PHE Meeting Slides

Lyme disease conference

#PHElyme13 9 October 2013

Lyme disease conference Welcome

#PHElyme13 9 October 2013

Lyme disease conference Welcome and introduction Countess of Mar

9 October 2013

Lyme disease conference

9 October 2013

Lyme disease conference Question categories:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

9 October 2013

Tests and diagnosis Treatment Ticks and prevention Lyme clinics, centres of excellence Persistence LB in children Medical education/awareness Public education/awareness Other tick borne infections Other means of transmission Research UK guidance and policy Private clinics Other

Lyme disease conference Overview of Lyme disease pathology and immunology Tim Brooks, PHE

9 October 2013

Overview Basics of an infection The race between man and spirochaete Anatomy of a pathogen: designed to fight Stepping through the infection process

The immune reaction and how to evade it Individuals and patterns

Invasion, multiplication & spread 2. Attachment

1. Ingestion

4. Systemic spread Secondary seeding

3. Local reproduction

Pathological Race Systemic symptoms Sequelae

Em

± treatment

Health

Start

Exposure

Attachment

Barriers

Local multiplication

Anatomy of a professional Outer membrane p66 porin

Borrelia membrane protein A

Inner membrane VlsE protein

OspC cell attachment protein

P 17/ Decorin binding protein Flagellin strands between membranes rotate to propel organism

P83 surface protein

Inside the spirochaete

Chromosome 997kbp, 3370 genes

Linear plasmid Lp28

Circular plasmid

Borrelia have at least 27 plasmids which can be exchanged in whole or part between organisms

P66 porin channel crosses membranes

In the tick Organism expresses OspA to bind to tick tissue

As blood rushes in when tick feeds, OspA is replaced by Osp C to suit life in mammals and spirochaete swims upwards reaching new host in 12-17 hours

Early infection

Rash may be absent in up to 30% of cases

IgM/G to p83 occasionally appear

VlsE antibodies appear a little later

If infection limits early or is treated antibodies may not have time to develop

IgM/G to BmpA appear in 30% of cases

As organism starts to proliferate IgM and then IgG to OspC appear. They are short-lived Many people develop p17 IgM/G

Organism can be found in skin biopsy

Disseminated infection Mycocarditis is rare

Antibody pattern All antibodies may appear OspC antibodies decline early IgM slowly disappears leaving variable patterns of IgG responses Pattern may correlate to species in some cases VlsE dominates

Neuroborreliosis Pcr occasionally positive IgM in CSF

Arthritis PCR Negative

Acrodermatitis chronicum atrophans Pcr may be positive

Making the VlsE protein Variable region creates variable parts of protein Linear protein LP28

Conserved region creates conserved protein A 6-mer peptide C6 is part of this region

Evading the immune system VlsE constantly changes so organism keeps ahead of immune system. At least 15 variants exist Conserved regions stay constant and C6 peptide stimulates antibodies across all variants As VlsE changes many people are anti-VlsE negative when tested on a single protein

Pattern of antibodies to VlsE epitopes is linked to persistence of symptoms

Antigen presentation Borrelia in phagosome

Macrophage recognises Borrelia and locks on

Macrophage engulfs Borrelia and processes it into protein fragments

Antigen is presented on macrophage surface in MHC complex and triggers CD4 T cells to help generate immune response

Antigen fragment

MHC and T-cell trigger complex

Persistent symptoms Tissue damage Cf. healing scars, poliomyelitis

On-going immune reaction against self antigens Cf. Goodpasture’s syndrome, Guillain-Barre syndrome, Rheumatoid arthritis

Untreated disease Re-infection Research is needed to define each of these

Summary Infection with Borrelia may: Be asymptomatic Cause Erythema migrans Cause infection with no rash Cause disseminated disease Abort at any stage The immune response May be abrogated by treatment May not appear if disease self-limits early Does not protect against re-infection Is present in established infection but may be variable

Lyme disease conference

9 October 2013

Lyme disease conference Short and long term wins in Lyme disease Stella Huyshe-Shires, Lyme Disease Action

9 October 2013

Short and long term wins in Lyme disease Stella Huyshe-Shires

Lyme Disease Priority Sharing Partnership 957 questions submitted by clinicians & patients In scope 60% treatment 40% diagnosis

Out of scope 50% - Policy & Clinician awareness

81 unique questions  7 - known answer  5 - subject of current trial  69 - true uncertainty needing further research

Interest in uncertainties? Clinicians

Patients

Wins Acknowledge uncertainties Close the gap between Them & Us

short long

Top 10 research priorities • • • • •

What is the best treatment ? How effective are the current UK tests ? What causes continuing symptoms ? Transmission by other means ? etc.

