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Environmental Health

Ticks Continue to Bite While State Loses Grip

Nonprofit agencies and businesses step up to provide a link to the public and health care providers on tick-borne illnesses in North Carolina.

By Nancy Beach

One of the best reasons to live in North Carolina is all the opportunities the state offers to enjoy the outdoors, all year long.

There is the ocean on the eastern border and the mountains to the west. There’s hiking, biking, rafting, swimming and skiing, and for the less athletic among us, we can simply enjoy gardening or going for walks in our neighborhoods and local parks.

Deer herds – and the ticks they carry – share space in neighborhoods. This family lives in the Thompson’s Cross area of Hillsborough, NC.

Deer herds – and the ticks they carry – share space in neighborhoods. This family lives in the Thompson’s Cross area of Hillsborough. Photo by Nancy Beach.

Spending time outside can also present some risks, however, such as accidents and unexpected encounters with wildlife, even in our own backyards.

When it comes to wildlife, how many of us consider a tiny, eight-legged, blood-sucking cousin of the spider to be a risk to our safety?

That creature is the tick, and its bite can transmit disease. Some of those diseases can cause chronic illness and even death.

Cases of tick-borne disease in humans have generally been on the rise over the last decade, both nationally and statewide. The cause is believed to be the rising populations of white-tailed deer, which make ideal hosts, in urban and suburban areas, and suburban sprawl, which brings humans into closer contact with both forested areas and wildlife.

At the same time, the economic slowdown and changing legislative priorities have cut both monitoring of the tick population and public education, leaving nonprofit agencies and private companies and individuals to fill the gap.

State budget swallows pest-control education and services

The North Carolina legislature’s 2011 budget bill dealt a significant blow to tick education and control efforts here.

An engorged black-legged female tick. Black-legged ticks, also known as deer ticks, are a major transmitter of Lyme disease. Photo courtesy of the Centers for Disease Control.

An engorged black-legged female tick. Black-legged ticks, also known as deer ticks, are a major transmitter of Lyme disease. Photo courtesy of the Centers for Disease Control.

The Department of Environment and Natural Resources was significantly reorganized, and its Division of Environmental Health was abolished. While some of its programs were transferred to other agencies, the Public Health Pest Management Section, which had housed the state’s tick control and research programs, was also eliminated.

The section had provided education, insect identification, population control and avoidance services to county health departments and the public about a number of pests besides ticks, including mosquitoes, fleas, lice, cockroaches and bedbugs.

Effective July 1, 2011, all employees of the section, which included two entomologists and three environmental scientists, were laid off.

“I was shocked by that, and I am still shocked by it,” said Marcia Herman-Giddens, a child and family health consultant and co-founder of the nonprofit group Tick-borne Infections Council of North Carolina (TIC-NC), based in Pittsboro.  “They provided bite-prevention materials and assistance and advice with control. Members of the public could also contact that section if they needed help with identifying what had bitten them, and now they have no one to call.”

“This is a huge loss to our state and to research because we collaborated with them to see where research is needed on this issue,” said Meagan Vaughn, a researcher who recently earned her doctorate from the epidemiology department at UNC’s Gillings School of Global Public Health for work done on tick-borne illness and its prevention.

State workers suffer the biggest bite

Herman-Giddens co-founded the all-volunteer TIC-NC in 2005 to assist in providing education to the public and health care professionals about tick-borne illnesses, and finds her group taking on ever more responsibility now that the state no longer provides these services.

A female American dog tick. These ticks are a major transmitter of Rocky Mountain Spotted Fever. Photo by James Gathany/Centers for Disease Control.

A female American dog tick. These ticks are a major transmitter of Rocky Mountain Spotted Fever. Photo by James Gathany/Centers for Disease Control.

While the axing of the division’s programs accounted for $500,000 of the $2.5 billion in budget cuts, Herman-Giddens questions if there is a true savings once balanced against the costs of lost work time and medical expenses related to illnesses that might be prevented if more was invested in educating the public on how to avoid tick-borne disease in the first place.

Kimberly Brownley, another TIC-NC board member and an assistant professor of psychiatry at UNC, added that state workers who spend a lot of time outside also lost a place to turn to for assistance and advice when the section shut down.

“The guys in forestry, the ones who dig ditches and work on roads, they’re out there every day. They have repeated exposures, and there’s no resource for them on the state level anymore,” she said.

Vaughn echoed this concern. “Due to the lack of research on this, we’re not sure exactly what the risks are to outdoor workers in the Southeast who are getting exposed repeatedly,” she said.

Lack of personnel to study trends in the tick population and the distribution of diseases they transmit also interferes with the ability to provide timely information on prevention and treatment for everyone in the state.

A need for a better reporting system to understand the problem

“We don’t have a good reporting system in place to keep track of how often and where these illnesses take place,” Brownley said.

