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Tick Borne Diseases

2 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Saturday, January 13, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

Understand how zoonotic diseases are transmitted, specifically tick-borne diseases. Recognize that although zoonotic diseases are typically endemic in geographic distribution, they require a high degree of clinical suspicion for early diagnosis through careful history and a thorough physical exam. Understand the clinical manifestations of tick-borne diseases ranging from no symptoms to tick paralysis and, eventually, respiratory failure. The course discusses practical interventions in preventing tick-borne diseases and provides clinicians with actionable steps they can immediately start applying in their clinical practices today.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Define tick-borne diseases
  2. Name 4 methods of transmission of zoonotic diseases
  3. Name a tick-borne disease which is considered to be an agent of biological warfare
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Berthina Coleman (MD, BSN,RN)

Epidemiology

Ticks are worldwide parasites that infect both animals and humans. They are hematophagous parasites meaning they feed on blood products and cause disease by transmitting toxins to the host organism. Ticks are some of the most common vectors of human diseases and come second only to mosquitoes in transmitting human diseases (Bolgiano et al., 2018).

They are typically encountered or acquired when the host travels to an endemic area, usually during summer. However, recently, there have been increasing reports of tick-borne disease in urban areas, even in patients who have no reports of recent travel. Obtaining a social history is imperative in raising clinical suspicion for tick-borne diseases (Bolgiano et al., 2018).

Tick-borne diseases are considered to be zoonotic diseases. Zoonotic diseases are defined as diseases that affect both animals and humans. According to the Center for Disease Control (CDC), tracking and reporting the incidence and prevalence of zoonotic diseases is necessary since tens of thousands of Americans have been infected annually (NCEDNZ, 2017).

According to the CDC, some tick-borne diseases such as tularemia can be used for biological warfare. As such, it is incredibly important to educate clinical providers and the public on preventing the spread of tick-borne diseases (NCEDNZ, 2017).

Zoonotic diseases can be mild or severe in their presentation. In addition, they can be transmitted by people or animals who appear healthy. According to the CDC National Center for Emerging and Zoonotic Infectious Diseases, 60% of all known infectious diseases in people are spread from animal vectors, while 75% of every new or emerging infectious disease is also spread from animals.

Methods of Transmission of Zoonotic Diseases

Indirect Contact

The disease is spread by exposure to contaminated surfaces, objects, or areas where animals live and roam. Indirect contact includes exposure to contaminated soil from infected animal urine and pet food and water dishes (NCEDNZ, 2017).

Direct Contact

Direct contact implies exposure to animal secretions such as feces, urine, saliva, mucus, or blood. This contact can occur while petting animals at a zoo, playing with pets at home or being exposed to an infected animal on a hike (NCEDNZ, 2017).

Vector-Borne

Common vectors include mosquitoes and ticks. Examples include being bitten by an insect, a tick, or a flea.

Foodborne

Humans can get sick from eating contaminated food. Examples include contaminated raw fruits and vegetables, undercooked meat, undercooked eggs, or unpasteurized milk.

Most humans, even those who appear healthy, can be infected with zoonotic diseases. However, some patient groups are at increased risk of experiencing severe disease courses that potentially lead to death. These include children under the age of 5, immunosuppressed patients, and the elderly (those older than age 65) (NCEDNZ, 2017).

How to Prevent the Spread of Zoonotic Diseases

Hand washing is extremely important and effective in preventing the spread of germs and diseases from one vector to another. Handwashing is incredibly important when exposed to an infected animal or animal bodily fluids. Teach people exposed to animals to wash their hands even though they were not touching the animals. Ideally, handwashing should be done with clean running water and soap. If clean running water is unavailable, soap and any available water should be used. Otherwise, consider using alcohol-based sanitizers containing at least 60% alcohol. However, note that alcohol-based sanitizers do not kill all germs, so hand washing should be performed as soon as soap and water become available (NCEDNZ, 2017).

Prevent animal bites and bites from other vectors such as ticks or insects, including mosquitoes and fleas. This prevention may mean dressing in the appropriate clothing while going on hikes or caring for animals. To that extent, protective apparel such as gloves and boots may be necessary when interacting with or caring for animals. This protection is very important for people working in animal shelters or zoos.

Certain occupations are at increased risk of tick-borne diseases. These include roofers, construction workers, laborers, mechanics, farmers, field workers, park workers, and landscapers. Typically, ticks are more active in the summer months (Durrani et al., 2014).

Suspicion for tick-borne diseases is based on two main factors; presenting symptoms and a history of possible exposure to ticks.

Common interventions that could help prevent tick-borne diseases include wearing long sleeve clothing, long pants tucked in boots or socks, light-colored clothing, and insect repellant spray (Durrani et al., 2014).

