MSc dissertation

At the same time as my fellowship travels I was working on a Masters degree, MSc Infection Prevention and Control with the University of the Highlands and Islands (UHI). My dissertation was titled ‘ What is the impact of Lyme disease on a patient’s quality of life in the Western Isles of Scotland?’. I completed in August 2019 and planned to write an article for publication about my study findings. I decided to wait until 2020 to write the article but COVID-19 took of and my work in the Health Protection team took over my life and my colleagues in health protection teams across Scotland, so the article went on the back burner.

In the summer of 2022 I decided to go back and start looking at writing the article, I sent a submission to the Nursing Times and it was accepted for publication- a bit of to-ing and fro-ing with changes and the article is ready and will be in the March 2023 issue. The citation will be MacInnes I (2023) How patients experience the impact of Lyme disease. Nursing Times [online]; 119: 3.

Attached to this post is a full copy of my dissertation.

dissertation-05017797Download

4 years on

It is hard to believe that my trip to USA and Canada was four years ago, I am very pleased to say that I have completed my Churchill fellowship report. Which also means that I can now add the letters CF after my name, adding to those I already have, RGN, RM, BA, MSc, CF.

I have been very quiet on the blog but on my return from my final trip in 2019, I finished my MSc, graduated and then concentrated on completing my Fellowship report and then covid hit. In public health our work pattern changed to an unprecedented level which was sustained for the two years- the changes in testing introduced in March 2022 has eased us back to a normal level which has allowed me to resume the tick and lyme disease work. I have submitted an article about my dissertation study to a nursing journal which has accepted it for publication- I will post more about this soon.

Anyway- this post was to add my fellowship report, the report details the places I travelled to, the many professionals I met where I found out about all the different aspects of the work they do.

The artwork on the front cover depicts the cycle of Lyme disease and is credited to Olaf. Ecology of Lyme (c) Olaf Hayek, 2017. Susan Elias at Maine Medical Research Institute as part of her PHD studies commissioned an artist to produce a drawing depicting Lyme disease. Hajek’s colourful painting titled “Ecology of Lyme” includes multiple interconnected factors associated with the infectious disease — Earth being altered by a changing climate, a deer, a mouse, invasive Japanese barberry, and three stages of deer ticks. The painting also includes a person infected with Lyme bacteria.

I have included a link to the report if you want to have a read:

wcmt-fellowship-report-d2Download

Summer of 2019

Apologies it has been a while since my last post, my blog has been looked at regularly throughout the year it is amazing the countries that it has reached. Wouldn’t it be good to see it all pink.

When I came back from France the team at the University of Glasgow shared the news that the project they are working on in the Western Isles received an award in recognition of the community and public engagement that has been undertaken with the collaborative group looking into Lyme disease in the Western Isles. Here I am pictured with the award:

Throughout the year we have continued holding awareness raising events and attended the North Uist tractor rally, in the picture below taken at the tractor rally are Jonny Yardley PhD student at University of Glasgow, me, Graham Charlesworth retired Vet who started my interest in Lyme disease, Elliot Stanton, Sophie Zanetti and Caroline Millins all from the University of Glasgow.

The title of the research project is ‘ Assessing factors associated with tick bites in the Outer Hebrides’ and will involve collecting ticks in a range of sites and habitats, testing the ticks for the presence of Borrelia and hopefully a couple of other bacteria. Trapping small mammals and analysing deer samples obtained through the estates. Crofters, pet owners and people living locally were invited to complete a survey to assess tick prevention and tick-borne diseases in livestock and in humans in the Outer Hebrides. The data obtained from all the different aspects will be used to postulate theories as to any identifiable causes for the increasing incidence of Lyme disease recorded in the Western Isles.

We also had stalls at the North Uist and South Harris agricultural shows and the Calloway show. The main aim for attending was to share information of the Glasgow University studies however these events are great opportunities to educate people on tick removal and the precautions they can take to avoid tick bites and also dispel some of the myths regarding particularly tick removal. Many people tell me they cover the tick in alcohol, touch the embedded tick with a lit match or cover the tick with Vaseline. NONE of these methods are recommended each of them can induce the tick to regurgitate into the blood stream of the person they are attached to increasing the risk of contracting a Lyme disease. NHS Western Isles have produced resources , leaflets and posters and a large banner which we distribute at any of the events we attend.

2018-2019 was my dissertation year so I had to work aspects of it around my fellowship trips. To complete my dissertation study I had to apply for ethical approval, this process took a lot longer than I expected, I had been due to complete the MSc by the beginning of May BUT I didn’t receive ethical approval until the end of March following which I had to advertise for participants and arrange and hold focus groups and then transcribe and analyse the data. This did affect the plans I had for summer I had to put the dissertation writing up on hold as I had taken nearly three weeks holiday for

* a family wedding on South Uist

Pic 1-DA and I

Pic 2- the newly married Mr and Mrs Ewen Henderson

Pic 2-Padraig MacInnes, Cameron MacInnes, Maria Henderson, Lennon MacInnes and Joseph MacInnes

Pic 4- Amy MacDonald Maria Henderson, Shona MacInnes and Sarah MacInnes

* our daughters graduation at University of Edinburgh

Dr Sarah MacInnes

* and some tennis at Wimbledon

I am an avid tennis fan and for the third year in a row was successful in the Wimbledon ballot so our gift to Sarah on her graduation was tickets to Women’s final 🎾🎾🎾. Sarah and I were at centre court when Simone Halep beat Serena Williams it was a short match 59 minutes I think but it was still fantastic to be there. ( Ballot application for 2020 has been submitted I really really want to be at an Andy Murray match).

Following my 17 day break I had to come back and get on with my dissertation I submitted a month later.

My dissertation title is ‘What is the impact of Lyme disease on quality of life of patients in the Western Isles of Scotland?’ I passed with distinction and I will publish a link to my dissertation next year.

NHS Western Isles publish a lovely glossy magazine a few times a year and the summer 2019 issue featured a double page spread about me 🤭 my work with ticks and the Churchill fellowship travels here is a screen shot of the item:

and a link to the full magazine http://wihbweb.wi.scot.nhs.uk/index.php/wi-intranet/adminmenu/slainte?task=document.viewdoc&id=2645 if you would like to have a look at some NHS Western Isles activities.

I completed my studies and graduated from UHI in October 2019 with an MSc in Infection Prevention and Control

A bit of an anti climax really I know I have more research to do into Lyme disease but how? I am employed as a Health Protection and Screening Nurse and not in a Nurse researcher role so I will need to look at the options for continuing.

