The Who/What/When/Where and WHY of Vector-Borne Diseases and Repellents - PowerPoint Presentation

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The Who/What/When/Where and WHY of Vector-Borne Diseases and Repellents Dana Balchunas, BSN, M.Ed, RN

April 19, 2019

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For many VBDs, prevention is the only optionVBDs are becoming more prevalentTYPES of VBDs are increasingPersonal protection for those at home/travelingWhy Care about Repellents?2

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Why personal protection is crucial to prevent bites from mosquitoes and ticksProper repellent choices and useEfficacySafetyWhat to do if you’re bittenKey Messages for Students, Parents and Others3

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Encourage parents, medical professionals to think VBD as a potential when they see flu-like symptoms Train students/parents/others on proper repellent useHelp school families to be knowledgeable about VBDs and prevention wherever they areAmong the Goals…4

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Regulation and use of EPA-registered repellentsSafety and efficacy informationProper applicationUrban legendsMessages that workDealing with special audiencesAnti-vaxxersEnglish as second language communitiesThose afraid of chemicals Learning Outcomes5

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“The Swiss Army knife of disease vectors” (National Academy of Sciences)Deliver bacteria, protozoans, virusesAround since the Jurassic eraMajor factor in illnesses worldwideAre opportunisticThey do not fall from trees…are in knee-high vegetationSurvive frigid climatesTicks

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700 hard tick species worldwide Of these, 241 are Ixodes 80 in USA, 4 exotic20 species of hard ticks in Oregon, but only four prey on humansWestern black-legged tickRocky Mountain wood tick, American dog tick Pacific Coast tick. Multi-year life span—all phases can be infected Tick populations are expanding7Tick Statistics

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Spring/Summer are peak seasons but there’s year-round activityIllnesses in “off season” reported November to March 2018-20198Seasonality

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West of the Cascades at lower elevationsWestern Deer TicksCo-infected with Lyme, anaplasmosis, Ehrlichia Southern OregonMiyamotoi—causes relapsing feverWestern Deer ticksCo-infected with Lyme (3.5%)Jackson County 7% are infectedOne human case confirmedEastern OregonAmerican dog ticks vector Rocky Mountain Spotted Fever9

Areas of Concern in Oregon

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Reported Cases of Lyme Disease Lyme: 95% of cases from 14 states Cases in OR have doubled

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11 Only the Females Bite

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Onset 7-14 days after attachmentBull’s eyePainless, doesn’t itchIdentified in 60-80% of cases Usually no associated symptoms

Most Common Symptom

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Atypical Erythema Migrans

Smith RP et al. Ann Intern Med 2002

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Can occur in isolation or as a co-infectionSpread by Ixodes ticks (Deer ticks)Transmission via blood transfusionBabesiosis

Reported cases of Babesiosis, 2014

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Anaplasmosis (HGA)Ehrlichiosis (HME)MMWR Recommendations and Reports / May 13, 2016 / 65(2);1–44

Human Ehrlichioses

By County 2000–2013

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http://www.cdc.gov/stari/geo/Lone Star Ticks are Aggressive Biters16

Not in Oregon yet but already in Southern California

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Southern Tick Associated Rash Illness (STARI)NOT bacterialPathogen as yet unknownSame symptoms as LymeAlso called Masters’ Disease17

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Rocky Mountain Spotted FeverR. parkeri Pacific Coast tick feverRickettsial pox Spotted Fever RickettsiosesIncidence of SFR by County, 2000-2013

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Cases of SFR, 1993-20176000 vs 30,000 annually for Lyme

http://www.cdc.gov/rmsf/stats/

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Primarily the American dog tick—found across the U.S.Vertical transmission for 6 generations=130 quintillion infected ticks from birth>50% recall prior tick encounterTick attachment >6 hours required for injection of bacteria

Rocky Mountain Spotted Fever

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Symptom onset 7 days (range, 2-14 days) after tick biteReported throughout the lower 48FIVE states account for 60%+ of all casesNC, OK, AR, TN, MOPRESENT IN OREGONRocky Mountain Spotted Fever

