Disease Control Bulletin: June 2005
- Tick Borne Disease in Vermont: The ticks are out!
- Update on Vermont Asthma Action Plan
- Recreational Water Illnesses
- Selected Reportable Diseases: Jan–Dec, 2004
Tick Borne Disease in Vermont: The Ticks are Out!
The risk of contracting Lyme disease in Vermont may be higher than many Vermonters suspect. Data on ticks submitted by veterinarians to the Department of Forests, Parks & Recreation as part of a special surveillance project indicate that the Lyme disease vector, the blacklegged tick (Ixodes scapularis, popularly referred to as the deer tick), can be found throughout the state. Nymphal blacklegged ticks, active between May and October, are implicated in the majority of Lyme disease cases because they often go unnoticed due to their small size and are therefore not removed before disease transmission can occur. Adult blacklegged ticks, active between March and June and again in the fall, can also transmit the Lyme spirochete (Borrelia burgdorferi).
Among 69 Ixodes scapularis ticks collected at Champlain island site in October 2004, 34 (49%) were positive for Borrelia. This result suggests that ticks are well established on the island. The infection rates of Ixodes ticks collected in Bennington County during the same month from zero to 20.8 percent, suggesting that the tick cycle may be emergent at those sites. The Health is collaborating with the Agency of Agriculture a Lyme disease surveillance and response plan for the state.
Presentation and Testing
Approximately 90 percent of patients infected with B. burgdorferi experience an expanding red rash called erythema migrans (EM) at the site of the tick bite. The rash varies in size and shape and may occur anywhere on the body; classic “bull’s eye” appearance is noted in fewer than half of cases. The rash is not painful or pruritic and may go un-recognized.
Of 50 confirmed Lyme disease cases among 2004 (acquired both in- and out-of-state), 29 (58%) presented with EM, and 16 of those were also confirmed serologically. Illness onsets ranged from February to November, with the majority of cases having onset in June, July and August. Among cases diagnosed with late manifestations, 26 had rheumatological presentations, two had neurological presentations, and two presented with atrioventricular block. Other clinical syndromes reported included fever (14), fatigue (15), headache (10), and myalgia (10).
A two-test approach (EIA or IFA followed by Western Blot for confirmation) is recommended for laboratory diagnosis. Early Lyme disease can be effectively treated with antibiotics. Treatment almost always prevents development of later stages of Lyme disease. Clinical response to therapy is often slow, and signs and symptoms may persist for several weeks even in successfully treated patients.
The efficacy of prophylaxis for tick bites is not proven. In most circumstances, treating persons with tick bites alone is not recommended. Although the risk of Lyme disease appears to be increased for those on whom a B. burgdorferi carrying tick has fed for more than 48 hours, there are no data to indicate that antimicrobial prophylaxis is beneficial even for this group. The July 2001 New England Journal of Medicine reports that in areas where Lyme disease is endemic, a single 200-mg dose of doxycycline given within 72 hours of a deer tick bite can prevent Lyme Disease.
Although not common, the tick borne rickettsial disease ehrlichiosis has been reported in Vermont. Both Human Monocytic Ehrlichiosis and Human Granulocytic Ehrhchiosis are acute, febrile illnesses that may be accompanied by rach, headache, chills, myalgia, arthralgia, nausea, vomiting and weight loss. Diagnosis is based on clinical and laboratory findings and detection of a change in antibody titre. Paired serum specimens may be tested by the CDC through the Vermont Department of Health Laboratory.
Lyme disease and ehrlichiosis are reportable to the Vermont Department of Health by calling 863-7240 or 1-800- 640-4374.
Patients should be counseled about tick borne disease prevention. Daily tick checks and prompt removal of ticks should be conducted after spending time in a tick habitat. Infected lacklegged ticks must feed for a minimum of 24 to 36 hours in order for the Lyme spirochete to move from the gut into the salivary glands and be transmitted to the host. Insect repellents that contain DEET are safe and effective when used according to the instructions on the label. Long pants should be tucked into socks so that no skin surface is available for tick attachment. Wearing light-colored clothing can make it easier to see ticks so that they can be removed prior to attachment
Update on Vermont Asthma Action Plan
In 2002, the Vermont Department of Health and its partners initiated efforts to increase awareness and use of the Vermont Asthma Action Plan (VAAP) (see image). The VAAP is a written management plan providing information on asthma medications and peak flow meters, describes the symptoms of an asthma episode, and assists in determining symptom severity. The triplicate nature of the VAAP provides one copy for the patient’s medical chart, one copy for the child’s school nurse (if applicable), and a third copy for the patient/family. Although initial efforts were focused on increasing use of the VAAP with children, it may also be used effectively with adults.
