When Neglected Tropical Diseases Knock on California's Door

When Neglected Tropical Diseases Knock on California’s Door

Anne Kjemtrup, DVM, MPVM, PhD California Department of Public Health Vector-Borne Disease Section Overview of Today’s Topics

• Neglected tropical diseases: setting the stage for impact on California • California Public Health Overview – Surveillance/response structure – Vector-Borne Disease program areas THE MONSTER RETURNS • Two examples: Peter McCarty – Arbovirus introduction (dengue, chikungunya, zika) – Re-emergence of Rocky Mountain spotted fever (not really NTD but similar principals) Neglected Tropical Diseases*

• Buruli Ulcer • Leishmaniasis • Chagas disease • Leprosy (Hansen disease) • Dengue and Chikungunya • Lymphatic filariasis • Dracunculiasis (guinea • Onchocerciasis (river worm disease) blindness) • Echinococcosis • Mycetoma • Endemic treponematoses • Rabies (Yaws) • Schistosomiasis • Foodborne trematodiases • Soil-transmitted • Human African helminthiases trypanosomiasis (sleeping • Taeniasis/Cysticercosis sickness) • Trachoma

* from: http://www.who.int/neglected_diseases/diseases/en/ Neglected Tropical Diseases

• Buruli Ulcer • Leishmaniasis • Chagas disease • Leprosy (Hansen disease) • Dengue and Chikungunya • Lymphatic filariasis • Dracunculiasis (guinea • Mycetoma worm disease) • Onchocerciasis (river • Echinococcosis blindness) • Endemic treponematoses • Rabies (Yaws) • Schistosomiasis • Foodborne trematodiases • Soil-transmitted • Human African helminthiases trypanosomiasis (sleeping • Taeniasis/Cysticercosis sickness) • Trachoma

California has vector and/or disease agent

State Reportable Diseases California Department of Public Health

l 81 human diseases or conditions (including all the national diseases), 2 animal diseases (rabies and plague) • Vector-Borne diseases include: • Anaplasma/Ehrlichiosis • Babesiosis • Colorado Tick Fever (to be removed next year) • Dengue • Hantavirus cardiopulmonary syndrome • Lyme Disease • Malaria • Plague (human or animal) • Relapsing fever • Rocky Mountain spotted fever • Tularemia • West Nile virus • Yellow Fever Intervention/Response Surveillance

(Improved) diagnosis, treatment(s) recommendations hospital Notifiable/reportable

Health care provider

Public education General pop.:Symptomatic

General pop.: (A)symptomatic infected Sero-surveillance, surveys

Vaccination, General population: exposure Disease burden Disease prophylaxis

Vector control Vector-surveillance Vector: presence/absence/abundance/distribution pathogen- pathogen control surveillance Risk Reservoir hosts: presence/absence/abundance/distribution

Public Health Surveillance, 101

Adapted from Braks et al, Parasites and Vectors 2011, 4: 192 7 Notifiable Disease Surveillance: Route of Information Reporting mandated by state law (Title 17 CCR)

Health care providers, laboratories, others, report to local health department (LHD)

LHD submits reports to CDPH

Reports transmitted to Centers for Disease Control and Prevention (CDC) Notifiable Disease Surveillance: Route of Information

Reporting mandated by state law (Title 17 CCR) Reportable TBD include: anaplasmosis, babesiosis, Lyme disease, relapsing fever (B. hermsii), spotted fever and non-spotted fever group rickettsia

Local health department (LHD) receives, follows-up, reviews reports

LHD submits reports to CDPH

Reports transmitted to Centers for Disease Control and Prevention (CDC) Vector-Borne Disease Section

