"Tekenscanner": a novel smartphone application for companion animal owners and veterinarians to engage in tick and tick-borne pathogen surveillance in the Netherlands

The SisaMob Information System: Implementation of Digital Data Collection as a Tool for Surveillance and Vector Control in the State of São Paulo

Information systems are essential instruments in managing resources, in the evaluation of the epidemiological situation, and for decision-making at all hierarchical levels. Technological advances have allowed the development of systems that meet these premises. Therefore, it is recommended to consider the optimization of data entry and its immediate georeferencing in order to obtain information in real time. To meet this objective, we describe the application introduction process for the implementation of the digital collection of primary data and its integration with the database through synchronization with the SisaWeb platform (Information System for surveillance and control of Aedes aegypti), developed to meet the needs of the Arbovirus Surveillance and Control Program in the state of São Paulo, Brazil. For this purpose, the application-SisaMob-was conceived in the Android Studio development environment, Google^®, following the same guidelines as the traditional collection method. Tablets equipped with the Android^® operating system were used. To evaluate the implementation of the application, a semi-structured test was applied. The results highlighted that 774.9% (27) of the interviewees evaluated its use positively and, replacing the standard bulletin, 61.1% (22) of the users considered it regular to excellent. The automatic collection of geographic coordinates represented the greatest innovation in the use of the portable device, with reductions in errors and in the time taken to complete the report in the field. The integration to SisaWeb allowed obtaining information in real-time, being easily presented in tabular and graphic modes and spatially arranged through maps, making it possible to monitor the work at a distance, and allowing preliminary analyses during the data collection process. For the future, we must improve the mechanisms for assessing the effectiveness of information, increase the potential of the tool to produce more accurate analyses, which can direct actions more efficiently.

Mapping and monitoring tick (Acari, Ixodida) distribution, seasonality, and host associations in the United Kingdom between 2017 and 2020

Tick-borne disease risk is intrinsically linked to the distribution of tick vector species. To assess risk and anticipate disease emergence, an understanding of tick distribution, host associations, and seasonality is needed. This can be achieved, to some extent, using passive surveillance supported by engagement with the public, animal health, and public health experts. The Tick Surveillance Scheme (TSS) collects data and maps tick distribution across the United Kingdom (UK). Between 2017 and 2020, 3720 tick records were received and 39 tick species were detected. Most records were acquired in the UK, with a subset associated with recent overseas travel. The dominant UK acquired species was Ixodes ricinus (Ixodida: Ixodidae, Linnaeus), the main vector of Lyme borreliosis. Records peaked during May and June, highlighting a key risk period for tick bites. Other key UK species were detected, including Dermacentor reticulatus (Ixodida: Ixodidae, Fabricius) and Haemaphysalis punctata (Ixodida: Ixodidae, Canestrini & Fanzago) as well as several rarer species that may present novel tick-borne disease risk to humans and other animals. Updated tick distribution maps highlight areas in the UK where tick exposure has occurred. There is evidence of increasing human tick exposure over time, including during the COVID-19 pandemic, but seasonal patterns remain unchanged.

The wild life of ticks: Using passive surveillance to determine the distribution and wildlife host range of ticks and the exotic Haemaphysalis longicornis, 2010-2021

Background

We conducted a large-scale, passive regional survey of ticks associated with wildlife of the eastern United States. Our primary goals were to better assess the current geographical distribution of exotic Haemaphysalis longicornis and to identify potential wild mammalian and avian host species. However, this large-scale survey also provided valuable information regarding the distribution and host associations for many other important tick species that utilize wildlife as hosts.

Methods

Ticks were opportunistically collected by cooperating state and federal wildlife agencies. All ticks were placed in the supplied vials and host information was recorded, including host species, age, sex, examination date, location (at least county and state), and estimated tick burden. All ticks were identified to species using morphology, and suspect H. longicornis were confirmed through molecular techniques.

Results

In total, 1940 hosts were examined from across 369 counties from 23 states in the eastern USA. From these submissions, 20,626 ticks were collected and identified belonging to 11 different species. Our passive surveillance efforts detected exotic H. longicornis from nine host species from eight states. Notably, some of the earliest detections of H. longicornis in the USA were collected from wildlife through this passive surveillance network. In addition, numerous new county reports were generated for Amblyomma americanum, Amblyomma maculatum, Dermacentor albipictus, Dermacentor variabilis, and Ixodes scapularis.

