasia, however, many studies since then have shown that the OspC (gene or protein) is present in all North American strains of Bb (Schwan, 2003; Carrol et al., 2003; Fingerle et al., 2000).

In 2004, Grimm et al. created and analyzed a Bb mutant that lacked OspC. All of the six mice that were challenged with the mutant spirochete remained sero-negative; spirochetes were not acquired by feeding ticks, and spirochetes could not be cultured from mouse tissues. Their findings showed that Bb strictly required OspC in order to infect mice and therefore is necessary to spread infection and could possibly influence the virulence of disease (Grimm et al., 2004; Schwan, 2003).

Bb spirochetes are able to change gene expression during tick feeding possibly through environmental signals such as temperature and pH. Several genes, including OspC, appear to be regulated in vitro by pH (Carrol et al., 2003).

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These differences in pH in culture are reflective of the pathway that the spirochetes would experience during the feeding cycle from tick (pH 8.0) to mammal (pH 7.0). As the pH is lowered, OspC is produced while OspA is downregulated. In addition, temperature has been shown to stimulate regulation of OspC. Changing the in vitro temperature from 24ºC to 37ºC stimulates spirochetes to produce OspC, yet changing the temperature back to 24ºC caused OspC production to cease (Schwan, 2003). This was another experiment that is reflective of the alterations that the spirochetes would experience during the feeding cycle. Clearly, to survive in both hosts, spirochetes have evolved mechanisms for sensing the different host environments and responding accordingly.

Furthermore, in an experiment done by Piesman and Burgdorfer (1991, as reviewed in Schwan, 2003), spirochetes in the midgut of unfed ticks that were OspC negative were not infectious when inoculated into mice, however, OspC positive spirochetes in recently fed ticks were found to successfully transmit disease. In addition, the migration of Bb from the tick midgut to the salivary glands is repressed when infected ticks feed on OspC immunized mice (as reviewed in Schwan, 2003). This finding could possibly support a role for OspC (in certain strains) to assist spirochetes in dissemination from the midgut to infect the host. Conversely, OspC negative spirochetes (strain B31-C1) have been detected in salivary glands of recently fed ticks, and in mouse skin associated with the mouthparts of ticks pulled from their hosts (Ohnishi et al., 2001). In another experiment, Bb (strain B31) was exposed to tick hemolymph at 28ºC in

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vitro and it was found to up regulate OspC (Johns et al., 2000). However, the significance of the effects of tick hemolymph on Bb OspC is unknown.

Since there are 300+ strains of Bb worldwide, some researchers are looking at how OspC is regulated in different strains. Carrol et al. (2003) developed and implemented a GFP reporter system in Bb that monitored gene regulation in response to pH and temperature in vitro. They concluded that strains B31 and N40 may differ in their mechanisms of OspC regulation, such that B31 clones down-regulated OspC at a pH of 8.0, while N40 did not display any change in the amount of OspC. Fingerle et al. (2000) also studied different strains (cPKo97 and N40 --common to Europe) using immunofluorescence micscoscopy and found that the two strains displayed different patterns of Osp expression. They concluded that OspA and OspC expression (with regard to temperature and cocultivation with tick cells) is comparable to Bb in other geographical regions outside of Europe, but the mode of regulation seemed phenotypically different since cPKo97 expresses OspA and OspC concurrently on a single spirochete, while N40 has either OspA or OspC on a single cell (Fingerle et al., 2000). Since distinct strains appear to differ in their regulation of Osps, further strains should be tested and compared to other North American strains if vaccine development (using Osps) is imminent.

OspC proteins are considered to be polymorphic; this variability also extends to genospecies collected from a single geographical area. Alleles of OspC collected from a single site (Shelter Island, New York) could be clustered

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into 19 major groups, based on DNA sequence homology (Wang et al., 1999). Of the 19 major groups only 4 were invasive, while the others are non-human pathogens or infect only the surrounding skin (Wang et al., 1999). This variabilty will obviously also have consequences in the development of OspC vaccines. This experiment, however, showed researchers that the sum of the variation within a local population is comparable to the variation of similar sized samples collected from the entire species (Wang et al., 1999).

