The majority of tick-borne illnesses found in Kansas are not mandatorily reported and due to the inaccessibility of testing, treatment of potentially fatal diseases may be a matter of guesswork.
Lyme disease, characterized by its flu-like symptoms and a distinctive rash, was first recognized in Old Lyme, Conn., in 1975. It was connected to the deer tick in 1981 by scientist Willy Burgdorfer.
Since then, scientists have discovered approximately 15 tick-borne diseases.
Dana Hawkinson, an infectious disease specialist at the University of Kansas Medical Center, said in an email that the most recently discovered diseases are not likely to be new diseases, but rather have been present all along, and either have been misdiagnosed or not diagnosed at all. Senior epidemiologist Daniel Neises of the KDHE Bureau of Epidemiology and Public Health Informatics agreed.
“The assumption is that our ability to differentiate different tick-borne diseases has gotten much better and the laboratory methods that we have to detect bacterial viruses are far better than they used to be,” Neises said in a telephone interview.
However the Bourbon virus, named for the Kansas county in which it was first discovered in 2015, is of a genotype that is commonly found in Europe, Asia and Africa and never before found in the Western Hemisphere, Hawkinson said in a video on the hospital’s website.
Early into the 2017 tick season, which typically starts in March and extends into the start of winter, eight cases of tick-borne diseases statewide had been reported as of April. Two of those confirmed cases, both Rocky Mountain spotted fever, have been reported in Allen County.
“We expect to continue receiving case reports until winter again,” Neises said.
Just one tick can infect a person with a combination of the diseases, and which diseases are transmitted depends on the type of tick. Why some tick-borne diseases are more prevalent in different areas of the country depends on the circulation of the bacteria that causes them, Neises said. The longer an infected tick is attached to the human body the better chance it has of transmitting disease.
The most common ticks found in Kansas are the American dog tick, the lone star tick, the brown dog tick and the black-legged tick. The Lyme Disease Association lists diseases on its website contracted by the four types of ticks that call Kansas home.
But not all of the diseases are being tracked by the state and screening does not routinely take place, according to both Neises and Hawkinson.
Of the tick-borne illnesses found in Kansas only ehrlichiosis- anaplasmosis, spotted fever rickettsiosis, Q fever, tularemia and lyme disease are mandatorily reported. In 2014, 212 cases of tick-borne diseases were reported in Kansas; 75 of those patients were hospitalized.
It is unclear how accurate the reported numbers are, Hawkinson said.
“In a rural area I would think a lot of physicians would be keyed into considering typical tick-borne illness high in the differential diagnosis and just treating based on that fact without need for testing,” he said. “ It is unclear how many of the cases may be diagnosed by interviewing and examining the patient and looking at the clinical picture, then making a presumptive diagnosis and treating with empiric treatment.”
Neises agreed and said how patients are diagnosed and the treatment they receive depends heavily upon whether a physician is aware of tick-borne diseases present in their region or where the patients have traveled.
BUT A lack of actual testing to confirm cases means a lack of reporting in the long run. Why so many of the tick-borne illnesses found in Kansas are not mandatorily reported may have to do with factors such as overall threat, endemicity, lack of information and available testing, according to Hawkinson.
“Many of the diseases either have no specific treatment other than supportive care or the same type of treatment, (the antibiotic) doxycycline. So empirically, the patient may be treated adequately anyway,” he said.
There is a lack of testing readily available to physicians. Both Neises and Hawkinson agreed that doctors have a limited menu of tests to choose from, and although tests for the more commonly known diseases are readily accessible, tests for the lesser-known unreported diseases are more difficult to obtain.
“It is just not as easy to test for powassan disease or the borrelia disease as it is for lyme disease or Rocky Mountain spotted fever or the diseases that we are more familiar with,” Neises said.
Due to the gap in testing and reporting, the possibility exists that tick-borne illnesses are underreported and misdiagnosed statewide, Hawkinson said.
“But that is not unique to tick-borne illness,” he said. “We try our best to diagnose and treat our patients, but medicine is not an exact science.”
Hawkinson said so long as Kansans are implementing protective procedures to avoid contact with ticks they have little to fear. Those who are bitten by a tick should preserve it by putting it in a plastic baggie and placing it in the freezer so if symptoms arise, the bacteria the tick carries can be later identified, Neises said.