Primary Vector Programs • Mosquito • Flea • Rodent • Tick Information for Action Rodent Borne and Flea-Borne Disease Surveillance • CDPH’s program for plague, hantavirus includes: • investigations of human and domestic felid plague cases; investigation of human hantavirus cases • serologic monitoring of wild carnivores (plague) • evaluation of bacterial/virus activity in rodents: • Exposure potential to humans from vector fleas assessed • Past history of epizootics and/or human plague cases in the region reviewed • Recommendations and actions taken to reduce vectors and public exposure Tick Surveillance Mosquito Borne Disease Surveillance Mosquito-borne diseases often have complex lifecycles requiring complex surveillance

West Nile virus transmission cycles in California

Rural cycles Urban cycle

?? Bird/Mosquito Culex Aedes, Culiseta Aedes, Culiseta Movement? pipiens stigmat. Culex tarsalis ?erythro.

Dead end hosts Mosquito-Borne Disease Surveillance Aedes albopictus and Aedes aegypti have arrived and become established in CA Aedes albopictus Asian tiger mosquito Aedes aegypti 2008: First introduced then Yellow fever mosquito eradicated 2013: Madera, Fresno, 2011: Los Angeles County San Mateo Counties Aedes modes of introduction into U.S.

Lucky Bamboo (California)

Imported used tires (Southeastern U.S.) Impact of invasive Aedes introduction to California • Vector: Dengue, chikungunya, Zika • Increased risk of introduction of exotic mosquito-borne viruses • Aggressive day-biting mosquitoes • Prefer to bite people (rather than birds or other animals) • Difficult to control: Breed in containers Aedes aegypti and Aedes albopictus Mosquitoes in California 125 cities/census designated places with Aedes aegypti and/or albopictus Aedes aegypti and Aedes albopictus Detection Sites by County/City Fresno Los Angeles (continued) Orange (continued) Clovis South Whittier* Mission Viejo Firebaugh Whittier Santa Ana Fowler Willowbrook* Buena Park Fresno Alhambra Garden Grove Kerman Altadena* Huntington Beach Mendota Arcadia Los Alamitos Sanger Avocado Heights* Mission Viejo Tranquillity* Azusa Newport Beach Imperial Baldwin Park Orange Andrade* Bradbury Santa Ana Brawley City of Industry Riverside Aedes aegypti Calexico Claremont Cathedral City El Centro Covina Coachella Heber* Duarte Corona Aedes albopictus Holtville El Monte East Hemet* Imperial Glendora Indio Seeley* Irwindale Palm Springs Kern La Cañada Flintridge Perris La Mirada Arvin Riverside La Puente McFarland San Jacinto La Verne Arvin Los Angeles San Bernardino Los Angeles Monrovia Colton Montclair Alhambra Monterey Park Upland San Mateo Avocado Heights* Pico Rivera Bell Rosemead San Diego Fresno Bellflower San Dimas Bonita* Bell Gardens San Gabriel Chula Vista Carson San Marino Coronado Cerritos Santa Fe Springs El Cajon Tulare Commerce Sierra Madre Escondido Cudahy South El Monte Imperial Beach Diamond Bar South Pasadena Lakeside* Downey South Whittier* La Mesa East Los Angeles* Temple City La Presa* Kern Florence-Graham* Walnut Lemon Grove San Bernardino Hacienda Heights* West Covina National City Hawaiian Gardens Whittier* Oceanside Huntington Park Madera San Diego La Mirada Santee Madera Los Angeles Spring Valley* Madera Ranchos* Los Angeles Maywood Parkwood* Tecate* Riverside Montebello Vista Orange Monterey Park Orange Carlsbad Imperial Paramount Anaheim San Diego Pico Rivera Buena Park ü Costa Mesa San Mateo San Diego Pomona Atherton Garden Grove Rosemead Menlo Park § New detection within the previous four weeks Orange Rowland Heights* Tulareü *Unincorporated Census-Designated Places Santa Fe Springs La Habra Exeter üNo Aedes detections in 2016 South Gate Lake Forest Climate Change and Invasive Aedes Mosquitoes in CA • Tropical species – Warm weather enhances survival, reproduction, and spread • Drought: unintended consequence – Residents store water in backyard buckets, containers, and rain barrels – Do not maintain swimming pools • Aedes establishment and spatial distribution may be enhanced due to climate change

