Ticked Off

Last year, after one of our members came down with erlichiosis from an encounter with some ticks on the Ozark Trail, I decided to find out some more information about ticks and the consequences of their bites. Luckily for us, we have a tick expert right here in Missouri, who also happens to be a mountain biker- Dr. Greg Cummins, who is a member of Earthriders out in Kansas City, and the author of the Tick-Borne Diseases section of Wilderness Medicine, which is kind of the bible for outdoor medical care. I contacted Greg and had a discussion with him about ticks and the local environment. Fortunately for me, he also mentioned that he would be working on a paper after many years of threatening to do so. So, I managed to win the battle of procrastination, and Greg has kindly allowed us to republish an article that originally appeared on the Earthriders website. He asked me to point out that while the article was written for the KC area, everything in it also applies to the STL as well. I've lightly edited out a few things that didn't really relate to mountain biking.

Despite our nicely groomed and well maintained trails, ticks are abundant at all trails, especially those around the Kansas City metro area. Tick-borne diseases affect everyone, not just those involved in outdoor activities. Building and maintaining trails especially exposes trail workers, as we are working directly in the leaf litter, where the ticks are found. Activities such as walking, working in the yard, sitting out on the patio, in addition to true outdoor sports expose you to ticks and the diseases they carry. Tick-borne diseases are common among us bikers, but are even seen in people who seldom or never go outdoors. They are much more prevalent in those who do spend a lot of time outdoors. Certain tick-borne diseases are five times more likely in pet owners, as they participate in activities more likely to expose the pet owners, and due to pets coming in and out of the residence. This may expose pet and homeowners to tick-borne diseases without actually encountering the outdoors. Ticks are generally non-preferential in regards to a host. In other words, they will get a blood meal wherever they can. Basically, they are not selective, and they suck.

Tick-borne diseases have increased significantly over the past 20 years, for various reasons, from increased suburbanization, increased reservoir host populations (such as deer, raccoons, opossums, coyotes, and numerous others--not to mention the all elusive bobcat or mountain lion), and the increase of people participating in outdoor activities and pet ownership. Additionally, there has been an extension of the warmer seasons, and overall change in weather patterns—call it global warming or climate change, whatever you want, it is indeed happening. Deer populations have increased 60 fold in the past 100 years due to decreased natural predators. Each deer can carry over 3000 ticks. Each female tick may lay over 3000 eggs. Deer are thus a significant contributor to tick populations. Combine these statistics with the increased suburbanization, and Houston, we have a problem.

Tick-borne diseases are often very hard to diagnose. They frequently mimic nonspecific summer flu or viral symptoms, such as general lack of energy, fatigue, headache, fevers, chills, body aches, dry cough, nausea and other gastrointestinal symptoms, among many other vague symptoms. If you experience any of these symptoms, with or without a rash, and with or without a confirmed tick bite, during warmer months (can occur any time of year, but typically March through November), go see your doctor. Doctors are becoming more aware of tick-borne diseases and can treat you and test for these diseases. Basic lab tests which are returned very quickly will indicate specific abnormalities consistent with some tick-borne diseases. Specific immunological tests for most of these diseases are available, though are often inaccurate and take some time to get results. If your doctor is really suspicious for a tick-borne disease, you should start antibiotics immediately.

The main tick-borne diseases to be aware of in this area include (in order of prevalence), with referral websites to CDC links for more information:

Ehrlichiosis (and anaplasmosis), also called the “spotless spotted fevers”—transmitted by 2-3 tick species, is the most common tick-borne disease found in this area. This disease is much like Rocky Mountain Spotted Fever (RMSF), and manifests with high grade fevers, and the above symptoms. The fevers in Ehrlichiosis are often in the 102-104 degrees Fahrenheit range. Twenty percent of adults may have a fine diffuse rash (meaning 80% DON’T have a rash), and up to 40% of children may have the rash. The incubation period for Ehrlichiosis is 3 days to 3 weeks, with a median incubation period of about 7 days. Ticks that transmit Ehrlichiosis typically need to be attached (feeding on you) 24-48 hours to transmit this disease. Untreated, Ehrlichiosis carries a 5% mortality rate, while 30-40% of patients will require hospitalization, so if you ride/work/run/walk on trails around here, see a doctor if you have any of the above symptoms. For more information go to http://www.cdc.gov/ticks/diseases/ehrlichiosis/ and http://www.cdc.gov/ticks/diseases/anaplasmosis/faq.html

Rocky Mountain spotted fever (RMSF) is very similar to Ehrlichiosis in signs and symptoms. The name is a misnomer, as >85% of the cases are from states east of the Rocky Mountains. We do see some around the KC metro area, though far less than Ehrlichiosis. It is also called “black measles” due to the black pimple/crater-like formations often seen. Typically also high grade fevers, >102 degrees Fahrenheit. RMSF is transmitted by various tick species. The incubation period, from time of tick attachment to disease manifestation is 2 days to 2 weeks. The ticks that transmit this disease only need to be attached (feeding on you) for 6 hours for disease transmission to occur. Mortality is 3-5% treated, 20-30% untreated, so don’t mess around with this one either.
For more information go to http://www.cdc.gov/ticks/diseases/rocky ... r/faq.html

