I was fortunate to be able to arrange some meetings that allowed for another road trip out of Portland. This did mean more driving for DA however he did get the opportunity to go around his first roundabout in USA, the roads are very straight!.
Augusta (not the one where the golf is played!) is the capital of Maine and just over an hour away from Portland. Below is a picture of St Augustine church, Augusta and The Memorial Bridge, also known as the Kennebec Memorial Bridge or the Kennebec River Bridge,it crosses the Kennebec River, joining the east and west sides of the city.
My first meeting was at Maine Centre for Disease Control (CDC)
I met with Kathy Murray(Entemologist), Catie Peranzi (Health educator) and Sara Robinson (Infectious Disease Epidemiology Programme Manager) I forgot to take a picture!).
Sara discussed her role with regard to surveillance of the many notifiable diseases, Lyme disease is a reportable condition in the USA and the department have extensive data which maps the increase of disease across the stat. Primary Care Physicians (PCP) are asked to reports cases and about 50% of practices return the form.
The form looks quite detailed but apparently it doesn’t take too long to complete. The question is what is the benefit to continuing with the surveillance? It is widely known and accepted that the prevalence of Lyme disease is high in the area, the form takes time for the PCP to complete and return and then for the CDC department to review, given that only 50% of practices report it would suggest that the data is not complete and there is also the suggestion that Lyme disease is under reported in general as people do not attend the doctor.
Sara also spoke about the real time monitoring that is taking place through some health care providers with regard to the burden on health services on people attending a centre stating that they have Lyme disease. The data is recorded when the patient registers, this data is helpful to determine how much resource is taken up by patients who think they have Lyme disease. This will also record how many people attend centres for tick removal. Once a patient is seen by a PCP their eventual diagnosis is also recorded and the data will be analysed to identify those who think they have Lyme disease and those that are subsequently diagnosed.
Kathy works as the Manager for the Integrated Pest Management for schools programme in Maine and within her role she actively works with school nurses to support schools to manage the problems associated with pests such as cockroaches, mice, bed bugs, head lice and off concern to a lot of nurses ticks.
Kathy also shared some of the resources she uses in school, cards, magnets, leaflet and tick remover tools. Kathy, Catie and I had a discussion about the tools as Catie had noticed that we encourage use of the twisting tool- this tool is encouraged by Vets in the US. They did acknowledge the importance of using the fine point tweezers and not blunt edge but we all agreed it would be good to find a study that identifies which is the best tool to use.
AND Kathy made me my very own resin cube with 2 ticks for showing people what they look like- I really like this and will endeavour to get a Western Isles version with our Ixodes ricinis ticks!
Catie spoke about her role as health educator across many programmes and ticks and Lyme disease is also one of the areas she is involved with. May is Lyme disease awareness month and they hold many events throughout the month. There is a poster completion for local schools-this is a good way to get families to consider the risks and the precautions they can take . The winning posters are then distributed widely for the next year. Here are two of the 2018 winning posters.
The department also attend locally organised events and host a table with information for the general public and distribute tick removers and literature. They have attended events at the retailer LL Bean who specialise in Outdoor clothing and resources and a home and Garden event. The CDC produce the literature and purchase tools that they offer free to organisations that raise awareness of ticks and Lyme disease. Posters, cards etc are distributed every year to National parks and emergency rooms and on a rotational basis to other departments last year they sent information to all elderly/geriatric services. Interestingly Catie informed me the highest incidence of Lyme disease is in the elderly and those aged between 5-18 years.
Catie told me her MSc project had been on health literacy and she has spent time improving the resources available, below demonstrates how she has improved the Lyme disease information sheet. The right hand leaflet is the older form which was all words and likely to put people off, on the left is Catie’s new version in an easy to read format with plenty of pictures.
My second meeting was in Orono at The University of Maine
It was a lovely campus and has around 12,000 students registered. They obviously take safety seriously as these emergency poles were dotted around the campus. I hadn’t seen these before but it appeared to be direct access to the local police department.
I met with Allison Gardiner who is an Assistant Professor of Arthropod Biology at the University.