The final bit of news in this blog is that an abstract of my dissertation research was selected for a conference in Liverpool. There were a few presentations on the work being undertaken with regard to Ticks and Lyme disease in the Western Isles but what was very evident is the gap in the work being done in the UK to find out about the impact of Lyme disease on patients. So watch this space ….

I attended the conference with the team from University of Glasgow who also shared presentations at the event

In the picture are Caroline Millins, me, Jonny Yardley, Lucy Gilbert and Roman Biek.

I am off now to concentrate on writing the report of my Churchill Fellowship which is a requirement of the award. Wish me luck 🍀 😉.

Final days in Paris

Muriel Vayssier-Taussat

Muriel spoke about the OHTICK project, which is a one health approach to identify the pathogens transmitted by ticks, pathogens that could be responsible for the unexplained syndromes suffered by many people particularly in those where Lyme disease has been excluded. The project follows on from a previous online collecting tool that had been piloted in France called citique. Muriel is the director of the OHTICK project, it is a multi disciplinary project combining veterinarians, doctors, scientists and sociologists who will work collaboratively to better characterise the diseases that are transmitted by ticks.

The project objectives included detecting, identifying and isolating the microorganisms collected from patients and animals that have been bitten by ticks, demonstrate the ability of ticks to transmit these agents and to provide elements for better management of tick borne diseases. The project is over four main sites in France and is projected to last for two years. Here is the link to read more about the project : https://www.ohticks.fr/en/ohticks-2/.

This is the advert looking for potential participants to respond to.

My final visit in France was to Vet-Alfort in Paris

Where I met Sarah Bonnet, who is a Biologist/Parasitologist and qualified as a medical and veterinary entomologist. Her PhD was on mosquitoes and malaria.

Sarah started by telling me she had just finished reading one of Peter May’s books and she was now thinking of travelling to the Western Isles.

The unit has a staff of approx 50 people and there are teams within the unit working on topics such as food borne pathogens (i.e. salmonella / campylobacter) and then there is the vector borne disease group and that is divided into 3 groups. Working on ticks and tick borne pathogens, initially the teams worked on bartonella and the studies were able to demonstrate that ticks were able to transmit bartonella, this was relevant for patients with persistent symptoms , particularly where Lyme disease is negative.

Other studies are undertaken on interactions of tick host pathogens, vertebrae hosts that are the reservoirs for pathogens and ecology; some of the projects the staff have been working include ; anti tick vaccine (for animals); developing tools for identifying many pathogens in ticks and vertebrate in one sample; tick/pathogen interactions; tick/host interactions/alpha gal syndrome; epidemiological studies; Anaplasma studies; impact of tick microbiom on the transmission of pathogens.The lab interacts with many groups across France and works in collaboration on many of the projects.

Sarah received a French prize for the development of a tick feeding system. The prize is awarded every two years and offered for new techniques that can be used to replace the use of animals in laboratories.

In the lab studies look at how ticks react to certain things; therefore ticks at the different stages (larvae, nymph and adult) are required. Previously ticks were engorged on a range of animals within the lab and the monitoring was undertaken. Sarah’s system means that animals do not need to be used for feeding ticks. Ticks are in the box and the blood is put in a glass vial which touches the membrane. Ticks have access to a blood meal by attaching to a membrane therefore mimicking the action of ticks feeding on host skin. The use of the system has been compared to how ticks feed on hosts and it was found to take approx 2 days longer for a tick to become fully fed through the system. The system was developed for feeding Ixodes ricinis ticks. Colleagues from laboratories in other countries have been to observe the system and it has been adapted by other laboratories to successfully engorge other tick species, each tick species requires some changes to the system to be effective. Another positive factor of the system is that by manipulating the membrane or the blood the system has been used successfully to infect ticks, treat ticks with acaracids, evaluate vaccine by putting some antibodies into the blood. It reduces the use of animals and offers the opportunity to experiment with ticks, the laboratory maintain a tick colony.

Sarah has many published research papers, and she is co- editor with Nathalie Boulanger of a book on ticks and Lyme disease in French, the book is to be published very soon (March 2019). The book is aimed at the general public and has chapters on what ticks are, the difference between ticks and insects, hard and soft ticks, how the tick bite works, the fact that ticks are vectors of pathogens, how to prevent tick bites and contact with ticks, how to control ticks, the most important tick species in France and Europe, the diseases that are due to ticks, chapter on the research being undertaken in laboratories, the book includes pictures to help people and it is also easy to read.

It is hoped the book will help the public to have a better understanding of ticks as mentioned previously lots of people have become afraid of ticks and the risk they pose. There is a lot of publicity from the people that have prolonged symptoms and the arguments are not balanced by those who have ticks bites, receive the correct treatment and suffer no further ill effects. This book wants to clarify that there are actions that the public can take to reduce risks of bites. Generally people need to be encouraged to be active and should not be put of because of ticks.

Final images from Paris

Clermont Ferrand

Clermont Ferrand is north of Lyon. I took a day trip from Lyon to meet with some of the staff at INRA.

INRA is the worlds second greatest producer of publications in the agricultural sciences. It has 250 laboratories and 45 experimental units across 13 scientific divisions and 17 research centres. It has a community of 13,000 people including 7903 permanent staff, 1849 full time researchers, 2353 interns and 556 PhD students with INRA grants. INRA has an annual budget of 850.89 million euros, 77% of funds come from the Ministry of Research and 20% from other public funded sources ( figures from 2017).Auvergne- Rhône- Alpes in Clermont Ferrand is one of the 17 centres in France

Clermont Ferrand is the capital of the Auvergne region, the city is overlooked by its dormant volcanic mountains. Isabelle told me the hills glow red in the summer:

Isabelle Lebert

Isabelle is a Research Engineer at the site in Theix,

In collaboration with other centres, Isabelle has been involved in building a tick risk map for France, it looks at the suitability for the presence of ticks. It looks at the landscape index, density of ungulates, density of humans and the climatic indicators. The project is ongoing and findings are not published yet.

