Economic Burden of Reported Lyme Disease in High-Incidence Areas, United States, 2014-2016.

Approximately 476,000 cases of Lyme disease are diagnosed in the United States annually, yet comprehensive economic evaluations are lacking. In a prospective study among reported cases in Lyme disease-endemic states, we estimated the total patient cost and total societal cost of the disease. In addition, we evaluated disease and demographic factors associated with total societal cost. Participants had a mean patient cost of ≈$1,200 (median $240) and a mean societal cost of ≈$2,000 (median $700). Patients with confirmed disseminated disease or probable disease had approximately double the societal cost of those with confirmed localized disease. The annual, aggregate cost of diagnosed Lyme disease could be $345-968 million (2016 US dollars) to US society. Our findings emphasize the importance of effective prevention and early diagnosis to reduce illness and associated costs. These results can be used in cost-effectiveness analyses of current and future prevention methods, such as a vaccine.

Willingness to Pay for Select Tick-Borne Disease Prevention Measures in Endemic Areas.

Tick-borne diseases (TBDs) are increasing despite prevention recommendations. We explored whether cost is a barrier to prevention use in Connecticut and Maryland, using a cross-sectional survey. Respondents were queried regarding their willingness to pay for chemical, natural, and rodent-targeted yard pesticide treatments and permethrin-treated clothing. We evaluated associations between demographics, TBD knowledge and attitudes, and willingness to pay for prevention methods. Most respondents would pay for yard treatments (85%); 95% preferring natural pesticide, and 82% would pay for permethrin-treated clothing. Most did not want to pay more than $99 for any of the yard treatments. Having a household income of $100 000 was associated with willingness to pay $100 or more for chemical, natural, or rodent-targeted treatments and $25 or more for permethrin self-treated and pretreated clothing. Yard treatments, especially natural pesticides, were acceptable for TBD prevention; however, current pricing may be cost-prohibitive. Permethrin-treated clothing may be an affordable and acceptable prevention method.

Assessment of Knowledge, Attitudes, and Practices Toward Ticks and Tickborne Disease among Healthcare Professionals Working in Schools in New York and Maryland.

Healthcare Professionals Working in Schools (HPWS) are responsible for providing health services to students and play a role in providing education to prevent illnesses, including tickborne diseases (TBD). Providing TBD education to children has been shown to increase prevention behaviors and knowledge of TBD symptoms, but little is known regarding the current state of TBD awareness among HPWS. In spring 2019 we conducted a cross-sectional knowledge, attitudes, and practices (KAP) survey of HPWS in two states with a high incidence of Lyme disease (LD) to inform design of TBD prevention programs. The survey queried general knowledge of TBDs, school practices regarding TBDs, and availability of TBD resources. Overall, higher confidence, experience, risk perception, prior training on TBD, and more years employed as a HPWS were independently associated with knowledge of LD transmission, symptoms, and correct tick removal practices. State and local health departments should consider prioritizing engagement with HPWS to provide educational opportunities about tickborne diseases.

Evaluating public acceptability of a potential Lyme disease vaccine using a population-based, cross-sectional survey in high incidence areas of the United States.

BACKGROUND: Lyme disease incidence is increasing, despite current prevention options. New Lyme disease vaccine candidates are in development, however, investigation of the acceptability of a Lyme disease vaccine among potential consumers is needed prior to any vaccine coming to market. We conducted a population-based, cross-sectional study to estimate willingness to receive a potential Lyme disease vaccine and factors associated with willingness. METHODS: The web-based survey was administered to a random sample of Connecticut, Maryland, Minnesota, and New York residents June-July 2018. Survey-weighted descriptive statistics were conducted to estimate the proportion willing to receive a potential Lyme disease vaccine. Multivariable multinomial logistic regression models were used to quantify the association of sociodemographic characteristics and Lyme disease vaccine attitudes with willingness to be vaccinated. RESULTS: Surveys were completed by 3313 respondents (6% response rate). We estimated that 64% of residents were willing to receive a Lyme disease vaccine, while 30% were uncertain and 7% were unwilling. Compared to those who were willing, those who were uncertain were more likely to be parents, adults 45-65 years old, non-White, have less than a bachelor's degree, or have safety concerns about a potential Lyme disease vaccine. Those who were unwilling were also more likely to be non-White, have less than a bachelor's degree, or have safety concerns about a potential Lyme disease vaccine. In addition, the unwilling had low confidence in vaccines in general, had low perceived risk of contracting Lyme disease, and said they would not be influenced by a positive recommendation from a healthcare provider. DISCUSSION: Overall, willingness to receive a Lyme disease vaccine was high. Effective communication by clinicians regarding safety and other vaccine parameters to those groups who are uncertain will be critical for increasing vaccine uptake and reducing Lyme disease incidence.