Local Mosquito Control Response Example Human Dengue, Chikungunya and Zika Surveillance in California Looking Beyond the Unfortunate Travel Souvenir Viruses and Transmission • Chikungunya is an alpha virus similar to WEE and Ross River virus • Dengue and Zika viruses are both flaviviruses similar to yellow fever and Japanese encephalitis virus • All are arboviruses and transmitted primarily human to human by Aedes aegypti and Ae. albopictus Dengue, Chikungunya, Zika mosquito transmission cycles Additional Modes of Zika Virus Transmission

• Mosquito-borne

• Congenital

• Sexual

• Care giving (rare)

• Blood transfusion Geographic spread Dengue virus area of risk

Spread of Chikungunya virus Arboviruses Ease of Introduction Chikungunya Virus

• Alpha virus (WEE, Ross River) • First identified in the 1950s in East Africa • In urban epidemics, humans are the primary reservoir for chikungunya virus • Confirmed chikungunya cases First detection of local reported in the Americas by transmission in the PAHO 180,000 Americas, December 2013 160,000 140,000 120,000 • 2014-2016 PAHO reported 100,000 80,000 220,939 confirmed cases 60,000 40,000 across the Americas 20,000 0 2014 2015 2016 Dengue

• Flavivirus (WNV, Yellow fever) • Dengue is endemic in at least 100 countries in Asia, the Pacific, the Americas, Africa, and the Caribbean • 2.5 Billion people live in areas with a risk of dengue transmission

• The World Health Organization Confirmed dengue cases estimates 50 to 100 million reported in the Americas by PAHO infections annually 700,000 600,000 • 2014-2016 PAHO reported 500,000 400,000 300,000 >1.4 million confirmed cases 200,000 100,000 across the Americas 0 2014 2015 2016 California, USA Dengue and Chikungunya in California and Location of Invasive Aedes

Aedes aegypti

Aedes albopictus

2015-2016 travel associated human dengue and chikungunya cases No reported cases San Mateo 1-10 reported cases Madera 11-20 reported cases Fresno >21 reported cases

Tulare

Kern San Bernardino

Los Angeles Riverside Orange

San Diego Imperial Zika

• Flavivirus (dengue, WNV, Yellow fever)

• Historically limited to Africa and South East Asia

– First outbreak in Pacific Islands 2007 and again 2013-2014 – First outbreak in the Americas began in Brazil, May 2015 • Since 2015, 47 countries or territories in the Americas have reported local transmission • 204,255 confirmed cases of Zika have been reported in the Americas by PAHO 2015-2016 • Florida and Texas reported local transmission in 2016 What was new with Zika? • New forms of transmission – Congenital – Sexual transmission – Blood banks • New departments and sections to work with – CDPH Center for Family Health – CDC Zika pregnancy registry – Medical and Health Coordination Center (MHCC) • Whole new prevention messaging – Move beyond protect yourself from mosquito bites – Prevent sexual transmission – Travel advisories, especially for pregnant women – Complicated testing recommendations Zika Virus Travel-Associated Cases U.S. Total = 4,780* (ArboNET)

1008

414

298 6 local 855 214 local

*as of February 8, 2017 https://www.cdc.gov/zika Zika Testing by Blood Banks • The Food and Drug Administration (FDA) mandated screening of blood products in California on September 23, 2016

• 4 cases of Zika in asymptomatic individuals have been identified in California through blood product screening – 5 false positives have been ruled out

• If donor tests positive for Zika virus – Defer for 120 days – Quarantine all blood products collected from donor in prior 120 days Travel-Associated Cases of Dengue, Chikungunya and Zika in California, 2014-2016