Lyme disease, as it is traditionally known, does not exist around here. There is a very close cousin to Lyme disease in the Midwest. True Lyme does exist just north of us, in the Wisconsin/Minnesota/Michigan area, as well as the northeastern US, and extreme western US. We do have Lyme-like disease around here. It is Southeastern Tick-Associated Rash Illness (STARI), as coined by the Centers for Disease Control (CDC). It has some of the symptoms of Lyme disease, but appears to be more self-limited and less severe in its presentation. Patients who apparently have STARI may present with a rash similar to the typical “Bulls-eye” rash seen in traditional Lyme disease. This is a newly discovered disease, but with appropriate treatment, there is no evidence of the long-term ramifications of true Lyme disease. Additionally, there are several websites and clinics dedicated to “Chronic” Lyme disease. In New England, these may be more appropriate, but in our geographic region, true Lyme disease does not exist, and thus there is no “Chronic” Lyme disease in this area. We are still learning a lot about STARI though.
For more information go to http://www.cdc.gov/ncidod/dvbid/stari/ and
http://www.cdc.gov/ncidod/dvbid/lyme/index.htm

There are a plethora of other tick-borne diseases, though the above are the main ones you may encounter in this area. If you travel much, either nationally or internationally, or spend much time hiking or camping, you will need to be aware of many other tick-borne diseases. Many of these diseases are specific to a certain region or environment. Make sure your doctor knows where you have been on recent trips if you have any unexplained symptoms and may have been exposed to any tick-borne diseases. And remember, travel exposure may not be in the traditional sense. Over 29 foreign tick species have been brought into the United States on imported reptiles legally brought into this country. These ticks may transmit a multitude of diseases not normally found nor expected in this area.

What can you do to reduce ticks and transmission of tick-borne diseases??

Do not let these facts scare you away from the outdoors—more of us should participate in and enjoy outdoor activities. Take preventive measures to decrease the chance of disease transmission. Wear light colored clothing, as it is easier to see ticks and remove them before they attach and begin to feed. Check yourself frequently and remove any moving or attached ticks immediately (see below for removal methods for attached ticks). Use a mirror to check those hard to see/reach places, or recruit someone to do this for you. Monitor for the above signs and symptoms if you notice an attached tick, and note the time of exposure/attachment of the tick and removal of the tick, and onset of symptoms. There is absolutely no need to simply start antibiotics for a uncomplicated tick bite (unless you are pregnant—if so, see your doctor right away). Go to your doctor as soon as you experience any of the above symptoms and give them a good history and timeline of events. I am personally not a huge fan of chemicals, though insect sprays containing near or equal to 100% DEET are good deterrents for ticks. Any less than 33% regular DEET will not deter ticks. Do not use high conentrations of DEET on children. A product called Permanone, or other permethrin containing tickicide is great for killing ticks. However, it is a skin irritant and is NOT to be used on, nor allowed to contact, skin, nor use for children. It will remain on clothing or fabrics through several washings at high enough concentrations to kill ticks. The fancy-dancy outdoor places like Cabela’s and Bass Pro Shops, as well as the internet, sell permethrin permeated clothing (www.exofficio.com; http://www.insectshield.com/AboutUs/BrandPartners.aspx, www.insectrepellentwear.com, and www.orvis.com) are a few.

Most tick-borne diseases are easily treated with oral antibiotics, and rarely ever need intravenous antibiotics. If you find a doctor wanting to start you on intravenous antibiotics, and you are aware of this, and not physically in the Intensive Care Unit, find another doctor. There are a few fraudulent “Lyme docs” out there. Most patients do very well with oral treatment, with early recognition. The key, however, is early recognition and treatment of these diseases.

How do I remove ticks once they’re on me??

For free ranging/non-attached ticks, simply pick them off and discard them (i.e., throw them out the window when going 60 MPH—they may bother somebody else, but not you), place them in a bottle with a lid, and dispose of them in the recycle bin, put them in a bottle of alcohol for morbid collection purposes, etc.

For larvae (seed ticks—less than 1mm in size), get some duct tape, and place on your skin where the ticks are (there can be hundreds or thousands of these) and simply peel them off. Another method is to scrape them off with a credit card/bank card, drivers license, etc. These ticks are TINY and have even tinier mouth parts, which only go into your skin a few microns.

For larger ticks (nymphs—the equivalent of juvenile delinquents, or adult ticks), follow the recommendations on the next page. Fancy tick removal tools exist, again, at the same stores mentioned above, but plain old tweezers work just as well, and cost way less. Keep one in your bike bag, or vehicle.

Safe tick removal method:

Gently grasp the tick close to the skin with fine forceps and gently and steadily retract backwards. This will reduce the chance of the tick to leave mouth parts in your skin, and will minimize disease transmission. Clean the area afterwards with alcohol and/or hydrogen peroxide, then cover and keep clean. Observe the area for any signs of infection, and if any redness occurs more than a few days after the tick removal/bite, see your doctor. You can get a local infection, as ticks do not use alcohol wipes to clean the area before they bite. If you get a local redness within a few days at the bite site, that itches a lot, it is a local reaction to the tick proteins they secrete to thin your blood and stay on. It should resolve within a few days. If not, see your doctor.
Also see: http://www.cdc.gov/ticks/tick_removal.html

DO NOT USE methods such as hot matches, Vaseline, alcohol, etc., and do not “snatch” the tick off. Use gentle steady traction straight out, in line with the ticks mouth parts. Place the tick in a bottle of alcohol, and label it with the date and time of removal and where it was found in case tick identification is needed for disease confirmation.

For questions regarding ticks and for tick identification, feel free to contact me via email. While I can not give you direct medical advice, I can help your physician identify ticks, and can help point you in the right direction for a physician if you do not already have one, or a local infectious disease specialist if needed, for more intensive review.

drgacummins(AT)gmail(DoT)com