Two of the invasive strains from Shelter Island, NY (HB19 and B31) were studied by Kumaran et al. (2001). They compared the electrostatic potential of the two strains with similar models of other non-invasive strains. It turned out that there was a key difference between invasive and non-invasive strains (in terms of electrostatic potential). The surface potential is highly negative for OspCs from invasive strains, while non-invasive strains are slightly more positively charged (Kumaran et al., 2001). If OspC is indeed involved in influencing the virulence of infection, perhaps the negatively charged regions interact with positively charged host molecules, (such as human fibronectin) thus increasing infection rate due to electrostatic attraction (Kumaran et al., 2001). This is a possible explanation as to why invasive strains have the negatively charged OspC while the non-invasive strains lack the negative charge. However, definitive proof of this theory is still lacking.

Variability in the pattern of OspC and OspA synthesis has been reported for different strains of Bb (Schwan, 2003; Wang et al., 1999; Kumaran et al.,

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2001) and a variety of OspA and OspC phenotypes can exist after infected ticks have fed (Schwan, 2003; Yang et al., 2004). However, most studies have shown that spirochetes in ticks up-regulate OspC during either dissemination from the tick midgut, immunoevasion while in the tick hemolymph, penetration of the salivary glands, or the initial colonization of the vertebrate host (Johns et al., 2000; Carroll et al., Schwan, 2003; Ohnishi et al., 2001).

Immune Response

The innate immune system, particularly the host complement system, plays an important role in the destruction of invading pathogens. Elimination of pathogens can be accomplished by the host complement system in a variety of ways. Consequently, pathogens have developed a wide range of strategies through the course of evolution to avoid complement attacks and to survive within the immunocompetent host. One strategy is the ability to acquire host fluidphase complement regulatory proteins (Kraiczy et al., 2001). Certain strains of Bb have developed strategies to prevent complement-mediated cell death (Kraiczy et al., 2002a). The majority of Bb genospecies show a complementresistant phenotype due to complement regulator-acquiring surface proteins (CRASPs). Bb express up to five different CRASPs that allow them to survive (through acquired resistance) even after the host complement system has been activated (Kraiczy et al., 2002b). Resistance is possible since the CRASPs interact with the human fluid-phase complement regulators FHL-1/reconectin and factor H (Kraiczy et al., 2001). Bb is able to bind to the human immune regulators

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at their C-terminal ends. This attachment orients the N-terminal complement regulatory domains of FHL-1/reconectin and factor H in such a way that prevents formation of toxic activation products on the spirochete surface (Kraiczy et al., 2001; (Friese et al., 1999). In addition, the external layer above the outer membrane of Bb is called the slime layer, or S layer, which provides the spirochete protection from the human immune system (Richler, 2004; Vancova, et al. 2003; Yigong, et al., 1998). The S layer serves to cover protein receptors on the surface of Bb, thus making it difficult for antibodies to bind - an essential step in many immune reactions. Additionally, most Bb species can significantly change their surface proteins enough during cell division in order to evade immune system response (Kraiczy et al., 2002a; Vanderhoof-Forschner, 1997). Therefore, once antibodies are secreted for a particular surface antigen, a new surface antigen can arise and new antibodies will need to be generated.

Bb is highly motile, capable of swimming through both blood and tissue thus facilitating their passage through the extracellular matrix and cell junctions in infected tissues (Yigong, et al., 1998). Unlike most pathogens, Bb is able to cross the blood brain barrier, which normally serves as protection from invasion by foreign organisms (Vanderhoof-Forschner, 1997; Lang, 1997). During the first few days of infection, Bb can cause the release of cytokines (proteins produced by white blood cells that act as chemical messengers between cells) that serve to breakdown the blood barrier (Richler, 2004; Vanderhoof-Forschner, 1997;

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Richler, 2004). This explains the neurological impediments that can occur in some people with Lyme disease.