400

350 335

300 282

250

Chikungunya 200 179

Case Count Dengue 141 150 139 131 Zika

100

50 34 17 3 0 2014 2015 2016 Year Chikungunya Dengue Zika Median 47 (range 1-87) 41 (range 0-88) 35 (range 0-89) Age Ethnicity Hispanic or 59% 29% 43% Latino Travel-Associated Zika Infections in California 2015-2017 Variable Value Total number 486 Percentage of female cases 65% Age range 0 – 89 years Median age 35 years

Pregnant women 81

Asymptomatic pregnant women 46

Live-born infants with birth defects 4 California Travel from Zika-Affected Countries 2015 Air Travel ~4.5 million travelers flew into CA from Zika affected areas • Final destination airports: – Los Angeles 54%, San Francisco 20%, San Diego 6% • Highest travel volume to CA occurred in July and August • 66.8% of flights originated in Mexico Sea Travel • 1.2 million travelers entered CA from Zika affected areas • Arrival ports: – Long Beach 65.1%, Los Angeles 20.2%, San Diego 8% Land Travel • 55 million travelers entered CA at US-Mexico border Countries of travel

Chikungunya Dengue Zika 1. Mexico 1. Mexico 1. Mexico (28%) (21%) (33%) 2. El Salvador 2. India 2. Nicaragua (20%) (14%) (11%) 3. Guatemala 3. Philippines 3. Guatemala (10%) (9%) (8%) 4. Nicaragua 4. El Salvador 4. El Salvador (8%) (8%) (6%) 5. India 5. Indonesia 5. Puerto Rico (7%) (6%) (5%)

Clinical Description

Symptom Chikungunya Dengue Zika Fever 85% 92% 50%

Joint Pain 83% 55% 51%

Rash 53% 50% 72%

Conjunctivitis 0.4% 3% 28%

Myalgia 64% 68% 28%

Hospitalization 49 (11%) 146 (32%) 5 (1%) Chikungunya, Dengue, and Zika Cases by Month of Onset, 2014-2016

120

100

60 Chikungunya

Case Count Dengue

Zika 40

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Arboviral Testing

VRDL Commercial Other Chikungunya 20% 85% 5% Dengue 16% 82% 2% Zika 55% 18% 27%

Zika: PCR Confirmed Zika: PRNT Confirmed 280 (77%) 82 (17%)

PRNT Unspecified Flavivirus Dengue 119 (25%) Zika Potential for local transmission is low • A viremic person would need to return to a region where there are Aedes mosquitoes and be bitten by an Aedes that would live long enough to be come infectious and bite another person who then becomes infected • Mitigating factors: – Patchy Aedes aegypti and albopictus distribution in CA – Use of AC, window and door screens – Better water management than in other countries – Good mosquito control • An outbreak would likely be limited in scope and duration • Outbreaks of dengue and chikungunya elsewhere in the US have been contained • US is unlikely to experience the same extensive outbreaks currently being experienced in Latin America However….. • Transmission is possible and aggressive response needed once a case without travel history has been reported • Ongoing surveillance and control of Aedes are critical • Individuals with Zika should be informed to take extra precautions to avoid mosquito bites during illness to avoid initiating local transmission • Public health risks associated with travel to countries where Zika is circulating must be conveyed to California residents; pregnant women should not travel California Zika Response Activities and Resources • Supplement to “Guidance for Surveillance of and Response to Invasive Aedes Mosquitoes and Dengue, Chikungunya, and Zika in California” • Recommends key activities and provides resources in 10 categories Maternal and Child Health Vector Control and Surveillance Surveillance and Response Public Health Surveillance and Rapid Birth Defects Monitoring Epidemiological Investigation and Follow-up Laboratory Testing Travel Health News Prevention of Sexually Transmitted Clinician Outreach and Zika Virus Infections Communication Prevention of Blood Transfusion– Risk Communication/Community transmitted Zika Virus Infections Education Lessons Learned 1. California is not immune to impact from global outbreaks – Travel – Immigration 2. Prevention of local transmission requires concerted collaboration and communication – Federal – State – Local 3. Know there will always be unexpected aspects of Zika – Congenital infections and Zika associated birth defects – Sexual transmission – Evolving understanding of viremia and testing algorithms