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RMSF RASHEarly (d2-4) Late (>day 4)

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Case Fatality Rate, RMSF2008-2013Children <10 years =6% of RMSF diagnoses, but 22% of RMSF deaths

“If you don’t treat by Day 5, they are DEAD by Day 8”—

CDC MD

Before antibiotics, fatality rate was 80% for all cases

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Virus, no cureTransmitted by Rocky Mountain Wood ticksFound throughout western USA and CanadaHIGH ALTITUDES—4-10,000 ft (ASL)Grassy areas near sage brushFebrile illness, non-specific symptoms, leukopenia30% of patients require hospitalizationUsually 1 case annually—in 2018 there were 4 Three suspected cases—2 were childrenPathogen circulating in central OregonMay-June are active periods but likely year round24Colorado Tick Fever—Oregon Makes the News

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Deer TicksAnaplasmosisBabesiosisBorrelia MiyamotoiLymePowassanLone Star TickEhrlichiosisHeartlandSTARITularemiaAlpha-galAmerican Dog TickRMSFTularemiaGulf Coast TickRickettsia ParkeriMaybe others?Co-Infections Compound the Risk

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Viral—so not treatable with antibioticsFatal in 10% of patients50% have chronic neurological issues afterwards (similar to WNV encephalitis)TICK ATTACHMENT TIME FOR VIRAL TRANSMISSION IS 15 MINUTESMost other tick-borne diseases have a 24-36 hour “window” before disease transmissionNo vaccine, no cureRare, but now being studiedWhat’s Powassan All About?27

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Powassan Virus Neuro-invasive Disease

http://www.cdc.gov/powassan/statistics.html.

Powassan virus neuroinvasive disease

cases reported by year, 2007-2016

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Other Emerging Tick-borne InfectionsB. miyamotoi hard tick relapsing fever (OREGON!)Heartland virusEhrlichia.muris-like organismBabesia MO-1R. parkeri and other spotted fever group RickettsiosesBourbon virus

AND THE LONGHORN TICK is capable of vectoring diseases in other parts of the world…stay tuned—9 states,

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ALWAYS USE REPELLENTLet clothing be a barrierUse permethrin on clothingWhen coming inside, put clothing into the dryer on high for 20 minutesDo a tick-check when you’re in the showerCheck all nooks and cranniesLook for moving frecklesNymphs emerge in early Spring…they’re one of the most dangerous life-forms—hard to spot, can be infected vertically (from mother)30

Tick Messages

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Tick RemovalWhat TO DOREMOVE the tick ASAP Time is of the essenceClean wound area with soap and water, antisepticPut the tick in alcohol to kill it

What

NOT

to do…

Burn it (gasoline, kerosene)

Smother it (petroleum jelly)

Poison it (fingernail polish)

Annihilate it (hot match tip)

Crush it

Use Dove soap

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Blood testing not accurate for 45+ daysResults are often confounded by PREVIOUS bitesPhysicians should treat on presumption of a tick-borne disease when there are symptomsMany ID experts tell us this treatment with antibiotics is a good diagnostic toolIf symptoms persist after antibiotics, they look for another diagnosisSome issues with Western blot test interpretation lead to erroneous diagnoses of LymeTESTING FOR TICK-BORNE DISEASES32

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If the child is symptomatic, DO NOT wait for test resultsDoxycycline is AAP’s and CDC’s recommendationNational survey 201235% of providers would not give to patients younger than 8 years old due to concern for dental coloration KEY MESSAGE: FOLLOW AAP/CDC GUIDELINES AND GIVE DOXYCYCLINE REGARDLESS OF THE PATIENT’S AGEMD and Parent Messages:Treatment For Tick-borne Diseases

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Not all Tick-borne Disease is Infectious….34

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Galactose-alpha 1,3-galactose (alpha gal) present in tick saliva and red meatReaction to meat consumptionSymptoms:Hives or skin rashNausea, stomach cramps, indigestion, vomiting, diarrheaStuffy/runny nose, sneezingBronchospasmHeadachesAnaphylaxisTick-Associated Red Meat AllergyLone Star Ticks are the Culprits