BOURBON virus to date has been known to affect two patients. An Oklahoma patient made a full recovery, while the first and only other case in Bourbon County, Kansas, was fatal. Symptoms included fever, fatigue, rash and muscle and joint pain, according to the Lyme Disease Association website. Although the patients had symptoms similar to other tick-borne illnesses, test results proved negative for the other diseases. Failure to effectively treat the Bourbon County patient resulted in the discovery of the disease, according to Neises. Special testing was requested and approved by the Center for Disease Control and Prevention, and researchers were able to isolate the virus that had not been discovered previously, he said. One symptom that makes it different from most other tick-borne illnesses is anorexia.
“It is likely that many ticks carry bourbon virus in the area we suspect to be its endemic area,” Hawkinson said of Bourbon County.
Research on the virus is being conducted by the CDC in collaboration with KU Health System and KDHE to determine more cases, develop an accurate diagnostic test and characterize the spectrum of the disease in patients, he said. But the progress that has been made since 2015 has been minimal.
“Zika virus issue caused a lot of refocus of resources at the national and state level last year,” Hawkinson said.
“I still do not believe anyone is just testing residents of Bourbon County to look for evidence of exposure.”
No commercial testing is available and at this time general supportive care is the treatment.
“No one knows the extent of the spread of the virus in the tick population or the prevalence of evidence of exposure to humans,” he said.
It is suspected that minor cases of the virus exist, according to Hawkinson. But until a test is readily available it will be difficult to begin the process of looking at actual prevalence and incidence rates throughout the community.
BABESIOSIS is a malaria-like disease caused by a parasitic infection of red blood cells. Symptoms can be mild to life threatening, with a high fever, sweats, nausea, headaches and fatigue, according to the Lyme Disease Association’s website.
“Babesiosis is not a reportable disease in Kansas,” Neises said. “Kansas maintains similar requirements for reporting tick-borne diseases as is held nationally.”
But human babesiosis became a nationally notifiable disease in January 2011, according to the CDC. During 2011 and 2012 there were 1,228 and 940 cases reported, respectively. Cases were reported from New England, New York, Wisconsin and Minnesota. In 2013, 27 states conducted surveillance for babesiosis infections from as far east as Maine, as far south as Louisiana and as far west as Oregon. The participating states collectively reported 1,762 confirmed cases. Blood-borne transmission of babesia, the most frequently identified agent of human babesiosis in the U.S., is not restricted by geographic region or season.
“It does not seem to be frequently identified (in Kansas) compared to other states, much in the same way lyme disease is not frequently identified,” Hawkinson said.
According to the Lyme Disease Association, infection of babesiosis usually produces no or only mild symptoms in healthy children and adults, although all ages can be severely affected. Babesiosis can be severe or fatal in the elderly, immunocompromised individuals and people without spleens. Death has been reported in about five percent of cases. Co-infection with the agents of ehrlichiosis or lyme disease can result in more severe or prolonged illness and overlapping clinical symptoms. Asymptomatic infection can persist for months or even years with a risk of transmission to others through blood transfusions. Blood donations are not accepted from people with a history of the disease.
“There currently is no Babesia test approved by the Food and Drug Administration (FDA) available for screening prospective blood donors,” according to the CDC’s website. “Although bloodborne transmission is thought to be uncommon, babesiosis is the most frequently reported transfusion-transmitted parasitic infection in the U.S.”
BARTONELLOSIS is a bacterial disease caused by a bacterium similar to what causes cat scratch fever. It starts with a red mark that can become swollen and discolored or resembles stretch marks. Symptoms include swollen lymph nodes, and it is often accompanied by conjunctivitis, heart or spleen problems, bone lesions, hepatitis, other eye problems and encephalitis. Research continues in order to gain a better understanding of the indirect clinical evidence that a group of “Bartonella-like organisms” can co-infect a lyme disease patient, according to the Lyme Disease Association. Although the bartonella bacteria can be found in wild and domestic animals including cattle and dogs, according to Neises, the disease is not mandatorily reportable in Kansas.
