Spatio-temporal patterns of tick-borne disease diagnoses in Indiana, USA (2009-2018).

AIMS: Although tick-borne disease (TBD) incidence has increased in the United States (U.S.) in the past decade, new evidence suggests that notifiable diseases surveillance records may not accurately reflect the true magnitude of TBD diagnoses. Furthermore, while regional electronic health records (EHR) are readily accessible their potential use as a more stable and consistent source of TBD diagnoses data has remained largely unexplored. METHODS AND RESULTS: In this study, we used EHR from a database of more than 100 hospitals, healthcare networks, and insurance providers in Indiana, U.S., to better understand incidence, spatio-temporal and demographic distribution of TBD Diagnoses from 2009-2018. Our results revealed that in Indiana, from 2009 to 2018, there were 5173 unique TBD Diagnoses across three diagnoses categories: Lyme disease (72.5%, n = 3751), Rickettsioses (12.0%, n = 623) and Other TBD Diagnoses (15.4%, n = 799). Using EHR, the average yearly Lyme disease diagnoses was more than double the cases obtained using notifiable disease surveillance data for the same period. Patients with a TBD Diagnoses were generally older (ages 45-59) and less racially diverse (96.3% white). Rickettsiosis diagnoses were reported more among male patients (55.2%), while Lyme disease diagnoses were higher among female patients (57.1%). Temporal data illustrated higher frequencies of diagnoses from May to July. Hot spot analysis identified a Lyme disease hot spot in northwest Indiana, while hotspots of Rickettsiosis and Other TBD Diagnoses category were identified in southwest Indiana. Extrapolated to the Indiana population, chi-squared (χ2) tests of independence revealed that the observed distribution of TBD diagnoses in our data was significantly different from the expected distribution in the Indiana population-based race, gender and age groups. CONCLUSIONS: Our study findings demonstrate that in Indiana, EHR provide a stable data source for elucidating TBD disease burden and for monitoring spatio-temporal trends in TBD diagnoses.

The Role of Permission, Supervision, and Precipitating Events in Childhood Pool/Spa Submersion Incidents, United States, 2000-2017.

Drowning is a leading cause of fatality among children in the United States, and pool/spa aquatic structures represent common locations of submersion incidents. This study employed narrative case review to understand characteristics related to permission, supervision, and precipitating events in childhood submersion incidents. Retroactive analysis of 1537 fatal and non-fatal submersion incidents among children age 13 years old and younger was conducted using the U.S. Consumer Products Safety Commission In-Depth Investigations dataset from 2000-2017. Narrative descriptions were coded according to the themes of permission, supervision, and precipitating events. In most (86%) incidents, the child did not have permitted water access, and 80% of narratives indicated the child was alone at time of incident. These attributes were significantly associated with a fatal outcome (No permission: OR 11.98, 95% CI 7.97-18.06; Alone: OR 34.93, 95% CI 19.69-61.96). The average length of inactive supervision time was 15.6 min; this duration significantly differed by non-fatal (3.2 min) and fatal (16.1 min) outcomes (p < 0.001). More than half of cases occurred under the supervision type of a parent (56%), followed by grandparents (14%) and childcare provider (10%). Submersion incidents with a non-parent supervisor were two times more likely to result in a fatal outcome (OR 1.87, 95% CI 1.07-3.64). The most frequently occurring precipitating events included outdoor play (46%), a social gathering (36%), and previous water play (15%). Narrative excerpts further illustrate how tragic submersion events can unfold quickly and unpredictably. Education campaigns should target all adults that supervise children and reiterate key findings in that many submersion incidents occur (1) without permitted pool use, (2) without active supervision, and (3) when a caregiver is distracted. Multiple strategies should be utilized to add layers of projection against submersion injury.

Tick trails: the role of online recreational trail reviews in identifying risk factors and behavioral recommendations associated with tick encounters in Indiana.