Bb can invade virtually any cell in the human body including B cells (immune cells that secrete antibodies). When exiting B cells, Bb is able to coat itself with the host B cell membrane (Lang, 1997; Richler, 2004). The immune system can thus be fooled because the B cell membrane provides it with a type of camouflage, making it difficult to recognize as a foreign antigen.

Current Vaccine Research

OspA was chosen for the primary antigen in the first recombinant Lyme disease vaccine for human use in the United States. LYMErix® (a vaccine distributed by GlaxoSmithKline) was removed from the market in February 2002 because of possible, debilitating autoimmune side effects (Vaccine, 2002). The vaccine contained buffered saline (in order to maintain pH), aluminum hydroxide (to boost immune system response), 2-phenoxyethanol (to prevent growth of other bacteria), sterile water, and lapidated OspA--strain 7S7 (Vaccine, 2002; LYMErix, 1998). Since OspA was suspected to aid in spirochete adhesion while inside the tick midgut, the basic mechanism of the vaccine was to have the vaccinated person’s own immune system kill the bacteria (by disrupting its attachment) while still inside of the feeding tick, thus preventing transmission (Vaccine, 2002; LYMErix, 1998; Simon et al., 1991).

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It was found that the Human leukocyte function-associated antigen I (hLFA-1a), which is found on multiple cells in the human body, is able to crossreact with the OspA used to create the vaccine (Vaccine, 2002). Upon vaccination of a genetically vulnerable person, the OspA-primed antibodies exhibited an autoimmune response by attacking and binding to its own hLFA-1a (Vaccine, 2002).

In March of 2000, Tufts researchers patented an OspA vaccine that caused less human autoimmune reaction than the current OspA vaccine (Vaccine, 2002). They modified the OspA sequence so that the resulting human antibodies would not interact with the vaccinated person’s cells and attack them as if they were spirochetes. When Tufts new OspA (FTK-OSP166-173) was tested on human blood, it was found to cause a less destructive reaction (Vaccine, 2002; Sikand et al., 2001).

Future Perspectives

Lyme disease is the most commonly diagnosed vector-borne disease in the United States, with over 99,000 cases reported to the Centers for Disease Control and Prevention from 1982 to 1996. During that time, the incidence of reported cases increased by at least 32-fold (LYMErix, 1998). Clearly a reliable test for detection of disease, and possible prevention technique (in the form of a vaccine) is essential to stop these numbers from growing.

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Great advances have been made in the area of Lyme disease research, but science still has a long way to go. Scientists are also studying ways that would cause a tick to rapidly detach or die before it is able to transmit disease (Vanderhoof-Forschner, 1997). This would be helpful for not only Lyme disease, but also for the additional co-infections that are usually present in the same tick. However, the consequences of disturbing the parasitic interaction between tick and vertebrate host in the ecological community is not known.

Until we have a more definitive test to determine who has Lyme disease and who does not, it will be challenging to measure how well a vaccine works. We would also need to resolve the long-standing debate about people who have continuing symptoms of illness. Some scientists believe that these people are persistently infected with Bb, while others believe that the problem is the failure of the immune system to shut down properly after eliminating infection. The answer to this question could have important implications for vaccine development because a vaccine could have negative effects on an overactive immune system (as was seen with the first recombinant OspA vaccine, LYMErix).

Up until now, only OspA vaccines have been researched. In the coming years, the possibility of an OspC vaccine will continue to be explored. However, some believe that experimental OspA and OspC vaccines have limited utility since they are usually only effective against challenge by the single strain (used to create the vaccine) and not by heterologous strains (Kumaran et al., 2001; Wang et al., 1999). Therefore, researchers are also interested in developing a

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mixture of different antibodies for perhaps both OspA and OspC or more Osps in one vaccine so that it may be effective against multiple strains in different countries (Kumaran et al., 2001; Vanderhoof-Forschner, 1997).

