Tick- and Mosquito-borne Diseases In Massachusetts

Catherine M. Brown, DVM MSc MPH

Deputy State Epidemiologist
State Public Health Veterinarian
Department of Public Health

William A. Hinton State Laboratory Institute

 Environment

Reservoir
Pathogen
Species

Vector
Humans

2
WNV and EEE Transmission

3
 Eastern Equine Encephalitis
Human Disease

• Rare but severe

• Children disproportionately affected
• Incubation period 3-10 days
• Abrupt onset fever, chills, headache, muscle
aches, nausea and vomiting, seizures, coma
• ~30-50% mortality
• ~80% of survivors residual neurological
deficits
Eastern equine encephalitis virus cases
reported by state, 2004–2013

7
Human EEE Cases by County of Residence,
1938-2014

4
1
15
9
1 1 23
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8
1
1
 West Nile Virus Infection
Human Disease

• Incubation period 3 to 14 days

• Age-related severity
• 80% Mild and sub-clinical infection
• 20% Headache, sore throat, fatigue, muscle and
joint aches, fever (moderate to high),
• <1% Aseptic meningitis, encephalitis,
meningoencephalitis
Human WNV Cases by County of Residence,
2001-2014

6
47
1 1 20
17
6 10
3
6
104 1
cases
1
Spread of Zika Virus

2013?
www.cdc.gov/zika

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 Zika Transmission Cycle

Human – Mosquito –Human

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 Zika Symptoms

• 80% of people will develop no symptoms

• 2-7 day duration of illness
• Self-limiting – no treatment required
• Severe disease with hospitalization is rare
• Symptoms:
– Fever
– Maculopapular rash, may be itchy
– Joint pain with swelling, often in the
extremities
– Conjunctivitis (inflammation of the white
part of the eye)
Identified Potential Complications of Zika

Fetal losses and birth defects, including microcephaly

Post infectious complication – Guillain-BarréSyndrome

AP Photo/Felipe Dana
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 Current Recommendations for
Pregnant Women
• Women that are pregnant or trying to become
pregnant should avoid travel to areas with known
Zika virus transmission OR be vigilant about
avoiding mosquito bites
• Test pregnant women with travel to an area with
known Zika virus transmission whether or not they
reported symptoms

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 Guidance on Timing of Pregnancy and
Prevention of Sexual Transmission

Updated interim guidance for women of reproductive age and sexually active men
Symptomatic women diagnosed with Zika 8 weeks after symptom onset before trying
virus or experiencing symptoms of possible to get pregnant
exposure

Symptomatic men diagnosed with Zika virus 6 months after symptom onset before
or experiencing symptoms of possible having unprotected sex
exposure
Asymptomatic men and women with possible 8 weeks after possible exposure before
exposure to Zika virus from recent travel or trying to get pregnant, men should wear a
sexual contact condom during all sexual contact

Asymptomatic men and women who live in an CDC recommends healthcare providers talk
area with active Zika transmission with their patients about pregnancy plans

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Adapted from cdc.gov/zika
Questions Still Being Investigated

• Why has microcephaly been reported more

from some places than other?
• When is maternal infection most risky?
• How often does infection of the fetus occur?
• Are there co-factors that precipitate the birth
defects/fetal losses?
• How often is Zika virus found in semen?
– How long can it be found there?
– How common is sexual transmission?
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 Personal Prevention
• Prevent mosquito bites
• use mosquito repellent with an EPA approved
ingredient such as DEET, Picaridin, Permethrin, Oil
of lemon eucalyptus
• if outdoors, wear a long-sleeved shirt & long pants
• avoid outdoor activities dusk to dawn
• cover playpen/carriage with mosquito netting if
outdoors
• make sure all screens in good repair
• Reduce mosquito populations
• eliminate standing water by clearing gutters and
turning over items that collect water
 Personal Prevention for Travelers
Take steps to prevent mosquito bites.
• Be aware that these mosquito vectors are active
during the day
• Wear long-sleeved shirts and long pants.
• Stay in places with air conditioning and window and
door screens to keep mosquitoes outside.
• Use Environmental Protection Agency (EPA)-
registered insect repellents. When used as directed,
these insect repellents are proven safe and effective
even for pregnant and breastfeeding women.
• Remove or stay away from mosquito breeding sites,
like containers with standing water.
Factors Associated with Increasing
Risk of Tick-borne Diseases

• Fragmented forest environment

– Expansion of habitat
– Increased deer population
– Increased white-footed mouse population
• Increased black-legged tick population
• Amplification of the pathogens
• More people exposed to “ticky” habitat
Reporting Volume

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Anaplasmosis - Noteworthy from 2015
• 763 confirmed and probable cases of HGA were reported. This was a
26% increase from 2014.
• Overall 1,476 suspect cases of HGA were investigated.
• Statewide, HGA incidence increased from 9.2 to 11.7 cases per
100,000 residents.
• One out of three patients with HGA (33%) was hospitalized. There were
no reported fatalities.
Babesiosis - Noteworthy from 2015
• 445 confirmed and probable cases of babesiosis were reported in 2015,a 14%
decrease from 2015.
• Overall, 812 suspect cases of babesiosis were investigated.
• Statewide, babesiosis incidence decreased from 7.9 to 6.8 cases per 100,000
residents.
• Approximately one out of three (35%) cases was hospitalized. There were at
least 4 fatalities.
• 12 confirmed cases (3%) had received a blood transfusion in the six months
prior to becoming ill and seven of those are confirmed or likely transfusion-
transmitted cases.
 Tick-borne Disease Co-infections

Lyme/Babesia Hotspots Lyme/HGA Hotspots

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 Borrelia miyamotoi

• Spirochete bacteria – closely related to tick-

borne relapsing fever
– Distantly related to Borrelia burgdorferi
• First identified as human pathogen in 2011
• First US case identified in 2013
• Case Series: Ann Intern Med. 2015;163(2):91

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Borrelia miyamotoi Massachusetts,
2013-2015
• 23 cases (19 confirmed, 4 probable)
– 2013: 8 2014: 10 2015: 5
• 12 male, 11 female
• Age range: 12-76, median 55 y/o
• Bristol, Nantucket, Norfolk and Plymouth
• Month of onset
– June, July, August, September
• At least one hospitalization
– No fatalities
 Powassan/Deer Tick Virus
• Powassan/Deer tick virus
– Flavivirus
– Ixodes cookei (woodchuck tick)/Ixodes scapularis
– Can be transmitted within 15 minutes of tick
attachment
– Eastern Canada and Northeast U.S.
– Severe disease – encephalitis, menigoencephalitis
 Deer Tick Virus

• High seroprevalence in burrowing mammals in

New England
• Rare disease in humans – but severe illness
associated with marked neurological sequelae
and 10-15% case-fatality rate
• Increased recognition with increased evaluation
of encephalitis because of WNV
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Questions?