BACKGROUND: Recreational trails abound across the United States and represent high risk areas for tick exposure. Although online reviews represent a rich source of user information, they have rarely been used in determining the risk of tick exposure during recreational trail use. Based on online user reviews and comments, the purpose of this study was to determine risk factors and behavioral recommendations associated with tick encounters (Tick Presence) on recreational trails in the state of Indiana, U.S. METHODS: We reviewed 26,016 user comments left on AllTrails.com for 697 Indiana trails. Reviews were evaluated to determine Tick Presence/Absence, the total number of Tick Presence Reviews per trail, and multiple trail and user behavioral characteristics. We used hot spot (Getis-Ord Gi*) analysis to test the hypothesis of whether there are clusters in the number of Tick Presence Reviews. Pearson chi-square tests of independence evaluated whether tick presence was associated with several trail characteristics. Finally, negative binomial regression evaluated the strength of the association between the number of Tick Presence Reviews and several trail characteristics. RESULTS: Tick Presence was recorded at 10% (n = 65) of trails and occurred most frequently in May. Hot spot analysis revealed statistically significant clusters of Tick Presence Reviews on trails in the Southern Indiana State Region. Results of χ2 tests indicated significant associations between Tick Presence Reviews and (a) State Region and (b) Land Management Type; Mann-Whitney U tests detected significant differences in Tick Presence Reviews based on Trail Length and Elevation Gain. Subsequent results of a negative binomial regression model indicated that Southern Indiana State Region, Federal and Private Land Management Type, and Elevation Gain were factors significantly associated with Tick Presence Reviews. Content of user reviews indicated several behaviors employed to prevent tick encounters, particularly Repellent Application and Recreational Deterrence; 25% included a behavior Recommendation to others. CONCLUSIONS: Online, user-generated trail reviews have the potential to serve as rich data sources for identifying recreational trails, where 1) the risk of tick exposure is great, 2) more robust active tick and tick-borne pathogen surveillance may be warranted, and 3) tailored prevention interventions are needed.

Using i-tree canopy vegetation cover subtype classification to predict peri-domestic tick presence.

While extant literature has generally indicated significant associations between vegetation cover and tick activity, no study has demonstrated the relative association between peri-domestic area vegetation cover subtypes and tick presence. In this study, we seek to determine whether neighborhood wood index and residential tick control practices confound or modify the effect of peri-domestic vegetation cover subtypes on tick presence. We conducted an ecological inventory of vegetation cover distribution using i-Tree Canopy on 210 private residential/peri-domestic properties in Indiana, USA. Results were paired with field obtained tick presence/absence data for each property together with online survey data provided by primary occupant of the property. Amblyomma americanum was the predominant tick species in peri-domestic areas. Higher proportion of vegetation cover in the peri-domestic area was significantly associated with tick presence. Of the four vegetation cover subtypes, (grass, shrubs, understory, and canopy), canopy was the most prevalent vegetation in peri-domestic areas of Indiana, USA. It was also the most significant predictor of tick presence. Among residential tick control processes, frequent leaf litter removal was significantly associated with reduced likelihood of peri-domestic tick presence. Neighborhood Wood Index (NWI) confounded the relationship between canopy and peri-domestic tick presence, while leaf-litter removal confounded the effect of understory vegetation subtype on peri-domestic tick presence. Compared to peri-domestic areas in neighborhoods with sparse NWI, those in neighborhoods with heavy/dense NWI had a 3.5x odd of peri-domestic tick presence (AOR = 3.46; 95 % CI: 1.23-9.65). Compared to peri-domestic areas in the central region, those in the southern region of Indiana were 8.7x more likely to have peri-domestic tick presence. Canopy as a vegetation cover subtype and frequent leaf litter removal represent particularly key peri-domestic variables that have significant implications for peri-domestic tick presence. Beyond parcel-scale landscape features, neighborhood wood index also plays an important role in peri-domestic tick presence. Additionally, i-Tree Canopy represents a promising methodological tool for identifying landscape features that predict tick presence.

Preventing tick-bites among children in Indiana, USA: An analysis of factors associated with parental protective behaviors.