Lymesnap study

Isabelle spoke about a project she was involved in called Lymesnap, the project wanted to collect information on episodes of Erythema migrans (EM). The project was developed in collaboration with the hospital in Clermont Ferrand, and people were recruited to participate in a study where they took photographs of the EM rash and completed a questionnaire and they were offered counselling on Lyme disease. When a picture was submitted they were reviewed to decide if they were EM and the discussion included whether the person had received appropriate treatment. The project was promoted throughout the region in the media, newspapers, visits to local businesses and at GP and Hospitals. The project is completed and analysis of the work continues.

Freqrando project

This project is looking at the human use of walking trails in Metropolitan France. The information provided by those hiking will make it possible to estimate the human exposure to tick bite, to identify the risk of bites and to propose preventative measures. Hikers are asked to register the area they are hiking by providing GPS co-ordinates and completing a questionnaire. It can be completed online and it is promoted widely.

This is the link to the reporting portal- if you open it in Google chrome the settings should translate it into English! https://www6.ara.inra.fr/epia/Sites-Web/FREQRANDO

The reporting portal also includes information on ticks and tick removal

Xavier Bailey

Xavier is a Biologist, with a particular interest in molecular biology. He is currently the director of the INRA research centre in Clermont Ferrand.

Xavier has been involved in a project which looked at the transmission cycles of tick borne pathogens. It is known that many pathogens are maintained by multiple hosts and can involve multiple strains with different phenotypic characteristics, investigating how different host species contribute to transmission is crucial to properly assess and manage disease risk. The study emphasised the importance of taking co-infection patterns into account to better understand the genetic structure of pathogen populations and to link these patterns with the way in which pathogens spread and are maintained in host communities. The work demonstrated that combining high throughput sequence typing with network tools and statistical modelling is a promising approach for characterising transmission cycles of multi host pathogens.

Other projects have looked at how Borrelia invades ticks?, How the tick responds to environmental changes?, Spatial patterns of risk of exposure to ticks and allow for mapping of human risk?.

Maude Jacquat

Maude came to have a chat with me at lunchtime as we had mutual acquaintances, Maude had been living and working up until 2018 with Caroline Millins and Roman Biek at Glasgow University. Caroline is a clinician in Anatomic Pathology and Roman is a researcher. Caroline and Roman are supervising the work being undertaken on the Western Isles.

Maude moved to Clermont Ferrand at the end of 2018 and is working on a range of projects which includes some work on ticks.

Sylvian Dernat

Sylvian joined by video conference to have a discussion on some of his work. He is an engineer in social sciences at INRA, he works with others on the social aspects of Lyme disease. His approach is to bridge the gap between Public health and sociology. In France there have been studies undertaken on peoples perceptions/social constructions of tick risk. People imagine the tick risk to be present everywhere and many people are very afraid, those living in urban areas are less likely to come into contact with ticks and therefore have minimal risk of contracting Lyme disease. It is suggested that Lyme disease has been portrayed to be a disease everyone should be fearful off, it was thought this social construction is made worse through media and politics.

A study was developed to look at peoples fear with the hope the results could be used to modify public health policies to help the prevention policies against ticks. The researchers wanted to gain an understanding of how people view the risks for themselves and their families and how they view the media constructions of the risk. Many social approaches were used within the study and in the rural areas of Clermont Ferrand Lyme disease has been known about for approx 50 years, discussing ticks was not new to them, contact with ticks is expected and the people know how to cope and they do not fear them. Generally people integrate the management of ticks into their life, they see it as normal, they do know many people with Lyme disease but they do not see it as a big problem. Their view is that climate change is a factor causing the increase in the problem.

In the study in cities the results are very different, generally people have no experience of ticks and their knowledge is based of the information provided by the media which has been seen as scaremongering. The study found that people interpretate the media messages as ‘ticks make you ill’ and ‘you should avoid forests/trees’, people link forests and mountains with tick risk. This understanding is a public health problem as it is causing people to stop taking part in outdoor activities.

The study identified that people need to be informed going out and speaking to people to provide information and challenge peoples interpretation of the media messages. Using the knowledge from published papers on tick risk, and the precautions that can be taken as they are key in prevention of Lyme disease. Social conflict theory demonstrates that information such as in the media can be taken at face value- people do not find out any other information or explore other views on the topic. This study found that speaking to people and explaining the risks can lead to people changing their mind. Although not everyone responds to this method, many farmers in France have Lyme disease and behaviour change education has been targeted but they are not willing to change. Health professionals, students and the general public especially those with children are very open to the behaviour change messages.

Lyon

My visit was to campus Veterinaire de Lyon.

I met with Karine Chalvet-Monfray who is a Vet and statistician and is the Director at the Lyon campus.

This is a picture of Karine downloading the data from the temperature/humidity/weather logger located at the site we dragged for ticks at.

Magalie Rene Martellet is a parasitologist and works as a researcher and also has a clinical role with management of exotic pets.

Magalie spoke about the tick species that are found in France

Magalie also spoke about some of the work she has been involved in, she has worked on Hyalomma tick and its role in the transmission of Crimean-Congo Haemorrhagic Fever virus which is a significant illness for humans. Hyalomma tick has only recently been detected in France this is the link to an article which discusses its emergence https://www.ncbi.nlm.nih.gov/pubmed/27568169

Fleatickrisk

Is a forecasting model that uses meteriological data to predict activity in different climates. Weekly updated maps show the risk of infestation by ticks, fleas, mosquitoes and sandflies in Europe to adapt pets treatment to protect them from parasites. This site can be used by people to check the area they are visiting for tick risk.

CLIMATIK Project

This is a multi site project across France. It started in 2014 and each area is collecting ticks to observe the changes. Each site use the same protocols and tick collecting is undertaken each month. The ticks are analysed to identify the pathogens they carry.

Tick dragging in Lyon

Karine and Magalie took me out to a park that they regularly drag for ticks in, they follow protocols that are used by all the areas participating in the project. This protocol dictates that amount, frequency and the repetitiveness of the sites drags. There were 10 sites marked within the park and each site was dragged 3 times using the flag technique- which is universally recognised as an appropriate method for collecting ticks. The third picture shows what we found at each drag, 9 nymphs were collected in total on the day and there was evidence of Larvae at 2 of the drags.

( Coincidentally Graham Charlesworth posted on the Southern Isles Veterinary Practice page in Benbecula that he had dragged on 24/02/19 in South Uist the day before my dragging lesson in Lyon and he found 60 ticks ).

Magalie summarised some of the projects that the researchers are involved in in collaboration with other campus’s in France.