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Appendix A: Laboratories for Tick testing

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Laboratories for Tick testing: BBI – North American Clinical Labs 75 North Mountain Road New Britain, Connecticut 06053 800-886-6254 860-225-1900 IGeneX, Inc. Reference Laboratory 797 San Antonio Road Palo Alto, California 94303 800-832-3200 New Jersey Laboratories, Inc. 1110 Somerset Street New Brunswick, New Jersey 08901 908-249-0148 Connecticut Veterinary Diagnostic Testing Labs University of Connecticut Department of Pathobiology 61 North Eagleville Road U-203 Storrs, Connecticut 06269 860-486-0808 Veterinary Research Associates 10 Executive Boulevard Farmingdale, New York 11735 516-753-4100 Medical Diagnostic Laboratories, L.L.C. 2439 Kuser Road Hamilton, New Jersey 08690 877-269-0090

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Appendix B: Documenting a Tick bite

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Documenting a Tick bite: Date: _______________________________ Name of person bitten: _______________________________ Town where bite occurred: _______________________________ How long tick was attached (estimated): _______________________________ Place on body bitten: _______________________________ How tick was removed: _______________________________ Type of tick (if known): _______________________________ Result of tick testing: _______________________________ Appointment and/or phone calls to physician: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Tests and results: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Symptoms: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Treatment: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

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Appendix C: HHS – Preventing Lyme Disease in Montgomery County

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Appendix D: Trends of Lyme Disease and Rocky Mountain Spotted Fever in Maryland (1990-2005) Maryland Department of Health and Mental Hygiene

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Appendix E: Local Agencies

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Local Agencies: National Institutes of Health (NIH) National Institutes of Allergy and Infectious Diseases Box AMS 9000 Rockville Pike Bethesda, Maryland 20891

Maryland Department of Health and Mental Hygiene - Maryland TickOff Office of Epidemiology and Disease Control Programs 201 West Preston Street, Third Floor Baltimore, Maryland 21201 410-767-6700 http://www.marylandtickoff.org

The National Capital Lyme & Tick-Borne Disease Association P.O. Box 8211 McLean, Virginia 22106-8211 703-821-8833 http://www.natcaplyme.org The National Capital Lyme & Tick-Borne Disease Association holds monthly meetings for the flagship Washington, D.C. Chapter at: The Sibley Memorial Hospital 5255 Loughboro RD NW Washington DC, 20016-2634 http://www.sibley.org

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Appendix F: Educational Materials

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Department of Health and Human Services Communicable Disease and Epidemiology July 2008 Name: __________________________________________

Prevention is key! Can you find the following words related to Lyme disease prevention? (words can go forward, backward, and diagonally!)

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Department of Health and Human Services Communicable Disease and Epidemiology July 2008

ANSWER KEY:

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Department of Health and Human Services Communicable Disease and Epidemiology July 2008 Name: __________________________________________

Use the first letter to begin a new sentence with a different fact about Lyme disease!

BE CREATIVE!

L yme disease is spread by the bite of an infected tick Y ou cannot catch Lyme disease from a friend______ M _______________________________________________ E _______________________________________________ D _______________________________________________ I _______________________________________________ S _______________________________________________ E _______________________________________________ A _______________________________________________ S _______________________________________________ E _______________________________________________

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Department of Health and Human Services Communicable Disease and Epidemiology July 2008 Name: __________________________________________

Lyme Disease Word Scramble

Unscramble the words below: 1. cikt________________ 2. ylem________________ 3. isedase________________ 4. ertdi________________ 5. acyh________________ 6. fever________________ 7. ashr________________ 8. doswo________________ 9. cdotor________________ BONUS: sctoinaibit________________

*hint: What spreads Lyme disease? How do you feel if you have Lyme disease? Who and What can cure Lyme disease?

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Department of Health and Human Services Communicable Disease and Epidemiology July 2008 ANSWER KEY: 1. cikt is tick 2. ylem is lyme 3. isedase is disease 4. ertdi is tired 5. acyh is achy 6. fever is fever 7. ashr is rash 8. doswo is woods 9. cdotor is doctor BONUS: sctoinaibit is antibiotics

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