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Treatment Alpha-Gal Allergy36

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“We never thought about tick-bites for this patient”—Grand Rounds, KC hospitalPatient age 17 died of Ehrlichiosis“The patient did not have a rash”—RMSF patient“We did not ask where the family had been…”Indiana medical team…toddler died after camping, was undiagnosed until it was too late.NJ—Medical professionals don’t realize there’s more than Lyme disease to worry aboutThere should be 1 case of Ehrlichiosis for every 2 Lyme cases NJ healthcare providers in Monmouth found 2 vs. 439 Lyme cases diagnosedComments about Ticks from Medical Professionals37

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Message SummaryLyme is most common, but regional Co-infections occurConsider Ehrlichioses and RickettsiosesNonspecific febrile illnessSpring/summer/fallPotential tick exposureRash may be a clue (but often absent)Don’t wait for lab confirmationEarly treatment may be LIFE saving

Doxycycline for ALL ages

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Kirby Stafford, PHD, CT tick expertRecommends “borders” at edge of the woods with gravel/wood chips/mulch to deter ticks from moving into your yard/school propertyKeep grass lowAvoid having knee-high vegetation on the edge of yard, playgrounds, athletic fields (ticks use it for “questing”)Landscaping Recommendations39

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Landscaping Ideas to Help Deter Ticks40

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Yard Design41

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174 species in the U.S.Texas has 85WVA has 24NYC has more than 50NJ has 63Oregon has 50Mosquitoes42

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WNV in eastern OregonFarming area, lots of irrigation and breeding spotsSt. Louis EncephalitisCache Valley virus—rare in humans, see in animals where it causes abortion and stillbirthWestern Equine Encephalitis in Southern Oregon43Oregon Mosquitoes Vector Important Illnesses

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West Nile Virus in OregonOregon began surveillance programs in 2001WNV first identified in humans, birds and horses in 2004 2006 was the peak year for human WNV human cases with 73

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History of WNV in OregonFrom 1999 – 2017 178 human cases 38 were neuroinvasiveIncidence of human WNV disease was low in Oregon in 2018

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West Nile Virus Testing and Surveillance The Oregon State Public Health Laboratory performs confirmatory testing of WNV human infection 13 vector control districts (VCDs) in Oregon collect, identify, and test mosquitoes and dead birds for WNV

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MosquitoesBehaviors and biting differ by speciesWNV night time biters (Culex pipiens and others)The 4 D’s: dress, dawn/dusk, defend (with repellent), and drain standing water48

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Outcome

Total Patients,

n (%) [95% CI]

Symptom

†

Fatigue

94 (96 [90-99])

Fever

79 (81 [72-87])

Headache

70 (71 [62-79])

Muscle pain or aches

61 (62 [52-71])

Muscle weakness

60 (61 [51-70])

Rash

56 (57 [47-66])

Neck pain or stiffness

54 (55 [45-65])

Difficulty concentrating

52 (53 [43-63])

Joint pain or aches

36 (37 [28-47])

Vomiting

27 (28 [20-37])

Diarrhea

26 (27 [19-36])

Sensitivity to light

21 (21 [14-31])

West Nile Fever

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34% of cases reported to CDC in kids are neuroinvasive (N=2397 1999-2016)Same incidence as in all other age groupsAdults present with encephalitis, kids with meningitis in the more severe casesFatality rate in older adults is 14%...1% in childrenMore cases WNV in kids than for all ages for SLE, LAC, EEE, and WEE combined!Pediatric WNV-Associated Neuroinvasive Disease: A Review of the Literature. Herring et al. Pediatric Neurology 2018.07.019West Nile in Children--US 50

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Eastern Equine Encephalitis51

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52Western Equine Encephalitis

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St. Louis Encephalitis53

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Carried by the eastern tree-hole mosquito (Aedes triseriatus)Daytime biter, aggressiveVertical transmission (eggs infected)Occurs most often in children under age 16Most cases are in Midwest, NC and WVA (100 annually)More Kid-FocusedLa Crosse54

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LaCrosse Encephalitis, 2007-2016https://www.cdc.gov/lac/tech/epi.html

