Telford Talks Ticks

What are the symptoms of the other tick-borne diseases?

All of the tick-borne infections have a nonspecific initial presentation, that is, there is no way to distinguish them just based on signs and symptoms. Yes, acute (new) Lyme disease cases usually have the expanding rash (more than 60 percent of the time, perhaps more…the rash can be under the hair on the scalp and easily missed) but someone with fever (more than two days), headache, chills, muscle aches, migratory joint pains, and fatigue could still have Lyme disease. But on Martha’s Vineyard it could also be anaplasmosis (also called human granulocytic ehrlichiosis or HGE), babesiosis, deer tick encephalitis, Borrelia miyamotoi disease (BMD), Rocky Mountain spotted fever (although a widespread “spotty” rash usually develops), or tularemia. You could even have West Nile fever or another of the three or four mosquito transmitted viruses, although most of these are marked by a stiff neck. You could also just have the flu or enterovirus, and many of the listed signs and symptoms could be seen the day after too much merry making. Usually, though, unless you were truly naughty, debauchery-based symptoms would not persist more than a day.

Lyme disease is the most common of all of the tick-borne infections, perhaps 4-10 times more common, and should be at the top of the list for the Island doc’s differential diagnosis for anyone with fever, headache, etc. during the summer (Memorial Day to Labor Day). Some docs will just assume that it is Lyme disease and issue a prescription for 3-4 weeks of doxycycline or amoxicillin (for those who are in the sun a lot). Doxycycline will treat Lyme, anaplasmosis, BMD, spotted fever and tularemia and so even if the exact diagnosis is not made, the patient gets better and there is no harm done. If amoxicillin is given and it is not Lyme disease or BMD, patients will come back sick and that will prompt a further workup. Babesiosis is not treated by these antibiotics and requires specific oral drugs. Deer tick encephalitis and the mosquito-transmitted infections have no treatment, other than supportive care.

The M.V. Tick Borne Disease Initiative has a Medical Education Committee that has made great progress in continuing education for Island health care providers, and has advocated for a standardized approach to the “summer fever” patient. Such a standardized approach would include appropriate use of testing, presumptive treatment using doxycycline, aggressive follow-up, and reporting of all cases.

Visit the MV Tick Borne Disease Initiative website, sponsored by the Island-wide boards of health (www.mvboh.org) for tips on prevention.

Sam Telford is Professor of Infectious Disease and Global Health at Tufts University Cummings School of Veterinary Medicine.

“Back in the day, tick bites were more of an annoyance but now a bite is much more likely to make you sick. The newspapers are increasingly writing about an ever-increasing list of disease-causing microbes transmitted by ticks. Is this due to more and more ticks or just that we are better able to recognize diseases?”

Ticks are “dirty,” but they would probably consider us dirty too. We have known since the late 1990s that deer ticks in Massachusetts contain at least four pathogens (those causing Lyme disease, babesiosis, ehrlichiosis/anaplasmosis, and encephalitis). But every living animal contains microbes, the vast majority of which comprise normal “flora.” Your mouth contains several dozen bacteria, and at least half a dozen of these can cause human disease. Normal flora typically does not cause disease…hence usually no hazard from deep kissing unless someone has just eaten a ghost pepper…but under certain circumstances such as aging, immune compromise, or accidentally being introduced into a new site (e.g., oral bacteria into the bloodstream) will do so.

The tricky part for epidemiologists is to actually prove that a microbe is the cause of the signs and symptoms under consideration, and how frequently it does so. So there is nothing novel about ticks containing multiple pathogens. What has changed is our capacity to identify microbial agents using powerful new DNA or RNA technologies. Often, we are able to do in an afternoon what would have taken weeks to do, if at all. We are way more interested in ticks; prior to the description of the first Lyme disease cases in the mid 1970s, there were maybe a dozen laboratories working on ticks globally, mostly on problems of cattle or other animals of economic importance. Now, in New England alone, there may be more than a dozen “tick labs.” The new diagnostic technologies also help physicians determine the cause of cases that they simply would have put down as “fever of unknown origin” and never given another thought.

