Negative impact of the COVID-19 pandemic on the timely diagnosis of tick-borne infections

Identifying the geographic leading edge of Lyme disease in the United States with internet searches: A spatiotemporal analysis of Google Health Trends data

BACKGROUND

The geographic footprint of Lyme disease is expanding in the United States, which calls for novel methods to identify emerging endemic areas. The ubiquity of internet use coupled with the dominance of Google's search engine makes Google user search data a compelling data source for epidemiological research.

OBJECTIVE

We evaluated the potential of Google Health Trends to track spatiotemporal patterns in Lyme disease and identify the leading edge of disease risk in the United States.

MATERIALS AND METHODS

We analyzed internet search rates for Lyme disease-related queries at the designated market area (DMA) level (n = 206) for the 2011-2019 and 2020-2021 (COVID-19 pandemic) periods. We used maps and other exploratory methods to characterize changes in search behavior. To assess statistical correlation between searches and Lyme disease cases reported to Centers for Disease Control and Prevention (CDC) between 2011 and 2019, we performed a longitudinal ecological analysis with modified Poisson generalized estimating equation regression models.

RESULTS

Mapping DMA-level changes in "Lyme disease" search rates revealed an expanding area of higher rates occurring along the edges of the northeastern focus of Lyme disease. Bivariate maps comparing search rates and CDC-reported incidence rates also showed a stronger than expected signal from Google Health Trends in some high-risk adjacent states such as Michigan, North Carolina, and Ohio, which may be further indication of a geographic leading edge of Lyme disease that is not fully apparent from routine surveillance. Searches for "Lyme disease" were a significant predictor of CDC-reported disease incidence. Each 100-unit increase in the search rate was significantly associated with a 10% increase in incidence rates (RR = 1.10, 95% CI: 1.07, 1.12) after adjusting for environmental covariates of Lyme disease identified in the literature.

CONCLUSION

Google Health Trends data may help track the expansion of Lyme disease and inform the public and health care providers about emerging risks in their areas.

Impact of the COVID-19 pandemic on delays in diagnosis and treatment of tick-borne diseases endemic to southeastern USA

BACKGROUND

The Coronavirus disease 2019 (COVID-19) pandemic was marked by an increase in diagnosis and treatment delays for a range of medical conditions. Yet the impact of the pandemic on the management of tick-borne diseases, which frequently manifest as an acute febrile illness similar to COVID-19, has not been well described.

METHODS

In this retrospective cohort study of patients with suspected tick-borne disease attending the University of North Carolina Health facilities, we compared the timeliness of diagnosis and treatment in a "pre-COVID" period (March 2019 to February 2020) and a "post-COVID" period (March 2020 to February 2021). Participants included patients with an ICD-10 diagnosis code of spotted fever group rickettsiosis or ehrlichiosis and a positive Rickettsia rickettsii or Ehrlichia indirect immunofluorescence assay immunoglobulin G antibody test result. Of the 897 patients who had an eligible diagnosis, 240 (26.8%) met the inclusion criteria. The main outcome was time from initial presentation to definitive diagnosis and treatment.

RESULTS

During the 2-year study period, 126 (52.5%) patients were grouped in the pre-COVID period and 114 (47.5%) were grouped in the post-COVID period; 120 (50.0%) were female; and 139 (57.9%) were aged > 50 years. Comparing the post-COVID to the pre-COVID period, the adjusted odds ratio (aOR) for delay in treatment > 0 days was 1.81 (95% confidence interval [CI] 1.07-3.07, P = 0.03), and for a treatment delay > 7 days, 1.65 (95% CI 0.94-2.90, P = 0.08). The odds of a delay in diagnosis were similar for patients in the post- and pre-COVID periods, with an aOR of 1.61 (95% CI 0.96-2.72, P = 0.07) for delays > 0 days, and aOR of 1.72 (95% CI 0.99-3.00, P = 0.05) for delays > 7 days.