Despite these efforts, data from the Behavioral Risk Factor Surveillance System (BRFSS), a statewide telephone survey of adults, show only 49 percent of Vermont households with children with asthma were given a written management plan for their child by their provider. Additional data from the BRFSS show that adult use of written management plans has decreased signi cantly over the past three years from 31.4 percent in 2001 to 20.7 percent in 2004.
Self Management and Asthma
The National Asthma Education and Prevention Program’s Guidelines for the Diagnosis and Management of Asthma recommends written action plans as part of an overall effort to educate patients in self-management.1 Self management is also one of the key principles in the Vermont Blueprint for Health. This partnership for improving care of Vermonters with chronic conditions has a central goal that, “Vermonters will be effective managers of their own health.”
Studies have shown that self-management interventions that include use of written action plans result in reduced emergency department visits and hospitalizations.2 In Vermont, costs due to asthma-related ED and hospital visits are substantial:3
- In 2002 Vermonters made 2,221 visits to the Emergency Department (ED) for their asthma, a rate of 36.1 visits/10,000 population, at a total cost4 of $880,944.
- During the same year costs associated with inpatient hospitalizations due to asthma exceeded $2 million.
Physician-School Nurse Coordination
The Health Department and its partners have focused on increasing the coordination between the child’s physician and school nurse, as this is crucial in providing the best possible care for children with asthma. The VAAP is an effective tool for increasing this coordination as one copy of the VAAP should be sent to the child’s school nurse. The bottom lines of the VAAP provide space for the physician and parents’ signatures, constituting permission for the school nurse to manage the child’s asthma at school.
In the spring of 2004, the Vermont Child Health Improvement Program (VCHIP) in collaboration with the departments of Health and Education began the School Asthma Project. The goal of this project is to improve coordination of care in Vermont communities for school-aged children who have asthma. Health providers interested in the VCHIP Provider-School Nurse Coordination Project should contact Kathleen Keating, Project Director, VCHIP, 802-847-9645 or e-mail Kathleen.Keating@uvm.edu.
More work needs to be done to increase the number of people given written asthma management plans. Over time, these plans should improve the quality of life for those suffering from asthma, reduce asthma-related hospitalizations and ED visits and reduce the costs of medical care.
- Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute
- Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma: Update on Selected Topics 2002, US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute
- Vermont Uniform Hospital Discharge Data Set
- Cost is defined as all charges billed for the hospitalization and does not include any indirect costs incurred by the hospital.
Recreational Water Illnesses
Recreational Water Illness (RWI) refers to illness associated with the use of recreational water venues, including swimming pools, water parks, hot tubs, and lakes. Waterborne pathogens may enter the body through inhalation, ingestion, or injured skin, and can cause a variety of illnesses including skin and soft tissue infections, and gastrointestinal illness.
Skin and Soft Tissue Infections
- Pseudomonas dermatitis/folliculitis (“hot tub folliculitis”)
- This superficial infection was first reported in 1975.1 Outbreaks have been associated with hotel whirlpools, home spas, swimming pools, water slides, and neoprene diving suits. Whirlpools and spas may be especially conducive to overgrowth of Pseudomonas aeruginosa because the higher water temperature, mechanical aeration by jets, and higher concentration of organic material make it dif cult to maintain a stable free-chlorine level.2 Clinically, folliculitis presents after an average incubation period of 48 hours, with a range of 8 to 120 hours. Pruritic papules 2 to 10 mm in diameter are generally located on the buttocks, thighs, arms, and axillae. The rash usually heals within two to ve days. Systemic or topical antibiotic therapy is not required, and topical corti-costeroids may delay resolution of the rash.