Love the ones you're with: Characteristics and behaviour of Maryland pets and their owners in relation to tick encounters.

We conducted a cross-sectional study to evaluate associations between pet characteristics and behaviours and risk of tick encounters among pets and pet owners. We defined a tick encounter as ticks found crawling on or attached to a pet or pet owner. Information about pet characteristics, interactions between owners and pets, and tick encounters were captured through an online survey. Associations were evaluated using univariate and multivariable analyses. In univariate analysis, walking dogs only on pavement reduced risk of tick encounter among owners (prevalence ratio (PR) = 0.51, 95% confidence interval (CI): 0.30, 0.84). Having a dog or cat that hunted small animals increased risk of tick encounter among owners (PR = 1.66, 95% CI: 1.30, 2.13; PR = 1.57, 95% CI: 1.05, 2.34, respectively). No direct interactions between owners and pets (e.g., pets sleeping on owners' beds) were associated with increased risk of tick encounters among owners. In multivariable analysis among dog owners, having a pet with a tick encounter within the last six months was associated with increased risk of owner tick encounter (adjusted odds ratio (aOR) = 4.17, 95% CI: 2.94, 5.92); in addition, having a dog that hunts small animals was associated with increased risk of owner tick encounter (aOR = 1.97, 95% CI: 1.25, 3.11). These results suggest that the location of pet-owner interactions may be more important than the type of interactions. Pet owners should avoid tick habitat with pets; when that is not possible, proper use of tick preventive products for pets, wearing repellents by owners and conducting tick checks for both pets and owners is critical for prevention of tick encounters and tick-borne disease.

Impacts of misclassification on Lyme disease surveillance.

In Maryland, Lyme disease (LD) is the most widely reported tickborne disease. All laboratories and healthcare providers are required to report LD cases to the local health department. Given the large volume of LD reports, the nuances of diagnosing and reporting LD, and the effort required for investigations by local health department staff, surveillance for LD is burdensome and subject to underreporting. To determine the degree to which misclassification occurs in Maryland, we reviewed medical records for a sample of LD reports from 2009. We characterized what proportion of suspected and "not a case" reports could be reclassified as confirmed or probable once additional information was obtained from medical record review, explored the reasons for misclassification, and determined multipliers for a more accurate number of LD cases. We reviewed medical records for reports originally classified as suspected (n = 44) and "not a case" (n = 92). Of these 136 records, 31 (23%) suspected cases and "not a case" reports were reclassified. We calculated multipliers and applied them to the case counts from 2009, and estimate an additional 269 confirmed and probable cases, a 13.3% increase. Reasons for misclassification fell into three general categories: lack of clinical or diagnostic information from the provider; surveillance process errors; and incomplete information provided on laboratory reports. These multipliers can be used to calculate a better approximation of the true number of LD cases in Maryland, but these multipliers only account for underreporting due to misclassification, and do not account for cases that are not reported at all (e.g., LD diagnoses based on erythema migrans alone that are not reported) or for cases that are not investigated. Knowing that misclassification of cases occurs during the existing LD surveillance process underscores the complexities of LD surveillance, which further reinforces the need to find alternative approaches to LD surveillance.

Knowledge, attitudes, and behaviors regarding tick-borne disease prevention in endemic areas.