CONCLUSIONS

The odds of a delay in treatment > 0 days were significantly higher in the post-COVID period than in the pre-COVID period. However, the odds of a delay in treatment > 7 days, or a delay in diagnosis, were similar between these two periods. Shifts in care-seeking, alternative care delivery models and prioritization of COVID-19 may contribute to diminished timeliness of treatment for patients with tick-borne diseases.

Initial Presentation and Time to Treatment in Early Lyme Disease

The erythema migrans (EM) rash is an important initial diagnostic sign of early Lyme disease. We tested the hypothesis that patients who noticed EM first differed from those who noticed viral-like symptoms first. "EM First" participants (167/271, 61.6%) had shorter illness duration before treatment (5.0 versus 6.2 days, P = 0.019), were more likely to have seen or removed a tick (P = 0.048) and to be non-Hispanic White (P = 0.025), and were less likely to present with disseminated lesions at the time of diagnosis (P = 0.003) than "Symptoms First" participants (104/271, 38.4%). In multivariate analyses, EM First participants had a 22% decrease in time to treatment (P = 0.012) compared with Symptoms First participants, suggesting that initial presentation affects time to treatment. In a large minority of patients, EM may not be the initial sign or symptom of early Lyme disease. There is a need for rapid diagnostics and improved physician awareness of the varied manifestations of early Lyme disease.

Increasing Incidence of Spotted Fever Group Rickettsioses in the United States, 2010-2018

Spotted fever group Rickettsia species are intracellular bacteria transmitted by tick or mite vectors and that cause human diseases referred to as spotted fever group rickettsioses, or spotted fevers. In the United States, the most recognized and commonly reported spotted fevers are Rocky Mountain spotted fever (RMSF) (Rickettsia rickettsii), Rickettsia parkeri rickettsiosis, Pacific Coast tick fever (Rickettsia species 364D), and rickettsialpox (Rickettsia akari). In this study, we summarize and evaluate surveillance data on spotted fever cases reported to the Centers for Disease Control and Prevention (CDC) through the National Notifiable Diseases Surveillance System from 2010 to 2018. During this period, there were 36,632 reported cases of spotted fevers with 95.83% (N = 35,104) reported as meeting the case definition as probable and 4.17% (N = 1528) reported as meeting the case definition as confirmed. The average national incidence of total cases, both probable and confirmed, was 12.77 cases per million persons per year. The highest statewide incidence was in Arkansas, with 256.84 per million per year, whereas the lowest incidence occurred in California, with 0.32 per million per year (note that spotted fevers were not notifiable in Hawaii and Alaska). Cases of spotted fevers were reported more frequently among males by gender, White by race, and non-Hispanic by ethnicity. The incidence of spotted fevers increased significantly from 2010 to 2018, but it is uncertain how many of the reported cases were RMSF and how many developed from more moderate spotted fevers. Improvement of the ability to differentiate between spotted fever group Rickettsia species is needed.

An intervention in general practice to improve the management of Lyme borreliosis in Denmark

Background

Our objectives were to improve the following outcomes in patients with Lyme borreliosis (LB) through an educational intervention in general practice: (i) increase the number of hospital referrals on suspicion of LB, (ii) increase the number of cerebrospinal fluid (CSF) tests examined for Borrelia burgdorferi antibody index, (iii) decrease the number of serum-B. burgdorferi antibody tests ordered, (iv) shorten delay from symptom onset to hospital in Lyme neuroborreliosis (LNB) patients, (v) increase LB knowledge among general practitioners.

Methods

A prospective non-blinded non-randomized intervention trial on the island of Funen, Denmark. The intervention included oral and written education about LB and was carried out in areas with an LNB incidence ≥4.7/100.000 between 22 January 2019 and 7 May 2019. Results were compared between the intervention group (49 general practices) and the remaining general practices in Funen (71 practices) 2 years before and after the intervention.