Conclusions

This study provided data on ticks collected from animals from 23 different states in the eastern USA between 2010 and 2021, with the primary goal of better characterizing the distribution and host associations of the exotic tick H. longicornis; however, new distribution data on tick species of veterinary or medical importance were also obtained. Collectively, our passive surveillance has detected numerous new county reports for H. longicornis as well as I. scapularis. Our study utilizing passive wildlife surveillance for ticks across the eastern USA is an effective method for surveying a diversity of wildlife host species, allowing us to better collect data on current tick distributions relevant to human and animal health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-022-05425-1.

Variation in haplotypes in single cysts of assemblages C and D, but not of assemblage E of Giardia duodenalis

Background

Giardia duodenalis, a single-celled intestinal parasite, is divided into eight assemblages (A-H), with differences in host specificity. Giardia duodenalis reproduces asexually and cycles between the binucleated trophozoite (4 N) and the infectious cyst with four nuclei (16 N). Interaction between the nuclei is limited. Therefore, genetic drift causes differences in genetic make-up between the non-daughter nuclei; the allelic sequence heterozygosity (ASH). The ASH is low (0.01%—0.0023%) for the related assemblages A and E, higher (0.43–0.53) for assemblage B and much higher (0.74% -0.89%) for the assemblage C and D at the root of the phylogenetic tree. The heterozygosity in assemblage F, in the same clade as assemblage A and E, was unknown. The heterozygosity in the sequences of the gdh and dis3 genes was used as proxy for the ASH and whole genome amplification of single cysts followed by cloning and Sanger sequencing of dis3 fragment could reveal the genetic variation within the cyst. The aim of the study was to determine the level of heterozygosity within pooled and single cysts of different assemblages.

Results

The heterozygosity in gdh and dis3 was determined in pooled cysts of the assemblages A to F. Heterozygosity in the isolates of the assemblages C (n = 2) and D (n = 1) ranged from 0.41% to 0.82% for gdh and dis3 and no heterozygosity was found in the isolates of the assemblages A (n = 4), E (n = 3) and F (n = 3). The heterozygosity in assemblage B (n = 7) was intermediate (0% to 0.62%). Next, the number of haplotypes of dis3 was determined for single cysts of assemblages C, D and E. In the assemblages C and D, two to four haplotypes were found per cyst, while in assemblage E only one haplotype was identified.

Conclusions

Having high heterozygosity is characteristic for the assemblages C and D, while having a low heterozygosity is characteristic for the clade with the assemblages A, E and F.

Presence of more than 1 haplotype per cyst in assemblage C and D suggests differences between the non-daughter nuclei, in contrast to the one haplotype in assemblage E.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-022-02581-3.

Monitoring of ticks and their pathogens from companion animals obtained by the "tekenscanner" application in The Netherlands

Ticks are vectors for many pathogens of veterinary and medical interest. In order to monitor ticks and tick-borne pathogens, the “Tekenscanner” (Dutch for Tick scanner), a citizen science project, was launched in The Netherlands. It is a smartphone application for pet-owners to get ticks from their dog or cat, identified and checked for pathogens for free. At the same time, information about the pet and the geographic location of tick infestation becomes available for research. The application was launched in 2018, and the results of the first 6 months after launch of the app were reported. Ticks were identified based on morphology, and DNA was extracted and amplified by a panel of tick-borne pathogen-specific primers. Next, the amplicons were subjected to reverse line blot with specific probes for important pathogens to determine their presence or absence. The present paper describes the results of 2019 and 2020. There were 2260 ticks collected from 871 dogs and 255 cats (26 ticks were from an unknown host) and all pet owners were informed about the results. Four species of ticks were collected: Ixodes ricinus (90.0%), Ixodes hexagonus (7.3%), Dermacentor reticulatus (2.8%) and Rhipicephalus sanguineus (0.1%). Ixodes ricinus was the tick with the most divergent pathogens: Anaplasma sp. (1.3%), Babesia sp. (0.8%), Borrelia spp. (4.8%), Neoehrlichia sp. (3.7%) and Rickettsia helvetica (12.6%). In I. hexagonus, R. helvetica (1.8%) and Babesia sp. (0.6%) were detected and Rickettsia raoultii in D. reticulatus (16.2%). One of the two nymphs of R. sanguineus was co-infected with Borrelia and R. helvetica and the other one was uninfected. The high numbers of different pathogens found in this study suggest that companion animals, by definition synanthropic animals, and their ticks can serve as sentinels for emerging tick-borne pathogens.