Visit the MV Tick Borne Disease Initiative website, sponsored by the Island-wide boards of health (www.mvboh.org) for tips on prevention.

Sam Telford is Professor of Infectious Disease and Global Health at Tufts University Cummings School of Veterinary Medicine.

Is babesiosis increasing in prevalence?

There is some evidence that babesiosis is catching up to Lyme disease; usually there are 5 to 50 cases of Lyme disease to one of babesiosis. It has moved into new areas, and can now be found in the Hudson Valley whereas a decade ago it was just starting to be seen there. Why remains to be fully understood. There is no evidence that there are more ticks infected now on the Vineyard compared to 10 or 20 years ago. Our lab methods for finding it, however, have greatly improved, so any apparent change is due mostly to that. The fact that more people are diagnosed each year now on the Vineyard has several explanations, a classic case of what we epidemiologists (disease detectives) call confounding. Hospitals are sending bloods out to labs with better tests. Doctors are more aware of the possibility of babesiosis. A big factor is that our demographics are changing. We are getting older, and our ability to fight infections, on average, diminishes with age. Then too, more people are surviving cancers with the help of miracle drugs that also tend to weaken our ability to fight infection. So the susceptible population has increased, meaning that babesiosis is more likely to need medical attention. It used to be thought that healthy “young” people (those less than 50 years; I really resent that definition) did not have any symptoms and even that it did not need treatment in them. It remains true that most younger people do not have a problem with babesiosis, but it does need to be treated because they could give blood and pass it on to someone. Babesiosis is now one of the most commonly reported transfusion infections. Preventing transfusion babesiosis is an important issue that local blood banks and the Red Cross are working on…which makes it even more important that those who do donate blood take as many precautions as possible to prevent tick bites.

Visit the MV Tick Borne Disease Initiative website, sponsored by the Island-wide boards of health (www.mvboh.org) for tips on prevention.

Sam Telford is Professor of Infectious Disease and Global Health at Tufts University Cummings School of Veterinary Medicine.

Is this red bump a tick bite?

Three weeks ago I was bitten by a tick. I’m sure I got it off before 24 hours, but the bite mark is still red, about the size of a pea. It hasn’t grown in size. Is it unusual to have a bite mark for that long? Could it be that the proboscis is still in there?

Everybody reacts differently to tick or mosquito bites. Then again, everyone has a different reaction to watching Duck Dynasty. And, there are three possibilities to consider even with individual variation in response to tick bite: (1) The tick creates a small hole in your skin. Therefore, like sticking yourself with a fish hook, you could get a local infection from skin bacteria (cellulitis). Any streaks of redness coming from a bite could be cellulitis and need to be evaluated by your doctor. (2) You could be allergic…my bites itch like crazy for weeks.  Ticks leave a little bit of their exoskeleton in the bite (the microscopic backwards facing barbs on the mouthparts sometimes come off) and this attracts immune cells that can cause local redness and itching. Pulling a tick out usually leaves behind even more tick mouthpart materials. Although some may think it gross, it is no different than getting a splinter, which is usually walled off by your body so that it is harmless (splinters too can cause cellulitis which needs to be seen by a doctor; someone in Rhode Island just lost a limb due to flesh-eating bacteria from thorn prick cellulitis). Or, it simply works itself out, depending on how deep it is, because the skin is constantly shedding flakes of the outermost layers. This is why it does not matter if the tick “head” is left in. (3) It could be Tularemia. The Vineyard is uniquely blessed with having dog (wood) ticks (we could say the same about tourists) that are not uncommonly infected by the bacteria that cause Tularemia. Everyone knows about landscapers breathing it in, but it is naturally out there as a tick-transmitted infection. When you get Tularemia from a tick bite, a red area doesn’t enlarge much but turns into an ugly divot and your nearest lymph nodes get big. Usually you will also have a high fever. So any ugly red divot in your skin, nearby swollen glands, and fever needs to be checked out pronto by a doc.

Visit the MV Tick Borne Disease Initiative website, sponsored by the Island-wide boards of health (www.mvboh.org) for tips on prevention.