North Carolina reports statistics on four tick-borne illnesses – Rocky Mountain Spotted Fever (RMSF), ehrlichiosis, Lyme disease and anaplasmosis – to the Centers for Disease Control and Prevention (CDC). While there is no consensus on the total number of diseases that can be transmitted via ticks here, the CDC provides information on 11 found in the United States.

A male Gulf Coast tick. This tick is a new arrival in North Carolina and may carry a disease similar to Rocky Mountain Spotted Fever. Photo by James Gathany/Centers for Disease Control.

A male Gulf Coast tick. This tick is a new arrival in North Carolina and may carry a disease similar to Rocky Mountain Spotted Fever. Photo by James Gathany/Centers for Disease Control.

One of the issues with reporting is that tests to confirm a patient’s tick-borne infection take too long to help a patient who is very ill.

“Sometimes a doctor will suspect a tick-borne illness and treat without testing because the test results won’t come back quickly enough to help the patient,” Vaughn said.

Without a positive test result and thorough report sent to the state, the true number of cases and their distribution is impossible to know.

Limited education and awareness is also at least partly responsible for North Carolina seeing more than its share of fatalities from tick-borne illness, virtually all from RMSF. Specific statistics are not kept on deaths, but the state Department of Health and Human Services reported a total of 598 suspected and confirmed cases of RMSF for 2012, compared with 322 for the previous year.

“We shouldn’t be having deaths,” Herman-Giddens said, noting that swift treatment with the antibiotic doxycycline is very effective in curing RMSF. “Sometimes people wait too long to see a doctor, but sometimes their health care provider doesn’t suspect Rocky Mountain Spotted Fever, and treatment is given too late.”

This sentiment is echoed in a scientific paper published in August in The Journal of Emergency Medicine. The paper, authored by Matthew E. Ravish, Daniel P. Krowchuk, Michael Zapadka and Avinash K. Shetty of the Wake Forest University School of Medicine, is a case report on a 6-year-old girl who was admitted to Brenner Children’s Hospital in Winston-Salem in 2011 after being sick for a week with a fever, headache and rash.

She died 24 hours later. Tests later confirmed she had RMSF.

The doctors stated in the paper’s abstract, “We present this case to raise awareness of RMSF in patients who present with a nonspecific febrile illness in tick-endemic areas in the United States.” They also emphasized the importance of prompt treatment, within five days of the onset of illness.

According to the CDC, North Carolina, Oklahoma, Arkansas, Tennessee and Missouri comprise 60 percent of all reports of RMSF in the country. In North Carolina, Wake, Chatham and Alamance counties have the greatest number of cases.

Herman-Giddens noted that Lyme is on the rise here as well, with 94 suspected cases in 2012, up from 68 in 2011. Wake, Guilford and Haywood counties in North Carolina are now considered endemic for Lyme, and more will likely follow. Meanwhile, the CDC acknowledges there could be 10 times more cases of Lyme than appear in official statistics.

Stepping up to provide education to families, kids

TIC-NC has been raising awareness of all diseases through their website, presentations, a newsletter and printed brochures.

A female Lone Star tick. Lone Star ticks are aggressive biters of humans and are thought to transmit at least a half dozen diseases. Photo by James Gathany/Centers for Disease Control.

A female Lone Star tick. Lone Star ticks are aggressive biters of humans and are thought to transmit at least a half dozen diseases. Photo by James Gathany/Centers for Disease Control.

One recent project, funded by a $5,000 grant from the Yahoo! Employee Foundation, enabled TIC-NC to provide education to Orange County school nurses about tick-related issues. The group is assisting in developing a standard procedure for treating any student who is found to have an attached tick.

In addition, a handout in both English and Spanish accompanied all 7,200 students’ end-of-year report cards describing ticks that are a danger to North Carolinians, the proper removal of ticks, symptoms of infection and what to do if symptoms occur after tick exposure.

“We’re far away from making an impact at the state level, but we are making progress locally and have really gained a lot of momentum in the last year,” Brownley said. “We’re working with the Orange County and Wake County schools, and we hope to add Chatham soon.”

Business solutions to preventing bites

Meanwhile, a local private company has also been offering solutions to prevent tick bites.

Insect Shield, a Greensboro-based firm founded in 2001, offers a line of clothing treated with permethrin, a man-made chemical similar to pyrethrin, a naturally occurring insecticide found in the chrysanthemum plant. It is considered safe for adults and children and is used in lice treatments for people and flea dips for pets.

In 1996, representatives from the Army approached Insect Shield’s current chief operating officer, Richard Lane, a textile expert, while he was working for another firm, asking him to engineer a way to treat clothing so it would repel insects.