Despite evidence to the effect that there is low parental adoption of tick-bite personal protective behavior (PPB) for their children - a population at high risk for tick exposure, very limited information is available on factors associated with parental adoption of PPB. The objective of this study was to identify the most significant factors associated with parental adoption of tick-bite PPB on behalf of a child or children at risk of tick encounters. A cross-section of parents in Indiana, USA whose child had spent time outdoors in tick habitat during the summer were recruited from representative online panels maintained by Qualtrics. Binary logistic regression was used to model determinants of five tick-bite PPBs. Our results revealed that the application of tick repellent (89 %, n = 718) followed by conducting a tick check of the child's body soon after returning from the outdoors (84 %, n = 676) were the PPBs most frequently adopted by parents. Conversely, tucking one's shirt into pants and pants into socks was the least frequently adopted PPB (48 %, n = 386). Compared to other factors evaluated in logistic regression models, parents who reported implementing one or more residential tick control practices were significantly more likely to adopt nearly all five tick-bite PPBs for their children. Additionally, parents who were more worried about their health due to ticks and reported being more likely to avoid the outdoors because of ticks were more likely to adopt at least three PPBs on behalf of their children. To ensure children can most safely engage in outdoor activity, identifying the factors associated with parental adoption of tick-bite preventive behaviors represents an important mechanism in the prevention of tick-borne diseases.

Predicting Chikungunya disease personal protective behaviors: Results of a cross-sectional survey of US-Caribbean travelers.

Background: Incidents of vector-borne disease have recently tripled in the United States. Chikungunya disease is a particularly common disease in the Caribbean, posing a threat to international tourists. However, the relationship between psychological variables derived from the protection motivation theory (PMT), and adoption of protective behaviors against the disease, is uncertain. This study sought to identify the psychological predictors of travelers' protective health behaviors, specifically (1) appropriate clothing use, and (2) indoor spatial repellent use. Methods: An online, retrospective survey of U.S. international travelers to Caribbean destinations measured the five constructs of the PMT in the context of Chikungunya disease: Perceived severity, perceived vulnerability, perceived response efficacy, perceived self-efficacy, and knowledge. Hierarchical logistic regression analyzed whether these five theoretical constructs predicted the two protective behaviors in respondents who met study criteria (n = 184). Results: Results suggest that the interaction between chikungunya knowledge and perceived chikungunya severity predicts both appropriate clothing use (odds ratio [OR]: 1.95, CI: 1.18-3.25, P =0.010) and indoor spatial repellent use (OR: 1.55, CI: 1.05-2.29, P =0.029). In the cases of appropriate clothing use, the interaction between perceived chikungunya severity and perceived vulnerability was also a significant predictor (OR: 9.67, CI:1.23-75.80, P =0.031). Additionally, indoor spatial repellent use was also predicted by the interaction of chikungunya knowledge and perceived vulnerability (OR: 1.88, CI:1.18-3.02, P =0.009). Conclusion : Two-pronged educational approaches may be most efficacious in increasing protective health behaviors. Such efforts could reduce incidents of chikungunya disease and other vectorborne diseases in travel destinations featuring high exposure risks.

Predicting consideration of cosmetic surgery in a college population: a continuum of body image disturbance and the importance of coping strategies.

Elective cosmetic surgeries are increasing in the American population with reasons linked to body image disturbance and body dysmorphic disorder (BDD). Little research exists documenting the continuum of body image disturbance and its relationship to seeking surgery. The present research examined data from 544 participants, 55 of whom were diagnosable with BDD. Using assessments for body image disturbance, problematic coping strategies, and BDD symptomatology, results provided evidence for a continuum of body image distress. Logistic regression analysis supported the hypothesis that increased levels of body image disturbance and one type of problematic coping strategy (Appearance Fixing) predicted consideration of cosmetic surgery. Of participants diagnosable with BDD, those who considered cosmetic surgery showed more severe body image disturbance and problematic coping than those who did not consider surgery. These results have implications for pre-surgical assessment as well as psychological interventions rather than invasive medical interventions.