There is work ongoing to develop a map to identify the risk of exposure to Ixodes ricinis ticks throughout France, the map is being developed taking into account of host abundance, climate impacts and the landscape in each area. The risk will also take into account the presence of humans within the areas.

Studies have been undertaken to look at the competency of squirrels to carry Borrelia and the role they have in transmission of the bacteria.

Images from Lyon

View of the Cathédrale St-Jean up on the hill

DA and I standing in front of the cathedral and overlooking Lyon

Some pictures of the Cathedral

Outdoor stations of the cross

Patisserie’s on every street- they cakes tasted as good as they looked

Visit to Strasbourg

In Strasbourg I have arranged a visit to the Institute of Bacteriology, parasitology and Virology at 3 Rue Koerberle.

Louis Pasteur who made some of the greatest breakthroughs in modern medicine in his era and is known for his work on the principles of vaccination, microbial fermentation and pasteurisation. He is remembered for his breakthroughs in the causes and prevention of disease and he created the first vaccine for anthrax and rabies, he worked within the institution I visited . The picture below is displayed within the building and it is a well known painting of Rabies vaccination in Pasteur’s clinic in Paris.

Nathalie Boulanger

Nathalie is a pharmacist and works as a medical Entomologist, Nathalie also teaches at the school of pharmacy, she has been working on ticks and tick borne disease within France since 2001-2002, since the France national plan in 2016 there is a large increase in the amount of people who now work in different aspects of ticks and tick borne disease and in particular on Lyme disease.

Nathalie spoke about how she has been involved in the field work of collecting ticks and this has been important over the years to generate the data, particularly when considering emerging pathogens and how they have increased over the years. Nathalie has also spent years working in the laboratory progressing the knowledge on the importance of the skin, and the reaction that occurs following a tick bite. Nathalie also spoke about the importance of speaking to people about ticks and tick borne disease, and particularly the primary prevention actions she shared some of the resources she uses to educate people. But it is difficult for researchers to balance the time to teach, undertake research and also to speak to the public as well as time to apply for grants to continue with the research.

Nathalie introduced me to one of her PhD students Pierre Boyer, he works as a Microbiologist and his Phd study is looking at proteomics to identify ticks, most researchers use looking under the microscope to identify ticks. Looking at proteins appears to be more accurate, rapid and low cost he is about to publish his results. He is also looking at emerging pathogens, particularly Borrelia miyamotoi and rickettsia. The 3rd aspect of his Phd is to develop a new tool to diagnose Borrelia, by looking at the proteins present in Erythema migrans skin biopsy samples, these studies have the potential to improve diagnoses and testing.

Nathalie has always been interested in research of the skin and the area around the tick bites as this does appear to be a very important factor and the main interface between tick and host and has recently published a book on the topic:

Nathalie is involved in collaborative groups that develop resources and undertake the awareness raising on ticks and tick borne diseases.

Professor Benoit Jaulhac

Professor Benoit Jaulhac is a clinical Microbiologist, who has a clinical role as well as Director of the reference laboratory.

He developed an interest at the end of the 1980’s when as a medical student he worked with people who were starting to look at the serology of a new bacteria, this bacteria was present in Austria and Germany he was then working in the laboratory to look at this bacteria using molecular biology and he suggested to his boss that it would be interesting to look using PCR, he has extensive experience and has been involved in many research publications. During our discussion he made some recommendations for articles to read regarding the characteristics and clinical outcomes of a national cohort of PCR-positive Lyme arthritis. I asked him about the diagnostic accuracy of serological tests which is frequently criticised and he emphasises as others have done that the results cannot be interpreted in isolation, history, symptoms and the patients presentation have all to be considered. If the conclusion is that it is not Lyme disease other investigations should be undertaken. Prof Jaulhac told me about a study published in 2018 in France that demonstrated only 10% of patients with ongoing symptoms had Lyme disease and the concerns that exist around over-diagnosis and over treatment of Lyme disease is increasing.

Link to article: https://www.ncbi.nlm.nih.gov/pubmed/30239603

Reference Lab visit: CNR Borrelia Centre National de Reference-Borrelia

Laurence Filliax is a laboratory engineer and Marine Engel is a laboratory technician and both work in the CNR Strasbourg laboratory and are involved in projects where ticks are collected regularly in locations across the region since 2014. Although in the next year the sites for sampling is being reduced.

This has helped to identify the ticks that are present in France and the pathogens that they carry.

The ticks most commonly found in France are Rhipicephalus, Ixodes ricinus, and Dermacentor- images below

The laboratory is currently participating in a study with the dermatology department, patients that agree to enroll have biopsies taken of acrodermatitis rash and the sample is analysed for the presence of Borrelia. A questionnaire is completed with the usual patient details but also includes details of the bite. Photographs are taken of the rash.

Some of the rash’s do not test positive for Borrelia and some do, on the day I attended one of the samples was positive and I was able to see live Borrelia under the microscope. In the picture circled in red are the Borrelia, the video shows them clearly moving. I have permission from the ‘CNR Borrelia–Centre National de Reference-Borrelia” to use the picture and video I recorded while on my visit there.

The reference lab test all the serology samples for the three hospitals in Strasbourg.

Testing for Lyme disease receives criticism for its accuracy and reliability, each practitioner I speak too emphasises that it is important when testing patients to consider everything, the patients symptoms, history of tick exposure and also general risk of tick exposure ( where people go, what activities they participate in etc), presence of erythema migrans ( acknowledging that sometimes patients may not have seen the rash) and the results of blood tests. The ELISA test and the Western blot are the two commonly used tests.

The ELISA ( enzyme-linked immunosorbent assay)test is used to detect antibodies against Borrelia burgdorferi.

The Western blot can be used to confirm a positive ELISA test. It checks for the presence of antibodies to specific B.burgdorferi proteins.

Polymerase chain reaction (PCR) is used to evaluate people with persistent Lyme arthritis or nervous system symptoms. It is performed on joint fluid or spinal fluid

This a picture of the Western blot results

Basically the 3 strips on the left are the controls and the strips further on the right have to present darker than the controls to offer a positive result, if the strips further to the right are lighter in colour than the controls the result is negative, if the reaction is darker they are positive, the colours change in reaction to IGG and IGM in the samples being tested.

Strasbourg for the tourist in me was lovely, many old beautiful buildings and the city is interwoven with rivers. There were some remnants of the Xmas markets to be seen around the city and I found the Xmas shop::

As always I managed to have a look at the local area, Strasbourg was a lovely city with some beautiful architecture:

Paris

You could not go to Paris without visiting some of its most famous sites. For February the weather was lovely, apparently it had been really cold the week before we arrived.