Anaplasma phagocytophilum infection rates in questing and host-attached ticks: a global systematic review and meta-analysis

Anaplasma phagocytophilum causes a multi-organ non-specific febrile illness referred to as human granulocytic anaplasmosis. The epidemiologic risk of the pathogen is underestimated despite human encroachment into the natural habitats of ticks. In this study, we performed a systematic review and meta-analysis to determine the global infection rates and distribution of A. phagocytophilum in tick vectors. We pooled data using the random-effects model, assessed individual study quality using the Joanna Briggs Institute critical appraisal instrument for prevalence studies and determined heterogeneity and across study bias using Cochran's Q-test and Egger's regression test respectively. A total of 126 studies from 33 countries across 4 continents reported A. phagocytophilum estimated infection rate of 4.76% (9453/174,967; 95% CI: 3.96, 5.71). Estimated IRs across sub-groups varied significantly (p <0.05) with a range of 1.95 (95% CI: 0.63, 5.86) to 7.15% (95% CI: 5.31, 9.56). Country-based IRs ranged between 0.42 (95% CI: 0.22, 0.80) in Belgium and 37.54% (95% CI: 0.72, 98.03) in Norway. The highest number of studies on A. phagocytophilum were in Europe (82/126) by continent and the USA (33/126) by country. The risk of transmitting this pathogens from ticks to animals and humans exist and therefore, we recommend the use of chemical and biological control measures as well as repellents and protective clothing by occupationally exposed individuals to curtail further transmission of the pathogen to humans and animals.

Community engaged tick surveillance and tickMAP as a public health tool to track the emergence of ticks and tick-borne diseases in New York

A community engaged passive surveillance program was utilized to acquire ticks and associated information throughout New York state. Ticks were speciated and screened for several tick-borne pathogens. Of these ticks, only I. scapularis was commonly infected with pathogens of human relevance, including B. burgdorferi, B. miyamotoi, A. phagocytophilum, B. microti, and Powassan virus. In addition, the geographic and temporal distribution of tick species and pathogens was determined. This enabled the construction of a powerful visual analytical mapping tool, tickMAP to track the emergence of ticks and tick-borne pathogens in real-time. The public can use this tool to identify hot-spots of disease emergence, clinicians for supportive evidence during differential diagnosis, and researchers to better understand factors influencing the emergence of ticks and tick-borne diseases in New York. Overall, we have created a community-engaged tick surveillance program and an interactive visual analytical tickMAP that other regions could emulate to provide real-time tracking and an early warning for the emergence of tick-borne diseases.

Infection rates, species diversity, and distribution of zoonotic Babesia parasites in ticks: a global systematic review and meta-analysis

Zoonotic Babesia species are emerging public health threats globally, and are the cause of a mild to severe malaria-like disease which may be life threatening in immunocompromised individuals. In this study, we determine the global infection rate, distribution, and the diversity of zoonotic Babesia species in tick vectors using a systematic review and meta-analysis. We used the random-effects model to pool data and determined quality of individual studies using the Joanna Briggs Institute critical appraisal instrument for prevalence studies, heterogeneity using Cochran's Q test, and across study bias using Egger's regression test. Herein, we reported a 2.16% (3915/175345, 95% CI: 1.76-2.66) global infection rate of zoonotic Babesia species (B. divergens, B. microti, and B. venatorum) in tick vectors across 36 countries and 4 continents. Sub-group infection rates ranged between 0.65% (95% CI: 0.09-4.49) and 3.70% (95% CI: 2.61-5.21). B. microti was the most prevalent (1.79%, 95% CI: 1.38-2.31) species reported in ticks, while Ixodes scapularis recorded the highest infection rate (3.92%, 95% CI: 2.55-5.99). Larvae 4.18% (95% CI: 2.15-7.97) and females 4.08% (95% CI: 2.56-6.43) were the tick stage and sex with the highest infection rates. The presence of B. divergens, B. microti, and B. venatorum in tick vectors as revealed by the present study suggests possible risk of transmission of these pathogens to humans, especially occupationally exposed population. The control of tick vectors through chemical and biological methods as well as the use of repellants and appropriate clothing by occupationally exposed population are suggested to curtail the epidemiologic, economic, and public health threats associated with this emerging public health crisis.

