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Bureau of Infectious Disease Control

Infectious
tick bitsstickDisease Surveillance
bites, especially peopleSection
who

2016 New Hampshire Tick-borne Disease Bulletin

Tick-borne Diseases in New Hampshire tick bites, especially people who spend time
In NH, there are several diseases that can outdoors in possible tick habitat, such as
be transmitted to people by the bite of an wooded or grassy areas. If you are bitten
infected tick. The most common of these by a tick, it is important to remove the tick
diseases are Lyme disease, anaplasmosis, as soon as possible.
and babesiosis. The only case of locally-
acquired Powassan virus infection was Table 1. Tickborne disease incidence in New
noted in NH for the first time in 2013. Hampshire by year, 2011-2015.
2011 2012 2013 2014 2015
During the past decade, Lyme disease has 1 1
Lyme Disease 1321 1456 1691 1416 1371
become increasingly common in NH, and in
recent years, diagnoses of anaplasmosis Anaplasmosis 30 52 88 130 110
and babesiosis have also increased, though Babesiosis 14 19 22 40 53
not to the same magnitude (Table 1). Most Powassan Virus 0 0 1 0 0
NH residents and health care providers are 1. Due to staffing vacancies and elimination of positions,
suspect cases of Lyme disease reported in 2014 and 2015
familiar with the risks of Lyme disease, but could not be investigated to determine whether or not
the health threats posed by anaplasmosis, they met the case definition for Lyme disease. The number
babesiosis and Powassan virus should also of cases in 2014 and 2015 was estimated based on the
number of reports received and historical data.
be carefully considered.
Figure 1. Number of reported Lyme disease cases by
Lyme disease, anaplasmosis, babesiosis and month of symptom onset, New Hampshire, 2011-
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Powassan virus are transmitted by the bite 2015.
of the blacklegged tick (Ixodes scapularis),
commonly known as the deer tick.
Blacklegged ticks have four life stages: eggs,
larvae, nymphs and adults.

Humans are often bitten by blacklegged tick


nymphs. Nymphs are very small and easy
to miss unless they become engorged with
blood, and are most active in the late
spring-summer months (usually May Methods to Prevent Tick-Borne Diseases
through August). The importance of the Lyme disease, anaplasmosis, babesiosis and
nymph in transmission of tickborne diseases Powassan virus disease are preventable.
is readily apparent when cases of Lyme The following guidelines will aid in
disease are examined by month of preventing tick bites and the transmission
symptom onset (Figure 1). of these diseases. Since the immature stage
(nymph) is very small and often goes
Blacklegged ticks are common in NH. All unnoticed while attached to people, NH
individuals should take precautions to limit DHHS recommends the simultaneous use of
NH Department of Health and Human Services
Division of Public Health Services June 2016
Bureau of Infectious Disease Control -1- 2016 New Hampshire Tick-borne Disease Bulletin
multiple prevention methods when in areas with tweezers. Grasp the tick firmly
with ticks. and as closely to the skin as possible.
Avoid tick-infested areas. If in tick- With a steady motion, pull the ticks
infested areas, walk in the center of body away from the skin. Avoid
trails to avoid contact with overgrown crushing the ticks body. DO NOT use
grass, brush, and leaf litter at trail petroleum jelly, a hot match, nail
edges. polish, or other products. Cleanse the
area with an antiseptic after removing
Use insect repellent. Apply insect the tick.
repellent containing 20% to 30% DEET
on clothes and exposed skin. Clothes If a tick is attached to your skin for less
(especially pants, socks, and shoes) than 36 hours, your chance of getting
may be treated with permethrin, Lyme disease, anaplasmosis, or
which kills ticks on contact. babesiosis is extremely small.
Permethrin can also be used on tents Powassan virus may be transmitted in
and some camping gear. Do not use a shorter amount of time, so it is
permethrin directly on skin. Always important to remove attached ticks
follow the manufacturers instructions promptly. You should monitor your
when applying any repellents. Further health closely after a tick bite and be
information regarding insect alert for signs and symptoms of
repellents can be found at: illness. Contact your physician to
https://www.epa.gov/insect- discuss testing and treatment.
repellents/find-insect-repellent-right-
you#search tool. Be mindful of the environment you
create around your home and in your
Wear protective clothing. Long pants community. Minimizing areas where
and long sleeves help keep ticks off hosts for the ticks, such as rodents
skin. Wearing light-colored clothing and deer, can congregate to eat, sleep
will help you spot ticks more easily. or feed may be helpful in reducing
Pant legs may be tucked into socks or your exposure to ticks. The
boots and shirts into pants to keep Connecticut Agricultural Experiment
ticks on the outside of clothing. Tape Station has produced a detailed
the area where pants and socks meet document on ways that individuals
so that ticks cannot crawl under and communities can address these
clothing. concerns.