Conclusion

• Risk of local dengue, chikungunya or Zika transmission is low • No locally acquired infections have been documented in California • The detection of Aedes aegypti and Aedes albopictus and viremic travelers in the same area is a public health concern

– Climate change/Drought may impact distribution/abundance of vector based on human response • Enhanced surveillance of both mosquitoes and case patients is necessary to reduce risk of autochthonous transmission Rocky Mountain Spotted Fever: a Re- Emerging Disease California has several endemic tick-borne pathogens in Rickettsiales order

Rickettsial diseases called, “spotted fever group” because rashes are typically seen with infections with these bacteria RMSF in Humans

• Clinical: – Nonspecific (can be difficult to diagnose) – Fever, headache, nausea, muscle aches 2-14 days after tick bite – Rash develops 3-5 days after fever – Decreased clotting cells leading to severe complications: Acute respiratory distress syndrome (ARDS), abdominal pain (leading to surgery), neurologic or bleeding disorders, loss of circulation (gangrene) – Case fatality reports ranging from 5-90%

53 RMSF in Humans

• Diagnosis: – Serology: Rising antibody titers (4X change in acute and convalescent samples). IFA or ELISA tests. – PCR, immunohistochemical staining of tissue, culture: (tissues difficult to obtain)

• Treatment: Doxycycline – adults and children – Can not wait for diagnosis – must treat on suspicion 54 Life cycle of Rickettsia rickettsii

• Mammal reservoir but… • Tick may be both reservoir and vector • Rarely find agent in the tick

American Dog Tick Rocky Mountain wood tick Dermacentor variabilis Dermacentor andersoni Rocky Mountain Spotted Fever Nationally

Source: CDC http://www.cdc.gov/rmsf/stats/ Rocky Mountain Spotted Fever, Arizona

• 2002-2004: 11 confirmed cases of RMSF identified in close geographic area in Arizona • No Dermacentor spp ticks found in area • Homes and areas around homes infested with brown dog ticks; many free-roaming dogs in area • R. rickettsia detected molecularly and cultured from area ticks • First time brown dog tick implicated as vector for RMSF in N. America RMSF Response: 2004-2005 SHORT TERM • Education for residents & clinicians • Tick control on dogs • Pest control around homes • Community clean-up LONG TERM • Animal control program • Sustained vector control • Structural changes to homes – skirting • Clean-up campaign: Tribal Members and others

Team: CDC, HIS, Tribes, ADHS, ORKIN®, WATSONIANS, USDA, Army – Ft. Huachuca 58 Tick Control for Dogs: Animal Services Agency Coordination • USDA, Army, CDC, IHS & ADHS • Zodiak® tick collars – (propoxur – 3 month residual) were placed on 1,000’s of dogs (est. 70%+ coverage) • Also, spot-on treatments & sprays

59 Not all dogs were approachable

60 Rocky Mountain Spotted Fever, Mexico

• Urban outbreak of RMSF in Mexicali, Mexico, 2009 • Brown dog tick-associated • > 1200 suspect cases, 217 confirmed • 6 deaths (2.3%) among confirmed cases

61 Brown dog tick habitat, Mexico

https://www.epa.gov/sites/production/files/2016- 02/documents/rmsf_on_the_border_where_children_con tagion_and_climate_converge.pdf Are dogs in California Affected?