Potential for online crowdsourced biological recording data to complement surveillance for arthropod vectors

Voluntary contributions by citizen scientists can gather large datasets covering wide geographical areas, and are increasingly utilized by researchers for multiple applications, including arthropod vector surveillance. Online platforms such as iNaturalist accumulate crowdsourced biological observations from around the world and these data could also be useful for monitoring vectors. The aim of this study was to explore the availability of observations of important vector taxa on the iNaturalist platform and examine the utility of these data to complement existing vector surveillance activities. Of ten vector taxa investigated, records were most numerous for mosquitoes (Culicidae; 23,018 records, 222 species) and ticks (Ixodida; 16,214 records, 87 species), with most data from 2019–2020. Case studies were performed to assess whether images associated with records were of sufficient quality to identify species and compare iNaturalist observations of vector species to the known situation at the state, national and regional level based on existing published data. Firstly, tick data collected at the national (United Kingdom) or state (Minnesota, USA) level were sufficient to determine seasonal occurrence and distribution patterns of important tick species, and were able to corroborate and complement known trends in tick distribution. Importantly, tick species with expanding distributions (Haemaphysalis punctata in the UK, and Amblyomma americanum in Minnesota) were also detected. Secondly, using iNaturalist data to monitor expanding tick species in Europe (Hyalomma spp.) and the USA (Haemaphysalis longicornis), and invasive Aedes mosquitoes in Europe, showed potential for tracking these species within their known range as well as identifying possible areas of expansion. Despite known limitations associated with crowdsourced data, this study shows that iNaturalist can be a valuable source of information on vector distribution and seasonality that could be used to supplement existing vector surveillance data, especially at a time when many surveillance programs may have been interrupted by COVID-19 restrictions.

Effect of Age, Breed, and Sex on the Health-Related Quality of Life of Owner Assessed Healthy Dogs

Using an app, this exploratory study generated information on HRQL in a large cohort of dogs deemed healthy according to the owner. It forms the basis for further studies investigating the natural history of HRQL of dogs to inform the interpretation of interventional studies, but highlights the risks of relying on owner impression of health status. A previously published health-related quality of life (HRQL) instrument (VetMetrica™) that generates scores in four domains of quality of life in dogs - Energetic and Enthusiastic (E/E), Happy and Content (H/C), Active and Comfortable (A/C), and Calm and Relaxed (C/R), generated information on HRQL in 4,217 dogs (3 months−21 years). Dogs were categorized by age; young, 3–47 months, middle-aged, 48–95 months, and old, 96 months and older. Owners considered 2,959 dogs (3–95 months) to be “in perfect health” and these were used to explore the relationship between age, sex, breed and HRQL in apparently healthy dogs. Mean score was significantly greater (better) in young compared to middle-aged dogs in E/E, H/C and A/C and declined with advancing age. In H/C there was a small but significant difference in mean score between female and male dogs (mean greater in females), with a similar rate of decline in each gender with advancing age. In E/E there were very small but statistically significant differences in mean scores between certain breeds. In A/C there was a statistically significant interaction between breed and age and the rate of decline with advancing age differed with breed. Overall, age, breed, and sex predicted very little of the variation seen in HRQL scores. Data from a subset of 152 dogs, for whom clinical information was available, were used to examine the agreement between clinical evidence and owner opinion. According to the clinical records, 89 dogs were healthy and 63 had evidence of chronic disease. There was an approximately 40% disagreement between owner opinion on health status and clinical evidence of chronic disease (35% disagreement in all dogs and 43% in old dogs). HRQL scores were generally higher in dogs for whom there was no evidence of disease in the clinical record.

Benefits and Drawbacks of Citizen Science to Complement Traditional Data Gathering Approaches for Medically Important Hard Ticks (Acari: Ixodidae) in the United States

Tick-borne diseases are increasing in North America. Knowledge of which tick species and associated human pathogens are present locally can inform the public and medical community about the acarological risk for tick bites and tick-borne infections. Citizen science (also called community-based monitoring, volunteer monitoring, or participatory science) is emerging as a potential approach to complement traditional tick record data gathering where all aspects of the work is done by researchers or public health professionals. One key question is how citizen science can best be used to generate high-quality data to fill knowledge gaps that are difficult to address using traditional data gathering approaches. Citizen science is particularly useful to generate information on human-tick encounters and may also contribute to geographical tick records to help define species distributions across large areas. Previous citizen science projects have utilized three distinct tick record data gathering methods including submission of: 1) physical tick specimens for identification by professional entomologists, 2) digital images of ticks for identification by professional entomologists, and 3) data where the tick species and life stage were identified by the citizen scientist. We explore the benefits and drawbacks of citizen science, relative to the traditional scientific approach, to generate data on tick records, with special emphasis on data quality for species identification and tick encounter locations. We recognize the value of citizen science to tick research but caution that the generated information must be interpreted cautiously with data quality limitations firmly in mind to avoid misleading conclusions.

