Ticky Situation
Public health officials race to raise awareness about tickborne illness to prevent the wider spread of disease in the West

By Phil McPeck
July 13, 2004

Registered nurses are at the center of a growing campaign to keep tickborne illnesses, especially Lyme disease, from compromising the health of Californians as it has tens of thousands of New Yorkers and others in the Northeast and upper Midwest.

It’s nurses who answer health advice lines and likely are the first to see tick-bite patients in rural health care and emergency department settings, said Anne Kjemtrup, PhD, DVM, a public health biologist with the California Department of Health Services. “RNs are also responsible for conveying safety awareness messages and seasonal alerts,” said Kjemtrup, whose doctorate is in epidemiology.

In Willows, Calif., “One of the boards in our front lobby is on Lyme disease and tickborne illnesses,” said Grinnell Norton, RN, public health nursing director for Glenn County.

Ticks “are pretty disgusting little critters, but they’re part of country life,” said Rita Leeseman, RN, EdD, MA. She recently retired as coordinating nurse for 32 school districts in the outdoors mecca of Humboldt County, and said it’s again time for an inservice to raise school nurses’ index of suspicion about Lyme disease. The RNs then pass on awareness to pupils and parents.

Lyme is the No.1 tickborne disease in California. It’s been confirmed in 55 of the state’s 58 counties. Ninety-five cases were reported in 2001, a pale shadow of the nation-leading 49,174 cases in New York that year, according to the national Centers for Disease Control and Prevention. The western black-legged tick, which transmits Lyme in California, has a far lower infection rate than do the deer ticks that carry it elsewhere.

Campaign trail

Californians owe their growing awareness of the disease to a Legislature-created committee of public health officers, a public health nurse, physicians, researchers, people who have been bitten by ticks, and a statewide education campaign.

Similar campaigns are under way in the Northeast, where Lyme disease was first identified in the late 1970s and later named for victims in the area around Lyme, Conn.; the Southeast, where Rocky Mountain spotted fever is quickly gaining ground; the upper and central Midwest; and the West, which includes Montana. There, a rash of peculiar cases in the past two years has the state epidemiologist and National Institutes of Health researchers wondering whether they are seeing a heretofore unknown cousin of Lyme disease.

Ticks embed their heads under the skin to feed on blood, and transmit through saliva glands the spiral spirochete that causes Lyme disease. Nymph-stage ticks, which are no larger than a poppy seed, are most active in spring; adult ticks are most active in the fall.

RNs, as health advisers and clinicians, are on the lookout for the signature bull’s-eye rash — a red rim around a pale center — that occurs in about 40% of Lyme disease cases and signals the need for antibiotic treatment. With or without the rash, Lyme also is characterized by flulike symptoms — fever, malaise, fatigue, headache, and stiff neck. If left untreated, it can progress to chronic and debilitating neurologic disease and severely arthritic joints.

“We know ticks,” said Sherrie Muhs, RN, CEN, an emergency department charge nurse at Avera McKennan Hospital and University Medical Center in Sioux Falls, S.D. For vacationers and residents alike — actually anyone who lives, works, or plays in the wild outdoors of California, the Northeast, or the Midwest — prevention is the main thing, Muhs said.

That means light-colored clothing to more easily spot ticks, long sleeves buttoned at the cuffs, long pants tucked into socks or footwear, and use of an insect repellant containing DEET. The chemical, N-diethyl-m-toluamide, however, is toxic to children younger than 2 and shouldn’t be used on them, Muhs said. Clothing, but not skin, also can be sprayed with a repellant that contains tick-killing Permethrin.

Be alert

Because ticks must feed at least 12 hours to transmit Lyme disease, discovering and promptly removing ticks is vital, according to Avera McKennan’s Ask-a-Nurse website (www.averamckennan.org).

Muhs said a fellow nurse who lives in the country goes through a nightly bedtime ritual with her family, inspecting themselves for ticks — especially their hair and scalps — where they can be difficult to detect.

In one of the more bizarre cases, she said the hospital’s emergency room staff once removed a tick attached to the eardrum of a child. Typically, though, removing ticks is something people can do themselves, in the same fashion that Muhs does.

Following guidelines widely publicized by the CDC and state departments of health, she uses tweezers as close to the skin as possible and pulls the tick body straight away from the skin with steady pressure.

She then treats the bite site with an antiseptic and advises patients to watch for infection, especially if the tick’s head is not fully removed, and for symptoms of Lyme disease, which may not occur for weeks.

Never, though, has a case of Lyme disease been the result of a tick bite in Montana. It is the only state that has never been the source of a case.

In Big Sky Country, state epidemiologist Todd Damrow, PhD, MPH, said the viral Colorado tick fever is the most common tickborne illness, followed by the bacterial tularemia. And once every year or two, Montana sees a case of potentially fatal Rocky Mountain spotted fever, which has made huge inroads in the Southeast in recent years.

Tick paralysis occurs worldwide, the toxin carried by a variety of ticks found in the Rocky Mountains and Northwest.

What’s puzzling Damrow, though, and has Montanans saving removed Rocky Mountain wood ticks for analysis by National Institutes of Health researchers, are patients with Lyme diseaselike symptoms. “We’d tell the people, ‘We don’t have the ticks that are capable of transmitting Lyme disease here in Montana, and you test negative, so you don’t have Lyme disease. “We don’t know what you have, but we know what you don’t have,’” Damrow said.

Then two years ago came a photograph in the mail — a picture of rash at the site of a previous tick bite on a person who had not been out of the state. “We’ve been blowing these rashes off as an allergic reaction to retained tick mouth parts or maybe a superficial skin infection. My heart sank because it was a perfect bull’s-eye rash,” Damrow said.

Coincidentally, federal scientists at that time were investigating a similar situation in the South and discovered a Lyme diseaselike agent in the lone star tick, Damrow said. The disease now is known as STARI: Southern tick-associated rash illness.

“We’ll see whether or not we have a cousin of Lyme disease that’s adapted to the wood tick,” Damrow said. “It’s really a hypothesis at this point, but it would not be without precedent. It happened in the South.”

California’s Kjemtrup said awareness of ticks is relatively high among residents of more rural counties and is equally low among urban dwellers who only occasionally venture into the state’s wilds, sometimes with a dog in tow.

“We always recommend that if you have dogs that are going to go into the same areas that you are, or live in these natural areas, it’s important to keep them on some kind of effective tick-bite prevention medication provided by their veterinarian,” Kjemtrup said.

“While dogs cannot transmit Lyme disease to people themselves, what they can do is bring the ticks that transmit it into and around your environment. These ticks can’t survive in your house very long, but if they’re crawling on the dog and you’re hugging the dog 85 .”

The risk of contracting Lyme disease from the western black-legged tick is relatively low; it’s estimated that 2% of adults and 13% of nymphs carry the disease vs. 50% of deer ticks.

However, regardless of whether the infected tick was one in a 1,000 or one in 100 million, the consequences of the disease, especially when not recognized or taken seriously, are the same.

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