Eiffel Tower- where we climbed the 700 steps to the 2nd level.

Sacre Coeur and the Monmatre district with the artists painting on the streets

Louvre and Madame Mona Lisa

Site seeing aside the reason for my trip was to visit Sante publique France

Since May 2016 the National Institute for prevention and Health education, the Institute for Public health surveillance and the Health Emergency and Response establishment have amalgamated to form Health France. This combined organisation works to serve the population in all aspects of public health based on scientific knowledge , data and information. The agency supports the government and society in improving the health and well being in the population. It applies a population based approach with the objective of reducing social health inequalities in all areas of public health i.e infectious diseases, non infection diseases, environmental and occupational health. The Agency mission revolves around anticipate, understand and take action:

With regard to Lyme disease I met with Dr Julie Figoni who is a medical epidemiologist with an interest in Infectious, parasitic and tropical diseases and Sandrine Randriamampianina who works on marketing of prevention within the agency.

Lyme surveillance by Sante publique has been recorded since 2009 and is based on 3 different data collecting methods.

The 1st method is through a network of volunteer GP practices that input data for Lyme borreliosis along with 8 other diseases such as mumps. Since 2009 senital surveillance of Lyme borreliosis has been carried out through selected GP practices. Annual incidence from these reports remained stable between 2009-2015 ranging from 41-55 cases per 100,000 persons. 2016 saw that increase to 84 per 100,000. Important regional differences was observed, with the highest incidence observed in Limousin, Alsace and Rhône -Alpes region. Among the cases 95% presented with Erythema migrans. Also, Brittany sees cases all year round, in east France cases are identified only in summer

The 2nd data collection method is to look at the hospital data, patients admitted into hospital and have a Lyme disease code assigned, these tend to be the patients that have symptoms of disseminated disease. This includes neurological, cardiac and arthritic symptoms. To clarify a diagnosis of Lyme borreliosis there is a validation of cases process undertaken to ensure only true cases are included this is a multi agency process which includes GPS, staff at Sante publique and the Lyme reference laboratory.

The 3rd method is to collect data from at risk populations such as forestry workers, there is a study looking at sero-prevalence in this group, blood samples are taken and analysed for the presence of a number of disease this has been going on for a few years and the numbers remain quite stable.

There are also plans to undertake sero-prevalence studies of blood donations this will look for correlation between the number of identified cases of Lyme borreliosis and it will also hope to identify if the numbers are higher for those who have evidence on previous exposure but no disease symptoms.

Julie and Sandrine.

The data collected and analysed by the agency is published annually and also appears in eurosurveillance -the range of publications published can be accessed on this link:<https://www.eurosurveillance.org/search?value1=Lyme&option1=fulltext>.

Within the agency data publication there is also information on ticks, symptoms, tick removal and treatment recommendations.

Leaflets, posters and local media information is made available in the high risk areas and in the spring/ summer seasons when the general public are more at risk of being exposed to ticks. Emphasis is placed on the precautions that can be taken to prevent tick bites and how to remove ticks.

The agency is involved in the development and progress of the France national plan for Lyme disease. Prior to the publication the agency were commissioned to undertake a knowledge, attitudes and behaviour study with the general population, 65% had heard of Lyme disease, 1 in 4 people and been bitten and 1 in 5 thought they were at risk of exposure to Lyme disease. The study demonstrated that it did not present as high an issue as other public health matters such as vaccine preventable disease like meningitis etc. It is therefore important to find the correct balance of the actual disease burden when compared to other conditions but to also ensure people are aware of the risks particularly in the acknowledged high risk areas. Actions should be appropriate and should not be alarmist it is imperative that people continue to enjoy the environment and participate in outdoor activities.

Lyme disease is a very emotive topic and there is much publicised about the patients who suffer with long term effects but that needs to be balanced with those who get bitten by a tick and don’t get Lyme disease, those who present with Erythema migrans receive the correct treatment and recover completely and those who go out in the environment regularly and never get bitten.

The national plan was driven by the ministry of health and involved a wide range of groups, professionals and patients, and it identified actions on Epidemiology, diagnosis, treatment and prevention. Aspects of the plan remain disputed by some of the groups involved but work continues to improve the knowledge available in France.

I will return to Paris at the end of my trip to meet with other people.

Phase 2 Churchill Fellowship travels to France

I cannot believe this time has arrived when I came back from the USA and Canada it felt like I had a lot of time until this trip.

I left home on South Uist on Friday and what a beautiful morning I left on:

This is Ben Mor on South Uist from my garden.

I know that some of those I met in Canada and USA look at my blog so I’ll share some pictures from South Uist to entice you all to visit !

These five pictures have all been taken in the last 5 days, the first one by me and the others by my brother in law Davy McComb.

I have already arrived in Paris. The map below shows where I hope to travel too…The trip involves visits in Paris to meet with people who work at Sante Publique France which is the French Public Health Agency.

In Strasbourg I will meet with staff who work at the National Centre for Borrelia and Borreliosis( Unistra)

In Lyon I will visit the campus Veterinaire de Lyon and will travel to its connected site at Clermont- Ferrand-Thiex.

I will also visit some of the well known and loved sites in these cities.

I will keep you updated..

Quebec City

We left St Hyacinthe with a snow weather warning and travelled to Quebec City. In Canada all cars have to be fitted with snow tyres, it is illegal to drive a car without them after the 15th on November, we travelled with the hire car without the snow tyres, but we needed have worried the roads were very clear.

Quebec City had lovely buildings

A castle on a hill

Lots of art shops with lovely paintings on displays

Snowy views

Two spectacular mural’s painted onto the side of two buildings

And they were going all out with the Christmas decorations

It was a lovely place to visit and we only really saw the old town, I would thoroughly recommend it for a holiday.

After a quick visit in Quebec City we made our way back to Boston for our five flights home! and I have to commend all the airlines we travelled on every single flight left on time and we made all the connections with time to spare.

It was a very wet Boston, but we ventured out.

And that brings to an end phase 1 of my Churchill travels ( phase 2 is France in February 2019). I have met lots of interesting people and saw lots of the work being done. I now have to collate all I have learnt and look forward to arranging the next trip. I hope you have enjoyed the blog, it has been like a diary for me of all the things I saw and did and I hope it will help when it comes to writing my fellowship report.