Any patient who experiences exposure to ticks or a tick bite should take a shower as soon as possible using soap and water.

Common Tick-Borne Diseases and Associated Pathogens

Zoonotic diseases can be caused by fungi, bacteria, viruses, and parasites.

Bacterial Diseases

Lyme disease is a bacterial disease caused by the pathogen Borrelia burgdorferi. The vector for Lyme disease is Ixodes scapularis, also known as the black-legged or deer tick. The average life span of the deer tick is 2 years. In the United States, the deer tick is mostly found in the Northeastern US. Other vectors include Ixodes pacificus, the western black-legged tick found in the upper midwestern US. Lastly, Ixodes ricinus, also known as the castor bean tick, is mostly found in Europe and the Pacific coast of the US (Bolgiano et al., 2018). Lyme disease will be discussed thoroughly later during the course.

Tularemia is a bacterial disease caused by Francisella tularensis. The arthropod vector for Tularemia is Ixodes scapularis, which is fully described above.

Rickettsial Diseases

Rocky Mountain Spotted fever is caused by Rickettsia rickettsii. The vector is Dermacentor andersoni, also known as the Rocky Mountain Wood Tick or the hard tick. The geographic distribution is predominantly in the southeastern US (Bolgiano et al., 2018).

Q fever is a rickettsial disease caused by Coxiella burnetii. The arthropod vector is Dermacentor andersoni, and the disease distribution is worldwide (Bolgiano et al., 2018).

Parasitic (Protozoan) Diseases

An example of parasitic tick-borne disease is Babesiosis, caused by Babesia microti. The arthropod vector is Ixodes scapularis (deer tick), and the geographic distribution is coastal New England (Bolgiano et al., 2018).

Viral Diseases

The Colorado tick fever is a viral disease caused by the Orbivirus. The arthropod vector is the Dermacentor andersoni (Rocky Mountain wood tick). The geographic prevalence of the mountain areas of the western US and Canada (Bolgiano et al., 2018).

How Ticks Feed

Ticks are arthropods that are different from insects. The best way to distinguish between insects and arthropods is by counting the number of legs. Arthropods have eight legs, while insects have six legs. Arthropods mainly have a head and an abdomen, while insects have a three-part body. Note that color is not reliable for identifying ticks since they can change color with the seasons.

There are four stages in the life cycle of a tick: the egg, the larva, the nymph, and the adult. How vectors transmit diseases is important to understand how they feed. Some vectors feed directly on blood from the capillaries, also known as solenophagic feeders, such as mosquitoes. While others feed on blood, tissue, and extracellular fluid, these are known as telmophagic feeders. Note that telmophagic feeders do not discriminate on the type of tissue they feed on. Ticks are telmophagic feeders.

Once ticks bite into their hosts, they are attached by a salivary secretion, cement-like, and a structural part of their sucking structure called a barbed hypostome. Note that ticks can remain attached to their hosts for up to 2 weeks.

During a tick bite, the physical destruction of the tissues by the biting apparatus and the inflammatory response to the saliva secreted. This bite leads to local swelling, bleeding, increased vascularity, and focal skin thickening. Eventually, the enzymes in the saliva break down the tissues, turning them into a liquid that the tick absorbs. Specifically, the deer tick releases a carboxypeptidase, which prevents inflammatory mediators from being released, which would cause hemostasis if released.

After a tick bite, there is a characteristic small reddish spot. This spot is different from the rash that occurs with disease progression.

Clinical Manifestations of Tick-Borne Diseases

Secretions from a tick will not only produce a local skin reaction but also transmit pathogens and cause systemic reactions such as febrile illness or paralysis. Soft ticks can attach for about 1 hour, while hard ticks can feed for up to 2 weeks.

Tick Induced Fever

In the absence of a pathogen being transmitted, tick-induced fever can occur, and it is associated with nausea, malaise, and headaches. It typically resolves in 36 hours or less after removing the tick (Jameson et al., 2020).

Tick Paralysis

It is an ascending flaccid paralysis secondary to a toxin transmission via tick saliva. It causes decreased nerve conduction, which eventually causes the neuromuscular block (Jameson et al., 2020).

Tick paralysis can be extremely frightening for the patient. The weakness begins in the lower extremities and is symmetric. It typically begins less than 6 days after the tick has been attached. The paralysis can ascend and eventually lead to cranial nerve paralysis and complete paralysis of the upper and lower extremities. On physical exam, the sensory examination is normal, but the motor reflexes are either absent or decreased. Once the tick is removed, the patient's condition improves in hours. Failure to remove the tick can lead to death by respiratory paralysis (Jameson et al., 2020).

Management of Tick Bites and Tick Paralysis

Tick removal is the most critical part of clinical management because it is directly linked to improving symptoms. A thorough physical exam and history-taking process are critical to raising clinical suspicion.