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Imported Arboviruses56

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Zika carriers are daytime biters—LOVE PEOPLESeeks out people FIRSTBites multiple people (“sip-feeder”)STEALTH biterBites through clothingLoves lower extremities (feet/ankles)“Urban” mosquitoes—”Cosmopolitan”Found 500 feet from where she emerged from larval stageAedes AegyptiPeople Need to Know Behaviors57

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HARD to repel—most experts recommend 25% DEET-based repellent. It’s the species used for testing repellents May be co-infected with Zika, dengue, CHIKV, Yellow FeverMosquitoesMore on the Aedes Aegypti58

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“Asian Tiger” MosquitoAnother stealth biterPrefer lower extremitiesDaytime bitersCompetent vector for dengue, CHIKVAlso tests positive for Zika, WNV, EEE and Japanese encephalitisFound in 30 statesAedes Albopictus59

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Estimated U.S. Range Aedes aegypti and Aedes albopictus60

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West Nile virus infection is the most common mosquito borne disease in the U.S. with <10% in childrenRange from asymptomatic infection (80%) to neuroinvasive disease (1%)Imported infections include Chikungunya, dengue and ZikaKnow where your students are going for breaks, school/family-related tripsUnderstand that mosquitoes can be a daytime and nighttime threat

Summary

:

Mosquito Messages

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Screened windows/doorsDump standing waterProper clothingClosed-toed shoes and socksLong sleeves/pantsShowerBuddy Tick CheckREPELLENTS

INTERVENTIONS

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FDA does NOT approve repellentsAll active ingredients for repellents and formulations are registered by EPA after safety/efficacy testingREPELLENT Regulations63

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What to Use?Always use a repellent with an EPA-registered active ingredientTested for safety andefficacyTested for specific vectors

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EPA has NO age limitations on any of the registered actives EXCEPT Oil of Lemon Eucalyptus (children must be 3 years of age)CDC/medical groups offer guidanceAm. Academy of PediatricsRecommends using DEET, picaridin, IR3535 on kids as young as 2 MONTHS of ageEPA Regulation65

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Aerosol spraysSpritz containersIndividual wipes in packets (easy to keep with you on the go)Creams“Dry” formulationsAesthetically pleasing formulations with floral scentsThe label is a legal document-- virtually illegibleProduct Types 66

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HOW You Apply Is Important WRONG!

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Got It 50% Right…OVER APPLICATION IS NOT NEEDED…APPLY SPARINGLY68

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Apply sparingly to exposed skin, smooth on like sunscreen or body lotionCDC and other experts: Use a 25% or higher product for Aedes speciesApply sparingly to clothing or under clothing if mosquitoes can bite through fabricRepellent washes off with perspiration/swimming/rain, so reapply as neededRepellent Use for Mosquitoes69

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Apply to exposed skin AND clothing, shoes, socks, pantsUse permethrin-treated clothing –KILLS on contact; CDC and other experts: Use a 20% or higher concentration of repellent for ticksLOWER concentrations don’t work well or very long A 25% concentration DEET product will last 5-6 hours for mosquitoes BUT 3-4 for ticks so REAPPLYDress appropriately—long pants tucked into socks. What Apperson does…Repellent Use for Ticks70

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Responsible adults should apply to their own hands, smoothing repellent evenly on child’s exposed skin Avoid fingers in very young childrenKeeps repellent out of eyes and mouthsNo need to apply beneath clothing unless ticks can get inside clothing easily OR if the mosquitoes can bite through the fabricAvoid rayon, leather with DEETFollow label instructions.DO’s and DON’Ts71

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DEET –500 productsPicaridin—40 productsIR 3535—45 productsOil of Lemon Eucalyptus—10 productsCatnip Oil—4 productsBIOUD—1 productOil of Citronella-3 EPA-Registered Repellents

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Available since 1948--billions of usesThe “Gold Standard” -- most widely usedMost widely studied active in all consumer products Repels mosquitoes, ticks, fleas, midges, chiggers, black flies, most others—but not bees, spiders, etc.20%+ recommended for longer protection from ticks25%+ for Aedes mosquitoesConcentrations 5-100%Sustained release products (34.5%)=12 HrsUsed by the military worldwide