Importation of Ticks on Companion Animals and the Risk of Spread of Tick-Borne Diseases to Non-Endemic Regions in Europe

Increased human mobility elevates the risk of exposure of companion animals travelling with their owners or imported from other regions to tick attacks. In this study, we highlight the potential role of dogs and cats taken for tourist trips or imported animals in the spread of ticks and tick-borne pathogens. The Rhipicephalus sanguineus tick, which is a vector of numerous pathogens causing diseases in animals and humans, is imported most frequently from endemic areas to many European countries. Additionally, alien tick species with high epizootic and epidemiological importance can be imported on dogs from other continents. Companion animals play an even greater role in the spread of autochthonous tick species and transmission of tick pathogens to other animals and humans. Although the veterinary and medical effects of the parasitism of ticks carried by companion animals travelling with owners or imported animals are poorly assessed, these animals seem to play a role in the rapid spread of tick-borne diseases. Development of strategies for protection of the health of companion animals in different geographic regions should take into account the potential emergence of unknown animal tick-borne diseases that can be transmitted by imported ticks.

Mitochondrial sequences of Rhipicephalus and Coxiella endosymbiont reveal evidence of lineages co-cladogenesis

Rhipicephalus ticks are competent vectors of several pathogens, such as Spotted Fever Group Rickettsiae (SFGR) and many Babesia species. Within this genus, different R. sanguineus s.l. lineages show an unequal vector competence and resistance regarding some pathogenic strains. Current literature supports that tick endosymbionts may play an essential role in the transmission ability of a vector. Indeed, the microbial community of Rhipicephalus seems to be dominated by Coxiella-like endosymbionts (CLE). Still, their co-evolutionary associations with the complicated phylogeny of Rhipicephalus lineages and their transmissible pathogens remain unclear. We performed a phylogenetic congruence analysis to address whether divergent R. sanguineus s.l. lineages had a different symbiont composition. For that, we applied a PCR based approach to screen part of the microbial community present in 279 Rhipicephalus ticks from the Iberian Peninsula and Africa. Our analyses detected several qPCR-positive signals for both SFGR and Babesia species, of which we suggest R. sanguineus-tropical lineage as a natural vector of Babesia vogeli and R. sanguineus-temperate lineage of SFGR. The acquisition of 190 CLE sequences allowed to evaluate co-phylogenetic associations between the tick and the symbiont. With this data, we observed a strong but incomplete co-cladogenesis between CLE strains and their Rhipicephalus tick lineages hosts.

Amblyomma hebraeum is the predominant tick species on goats in the Mnisi Community Area of Mpumalanga Province South Africa and is co-infected with Ehrlichia ruminantium and Rickettsia africae

Background

In sub-Saharan Africa, Amblyomma ticks are vectors of heartwater disease in domestic ruminants, caused by the rickettsial pathogen Ehrlichia ruminantium. Immature tick stages often bite humans, whereby they act as vectors of tick-bite fever caused by Rickettsia africae. Moreover, Amblyomma ticks cause damage to livestock due to their feeding behaviour. In South Africa, we studied the abundance of Amblyomma hebraeum ticks on goats of emerging farmers in Mpumalanga Province. A selected number of A. hebraeum nymphs and adult ticks was tested for co-infection with E. ruminantium and R. africae.

Methods

A total of 630 indigenous goats, belonging to farmers in the Mnisi Community area, were examined for ticks in 2013 and 2014. All ticks were identified, and a selected number was tested by PCR with reverse line blot hybridisation.

Results

In total, 13,132 ticks were collected from goats distributed over 17 different households. Amblyomma hebraeum was the predominant species, followed by R. microplus. Rhipicephalus appendiculatus, R. simus and R. zambeziensis were also identified. Amblyomma hebraeum was present throughout the year, with peak activity of adults in summer (November) and nymphs in winter (July). The ratio between adults and nymphs ranged from 1:2.7 in summer to 1:55.1 in winter. The mean prevalence of infection for E. ruminantium by PCR/RLB in adult ticks was 17.4% (31/178), whereas 15.7% (28/178) were infected with R. africae. In pooled nymphs, 28.4% were infected with E. ruminantium and 38.8% carried R. africae infection. Co-infections of E. ruminantium and R. africae in adult and pooled nymphal ticks were 3.9% (7/178) and 10% (14.9), respectively. Lameness of goats due to predilection of ticks for the interdigital space of their feet was observed in 89% of the households.