Wins Acknowledge uncertainties Close the gap between Them & Us Research into treatment & diagnosis

short long long

Guidelines

Guidelines

For anything other than erythema migrans “ Refer to a specialist”

Experts?

Wins Acknowledge uncertainties Close the gap between Them & Us Research into treatment & diagnosis Engage the expert patients Remove BIA position statement

short long long short short

EFNS Guidelines

Response criteria • Complete recovery at 12 mo • Persisting remission in 24 mo • Normal neurological findings • Absence of objective symptoms • Clinical improvement

Wins Acknowledge uncertainties Close the gap between Them & Us Research into treatment & diagnosis Develop / engage expert patients Remove BIA position statement Patient based outcomes / PROMs

short long long short short long

Improving patient outcomes “We must put citizen and patient voice absolutely at the heart of every decision we take in purchasing, commissioning and providing services.” Tim Kelsey National Director of Patients and Information NHS England

Wins Acknowledge uncertainties Close the gap between Them & Us Research into treatment & diagnosis Develop / engage expert patients Remove BIA position statement Patient based outcomes / PROMs Promote LDA support services Regional centres of expertise

short long long short short long short long

Engagement

Wins Acknowledge uncertainties Close the gap between Them & Us Research into treatment & diagnosis Develop / engage expert patients Remove BIA position statement Patient based outcomes / PROMs Promote LDA support services Regional centres of expertise

short long long short short long short long

Ad hoc International Lyme Group “This battle cannot be won on a scientific front; we need to mount a socio-political offensive.”

Lyme disease conference

9 October 2013

Lyme disease conference The patient’s need for scientific integrity Wendy Fox, Borreliosis and Associated Diseases Awareness UK (BADA)

9 October 2013

Copyright BADA-UK Ltd 2013 www.bada-uk.org

Borreliosis & Associated Diseases Awareness UK. A self-funded, volunteer-run, registered charity dedicated to the prevention of tick-borne disease in people and pets throughout the UK and Ireland. Principle activities:  Educational exhibits at UK-wide events (e.g. agricultural & country shows, pet events and outdoor pursuits shows).  National Tick Bite Prevention Week since 2007.  Advise service (tick control, tick removal, tick bite prevention in people and animals, general information on diagnosis and treatment, and emotional support of patients).

Significant lack of awareness about: 

What ticks are.

GENERAL PUBLIC 

Where ticks are found.

DOCTORS 

How small ticks can be.



Ticks bite people as well as animals.



Ticks in the UK and Ireland can transmit disease.



What Lyme disease is and how it is transmitted.



Symptoms.



Treatment.

VETS

Significant lack of awareness about: What ticks are. Example of “ticks” sent to BADA-UK for identification

Deer Ked - Lipoptena cervi

Significant lack of awareness about: What ticks are. Example of “ticks” sent to BADA-UK for identification

Pond leech - Erpobdella testacea

Significant lack of awareness about: What ticks are. Example of “ticks” sent to BADA-UK for identification

Thrip - (thunderfly / thunderbug)

Significant lack of awareness about: Where ticks are found. New Forest, Exmoor, other woodland or heathland areas of southern England, the Lake District, the Scottish Highlands and Islands, North York moors, Thetford Forest, and the South Downs. “Although these are high risk areas for Lyme borreliosis, any area where Ixodid ticks are present should be regarded as a potential risk area”. Health Protection Agency Website

Significant lack of awareness about: Where ticks are found.

Statements reportedly made by UK GPs in 2012 – 2013 “There’s no Lyme disease in the UK”.

“There’s no Lyme disease in this area”. “There are no ticks in the UK”.

“There are no ticks in this area”.

Significant lack of awareness about: How small ticks can be.

“Lyme disease is transmitted by the bite of an infected tick, but many patients do not recall the bite or find a tick on their bodies”. Public Health England GP poster

Significant lack of awareness about: Ticks bite people as well as animals.

Significant lack of awareness about: Ticks in the UK and Ireland can transmit disease.

Significant lack of awareness about: What Lyme disease is and how it is transmitted.

Significant lack of awareness about: Symptoms.

Significant lack of awareness about: Symptoms.

Significant lack of awareness about: Symptoms.



GPs can be unaware of the variation in erythema migrans.