At West Point Military Academy, “Cadets were getting Lyme disease and some got so sick and missed so much time they washed out of the program,” said Jason Griffin, president of Insect Shield. “They were being given a spray to use, but some of them would either not use it properly or forget to use it at all.”

In 2002, all of the academy’s uniforms were treated with the Insect Shield process, and the following year cases of Lyme among the cadets dropped to zero.

Griffin says permethrin has both repellant and killing properties. In testing, “We’ll stretch samples of treated and untreated cloth across a board and then elevate them so they are oriented vertically. The ticks on the untreated side will just crawl around, happy as can be. The ones on the treated side will drop off in less than 10 seconds,” he said.

Insect Shield now partners with a number of popular apparel sellers, including L.L. Bean and Orvis, to provide them with the process for some of their outdoor clothing lines. The treatment is colorless, odorless and lasts for 70 launderings, the typical lifespan of a garment.

This public service announcement on tick safety was developed in conjunction with TIC-NC and journalism students at UNC’s School of Journalism and Mass Communication.

Research holds promise for more knowledge

Vaughn’s research in prevention of tick-borne illness has used Insect Shield’s technology.

“My adviser, Dr. Steven Meshnick, who is a very well-known malaria researcher, was approached by them as an outreach to see if their technology might be useful with mosquitoes,” she said.

The idea for a study on the effectiveness of using treated clothing to prevent tick-borne illness evolved from there.

Their initial study was small, with 16 state Division of Water Quality staff participating. That study ran from March to October of 2009 and involved nine workers wearing uniforms with Insect Shield’s treated clothing and six not.

The results – 93 percent fewer tick attachments among workers wearing treated uniforms – were positive enough to motivate Meshnick, Vaughn and Charles Apperson, an entomologist and William Neal Reynolds Distinguished Professor Emeritus at N.C. State University, to secure a grant for a longer, more rigorous study.

In 2010, they earned a four-year, $1.1-million federal grant funded by the CDC and the National Institute for Occupational Safety and Health, “Preventing Exposure to Ticks and Tick-Borne Illness in Outdoor Workers.”

They recruited 159 state workers from the Forest Service, Parks and Recreation and Wildlife Resources Commission for the study. Some workers wore treated uniforms, while others did not. Neither the researchers nor the workers knew which group they were in until the end of the study.

Data collection ran through September 2012 and a manuscript based on the study is now under peer review. Vaughn hopes their findings will be available sometime in the next few months.

“These studies give us direction on where new research is needed,” she said, adding that acquiring funds for tick-borne illness research is a struggle, and that many more long-term studies are needed.

She said she also hopes the research she and her collaborators are doing can inform governments on what they should do for workers who are repeatedly exposed to tick bites.

“I hope what we learn from this research can help policymakers make informed decisions on the benefits [of providing treated uniforms] in comparison to the costs of lost work time, workers’ compensation claims, medical costs and so on,” Vaughn said.

In the meantime, it’s up to each person to protect themselves from illness.

“There are no vaccines for any of these diseases,” she said. “It’s up to the individual to use personal protection to prevent themselves from getting sick.”

Quick facts on staying safe from tick bites and illnesses

Protect yourself from bites:

  • Prevent yourself from being bitten by ticks in the first place – walk on trails, and wear long pants and long sleeves. Tuck pantlegs into boots or shoes and shirts into pants. Stay out of leaf piles and dense vegetation.
  • Wear insect repellant. DEET is a common and effective repellant found in many popular  products and is safe for both adults and children.
  • If you work outdoors or spend significant time outside, consider treated clothing and/or blankets for protection. It’s convenient and reliable.
  • Check for ticks when you have spent any time outside. Don’t forget to include areas such as the scalp, and be sure to check children, since they spend more time outdoors than adults. The less time a tick spends attached to its victim, the less opportunity it has to spread disease.
  • In the South, ticks do not take time off. While most tick bites happen between March and October, when people spend the most time outdoors, it’s possible to be bitten at any time. Black-legged ticks, the major transmitters of Lyme disease, are just one species still active in winter.

If you are bitten by a tick:

  • Use a pair of pointed tweezers to remove it, not your bare fingers. Grasp the tick as close to the skin as possible and use even pressure to pull it away. Do not twist or squeeze the tick.
  • Do not burn or use any substance on the tick, which may cause it to release infectious materials into the bite wound.
  • Use alcohol to clean the wound and the tweezers.
  • Save the tick by taping it to a card or preserving it in a small container of alcohol. Mark it with the date you found it and where on the body it bit you.
  • Watch for flu-like symptoms such as fever, chills and aches. Some tick-borne illnesses many also result in a rash. Be sure to mention to any health care providers that you were bitten and take the saved tick to the appointment with you.

Recommendations from TIC-NC and the Department of Entomology, NC State/NC Cooperative Extension.

Nancy Beach is a web editor, graphic designer and writer from Hillsborough.

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