• Dogs are a common tick host for R. rickettsii tick-vectors. They can get ill- even die- from infections with R. rickettsii. • Reports in the literature of concomitant infection of owners and their dogs, suggesting a common exposure • Anecdotal reports of RMSF in CA dogs The Infestation of Rhipicephalus sanguineus in a Residential Area, Riverside, 2005 Dog Mansion

• More than 200 Rh. sanguineus ticks collected

• R. rickettsii DNA was detected in 1 of 62 (1.6%) adult Rh. sanguineus ticks by CDC (different from those isolated from Montana and Arizona.) Does Spot get Spots? Survey for Canine Cases of Rocky Mountain Spotted Fever in California. Results

• 338 completed responses • Predominately small animal practices though a few mixed and exotic-mixed practices also responded. • Practice size ranged from 5- 50,000 dog visits per year (median 2500 dog visits). RMSF diagnosed in Californian dogs, CDPH Survey, 2007

# Reported Number of responses County (n=338) RMSF Cases 21-41 Orange 6 11-20 San Diego 5 2-10 Contra Costa 3 1 San Mateo 3 Alameda 2 Calaveras 1 Kern 1 Los Angeles 1 Riverside 1 Sacramento 1 Santa Barbara 1 Total 25

68 Clinical Presentation

Number Clinical Sign (percentage) n=25 Fever 17 (68%)

Other* 11 (44%)

Multiple painful joints 11 (44%) tiny hemorrhages on *Tiredness gums, mucous 4 (16%) most common membranes “other” sign Abdominal Pain 3 (12%)

Edema (swelling) 2 (8%) Comparison of reported tick species between veterinary practices with and without RMSF K9 cases

90 80 Practices with NO RMSF (n=321) 70 Practices with RMSF (n=17) 60 50 40 30 20 Percentage of practices of practices Percentage 10 0 Brow n dog Unknow n American None to Western Pac if ic Roc ky Mtn Lone Star Winter tick tick spp. dog tick rare tick black- Coas t tic k Wood tick tick legged tick Tick Species

Small number of clinical cases precludes statistical comparison, however, note that a large percentage of clinics with RMSF dogs reported high exposure in their general practice to the brown dog tick, followed by the American dog tick and the western black-legged tick when compared to all practices. “Does Spot get Spots?” Conclusions • RMSF is rare in dogs in California • Large number of cases reported from urban areas and with no travel history supports idea that RMSF ecology has changed over the past 50 years. • Spot does get spots, though rarity of disease both in humans and dogs and complexity of surveillance precludes using canines as regular “sentinel” for human disease. Evidence for dogs in S. California to be infested with infected brown dog ticks (CDC, CDPH and Imperial Co. DOH study)

• City Animal Shelter in Calexico

• County Animal Shelter in El Centro Training Animal Shelter Staff Results

• 116 dogs examined (45 in Calexico and 71 in El Centro) March - April 2009 • Ticks found on 35 (30%) dogs (16 in Calexico and 19 in El Centro) • Overall, 200 ticks were collected (111 females, 87 males, and 2 nymphs) and all were identified as Rh. sanguineus • PCR testing results showed that one female tick was presumptively positive for rickettsial DNA but species (or strain) was not confirmed Conclusions

• Rh. sanguineus infestation on dogs in Imperial Co. is more heavier than initially thought and the ticks can be potentially relocated into neighboring areas • Lack of R. rickettsii detection in ticks suggested that the risk of RMSF in the area is minimal at the time • Active tick surveillance and control of free- roaming dogs are important aspects for keeping the risk of RMSF below epidemic thresholds 2013 • Resident, Fresno county • Presented late December 2012 to local ED with fever, headache, muscle aches, rash on wrist, leg, and torso. • Patient succumbed to illness • Organ tissues tested positive by immuno- histochemistry and PCR at CDC • Patient had history of visiting local rural California areas one week preceding disease onset • 36 Dermacentor spp. ticks recovered from one area patient visited; all tested negative 2014 • Resident, Imperial County • Presented May to local ED with fever, nausea, vomiting • During course of illness, RMSF serologic tests showed rising titer (confirmed case) • Patient could not recover and died late June • Patient’s mother traveled with dogs across Mexican border • Brown dog ticks present in and around home; 1/95 positive for R. rickettsii • News release issued by Imperial County after patient’s death to increase awareness of disease, importance of treating tick infestations Life cycle of Rickettsia rickettsii Tick Vectors in California