After being outdoors, wash and dry It is imperative for responsible adults to
clothing at a high temperature to kill assist children in applying repellents and
any ticks that may remain on clothing. performing tick checks as they are less able
to perform these activities safely and
Perform tick checks after you or your effectively.
pets have been outdoors. Early Disease Specific Information
removal of ticks can reduce the risk of The tickborne diseases present in NH are
infection. Inspect all body surfaces also found throughout the northeast and
carefully, and remove attached ticks upper midwest in significant numbers

NH Department of Health and Human Services


Division of Public Health Services June 2016
Bureau of Infectious Disease Control -2- 2016 New Hampshire Tick-borne Disease Bulletin
relative to the rest of the country. White
footed mice are the main, although not As is expected, there is a clear age and
only, reservoir for these pathogens and are gender risk for Lyme disease, and other
common throughout these geographical tickborne diseases. Children are more likely
areas. to spend time outdoors, as are middle-aged
to older males due to the nature of work,
Lyme Disease play and hobby patterns among these
Lyme Disease is caused by the bacterium populations (Figure 2).
Borrelia burgdorferi, with early symptoms
of the disease often including a red, There are significant differences between
expanding bulls-eye rash at one or more incidence rates for Lyme disease among
locations accompanied by fever, headache, counties in NH (Figures 3 and 4). Over time,
fatigue, stiff neck and muscle or joint pain. it has been observed that northern and
Symptoms usually begin within 30 days western counties are experiencing an
after being bitten by an infected tick. If not increase in Lyme disease incidence,
treated, complications such as nervous whereas incidence rates, though highest,
system disorders, heart abnormalities, and have stabilized in the southeast part of the
intermittent episodes of joint swelling and state. This is a reflection of vector
pain may occur. Typically, antibiotics are distribution and population densities and
effective in treating Lyme disease. Early behaviors, as well as diagnosing and
diagnosis improves the outcome of reporting patterns of healthcare providers.
treatment so it is important for individuals Expansion of the blacklegged tick home
to contact their health care provider if they range in NH has been documented through
feel sick or develop a rash. tick surveys performed by University of
New Hampshire extension specialists.
Figure 2. Average annual incidence of reported cases of Lyme disease by age group and sex, New Hampshire, 2010-
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2015.

NH Department of Health and Human Services


Division of Public Health Services June 2016
Bureau of Infectious Disease Control -3- 2016 New Hampshire Tick-borne Disease Bulletin
Figure 3. New Hampshire counties with established Babesiosis
(endemic) high-incidence rates of Lyme disease, Babesiosis in the United States is most
1
2010-2015. commonly caused by Babesia microti, a
parasite that infects red blood cells,
although there are other species that are
capable of producing human illness.
Symptoms of babesiosis vary and typically
occur within one to six weeks following the
bite of an infected tick. Some people
infected with Babesia never feel ill, while
others may have flu-like symptoms such as
fatigue, fever, sweats, and muscle aches.
Figure 4. New Hampshire counties with increasing Symptoms of nausea, vomiting, headache,
(emerging) incidence rates of Lyme disease, 2010- and bloody urine can also occur. Severe
1
2015. and fatal cases most often occur in patients
who are older or have a weakened immune
system, such as those without a spleen.
People can be successfully treated with
anti-parasitic medications, so it is important
for individuals to contact their health care
provider if they feel ill or develop flu-like
symptoms.
Figure 5. Reported anaplasmosis and babesiosis
cases by year, New Hampshire, 2006-2015.

Anaplasmosis
Anaplasmosis is caused by the bacterium
Anaplasma phagocytophilum. Some people
who are infected have no or mild
symptoms. Symptoms typically occur within
5-21 days following the bite of an infected
tick and often resemble the flu, with fever,
chills, headache, fatigue, muscle aches,
nausea, and/or vomiting. Some individuals Reports of anaplasmosis- and babesiosis-
may also have a rash. Some people, related illnesses have been increasing in NH
particularly elderly persons or those with over the last five years (Figure 5). This may
weakened immune systems, may have a be due to many factors including expansion
more severe illness. People can be of the pathogens, reservoirs and vectors as
successfully treated with antibiotics, so it is well as an increased awareness of these
important for individuals to contact their infections.
health care provider if they develop a fever
or flu-like symptoms.