Results

In the study period, 196 patients were referred on suspicion of LB, a 28.9% increase in the intervention group post-intervention, 59.5% increase in the control group (P = 0.47). The number of CSF-Borrelia-antibody index tests increased 20.8% in the intervention group, 18.0% in the control group (P = 0.68), while ordered serum-B. burgdorferi antibody tests declined 43.1% in the intervention group, 34.5% in the control group (P = 0.30). 25.1% had the presence of serum-B. burgdorferi antibodies. We found no difference in LNB pre-hospital delay before and after intervention or between groups (P = 0.21). The intervention group performed significantly better on a follow-up questionnaire (P = 0.02).

Conclusion

We found an overall improvement in LB awareness and referrals among general practitioners but could not show any effect of the intervention on clinical outcomes of LNB.

Prevention of tick-borne diseases: challenge to recent medicine

Abstract

Ticks represent important vectors and reservoirs of pathogens, causing a number of diseases in humans and animals, and significant damage to livestock every year. Modern research into protection against ticks and tick-borne diseases focuses mainly on the feeding stage, i.e. the period when ticks take their blood meal from their hosts during which pathogens are transmitted. Physiological functions in ticks, such as food intake, saliva production, reproduction, development, and others are under control of neuropeptides and peptide hormones which may be involved in pathogen transmission that cause Lyme borreliosis or tick-borne encephalitis. According to current knowledge, ticks are not reservoirs or vectors for the spread of COVID-19 disease. The search for new vaccination methods to protect against ticks and their transmissible pathogens is a challenge for current science in view of global changes, including the increasing migration of the human population.

Highlights

• Tick-borne diseases have an increasing incidence due to climate change and increased human migration

• To date, there is no evidence of transmission of coronavirus COVID-19 by tick as a vector

• To date, there are only a few modern, effective, and actively- used vaccines against ticks or tick-borne diseases

• Neuropeptides and their receptors expressed in ticks may be potentially used for vaccine design

Incidence of Tick-Borne Encephalitis during the COVID-19 Pandemic in Selected European Countries

Ixodes ricinus ticks are one of the most important vectors and reservoirs of infectious diseases in Europe, and tick-borne encephalitis (TBE) is one of the most dangerous human diseases transmitted by these vectors. The aim of the present study was to investigate the TBE incidence in some European countries during the COVID-19 pandemic. To this end, we analyzed the data published by the European Center for Disease Prevention and Control (ECDC) and Eurostat on the number of reported TBE and COVID-19 cases in 2020 and TBE cases in 2015–2019 (reference period). Significant differences in the TBE incidence were found between the analyzed countries. The highest TBE incidence was found in Lithuania (25.45/100,000 inhabitants). A high TBE incidence was also observed in Central European countries. In 12 of the 23 analyzed countries, there was significant increase in TBE incidence during the COVID-19 pandemic during 2020 compared to 2015–2019. There was no correlation between the incidence of COVID-19 and TBE and between the availability of medical personnel and TBE incidence in the studied countries. In conclusion, Central Europe and the Baltic countries are areas with a high risk of TBE infection. Despite the COVID-19 pandemic and imposed restrictions, the incidence of TBE is increasing in more than half of the analyzed countries.

Diseases Transmitted by the Black-Legged Ticks in the United States: A Comprehensive Review of the Literature

The black-legged tick is endemic to the midwestern, northeastern, western, south-eastern, and southern regions of the United States. There has been an increased burden of black-legged ticks in humans in recent years. COVID-19 pandemic has further heightened this burden. We thereby reviewed the literature to discuss the seasonality, infections, and clinical spectrum of diseases transmitted by the black-legged ticks. We also discuss the reported delay in the diagnosis of these diseases during the pandemic situation, the alpha-gal syndrome, the importance of prompt diagnosis, and early medical intervention with an aim to increase awareness of the black-legged tick-borne diseases.