As part of a TickNET collaboration we evaluated the knowledge, attitudes, and behaviors related to tick-borne disease (TBD) prevention among persons living in endemic areas of Connecticut (CT) and Maryland (MD). Up-to-date information on the use of various prevention methods, as well as attitudes toward available and potential prevention options, is critical for effective promotion of recommended behaviors. During 2016-2017, printed invitations were mailed via the post office to 27,029 households requesting participation in an online survey regarding knowledge of TBD, risk perceptions, and prevention behaviors. Prevention behaviors included tick checks, showering/bathing, insect repellents, pet tick control, and chemical or natural pesticide use on residential properties. Associations of sociodemographic characteristics and knowledge and attitude variables with prevention behaviors were assessed in unadjusted analyses and multivariable models to calculate adjusted odds ratios (aOR). Participants were also asked if they would be willing to get a Lyme disease (LD) vaccine, if one becomes available. Overall, 1883 (7%) persons completed the survey. Participants reported using preventive behaviors most of the time or always as follows: pet tick control (83%), tick checks (58%), showering/bathing (42%), insect repellent (31%), and chemical (23%) or natural (15%) pesticides on property. Self-rated knowledge of LD, perceived prevalence of LD, perceived severity of LD, and perceived likelihood of contracting LD or another TBD were significantly (p < 0.05) associated with performing a tick check [aOR 2.5, aOR 1.71, aOR 1.36, aOR 1.83, respectively]. Female gender and perceived prevalence of LD were significantly associated with applying insect repellent [aOR 1.56, aOR 1.64, respectively]. Perceived prevalence of LD was significantly associated with showering or bathing, insect repellents, and pet tick control [aOR 1.42, aOR 1.64, aOR 1.92, respectively]. Income > $100,000 was significantly associated with applying a chemical or natural pesticide to one's property [aOR 1.29, aOR 1.40, respectively]. A majority of respondents (84%) reported that they were very likely or somewhat likely to get a LD vaccine if one were available. Few behaviors (tick checks and pet tick control) were reported to be practiced by more than half of the respondents living in LD endemic areas. Perceived prevalence of LD was the only factor associated with performing most of the prevention behaviors (tick checks, showering/bathing, use of insect repellents, and pet tick control). Use of chemical or natural pesticides appears to be driven by income. Greater efforts are needed to encourage use of prevention behaviors in endemic areas, and this may be facilitated by increasing awareness of local prevalence.

Tuberculosis control in a large urban jail: discordance between policy and reality.

OBJECTIVE: This study evaluated adherence to tuberculosis control guidelines, published by the Centers for Disease Control and Prevention in 1996, in a large urban jail. Jails are a critical locale because of high risk for tuberculosis transmission in a congregate setting. METHODS: Symptom screening at intake into the facility was systematically observed. Medical records were reviewed to measure timing of tuberculin skin testing (TST) and chest radiograph (CXR) screening. Isolation records were examined for airborne infectious isolation practices. Contact investigation practices were evaluated for ease of data retrieval and adherence to CDC guidelines. RESULTS: A TB symptom screening question was asked correctly during 28/97 of intake health interviews. Median time from intake to TST was 3 days for men and 2 days for women. Median time from referral to CXR was 2 days for men and 7 days for women. Delays were noted in diagnostic testing of 51 detainees isolated for suspected TB. Contact investigations lacked comprehensive procedures, data collection forms, and databases for managing information. CONCLUSION: Findings were used to refine protocols for TB control. This evaluation illustrated the need for ongoing assessment of adherence to TB control protocols in short-term correctional settings to prevent the spread of TB.

Review of the Mid-Atlantic Tick Summit III: A model for regional information sharing.

Ticks are the most significant vectors of infectious diseases in the United States, inspiring many researchers to study aspects of their biology, ecology, and their effects on public health. However, regional differences in tick abundance and pathogen infection prevalence result in the inability to assume results from one area are relevant in another. Current local information on tick ranges, infection rates, and human cases is needed to assess tick-borne disease risk in any given region. The Mid-Atlantic Tick Summit III brought together over 100 area experts and researchers to share regional updates on ticks and their associated pathogens. We report some meeting highlights here. Regional meetings foster cross-disciplinary collaborations that benefit the community, and open novel lines of inquiry so that tick-bite risk can be reduced and tick-borne diseases can be treated effectively.