Sam Telford is Professor of Infectious Disease and Global Health at Tufts University Cummings School of Veterinary Medicine.

Why don’t nudists get Lyme disease?

Believe it or not, there was actually a small study reported in the New England Journal of Medicine back in the late 1980s claiming that nudists don’t get Lyme disease. Although no one has replicated the study, there are many reasons why a nudist might be less likely to get a tick bite. For one, nudists tend to avoid the brush habitat where there are deer ticks…poison ivy and greenbrier don’t go too well with certain body parts. Nudists may look at their skin or that of their fellow nudists frequently and find ticks easily. And, ticks tend to crawl around a lot on a body looking for a dark, clothing constricted place under which to attach. It could also be that nudists use more repellent (mosquito bites and certain body parts don’t mix either).  Perhaps the Vineyard boards of health should advocate for town officials “turning the other cheek” to episodes of public nudity, particularly in the woods. Get rid of those “no nudity” admonitions on all the Land Bank and other trailhead signs!

Nude or clothed, it is tick season and you should try to prevent tick bites.  Use repellents and treated clothing if you wear any.  Visit the MV Tick Borne Disease Initiative website, sponsored by the Island-wide boards of health (www.mvboh.org) for tips on prevention.

Sam Telford is Professor of Infectious Disease and Global Health at Tufts University Cummings School of Veterinary Medicine.

Should I use a lit cigarette to burn an attached tick off of my leg?

There is as much mythology about removing a tick as there is on catching a bluefish.

Over the years, I have known a guy to have burned a tick off his penis with a lit cigarette and a cut-happy surgeon to have cut a tick out of an upper arm, leaving a large divot. C’mon folks, it is just a tick bite. It is not like getting bitten by a taipan (a snake with a highly lethal bite) in the Australian outback, where there is some justification in immediately amputating the bitten body part. An attached tick does not need to be covered in Vaseline, allegedly because it suffocates the tick gradually so that it won’t get panicked and transmit microbes; this is baloney, the tick is not consciously transmitting and nothing you do will speed up or slow down the process. Ticks do not need to be poisoned by kerosene; nor do you need to buy a special tool that rotates the tick counterclockwise. Just pull it out. Use your fingers if you can.  Even better, use some fine forceps or tweezers and grasp the head as close to the skin as possible. Pull steadily upwards. It does not matter if you leave the “head” in, it will be walled off or work itself out like a splinter. You cannot squeeze a disease-causing microbe into you. The tick has a valve in its feeding tube (25-cent word:  pharyngeal valve) that only allows fluids to flow inward so that there is no regurgitation into the feeding cavity. The microbes that cause disease are delivered in tick spit. As you spit out your morning coffee thinking of ticks spitting into you, it should be noted that whereas our spit is a crude mix of starch digesting enzymes, mucus, water, and bacteria, tick spit has evolved over millions of years to contain chemicals that prevent blood from coagulating, immune cells from attacking the tick’s internal parts, and preventing inflammation and pain. This is why some of us believe that ticks are more highly evolved than those other notorious bloodsuckers…lawyers.

Tick bites can be prevented. Wear repellent or treat your clothing. Take a shower. Check for ticks. Visit the MV Tick Borne Disease Initiative website (www.mvboh.org) for tips on prevention.

Sam Telford is Professor of Infectious Disease and Global Health at Tufts University Cummings School of Veterinary Medicine. He is a member of the MV Tick Borne Disease Initiative, which is sponsored by the Island-wide boards of health.

Are there more ticks and diseases now than before?

Tick expert Dr. Sam Telford answers questions about the Island’s most insidious insect and how to prevent the bacteria it can inject.

Dear Sam.

Back in the day, tick bites were more of an annoyance. But now a bite is much more likely to make you sick. The newspapers are increasingly writing about an ever-increasing list of disease-causing microbes transmitted by ticks. Is this due to more and more ticks or just that we are better able to recognize diseases?