Epidemiological Surveillance of Lyme Borreliosis in Bavaria, Germany, 2013-2020

Lyme borreliosis (LB) is the most common tick-borne disease in Germany. Mandatory notification of acute LB manifestations (erythema migrans (EM), neuroborreliosis (NB), and Lyme arthritis (LA)) was implemented in Bavaria on 1 March 2013. We aimed to describe the epidemiological situation and to identify LB risk areas and populations. Therefore, we analyzed LB cases notified from March 2013 to December 2020 and calculated incidence (cases/100,000 inhabitants) by time, place, and person. Overall, 35,458 cases were reported during the study period (EM: 96.7%; NB: 1.7%; LA: 1.8%). The average incidence was 34.3/100,000, but annual incidence varied substantially (2015: 23.2; 2020: 47.4). Marked regional differences at the district level were observed (annual average incidence range: 4–154/100,000). The Bavarian Forest and parts of Franconia were identified as high-risk regions. Additionally, high risk for LB was found in 5–9-year-old males and in 60–69-year-old females. The first group also had the highest risk of a severe disease course. We were able to identify areas and populations in Bavaria with an increased LB risk, thereby providing a basis for targeted measures to prevent LB. Since LB vaccination is currently not available, such measures should comprise (i) avoiding tick bites, (ii) removing ticks rapidly after a bite, and (iii) treating LB early/adequately.

Lone Star Ticks (Amblyomma americanum):: An Emerging Threat in Delaware

Public health messaging in the eastern United States has historically underemphasized the risks posed by lone star ticks (Amblyomma americanum), focusing instead on blacklegged ticks (Ixodes scapularis). This gap persists despite mounting evidence that lone star ticks also play an important role in disease ecology as confirmed vectors for a wide variety of tick-borne pathogens. These pathogens include several distinct bacterial agents that cause ehrlichiosis and tularensis in humans and dogs, a protozoal agent that causes cytauxzoonosis in cats, and emerging viruses such as Heartland, Bourbon, and Tacaribe. Lone star ticks are additionally linked to Rocky Mountain spotted fever, southern tick-associated rash illness, and alpha-gal syndrome, a condition marked by immune reactions to ingestion of mammalian meat. Moreover, their distribution in North America is expanding due to changing climatic factors and land use patterns. Lone star ticks are the most commonly encountered tick in Delaware, especially in Sussex and Kent Counties, and make up the vast majority of ticks collected in the first two years of the state’s tick surveillance program. Given the magnitude of lone star ticks’ medical and veterinary import, it is vital for healthcare professionals and health educators to devote more attention to this emerging threat.

A case of Bartonellosis presenting as a puzzling multisystem disorder complicated by nosocomial COVID-19 infection

The most commonly considered infection with a Bartonella species is cat-scratch disease caused by Bartonella henselae Here, we discuss a unique case of a 60-year-old man who presented with Bartonella infection complicated by nosocomial COVID-19. He was admitted with a history of chest pain, persistent fever, rash and influenza-like symptoms. Positive Bartonella serology confirmed diagnosis and the patient developed complications of pericardial effusion in addition to COVID-19 infection, requiring non-invasive ventilation and admission to the intensive care unit. We discuss his symptoms, investigations, treatment and outcomes, while also highlighting the challenges of assessing patients presenting with fever of unknown origin during the COVID-19 pandemic.

Lyme Disease in the Era of COVID-19: A Delayed Diagnosis and Risk for Complications

We describe a patient with fever and myalgia who did not have COVID-19 but instead had Lyme disease. We propose that the co-occurrence of COVID-19 and Lyme disease during the spring of 2020 resulted in a delayed diagnosis of Lyme disease due to COVID-19 pandemic-related changes in healthcare workflow and diagnostic reasoning. This delayed diagnosis of Lyme disease in the patient we describe resulted in disseminated infection and sixth nerve palsy. We present the use of telemedicine to aid in the diagnosis of Lyme disease and to provide prompt access to diagnosis and care during the ongoing COVID-19 pandemic and in the future.