With tick season in full swing, we are seeing a large number of patients with new tick bites and questions regarding tick prevention, tick removal, and ways to have ticks tested. Please carefully read the information contained in Dr. Horowitz's recent Facebook post and these documents. Please note that tick repellents do not kill ticks.
Yours in health,
The longhorned tick or bush tick (Haemaphysalis longicornis) appeared in NJ last year. This asian tick mysteriously turned up on a New Jersey sheep, and was confirmed to have survived the winter in NJ. It now has been reported in West Virginia as well.
The tick has been associated with a phlebovirus, called the SFTS virus, which is an emerging hemorrhagic fever discovered in China (other tick-borne phleboviruses, such as the Powassan virus, are spreading here in the US), and it also has been associated with the alpha gal meat allergy in other parts of the world.
Severe Fever and Thrombocytopenia Syndrome (SFTS) is not new, and recently led to the death of a Japanese woman. The major clinical symptoms are similar to other tick-borne viral infections such as the Bourbon and Heartland viruses in the Midwestern US, and include low white cell counts (leukopenia), low platelet counts (thrombocytopenia) and G.I. manifestations (elevated liver functions, i.e., transaminitis) with associated fever, vomiting, diarrhea and multiple organ failure (Yu XJ, Liang MF, Zhang SY, Liu Y, Li JD, Sun YL, et al. Fever with Thrombocytopenia Associated with a Novel Bunyavirus in China. N Engl J Med. 2011 Apr 21;364(16):1523-32.; Lam TT, Liu W, Bowden TA, Cui N, Zhuang L, Liu K, Zhang YY, Cao WC, Pybus OG (2013) Evolutionary and molecular analysis of the emergent severe fever with thrombocytopenia syndrome virus. Epidemics 5(1):1-10).
Alpha gal meat allergy is due to an allergic reaction secondary to the bite(s) of ticks (usually the lone star tick, Ambylomma americanum in the US), where individuals can get delayed anaphylactic reactions several hours after eating meat.
Sensitive individuals can get an anaphylactic reaction, with hives and swelling, shortness of breath, low blood pressure (hypotension), vomiting and diarrhea 3-6 hours after eating the offending food. Triggers include not only beef, but also pork, lamb, venison, goat, and bison. It can also can be triggered by animal-based products containing gelatin.
Ticks and emerging species, as well as associated co-infections and diseases, are constantly evolving in both number and geographical location. Prevention is more important than ever! We are getting frequent calls that patients are getting bitten, so please follow tick prevention essentials, which include the following:
• Avoidance of ticks is obviously key: avoid high grass, wooded areas, leaf piles, walking on the edges of paths/woods...
Clothing for additional protection includes:
• Light color clothing and hats to easily spot ticks
• Long pants taped at socks
• Long sleeve shirts and tucked in at waistline
• Wear permethrin treated clothing (take the clothing outside and spray it (not while wearing it) or buy permethrin treated clothing; put IR3535 (Avon SSS) or picardin on the skin (lemon eucalyptus oil can also be helpful as a natural product), or 20% DEET if in a high risk area.
• Do frequent tick checks, while properly removing ticks to prevent transmission. Place clothes in the dryer on high heat after coming inside (for at least 6 minutes) will also help kill ticks.
• Finally, tick prevention integrated pest management approaches may be helpful to reduce exposure in your yard and garden (companies like NY Tick Control can evaluate your property and evaluate the risk/benefit of spraying, bait boxes, etc).
Stay safe during the warmer weather. The ticks are out in large number!
“NO TICK BITE IS A GOOD TICK BITE”
Your best defense is to avoid getting bitten by a tick in the first place. Wear permethrin-treated clothing and spray bare skin with IR3535, picaridin, or 25% DEET (“deep woods” version). Once indoors, check your clothing and pets for ticks—and don’t forget to do a full body
Avoid high risk areas (high grass, edges of woods..); Wear protective clothing (permethrin kills ticks; take your clothing outside and spray it with permethrin, let it dry, and it will offer protection for up to two weeks; or buy permethrin treated clothing), use tick sprays (such as IR3535 and picardin which safely repel ticks, lemon eucalyptus oil also has some proven efficacy), and do frequent tick checks when outdoors. Immediately remove a tick if found (get underneath it with a tweezer or tick removal device) and contact your primary care physician for advice after a bite. The tick can be saved in a baggie with a blade of grass, or vial with alcohol, and sent to a local laboratory for tick and pathogen identification. Tick bites can transmit certain bacteria and viruses in as little as 15 minutes, with engorged ticks (attached for greater than 24 hours) having a much higher risk of transmission of Lyme disease, although cases have been reported within hours of a bite. Therefore, act quickly and contact your health care provider after a tick bite, especially if you experience any new physical or mental symptoms. Suspect Lyme disease if you experience sudden unexplained fatigue, migratory pain (joint, muscle and/or nerve pain), memory and concentration problems, depression, anxiety and mood swings, headaches with a stiff neck, dizziness with light and sound sensitivity or other symptoms like resistant insomnia—especially if you have no history of these problems. Such symptoms can occur within 24 hours of the bite, although they might not appear for weeks or months.