EPA Registered Actives

:

DEET

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Picaridin (40 products) and IR3535 (45 products)Not widely available in higher concentrationsMosquitoes, biting flies, ticks, fleas, chiggersIntroduced in US in 2005 and 2000, respectively IR3535 not available in wipe formUse instructions are the SAME as for DEETWash when returning inside, etc.Use on children two months of age and olderOther EPA-Registered Actives74

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Oil of Lemon Eucalyptus/PMDChildren -3 YEARS of age or olderEssential oils can cause skin irritationRepels mosquitoes, flies, gnats, ticksAvailable since 200010 productsMore EPA-Registered Actives

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Catnip Oil (4 products)Registered in 2016Mosquitoes and black fliesOil of Citronella (3 products)Not all products are registeredGnats, mosquitoesChildren must be 6 months or olderBioUD (1 product)Registered but not widely marketedMore EPA-Registered Actives76

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Concentration is the KeyThe higher the concentration the LONGER the repellent helps protect More isn’t BETTER, it’s LONGERDuration of efficacy is comparable at comparable concentrations for the EPA-registered actives5% picaridin lasts an hour --same FOR DEET-based productsPick the concentration that matches your time of exposureProtection times are SHORTER for ticks than mosquitoes

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100% = @12 hours34.5% sustained release = @12 hours30% = up to 8 hours25% = up to 6+ hours15% = up to 4+ hours10% = up to 2+ hours5% DEET-based product = @90 min Protection levels off at @ 50%Typical

MOSQUITO

Protection Times (DEET-based Products)

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Gender Activity – sweats offTime of day, temperature, humidityBody chemistryType of vectorSpecies of vectorProtection Times VARY79

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Use on KidsChildren 2+ months can use DEET-based repellents in concentrations up to 30%AAP Guidance since 2003Reviewed all safety dataSame for picaridin and IR3535MUST BE 3+ years for Oil Of Lemon Eucalyptus/PMD (EPA REGULATION

)

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DEET-based products recommended byCDCWorld Health OrganizationAmerican Academy of PediatricsAmerican College of Obstetrics and GynecologyStudy in Thailand showed no issues with moms or childrenExtensive animal tests also show no issuesRepellent for Pregnant Women and Nursing Mothers

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Apply sunscreen first, then repellentReapply sunscreen oftenReapply repellent when bugs returnSunscreen and Repellent82

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THE ELEPHANT IN THE ROOM83

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Eye stinging most common AEAlcohol in formulationsA mild irritantResolves immediately by flushing eyes with waterVERY RARELY skin irritationIndividuals may find non-fragranced formulation works for themDEET Safety84

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Follow label directions“A long record of safe use…” per independent experts in peer-reviewed journals, etc.Environmental Working Group…NGO that resonates with “non-vaccine” users and chemophobesWhat Experts Say85

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“…DEET…is widely used but much maligned.  … Safety profile is better than many people assume. …Effectiveness at preventing bites is approached by only a few other repellent ingredients. DEET isn't a perfect choice nor the only choice.  But weighed against the consequences of Lyme disease and West Nile virus, we believe it is a reasonable one.” http://www.ewg.org/research/ewgs-guide-bug-repellentsEnvironmental Working Group86

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Causes seizuresExtensive independent meta-analysis and other reviews show this is not trueHigher concentrations are more dangerousNo relationship between adverse events and concentration when used according to directionsChildren are at greater riskAdverse events not related to age Causes deathIngestion of substantial amountsLabel directions are “scary” (wash, etc.)SAME directions on all EPA-registered repellentsDEET Urban Legends

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Essential oil concoctions (20 min for mosquitoes, 0 min for ticks)Wrist bandsCitronella plantsTorches (it’s the smoke)Waist band products (unless it’s not windy and you don’t move)Dryer sheetsB-1Phone apps, gismos of all sortsMORE Urban LegendsNONE of These Work88