Lyme disease in Canada : A Federal Framework

Telephone conference with Federal Government staff at Ottowa

Rukshanda Ahmad (Medical Advisor), Michel Deilgat (Medical Advisor), Julie Theriault (Nurse Consultant), Lindsay Colas (Manager of tick-borne diseases policy team), Annie-Claude Bourgeois (Manager of vector-borne team), Karyn LaCroix (Senior policy analyst in the tick-borne unit), Anne Magnan (Policy analyst) and Nick Ogden and I in St Hyacinth.

The team gave me an overview of the Framework and their roles to co-ordinate and report on the activities tasked in the framework, the team are 1 year into the implementation and have to report progress in year 5 (2022).

The full document is available at : https://www.canada.ca/en/public-health/services/publications/diseases-conditions/lyme-disease-canada-federal-framework.html

The document is centred around 3 pillars

* Surveillance

* Guidelines and best practice

* Education and Awareness (Public and Health Professionals)

Year 1 has been spent planning, engaging with stakeholders and looking for collaborators. There was a round table event in June 2018 which included Provincial representatives, public health authorities, health professionals, academics and patient advocates.

To support framework delivery –$4 million has been committed for a Pan-Canadian Research Network on Lyme Disease in order to generate knowledge to improve diagnosis and treatment, and an additional $1.25 million to increase Canada’s capacity to respond to the health impacts of Lyme disease. More information available at https://www.canada.ca/en/institutes-health-research/news/2018/10/government-of-canada-takes-action-to-address-lyme-disease.html

---

Enhanced Surveillance reporting

The framework is committed to collecting accurate data and as I discussed in another post Jules at PHAC in St Hyacinthe has been instrumental in the design of the surveillance system.

Reporting form- this is 1/2 of the first page

(3 pages in total) link below to the complete form

https://www.gov.mb.ca/health/publichealth/cdc/protocol/mhsu_8232.pdf

The surveillance data published to date is available for viewing online at :

---

Professionals guidance and best practice resources

Monitoring and review is performed of all guidance and practice documentation that includes review of NICE guidance published in the UK in June 2018.

Management protocol

Guidance is available to health professionals with diagnosis, testing and treatment.

Defines how to diagnose the different stages and the testing that is required

https://www.gov.mb.ca/health/publichealth/cdc/protocol/lyme.pdf

An online resource is available for staff in Quebec

Institute for Santa de

https://www.inspq.qc.ca/nouvelles/un-guide-d-identification-des-tiques-du-quebec-pour-les-professionnels-de-la-sante

Prophylaxis

At a couple of the meetings I attended this week reference has been made for the use of prophylaxis in patients with a tick bite, the tick bite has to have been received in an area identified in Canada as a highly endemic area. This is not encouraged in the UK or USA.

The current use of prophylaxis can be seen on this link: https://www.canada.ca/en/public-health/services/diseases/lyme-disease/health-professionals-lyme-disease.html

The research paper that provides the recommendation for use of prophylaxis is Nadelman et al (2001) Prophylaxis with single-dose Doxycycline for the prevention of Lyme disease after an Ixodes Scapularis. The New England Journal of Medicine, 345(2).

---

Health education and awareness

Government staff have participated in outreach activities at national conferences attended by primary care physicians.

Speak at family medicine forums, about clinical aspects, and treatment of all tick borne diseases.

This has led to the creation of a zoonotic/climate change group to find out physicians priorities and identify areas they want to increase knowledge

Toolkits are being developed for clinical guidelines for obstetricians due to the concerns that have been raised about maternal/foetus transmission.

The school of Nursing is also committed to adding some modules into the training programme.

Resources

I have included some of the resources I have seen or were recommended to me while here in Canada, this list is not exhaustive there are other resources too.

Land management tips

Kirby Stafford from the Connecticut Agricultural Experiment Station, has a book that is the most referenced resource for environmental tick management . Kirby very kindly gave me a copy and he said the book is being reviewed and updated.

Other resources used in Canada

General public information leaflets

Small Information cards

More information available at:

https://www.gov.mb.ca/health/publichealth/factsheets/lymedisease.pdf

https://www.gov.mb.ca/health/publichealth/cdc/tickborne/docs/tbd_children.pdf

Tick warning poster I saw displayed in Bromont

Cards that were available at St Bruno National Park

---

INSPQ (Institute National de Santa Publique)

A website that is accessible to all and contains lots of information about all public health issues including the mapping of Lyme risk (in French).

Website address:https://www.inspq.qc.ca/en

An anecdote from one of the meetings I attended which mentioned the INSPQ website is that until 2 weeks ago Lyme disease was the most viewed page on the INSPQ website, that changed when Cannabis was legalised- looking at Cannabis has overtaken Lyme disease.

---

I participated in a telephone conference with Dr Ariane Adam-Poupart, Dr Alejandra Irace-Cima, Catherine and Nick (from Rue Sicotte)where they discussed the work of the Ministry of Health , this includes public and health professional awareness.

The ministry develop notices and distribute them to parks etc.

They arrange annual meetings with Dr’s, Nurses and Pharmacists in regions- the intensity of information does depend on the risk in the area- as the risk. Maps demonstrate not all areas are affected so it is important to target activities that are relevant.

They are working on projects with outdoor workers and their employers to increase awareness , developing elearning/videos etc. They are educating workers to collect data in their own parks and hey had a small pilot last year with 60 workers. Phase 2 is a ‘train the trainers’ event and extend the range of parks they work with and widen the project to include public education.

Some other ideas being considered are offering free bug spray (insect repellant) with the hand gel in parks.

At this meeting I heard about the use of prophylaxis in tick bites

St Hyacinthe

More about the staff I met at the Agence de la Santa publique du Canada in St Hyacinthe

Erin Rees

Erin is an epidemiologist who uses quantitative methods to study issues of population health for wildlife, food production animals and humans. Her research outcomes are applied to advising management of population health. This includes developing strategies to optimise use of surveillance data, identify vulnerable individuals and populations, and evaluate the effectiveness of management and disease control strategies.

Erin is also involved in the Global Public Health Intelligence Network(GPHIN). GPHIN’s mission is to be an indispensable source of early warning for potential public health threats worldwide including chemical, biological, radiological and nuclear (CBRN). The network scans news sources, social media etc for words and analysis the wording and starts to build a picture of threats as they develop.