Conclusions

Goats act as important alternative hosts for cattle ticks, which underscored the necessity to include goats in control programs. It is suggested to use acaricide-impregnated leg-bands as a sustainable method to kill ticks and prevent lameness in goats. The challenge of goats by considerable numbers of E. ruminantium-infected ticks is a major obstacle for upgrading the indigenous goat breeds. Humans may be at risk to contract tick-bite fever in this area.

First records of adult Hyalomma marginatum and H. rufipes ticks (Acari: Ixodidae) in Sweden

From July 2018 to January 2019 we recorded 41 specimens of adult Hyalomma ticks, which had been found on horses, cattle or humans in 14 Swedish provinces. In 20 cases we received tick specimens, which were identified morphologically as adults of H. marginatum (n = 11) or H. rufipes (n = 9). These are the first documented records in Sweden of adults of H. marginatum and H. rufipes. Molecular tests for Crimean-Congo haemorrhagic fever virus and piroplasms (Babesia spp. and Theileria spp.) proved negative; 12 out of 20 tested specimens were positive for rickettsiae (R. aeschlimannii was identified in 11 of the ticks). All ticks originated from people or animals that had not been abroad during the previous two months. These data suggest (i) that the adult Hyalomma ticks originated from immature ticks, which had been brought from the south by migratory birds arriving in Sweden during spring or early summer; and that (ii) due to the exceptionally warm summer of 2018 these immature ticks had been able to develop to the adult stage in the summer and/or autumn of the same year. The rapidly changing climate most likely now permits these two Hyalomma species to develop to the adult, reproductive stage in northern Europe. There is consequently a need to revise the risk maps on the potential geographic occurrence of relevant tick species and related tick-borne pathogens in Sweden and in the neighbouring countries.

Usability and Feasibility of a Smartphone App to Assess Human Behavioral Factors Associated with Tick Exposure (The Tick App): Quantitative and Qualitative Study

Background

Mobile health (mHealth) technology takes advantage of smartphone features to turn them into research tools, with the potential to reach a larger section of the population in a cost-effective manner, compared with traditional epidemiological methods. Although mHealth apps have been widely implemented in chronic diseases and psychology, their potential use in the research of vector-borne diseases has not yet been fully exploited.

Objective

This study aimed to assess the usability and feasibility of The Tick App, the first tick research–focused app in the United States.

Methods

The Tick App was designed as a survey tool to collect data on human behaviors and movements associated with tick exposure while engaging users in tick identification and reporting. It consists of an enrollment survey to identify general risk factors, daily surveys to collect data on human activities and tick encounters (Tick Diaries), a survey to enter the details of tick encounters coupled with tick identification services provided by the research team (Report a Tick), and educational material. Using quantitative and qualitative methods, we evaluated the enrollment strategy (passive vs active), the user profile, location, longitudinal use of its features, and users’ feedback.

Results

Between May and September 2018, 1468 adult users enrolled in the app. The Tick App users were equally represented across genders and evenly distributed across age groups. Most users owned a pet (65.94%, 962/1459; P<.001), did frequent outdoor activities (recreational or peridomestic; 75.24%, 1094/1454; P<.001 and 64.58%, 941/1457; P<.001, respectively), and lived in the Midwest (56.55%, 824/1457) and Northeast (33.0%, 481/1457) regions in the United States, more specifically in Wisconsin, southern New York, and New Jersey. Users lived more frequently in high-incidence counties for Lyme disease (incidence rate ratio [IRR] 3.5, 95% CI 1.8-7.2; P<.001) and in counties with cases recently increasing (IRR 1.8, 95% CI 1.1-3.2; P=.03). Recurring users (49.25%, 723/1468) had a similar demographic profile to all users but participated in outdoor activities more frequently (80.5%, 575/714; P<.01). The number of Tick Diaries submitted per user (median 2, interquartile range [IQR] 1-11) was higher for older age groups (aged >55 years; IRR 3.4, 95% CI 1.5-7.6; P<.001) and lower in the Northeast (IRR[NE] 0.4, 95% CI 0.3-0.7; P<.001), whereas the number of tick reports (median 1, IQR 1-2) increased with the frequency of outdoor activities (IRR 1.5, 95% CI 1.3-1.8; P<.001).

Conclusions

This assessment allowed us to identify what fraction of the population used The Tick App and how it was used during a pilot phase. This information will be used to improve future iterations of The Tick App and tailor potential tick prevention interventions to the users’ characteristics.