“It can be pretty wide-spread,” he said. “It can be found in fleas, lice and ticks.”
BORRELIA miyamotoi is a recently discovered tick-borne infection that is distantly related to the bacterium that cause lyme disease, and a January 2013 study in the New England Journal of Medicine suggested that the infection may be prevalent in areas where lyme disease is endemic in the U.S. Patients with this infection are most likely to have relapsing fever, chills, headache, fatigue, body and joint pain. Left untreated, it can progress into a disease that causes cardiac, neurologic and arthritic problems, according to the Lyme Disease Association. The disease was not recognized prior to 1995. There is a possibility that because of the similarities in symptoms of borrelia miyamotoi and lyme disease, patients have been incorrectly diagnosed with lyme disease, according to Neises.
“We assume that it existed before,” he said. “So there is always going to be a period of time before we are able to have a laboratory test that identifies these diseases, so there’s no reason to think that people prior to 1995 weren’t infected with that type of bacteria and diagnosed with something else.”
But Hawkinson disagreed and said misdiagnosis would not be possible since the two bacteria associated with the diseases are detected through different tests. The use of the antibiotic doxycycline to treat them is the same however, so it is possible that if a patient was infected with both diseases they could have been unknowingly treated for borrelia miyamotoi while being treated for lyme disease.
“The CDC is still working on accurate diagnostic tests,” he said.
POWASSAN encephalitis is a viral brain infection causing seizures, aphasia, muscle weakness, dementia and death. There is currently no effective treatment and the onset of the illness is rapid, according to the Lyme Disease Association. The disease is rare and reporting is not mandatory, Neises said. If a person tested positive for the deadly disease it would most likely be reported due to its rarity, he said. But just how rarely the disease occurs in Kansas can not be known for sure, according to Hawkinson.
“Certainly if reporting is not mandatory for powassan virus, the actual number of cases may be more than(what is reported to) actually occur,” he said. “ It is difficult to say whether it is actually more rare or not.”
SOUTHERN tick-associated rash illness, according to The Lyme Disease Association, is transmitted by the lone star tick. Early STARI symptoms include a circular rash, similar to the symptoms of early lyme disease. The rash may be accompanied by fatigue, headache, fever and joint pains.This disease is more commonly found in the eastern and southeastern part of the U.S. and diagnosis in Kansas is more rare than in those regions, Neises said.
TICK paralysis is the loss of motor function and increasing paralysis caused by a toxic reaction to saliva from female ticks, according to the Lyme Disease Association’s website.
EHRLICHIOSIS/anaplasmosis is a rickettsial infection similar to rocky mountain spotted fever that affects the white blood cells. A rash may occur. Severe illness may have neurologic complications, and according to the Lyme Disease Association, delayed treatment can result in death.
ROCKY Mountain spotted fever is transmitted by the American dog tick and the brown dog tick. It can cause a reddish-to-black rash resembling measles, and can be severe or even fatal if not treated in the first few days of symptoms, according to the Lyme Disease Association.
During the tick’s life cycle it would have to pick up the specific bacteria that causes the disease, according to Neises. It is one of the most widely recognized tick-borne illnesses in Kansas.
TULAREMIA is a bacterial infection also known as rabbit fever.The onset of the disease is marked by an ulcer at the site of infection. The symptoms can range from spiking fevers, inflamed lymph nodes and eyes, pneumonia and weight loss, according to the Lyme Disease Association..
“(Kansans) are actually in the region of the United States that sees the most of it,” Neises said of the disease.
Ticks are not the only source of this infection. Consuming an undercooked infected rabbit, running over an infected carcass with a lawn mower and breathing in the bacteria can also infect a person, he said. A tick that fed off of an infected rabbit can spread the disease to humans.
Q FEVER, according to the CDC’s website, is a disease caused by a bacterium that is found worldwide. Some animals, such as goats, sheep and cattle, are natural carriers of it. People can get infected, not just by ticks, but also by breathing in dust that has been contaminated by infected animal feces, urine, milk, and birth products. Some people never get sick; however those that do usually develop flu-like symptoms including fever, chills, fatigue, and muscle pain.
More information on ways to prevent tick bites and how to remove ticks is available on the CDC’s website.