Erin’s work with regard to Lyme disease involves developing a model to estimate tick abundance while considering the contributing covariates such as forest, elevation and temperature

---

Dragging for ticks in Bromont with Camille Guillot

Camille is a veterinary student ( who graduated from Edinburgh University as a medical Doctor in 2015) but she loves to study and enjoys the Zoonoses aspect, so she is now training to be a vet. Camille is helping to collect ticks. Bromont is a beautiful area up in the hills and surrounded by trees .

The community were aware of the risks and came forward looking for help/ support for the area. The studies are starting with identifying tick abundance, location of ticks ( peri-domestic or public areas) with a view to progress to testing management solutions as the project moves forward.

We found 10 ticks, which will be sent for analysis.

Camille pointed out an area which was set up for collecting maple syrup from the trees. On the first picture you will see a network of green tubing going from tree to tree and the second image is a close up of one of them. This is the modern way of collecting historically it used to be buckets/ containers sitting at the base of the tree collecting when the tree would start in ooze the syrup. The trees actively leak! the syrup in the spring after the winter frost has started to thaw.

At the beginning of the area we dragged at I noticed a couple of signs and was very disappointed to not see any tick warning notices

However further in on the path, this was displayed!!

This was very encouraging.

---

Jules Konan Koffi

Jules has worked for PHAC since 2009, in the Centre for Food-borne , Environmental and Zoonotic Infectious Disease he was tasked with designing a Lyme disease surveillance system.

There is a national notifiable surveillance system for a range of disease and there is a second enhanced surveillance system for Lyme disease.

Lyme disease is reported from the Doctor – Regional Government- Provincial Government -Federal Government. Currently it is a paper system which requires the data to be transferred. The data has to be validated and checked before it can be released as the national statistics and due to the way the data is collected it is a time consuming exercise. The working group can be put under pressure from Lyme advocacy groups about the release of the data but the process is adhered to strictly to ensure the data going into the public domain is correct.

There is a national working group which includes representation from the 10 Provincial governments, only 9 provinces currently input data for the Lyme enhanced surveillance but they are engaged in the process.

---

Yann Pelcat

Yann is a medical geographer who started with PHAC in 2009. Prior to that he worked as a neogronomist within the agriculture field.

In his role in PHAC he specialises in Geographic Information Systems (GIS), this software allows you to map out disease. Authorities provide precise data/information of cases, locations etc on a data spreadsheet and Yann transfers that onto maps.

The first map is of tick known endemic areas and suspected endemic areas

This map shows the movement of West Nile virus

This form of mapping is used nationally to map diseases and requires each province to provided consistent data.

Yann’s mapping skills have been used to support the two emergency operations centres in Canada that were used to support the response to the Ebola outbreak in the Congo.

---

VISIT TO ST BRUNO NATIONAL PARK

DA, Nick and I went to visit the National park at Mount Saint Bruno. Canada operates a no right to roam policy so people who wish to walk are restricted to roadside walking or travelling to the national parks. This park was lovely, it cost DA and I $17 to get in but Nick and people who live close by pay an annual membership and it gives access to all the parks in Quebec. Tick research is being undertaken within the park by a PhD student called Ariane Dumas (Ill tell you about it next).

In the summer the park is an array of walking trails and in the winter with the snowfall it becomes a cross country ski location. More information is available on the park website: https://www.sepaq.com/pq/msb/

DA and Nick

Infected ticks have been collected in the park so it was reassuring to see warning notices.

Outside display

Leaflets on tick and mosquitoes were available inside

---

On Friday I listened in on a teleconference with Ariane Dumas, Nick Ogden and smiling on the phone! are Robbin Lindsay and Antonia Dibernardo in Winnipeg.

The group met to discuss Ariane’s studies at St Bruno national park. Ariane is a student of the University of Montreal.

Her PhD title is ‘Ecology and emergence dynamics of Lyme disease at a fine spatial site’.

Ariane has been undertaking sites visits since 2016 , she identified 32 sites within the park and collected ticks by dragging, trapped rodents, birds and small mammals to examine them and remove ticks for analysis and identified environmental factors within the park.

The study will be looking at tick abundance, transmission hosts, environmental factors and observe changes in these over the 3 years of data collection as well as look for Borrelia burgdorferi and identify any other strains and look at what strains are prevelant in which hosts and gain information on the host activity.

Robbin and Antonia undertake the laboratory testing.

---

Rue Sicotte social activities

Thursday lunch with staff at Rue Sicotte (DA was there too) luckily as we struggled with the menu in french and ended up with enough chicken, rice and salad for 2 meals each.

Pandemonium

Staff are involved in a music group and they are practicing for the Christmas party!

Catherine and Camille with the Miranda Forrest glass necklaces I gave them as gifts.

Public engagement activities-eTick.ca

A public platform for image-based identification and population monitoring of ticks in Canada

Description: The emergence of Lyme disease and the rapid geographical range expansion of certain tick species in Canada are important issues for public health authorities and the public in general. Following tick populations on such a large territory is also expensive and logistically challenging. The citizen science project eTick.ca therefore invites the public to participate in the monitoring of ticks in Canada by submitting tick photos on eTick.ca for identification by a professional. The identification results, combined with other data such as collection date and locality can then be consulted and mapped so that all users may visualize the information related to any/all species for any given year and/or geographical area. 

Access to eTick.ca is free and it is not necessary to contribute data in order to consult the database.website where people are encouraged to document their experience of tick exposure.

Map- dots indicate where people have inserted data:

Next image is where I selected a dot and it shows the data that was added

The site can be accessed with this link:https://www.etick.ca/en/

The University of Montreal in collaboration with other organisations are currently looking at a project to develop a tick app. If funding is secured it will be an integrated tool for tick borne disease prevention and public health surveillance. Tick and Lyme risk is different across the regions of Canada therefore the risk communication messages would have to be adapted – the traditional communications activities delivered through websites and media would not be able to differentiate the messages for the changing risk areas.

Another public engagement online site is from Rhode Island University ‘Tick encounter.org’

It’s a very interactive site with lots of Information.

https://tickencounter.org/

Canada

We left Boston and flew to Montreal and onto Quebec, hired a car and drove to St Hyacinthe.

I am based for the week at the Public Health Agency for Canada in St Hyacinthe in Quebec.

Dr Nicholas Ogden is the Director of the Public Health Risk Sciences Division at the Public Health Agency of Canada/University of Montreal in St Hyacinthe. He started off as a Vet in the UK, and since his PhD he has continued to work in the research of ticks and tick borne disease.