When ticks are being removed, it should be done with forceps applied as close as possible to the point of attachment. Patients bitten in an area endemic to Lyme disease should receive prophylactic treatment with a single dose of doxycycline.

Lyme Disease

Lyme disease is the most common disease transmitted by a vector in the US. It was first identified in 1975 when two parents noticed an abnormal amount of juvenile rheumatoid arthritis diagnosis in their community in Connecticut. They decided to inform Yale University physicians and alerted the department of health. The disease was eventually named after their community, Lyme disease from Old Lyme, Connecticut (University of Rhode Island, 2018).

Cases of Lyme disease have been reported worldwide except for the continent of Antarctica. However, most patients diagnosed with Lyme disease do not remember being bitten by a tick. Most cases of early Lyme disease occur between May and August. Later manifestations of Lyme disease can occur throughout the year (University of Rhode Island, 2018).

There is some heterogeneity in Lyme disease's clinical course and clinical presentation. It is unclear why this heterogeneity occurs, but some patients with chronic manifestations of Lyme disease are reported to have an increased frequency of human leukocyte antigens.

Clinical Manifestations of Lyme Disease

Clinical manifestations of Lyme disease are divided into 3 stages; early localized, early disseminated, and late disease. Early Lyme disease is characterized by a rash and other constitutional symptoms suggestive of a viral syndrome. The rash associated with Lyme disease is called erythema migrans and is often described as a "bull's eye pattern." Early dissemination is characterized by cardiac, neuro or joint symptoms. While the late disease is characterized by chronic arthritis. Patients may be asymptomatic at any given time in the disease course (Bolgiano et al., 2018).

Treatment and Management of Lyme Disease

Currently, there are no vaccinations for Lyme disease available in the US. Prophylactic treatment is currently recommended in patients who have been exposed. Prior to administering doxycycline, certain criteria must be met:

  • The tick must be an adult or a nymphal
  • The tick must stay attached for 36 hours or more
  • Prophylaxis can be started within 72 hours after
  • The local rate of infection of the ticks by Borrelia burgdorferi is 20% or more
  • Doxycycline is not contraindicated (Bolgiano et al., 2018)

Typically doxycycline is administered as a single dose.

Clinical Scenario

You are a school nurse chaperoning a group of students on a field trip to a local park. About 30 mins after arriving at the park, the class spots a deer in the bushes, which promptly dashes away after only a few seconds. The kids play in the park and surrounding bushes for a few hours, and then the class returns to school without incident. The next day one of your student's mothers calls to report that her son has a fever of 101 and inquires if anything unusual happened at school the day before. She also wants to know if she should keep giving Tylenol and watch the patient at home.

Discussion

You should immediately instruct the parent to contact their pediatrician, who will further direct them to either present in a clinic or present to a local emergency room. In addition, you should inform the mother of the potential exposure to a deer's secretions or excretions since the boy played in the bushes and may have been exposed through direct or indirect contact. This information should be relayed to the medical staff. In addition, ask the mom to report pertinent information such as the presence or the absence of a rash. Ultimately, the patient was seen by their pediatrician, who elected to treat the patient prophylactically.

Conclusions

Ticks are incredibly tenacious vectors that efficiently transmit diseases to their hosts. Note that ticks may remain infectious for multiple generations without being re-infected by the host. Patient education should be focused on disease prevention by mitigating patient exposure. Finally, some tick-borne diseases can be used as biological weapons, especially in the era of antibiotic resistance.

Given that tick-borne diseases are varied in both the type of pathogens as well as the vector, it is essential that clinicians not only understand the clinical presentation and clinical course of tick-borne diseases but they must also maintain high clinical suspicion for these diseases in order to provide timely diagnosis and treatment, which could potentially save the patient's life.

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References

  • Bolgiano EB, Walls RM, Hockberger RS, Gausche-Hill M, Sexton J. Tickborne Illnesses. In: Rosen's Emergency MEDICINE: Concepts and Clinical Practice. 3rd ed. Philadelphia, PA: Elsevier; 2018:1657-1681.
  • Durrani TS, Ladou J, Harrison RJ. Occupational Infections. In: Current Diagnosis & Treatment: Occupational & Environmental Medicine. New York: McGraw-Hill Education; 2014.
  • Jameson JL, Jameson J, Fauci AS, et al. Bites, Venoms, Stings, and Marine Poisonings. In: Harrison's Manual of Medicine. New York: McGraw-Hill Education; 2020.
  • National Center for Emerging and Zoonotic Infectious Diseases. Zoonotic diseases. Published July 14, 2017. Accessed December 2, 2019. Visit Source.
  • University of Rhode Island Tick Encounter Resource Center. Tick Encounter resource center. Published 2018. Accessed December 3, 2019. Visit Source.