Why do you need to know?
Year round prevention (extra vigilant from April to September)
It's the #1 vector-born illness in the United States. https://health2016.globalchange.gov/vectorborne-diseases
- Climate change has made tick borne illnesses a greater risk. https://www.nytimes.com/2017/07/24/health/ticks-disease-united-states.html?mcubz=1
- Ticks can carry many diseases (bacteria, viruses and protozoa). Some can be debilitating and quite serious. Transmission of a disease can be as short as 15 minutes after the bite. www.mdpi.com/2076-3298/4/2/37/pdf
- People are often misdiagnosed due to symptoms mimicking other illnesses, like Chronic Fatigue Syndrome, Fibromyalgia, autoimmune diseases (MS, rheumatoid arthritis, lupus), and neuropsychiatric conditions (depression, anxiety, OCD, dementia with memory problems)
- Illness in humans typically presents with fever, headache, fatigue, migratory pain (muscle, joint, nerve), with sleep and memory/concentration problems. In approximately 50% of individuals, there a characteristic skin rash called erythema migrans. Half resemble a bullseye, and half a spreading, solid rash, that can be mistaken for a skin infection or spider bite. If left untreated, the infection can spread to joints, the heart, and the nervous system.
Clothing for additional protection
- Avoidance of ticks is key: avoid high grass, wooded areas, leaf piles, leaving your golf towels or sitting on the golf course grass
- Repellants: 20% DEET, picaridin, or IR3535 (repeat application is required and only effective on covered areas)
- Buy Tick Repellant sprayed clothing http://www.tickencounter.org/prevention/insect_shield_your_own_clothes or spray clothing with 0.5% Permetherin (spray on shoes, sox and pants. Must follow directions)
Where ticks tend to hide: They prefer dark warm places like armpits, hairline, groin, waistband, behind the knees, etc.
- Light color clothing and hats to easily spot ticks
- Long pants and taped at sox or wear permethrin sprayed gators
- Long sleeve shirts and tucked in at waistline
After each round of golf:
1. Do a quick check from head to toe. Teammates should assist one another with checking the back side of the body.
1. Take a shower within 2 hours of the round and examine your body in a full length mirror. Check your scalp and behind the ears too.
2. Wash clothes after one use and dry on hot for at least 15 minutes.
What May surprise you about Ticks?
It is a high probability that more than one illness will be transmitted. Other infections can be serious and life threatening.
- Many animals (birds, squirrels, deer, rodents) carry them. Most exposure is by brushing up against foliage that has ticks on them waiting for a host (like in the rough at a golf course)
- When they bite you, they anesthetize the area, so you so you can't feel pain, and they secrete adhesion molecules to "cement" themselves on
- Most people never see the tick on their body (nymphs are the size of a poppy seed)
- More than 50% of patients never get the classic erythema migrans rash (also known as the bullseye rash)
- You can get an infection in as little as 10-15 minutes (Rocky Mountain Spotted Fever, Powassan Virus). Babesiosis, a malarial like parasite, is often transmitted with Lyme, and can cause fevers, day and night sweats, chills, and shortness of breath which require specialized treatment.
- If you improperly remove ticks, they will likely regurgitate infections, with a greater transmission risk
- The standard blood testing for Lyme, i.e., getting an ELISA test, has a false error rate of 50%, missing 1/2 the infections
- There are over 100 species of Borrelia (Lyme) in the United States and over 300 species around the world. The standard test only tests for the single species Borrelia Burgdorferi
- A validated screening questionnaire (HMQ) is available to check your risk of infection: https://www.dovepress.com/articles.php?article_id=34560, A score <21= not likely, 21–36= possible,
36–62= likely, and ≥63= highly likely