Nick spoke about some of the research he has been involved and also the Department of Risk Sciences that he is the director off. The department is a division of the Public Health Agency of Canada(PHAC) and works closely with the University of Montreal.

The research group in the Epidemiology of Zoonoses and Public Health is a research group of the Faculty of Veterinary Medicine of the University of Montreal, and the result of a partnership between professors of the University of Montreal and researchers from the Public Health Agency of Canada.

The staff are all involved in research themselves and they are also tutors delivering courses in the University and the MSc and PhD Students under their supervision complete research projects that relate to ticks and Lyme disease. This structure allows for fluidity in the research and ensures it all ties together and progresses the knowledge in a structured way as opposed to students choosing random projects. Over the week I will spend time with the staff finding out about their research.

Canada has three levels of government Federal, Provincial and regional. Federal- seated in Ottawa, this level deals with the law and matters that affect the whole of Canada. The federal government published the Federal action plan for Lyme disease. Available at : https://www.canada.ca/en/public-health/services/publications/diseases-conditions/lyme-disease-canada-federal-framework.html

The framework acknowledges that Lyme disease is an emerging infectious disease in many parts of Canada, and the Government of Canada recognizes the impact that it has on Canadians and their families. Efforts to prevent and control Lyme disease are being made by a variety of stakeholders. The interim Chief Public Health Officer, expressed concern about the challenges associated with Lyme disease in Canada. The plan includes the establishment of a Lyme disease research network. As an emerging disease it is important that researchers come together with an evidence-based approach, and address knowledge gaps through further research. However Provincial governors (10 provinces 3 Territorials with responsibility for areas such as education, health care, natural resources and road regulations) and Municipal governors (city, town or district level with responsibility for libraries, parks, water systems, local police, roadways and parking) are left to prioritise what is done within their own localities, which means that there is no consistent structure to how areas mange ticks and Lyme disease.

The Public Health Risk Sciences division in collaboration with others are at the forefront of progressing research being undertaken. In response to the Federal framework a Canadian research network has been proposed, a multidisciplinary, patient-centered research program, from discovery to implementation, with the ultimate vision of reducing the impact of Lyme disease on the health of Canadians. The network will integrate researchers, patients, HCPs, public health & non-researcher stakeholders into the planning, advisory, and oversight capacities of all research activities to create short and long-term outcomes that are specific, measurable, accountable and transparent. Solutions and strategies will be developed by facilitating engagement across stakeholder groups. Patient engagement will be guided by provincial Strategy for Patient Oriented-Research (SPOR) units and patient/citizen engagement experts. Training and development of highly qualified personnel will be integrated across all research areas. We will accomplish our vision by creating foundational resources and spearheading new research initiatives.

It has been suggested that many critical knowledge gaps exist in Canada including: conflicting views on the natural history of disease, including the impact that LD strains have on the effectiveness of current diagnostic tests and on disease clinical presentation and patient outcomes, and lack of evidence on prevention/intervention strategies to reduce risk and long-term sequelae. Further, training and education of healthcare providers (HCP) is required to improve awareness and understanding of LD.

More information on the network can be seen on the website: https://www.clydrn.ca/

Dr Ogden has been involved in projects looking at the risk modelling for developing knowledge on Lyme disease. Many researchers have been involved in passive and active surveillance and there are many challenges associated with these methods, particularly when the territory under surveillance is very large and available resources are limited. The use of risk modelling has been able to predict the spread of Lyme disease and this has allowed for identification of high/low risk areas and could ensure surveillance activities were delivered in a targeted way.

The method is now being used to look at other vectors i.e Lone Star Tick movement into Canada and the progress of West Nile Virus.

---

Serge Olivier Kotchi

Serge is a Medical Geographer who is an expert in geomatics and earth observation. One of his recent projects was ‘Earth observations based risk maps for Lyme disease Infection in Eastern Canada’. Serge gave me permission to use his slides to explain his study.

The study used multi scale land cover variable estimations and vector habit mapping, The estimates were developed using MODIS images, MODIS is a sensor on board earth observation satellite, Landsat satellites and annual crop inventory maps from Agriculture and Agri-Food Canada

Microclimate indicators (temperature/humidity) using similar technologies.

The images developed show

And this information can now be used to compare Ixodes scapularis risk maps to active surveillance data.

Using Earth observation images will help to guide targeting of national research, surveillance and prevention and control activities in known or newly identified areas.

---

Catherine Bouchard

Is a veterinary epidemiologist and Professor Adjuvant at the Department of Epidemiology of the University of Montreal, she completed her PhD by looking at the variability of tick abundance across 30 micro sites.

Catherine teaches an online Epidemiology class and Conducts and co-ordinates Veterinary students undertaking PhD and MSc projects. She was very enthusiastic about the close links with the University as it ensures all studies are linked and allows for consistency in the studies and also offers future employment opportunities to the students as she acknowledges that is how she started working in PHAC.

Catherine is very interested in how the general public perceive Lyme risk and recognises the importance of sharing the knowledge of tick abundance with those in the areas affected, Catherine feels that how this is done needs to improve as many people are not aware of the risks. The data is available on websites but that is not always accessible to everyone, the difficulties with service delivery across the regions/municipalities does not help as small areas are free to decide for themselves what they do for their own community. A suggestion could be that at a Federal level communications departments and Scientists undertaking the research could collaborate more to look at innovate ways to inform people of study results.

Catherine has personal experience of field surveillance and supervising students who carry out surveillance, so is very knowledgable on the results of previous sentinel surveys and the importance on monitoring the expanding edge of areas that have previously been recorded as demonstrating high tick abundance. It is more beneficial to observe the situation in the areas out-with than to continually drag sites that are already recorded and known about. Testing also needs to expand further to check the abundance in public sites/parks and peri-domestic sites.

Catherine and I participated in a telephone conference to Sandie Briand who works at the Institute National de Santa Publique de Quebec. Sandie spoke about the work of the Lyme disease enhance surveillance working group.

Catherine and I with Sandie on the phone!!!! (First selfie on the blog)

Risk is based on data collected from human surveillance, passive tick surveillance and active tick surveillance, the map indicates the risk identified for each area, although it is in french you can still figure it out!

Sandie also spoke about some of the resources available online from INSPQ.

This link takes you to the page: https://www.inspq.qc.ca/guide-d-identification-des-tiques-du-quebec