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Repellents REPEL insects –they don’t killInsecticides (Permethrin) KILL themApply to clothes, shoes, bed nets, camping gearEPA-registeredAvoid use on skinFOLLOW DIRECTIONSInsecticides

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Use 20%+ concentration repellent on exposed skin and clothing for longer lasting protectionUse permethrin only on clothingDress appropriatelyShower and do tick checksRemove ticks asap—the longer the tick is attached, the greater the risk of disease transmissionUse tweezers, pull straight upThe tick cannot release itselfDO NOT use matches, chemicals, DAWN or other wives’ tale remedies to remove itKey TICK Messages

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If you have pulled a tick out and the head remains, don’t panic…the body is the part that really mattersUse an antibiotic ointment or spray on the bite areaFor some tick-borne diseases, there are no cures –protection is the ONLY optionIf bitten by a tick and you have NO symptoms, there is no need to see a healthcare professional and no need for antibioticsMany fearful of Lyme disease do so anywayMore Tick Take-Aways

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PROMPT treatment is crucial Children may present different symptoms than adults to the same diseaseBacterial infections respond to doxySome infections (Ehrlichiosis and others) can be fatal quickly without prompt treatmentRMSF—”If you don’t treat by day 5, the patient may be dead by day 8”If Symptomatic92

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Use a concentration to match your time of exposure (5%=60 minutes, 30%=8 hours)25%+ concentration repellent on exposed skin and clothing for Aedes protectionUse permethrin only on clothingDress appropriatelyJust because you don’t feel mosquito bites does not mean you’re not being bitten…same for your studentsProtection times VARY via perspiration, etc. THERE ARE NO CURES –PROTECTION IS CRUCIALKey Mosquito Take-Aways

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Comments about WNV from consumers“I didn’t know it was still around”People don’t understand WHY condoms are important to prevent ZikaThe SAME people who refuse to vaccinate also refuse to use repellents“Traveling” isn’t viewed the same by those from Mexico, Central America, and South America.They call it going home, not traveling—they ignore adviceWhat We Have Learned in Other States94

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“Repellent” may not be a familiar productThey think it is RAID and spray it at mosquitoes, on screens, in the air—but not on their skinThey use it AFTER a mosquito bite to stop the itch. (It doesn’t)They spray a fog around themselves and others Afraid to use repellentLessons from Those for Whom English is a Second Language95

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Tourism is important so there’s not much talk about Zika, Dengue, ChikV, Malaria or Yellow FeverKNOW BEFORE YOU GO and take repellent with youEthnic challengesUsing repellent—”NO, didn’t like the way it felt”Using condoms—”It’s an insult to use a condom with a committed sexual partner…”Getting your partner/wife pregnant is a demonstration of virilityIn Endemic Areas96

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In CO at the height of WNV in Larimer County, residents who got the severe form of WNV said:I didn’t use repellent because I just dashed out to get the mail (sick for 6 months)If I had known how MANY of the mosquitoes were infected (1/100) I would have used repellent every time. (Thought it was 1/10K)Blinded by WNVMESSAGE: Encourage public health officials to be up front about the risks in the communityWhat’s the Risk?97

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Behavioral interventionsAir conditioners or screensRemove standing waterCover upShower and buddy check for ticksAvoid where the vectors are likely to beEPA -registered repellents are ESSENTIALDEETPicaridinIR3535OLEInsecticides—permethrin treated clothing

Basic Messages

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CDC.govUniversity tick labsU MassU Rhode IslandU WashingtonOregon State U800-789-3300 info@deeteducationprogram.orgRESOURCES99

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Questions?

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ReferencesWest Nile virus – Oregon Health Authority https://www.oregon.gov/oha/PH/DISEASESCONDITIONS/DISEASESAZ/WESTNILEVIRUS/Pages/survey.aspxWest Nile Virus Activity Oregon 2018 https://www.oregon.gov/oha/PH/DISEASESCONDITIONS/DISEASESAZ/WESTNILEVIRUS/Documents/countymap18.pdfState of Oregon West Nile Virus Summary Report, 2017 https://aix-xweb1p.state.or.us/es_xweb/DHSforms/Served/le9416b.pdf