Allison spoke to me about her role and in particular a couple of the projects that she is involved in. She works in research and is looking into the practices that influence tick abundance, at the moment looking at Ocadia National Park which has a high incidence of ticks that are positive for borrelia with a positivity rate of about 30%. A high number of visitors go to the park each year with a subsequent high level of visitors going on to report they have Lyme disease following a tick bite in the park. Social research has been undertaken with visitors in the park looking at how they think climate change will impact on the park, the survey had not been looking at tick borne disease initially but it turned out to be one of the most common themes in the responses. This led to the opportunity to look at tick borne disease and combining social research as well as environmental research.
Over 70 sites within the park have been sampled by dragging and small mammal trapping over the summer 2018, to identify the areas with higher tick abundance. The information will be used to develop a risk map for the area, the social research aspect has been looking at where visitors go in the park and the activities they undertake and the two sets of data will be combined with a view to targeting risk messages for the areas most used by visitors and most affected by tick burden.
The last check of tick abundance in Ocadia was done 30 years ago. There was a big fire in the park in 1947 and that area does appear to have a higher tick abundance, further analysis will be performed to try to understand the reasons behind this. The project is also going to observing the areas that have been burned in the last five years as the park use burning as a tool to manage vegetation. Previous evidence has demonstrated an initial drop in tick numbers following a burn but in the following years the numbers are higher than ever.
The social research has identified that people attending the park know a lot about ticks and tick borne disease but not everyone was so clear about tick removal there are still many people who remove ticks incorrectly. Therefore these responses will be used to identify areas of education that are required.
The other project Allison is working on is with private landowners and tick borne risk, this will look at the impact of a range of land management practices have on tick borne disease. Looking particularly at timber harvesting, forest management and other areas that are just left with no management at all. The project is in its infancy and plans include dragging for ticks, mammal trapping and how the burden of ticks change depending on the land management practice in the areas. It is hoped the project will generate recommendations for the best practices. The social aspect will look at what the landowners do to protect themselves and what their knowledge of ice borne disease is. Landowners will be encouraged to monitor their own land for tick burden which is something that should be encouraged everywhere.
While I was talking to Allison, DA went to watch the local ice hockey team practice:
On our way back to Portland we stopped at a ‘Texas Steakhouse’- you choose your steak as you walk in?
Another contact I made was with Danielle Buttke in Colorado- too far for a road trip so we had a telephone call instead.
Danielle is a Vet Epidemiologist/ Zoonotic disease Specialist, Danielle works with national parks to prevent and manage human, animal, and environmental health issues. She helps the U.S National Park Service take a holistic approach that is needed to understand, protect, and promote the health of all species –the concept of One Health– because human and animal health are inextricable linked.
Danielle has been involved in the project in Ocadia ( mentioned by Allison Gardner), the questionnaires used with visitors to the park were looking to understand knowledge and the preferred prevention behaviours. Many British tourists completed the forms and it was felt they had good knowledge around ticks and Lyme disease risk and also it did not put them off participating in outdoor activities which is a very important aspect to get through in risk messaging.
Danielle has attended the park herself with the survey and directly asking people the questions and one of the things she noticed was people would say they knew to tuck trousers into socks as a method to reduce risk but on looking at the person they had NOT taken the precaution ( not tucked trousers into trousers).
This has led to consideration for activities that prompt people to look for ticks before they leave the park, ideas being explored are signs at the trails with magnifying glasses and pictures of ticks or making one of the toilet cubicles a tick checking area with mirrors
I asked about general information in the parks on ticks and some parks do have trail head signs and all parks are sent the CDC posters, leaflets and literature to display.
Danielle is sure public engagement is the key and she attends lots and there are always questions about tick borne disease, attending events and answering questions is key to informing the public. It also helps to build relationships and ensures people have the correct information. Danielle is coordinating projects around the parks for tick collection and subsequent identification of infection prevalence. They have identified an Borrelia infection prevalence of 4-36%, they also look for myosotis, Babesiosis and Anaplasma and are looking at adding arbovirus into the panels.
We spoke briefly about host blood meal analysis and she was aware that Cornell university have submitted a grant application to CDC to look at this. Financial constraints impact on a lot of studies and actions that can be taken and there is a very limited amount to manage risk.