NH Department of Health and Human Services


Division of Public Health Services June 2016
Bureau of Infectious Disease Control -4- 2016 New Hampshire Tick-borne Disease Bulletin
Map 1. Reported cases of Lyme disease in New
Hampshire, 2014.

The Bureau of Infectious Disease Control


publishes maps to provide the public with
information on where Lyme disease is most
commonly seen and what the burden of
disease is. Over the last several years, a
westward and northward expansion of
Lyme disease has been observed in NH. This
is a possible reflection of expansion of the
geographic range of the blacklegged tick,
changes in habitat suitability of the ticks
primary hosts (deer and white-footed mice)
and changes in housing developments and
recreational behaviors that increase the
likelihood of NH residents coming into
contact with tick habitat. Maps from
previous years are available at:
http://www.dhhs.nh.gov/dphs/cdcs/lyme/publicatio
ns.htm

Map 2. Proportion of adult blacklegged ticks infected


with Borrelia burgdorferi (Lyme disease), Fall 2013-
2014 samplings.

Ticks were collected and tested from 2013-


2014 to understand how common it is for
adult blacklegged ticks in NH to be infected
with Borrelia burgdorferi, the bacterium
that causes Lyme disease. The map
demonstrates that infection with this
bacterium among ticks is very common,
with about 60% of ticks across the state
being infected. Additional surveillance of
ticks in future years may be performed if
funding allows.

NH Department of Health and Human Services


Division of Public Health Services June 2016
Bureau of Infectious Disease Control -5- 2016 New Hampshire Tick-borne Disease Bulletin
Powassan Virus Disease (http://www.dhhs.nh.gov/dphs/cdcs/ly
Powassan virus disease is a rare but me/index.htm)
potentially serious illness caused by the 5. Tick Management Handbook-
Powassan virus, which is part of the same Connecticut Agricultural Experiment
family of viruses as West Nile virus, and is Station
transmitted by the blacklegged tick or the (http://www.ct.gov/caes/lib/caes/docu
less common woodchuck tick. Symptoms ments/special_features/TickHandbook.
generally begin one to four weeks after the pdf)
bite of an infected tick and might include 6. Insect Repellents: Dr. Alan Eaton, UNH
fever, headache, muscle weakness, stiff Cooperative Extension
neck, fatigue, paralysis and confusion. (http://extension.unh.edu/resources/fil
Powassan virus can cause brain es/Resource000963_Rep1073.pdf)
inflammation (encephalitis) and 7. Biology and Management of Ticks in
inflammation of the membranes New Hampshire: Dr. Alan Eaton, UNH
surrounding the brain and spinal cord Cooperative Extension
(meningitis). Although Powassan virus (http://extension.unh.edu/resources/fil
disease is very rare, it has been found in es/Resource000528_Rep1451.pdf)
several northern states including New 8. Tickborne Diseases of the United States:
Hampshire, Maine and New York. The exact A Reference Manual for Health Care
length of time required for a tick to transmit Providers-CDC
Powassan virus is unknown, therefore it is (http://www.cdc.gov/lyme/resources/Ti
important to do frequent tick checks and ckborneDiseases.pdf)
remove any attached ticks promptly.

Contact Information
Additional Resources
Carolyn Fredette, MPH
The resources listed below may provide
Vectorborne Disease Surveillance Coordinator
additional information about ticks and how Telephone: 603-271-0273
to protect yourself against tick-borne Email: carolyn.fredette@dhhs.nh.gov
diseases.
1. CDC Tickborne Diseases Webpage Abigail Mathewson, DVM, MPH
Surveillance Epidemiology Program Manager
(http://www.cdc.gov/ticks/)
Telephone: 603-271-0274
2. EPA Repellent Selection Tool Website
Email: abigail.mathewson@dhhs.nh.gov
(https://www.epa.gov/insect-
repellents/find-insect-repellent-right- NH Department of Health and Human Services
you) Division of Public Health Services
3. State of New Hampshire Tickborne 29 Hazen Drive
Disease Prevention Plan Concord, NH 03301
(http://www.dhhs.nh.gov/dphs/cdcs/ly Phone: 603-271-4496
me/documents/tbdpreventionplan.pdf) Toll-free (in NH): 800-852-3345 x4496
4. DPHS Tickborne Disease page Fax: 603-271-0545
http://www.dhhs.nh.gov/

NH Department of Health and Human Services


Division of Public Health Services June 2016
Bureau of Infectious Disease Control -6- 2016 New Hampshire Tick-borne Disease Bulletin