— Ian, Oak Bluffs

Ian, when I first started as a graduate student in 1984, my fellow students couldn’t understand why I would want to work on diseases that “only infected a few rich people.”  Those of us eccentric enough to study ticks knew that our scientific forebears found many different microbes in ticks that had not yet been proven to be a health issue for people. Lyme disease was found in museum specimens of mice from Cape Cod collected in 1896, and we know from the scientific literature that babesiosis and ehrlichiosis were in Vineyard mice in 1938…but these infections were not recognized as human problems until 30 or 40 years later, coinciding with the rise in deer tick populations in the 1980s. More people are now messing around in the bushes wearing shorts and sandals, and so more people are exposed to ticks than ever. But our recognition of all the “new” tick-borne diseases is also a tribute to our physicians and research laboratories who have been suspicious of what used to be called “summer fever” and worked a bit harder to identify the causes. It helped that the few rich people who had been the victims in the early years squawked to their legislators and federal money became available to ensure that guys like me would always have a job chasing the next tick-borne disease. Now, of course, deer tick-transmitted infections do not discriminate — rich, middle class, and poor are equally afflicted.

Don’t become the poster child for the next new tick-borne disease, or the umpteenth victim of the known ones. NO tick bite is a good tick bite. Protect yourself. Use repellents and clothing treatments. Take a shower as soon as you can after being in places where there may be ticks; ticks can be indecisive about where to attach. Check yourself for ticks every night, preferably in the shower, feeling for new bumps after soaping up. If you can, have a partner help you check! And always, always, have an unexplained fever checked out by a health care professional. All tick-borne infections present with a fever in their early stages, although Lyme disease may present just as an expanding rash. (If a tick is still attached, or the red patch on your skin does not grow in size, it is not Lyme disease. However, a rash does not have to be a bull’s-eye to be Lyme disease. The important factor is that it gets larger over time.)

Visit the MV Tick Borne Disease Initiative website (www.mvboh.org), sponsored by the Island-wide boards of health, for tips on prevention.

Sam Telford is Professor of Infectious Disease and Global Health at Tufts University Cummings School of Veterinary Medicine. He works on the epidemiology of tick-borne infections and for the last 20 years has been sneaking around the tick-infested Vineyard doing his part to take away as many ticks as he can. He is a member of the MV Tick Borne Disease Initiative, which is sponsored by the Island-wide boards of health.

Can swimming help keep ticks away?

Tick expert Dr. Sam Telford answers questions about the Island’s most insidious insect and how to prevent the bacteria it can inject.

Can a dip a day help keep Lyme away?

It is possible that swimming could wash off any ticks that have made it off your clothes and onto your skin, but have not yet attached. Ticks can be finicky about where they attach. They prefer dark, moist areas and particularly where there is a constriction due to clothing, such as a panty line. Ticks certainly can and do attach on upper arms and backs, but perhaps this may be because the tick is really hungry (hungry ticks are not picky) or the person has a really good animal smell. So if the tick is still crawling around trying to decide where to put on the feed bag, a shower or even a good swim could wash them away. Ticks cannot swim but are kind of waterproof, as anyone who has discarded a live dog tick into the toilet can tell you.  The tick can sit there in the bowl for days and if given the opportunity, can crawl up and walk away none the worse for wear. The surface tension on their waxy bodies keeps a thin film of air available to their breathing system (some pores on both sides of their body). However, if you add something to break the surface tension, such as soap, the ticks will sink and die within hours. Salt water won’t kill them in the short time you are swimming, so if the tick is attached it will go on merrily feeding.

Of course, it is better to use repellents and treated clothing whenever possible and not have to rely on swimming or tick checks to help prevent tick bites. Visit the MV Tick Borne Disease Initiative website (www.mvboh.org), sponsored by the Island-wide boards of health, for tips on prevention.

Sam Telford is Professor of Infectious Disease and Global Health at Tufts University Cummings School of Veterinary Medicine. He works on the epidemiology of tick-borne infections and for the last 20 years has been sneaking around the tick-infested Vineyard doing his part to take away as many ticks as he can. He is a member of the MV Tick Borne Disease Initiative, which is sponsored by the Island-wide boards of health.