- Acute diffuse otitis externa (“swimmer’s ear”)
- Acute diffuse otitis externa is also usually caused by P. aeruginosa and may occur in the same patient as Pseudomo-nas folliculitis. Swimmer’s ear is more common, and can be recurrent, in swimming pool users than hot tub users, who tend to keep their heads above the water. Clinical presentation includes discharge from a pruritic and painful external auditory canal. Most cases resolve spontaneously. Two percent acetic acid otic solution impairs the growth of P. aeruginosa. Eardrops containing topical steroids and antibiotics can be used.
- Schistosome dermatitis (“swimmer’s itch”)
- Schistosome dermatitis occurs when the cercariae of schistosome parasites in water penetrate the skin and cause an acute in ammatory response resulting in a pruritic rash. The illness usually follows swimming or wading in lakes, with a peak intensity 48 to 72 hours after exposure. The clinical manifestation includes urticaria with persistence of pruritic macules that may evolve into papules or pustules. The severity of the reaction varies from person to person; in most, symptoms subside in four to seven days. There is no specific therapy, although topical and systemic medications can control the pruritis.
Gastrointestinal illnesses are the most common RWIs, and can have serious effects on those most susceptible to these illnesses: the young, the elderly, pregnant woman, and those who are immuno-compromised. The illnesses most associated with recreational water exposure include Cryptosporidiosis, E. Coli O157:H7 infection, Shigellosis, Giardiasis, and No-rovirus infection.3
Swimmers can be infected by small doses of contaminated water. Proper maintenance of water facilities and chlorination can usually control these pathogens. However, some of these agents have a high resistance to chlorine. For instance, normal chlorine levels of 1 ppm can eradicate E. coli O157 in less than one minute, while giardia can persist for 45 minutes and Cryptosporidium parasites can persist for more than six days.4 Other agents, such as Norovirus, have unknown chlorine resistance levels.
These pathogens are commonly introduced into recreational waters by fecal accidents or leaky diapers. Patients with diarrhea and parents of young children should be advised of the risk they may pose to other swimmers. Those with symptoms of diarrheal illnesses should be advised not to swim for up to two weeks after symptoms cease.
The Vermont Department of Health urges providers to educate their patients about safe swimming behaviors in order to prevent the transmission of common RWIs. In addition to not swimming while ill, swimmers should practice good hygiene when using recreational water venues. This includes showering before going into the water and thorough hand washing after using the bathroom. Children should be taken on frequent bathroom breaks to avoid accidents, and diapers should be changed in the restroom, not at poolside. Swallowing recreational water should be avoided.5
Routine enteric and parasite testing conducted at the Vermont Department of Health Laboratory can detect these illnesses. With detection and prevention starting with the provider, recreational swimming waters can be safer for everyone this summer.
For more information about safe swimming behaviors, as well as additional preventative tips for the public, providers and pool staff, please visit the CDC’s healthy swimming website at www.cdc.gov/healthyswimming.
- McCausland WJ and Cox PJ. Pseudomonas infection traced to motel whirlpool. J Environ Health 37:455-459, 1975.
- Ayi B and Dworzack D. Freshwater: from lakes to hot tubs, p. 83. In D Scholssberg (ed.), Infections of Leisure, 3rd ed. ASM Press, Washington, D.C.
- Castor, Mei. Safe Swimming: Talk to parents about preventing recreational water illness. American Academy of Pediatrics Newsletter. 226-227, May 2004.
- Healthy Swimming: Fecal Accident Response Recommendations for Pool Staff. Centers for Disease Control. www.healthyswimming.org
- Castor M. and Beach M. Prevention of Recreational Water Illnesses. Infectious Diseases in Children. Vol. 17:5, May 2004.
Vermont Selected Reportable Diseases: January–December 2004
Report Disease: Vermont Toll-Free 1-800-640-4374 or 1-802-863-7240
Vermont Department of Health
Division of Health Surveillance P.O. Box 70 Burlington, VT 05402-0070
Agency of Human Services
Paul E. Jarris, MD, MPH
THIS BULLETIN IS PRODUCED BY THE DISEASE CONTROL BULLETIN EDITORIAL STAFF.
Curt Lohff, MD, MPH
Report Disease: Vermont Toll-Free 1-800-640-4374 or 1-802-863-7240