• Mammal reservoir but… • Tick may be both reservoir and vector Brown Dog Tick • Rarely find agent Ripicephalus sanguineus Urban areas and natural areas in the tick throughout California

American Dog Tick Rocky Mountain wood tick Pacific Coast tick, CA Dermacentor variabilis Dermacentor andersoni Dermacentor occidentalis Natural areas throughout Natural areas northeastern Humid, natural areas throughout California California California Rocky Mountain Spotted Fever in Humans in California 2002-2014 2002 Since 2002 there have been 13 confirmed 2012a 2003 2012a cases of RMSF reported in California 2011 a Travel history out of county 2004 b Fatality 2013a,b

County of residence of confirmed RMSF human cases 2011

2010 2002, 2014a,b 2014a 2014b Number Confirmed and Probable RMSF Cases, 1997 - 2014 RMSF Seasonality

Nationwide, 1993 -2010 California, 1997 -2014 Demographics, RMSF Confirmed and Probable Reported Cases, 1997 – 2014

Frequency Percent 95% CI Lower 95% CI Upper

Female 24 43.6 % 30.3 % 57.7 %

Male 31 56.3 % 42.3 % 69.7 %

TOTAL 55 North/South Distribution County of Residence, RMSF Case Patients

Southern California Northern California

Proportion of case-patients (confirmed and probable) whose county of residence is in North/South CA, by year of symptom onset, p < 0.05 . Frequency of Hispanic/Latino ethnicity self reported, by year

-Trend (not significant) toward greater frequency of Hispanic/Latino ethnicity, (N=39) Chi Squared (MxN) p > 0.05

NonHispanic/NonLatino Hispanic/Latino Typical Dermacentor spp Life Cycle Brown Dog Tick (Rhipicephalus sanguineus) typical life cycle Impact on Messaging For both tick vectors: • Awareness of Disease • Avoid tick bites – Remove ticks promptly and correctly – Inspect pets and remove ticks • See physician if develop fever, headache or rash after tick bite • Take pet to veterinarian if it develops fever, lethargy after tick-bite Impact on Messaging: Dermacentor spp

• Awareness of RMSF Disease – More general approach – Target audience (California): outdoor enthusiasts, rural residents • Avoid tick bites – Stay in middle of trails – When in tick habitat: wear repellents containing DEET or clothing treated with permethrin – Remove ticks promptly and correctly • See physician if develop fever, headache or rash after tick bite • Take pet to veterinarian if it develops fever, lethargy after tick-bite Impact on Messaging Brown Dog Tick (Rhipicephalus sanguineus)

• Awareness of Disease – May need community approach • Local resident/physician awareness • Avoid tick bites – Host and environmental issue • Keep dogs on tick prevention (collars, vet- approved product) • Environmental treatment may be required by licensed pest-control operator (multiple treatments sometimes necessary) • Clean up yard to remove debris where ticks can hide – Remove ticks promptly and safely – Inspect pets and remove ticks • See physician if develop fever, headache or rash after tick bite • Take pet to veterinarian if it develops Source: Az. Dept. of Health Services fever, lethargy after tick-bite Treating Brown Dog Tick Infestations

Conclusions: re-emerging Rickettsia

• Newly identified tick vector for California demonstrated • Potential south to north introduction • Impacts health education messaging • One health approach (canine/human) useful for surveillance and control – Sustained surveillance/control effort needed for brown dog tick-transmitted RMSF Final Thoughts on Diseases at California’s Door • More pandemics likely to be seen “knocking” at the door • Air travel/massive rapid movement of people • Increased income disparity will contribute to emergence • Climate change may influence vectors as well as social structure that will encourage more migration • Public health infrastructure allows for early detection and planning for introduced disease • Ongoing, systematic surveillance • Build on previous experience (e.g. West Nile virus) and multi-agency (One-Health) THE MONSTER collaboration RETURNS Peter McCarty

Questions?