An erythema migrans may not always be observed.



Early erythema migrans are often homogeneous.

Patients & doctors can fail to distinguish between the various complications of tick bites.

Bite site adult female attached

Bite site immediately after tick removal

24 hours after tick bite - hypersensitivity reaction 14 day course doxycycline prescribed by GP, as if for erythema migrans.

Where do patients go when they lose faith in their GP?

Where do patients go when they lose faith in their GP?

A quagmire of good and bad sources of information

Private testing routes  In-house assays - own criteria (difficult for patients to establish the accuracy of tests plus a potential for misleading results).  Tests on non-blood samples such as urine (The clinical usefulness of such tests have not been proven).  Patients can be left very distressed when the results of unvalidated tests are rejected by clinicians.

Private testing routes Snake Oil

Private testing routes Snake Oil

Significant lack of awareness about: Treatment

 Under-treatment and over-treatment with antibiotics.  Inappropriate choice of antibiotics.  How to manage post-treatment symptoms. (treatment failure? Post Lyme disease symptoms? Post Lyme disease Syndrome?)

Significant lack of awareness about: Treatment Where can patients end up?  Neural Therapy - Brain healing technique Local anaesthetic (Procaine/Novocain) injections into various body points to restore electrochemical function of tissues.  Salt / Vitamin C treatment protocol Increasing sodium chloride concentration in the body creates a hostile environment for Lyme bacteria and co-infectors, causing them to die from osmotic shock.

Significant lack of awareness about: Treatment Where can patients end up?  Miracle Mineral Supplement (MMS) Kills Lyme bacteria and co-infectors which suppress the immune system and allows the immune system to restore normal function. MMS is a solution of 27 - 28% sodium chlorite in distilled water to be mixed with citric solution (e.g. lemon / lime juice) = chlorine dioxide (bleach). “If you notice diarrhea, or even vomiting that is not necessarily a bad sign. The body is simply throwing off toxins and cleaning itself out”. MMS website No randomised, controlled clinical trial to date.

Categories of patients seeking support from BADA-UK: 1. Self diagnosed via Internet – no discernible history of tick exposure / bite. 2. Tick bite and / or rash history but told they can’t have Lyme borreliosis.

3. Negative test excluded diagnosis. 4. Diagnosed and treated but still have symptoms.

Out of 100 patient support cases between 2012 – 2013:

 60% had pursued NHS diagnosis or were unevaluated.  40% had pursued diagnosis and treatment privately.

Out of 60 patients

Out of 40 patients

Out of 50 patients >12 months post treatment

Patients  Failure to practice bite prevention behaviours.  Failure to practice correct tick-removal techniques.

 Failure to recognise early signs and symptoms of Lyme borreliosis.  Lack of knowledge about appropriate diagnostic procedures and treatment.

Doctors  Ignorance regarding the existence / prevalence of ticks and Lyme borreliosis in the UK and Ireland.  Disregarding Lyme borreliosis during patient evaluation.  Failure to test when appropriate.  Testing when inappropriate.  Prescribing inappropriate treatment.

 There’s a lot we do know.

 There’s a lot we don’t know.  There’s probably more that we don’t know we don’t know.  Recommendations for prophylaxis, diagnosis and treatment should always be evidence based.  There is a need for evidence-based information to actively and widely be disseminated, to help combat disease cases and improve patient outcomes.  It should be highlighted that further research will help to increase understanding of Lyme borreliosis in the future.

Without the provision of evidence-based information:

 Prophylactic behaviours are less likely amongst the general public.  Doctors may remain misinformed.  Patients may pursue unvalidated tests and potentially harmful treatment.

 A lack of trust in doctors will perpetuate amongst patients.

www.bada-uk.org

Lyme disease conference

9 October 2013

Lyme disease conference RIPL assays and service Tim Brooks, PHE

9 October 2013

Overview Who we are and what we do Tests for Lyme Disease How we report information Our clinical service Other tests & when we will apply them

Lyme service at RIPL Started 1 June 2012 Fully automated testing Allows paperless data transfer Based on C6 ELISA as screen

Immunetics® IgM/IgG combination Virastripe printed blots Read by densitometer

Lyme C6 assay DS2 ELISAbot

Q-pulse automated Levy-Jennings QC

Blots

Why use a printed blot? Defined bands Machine readable No background Only the bands you want

Wider testing Bartonella Currently via Colindale Rickettsia EuroImmun IF IgM & IgG

Anaplasma/Ehrlichia Babesia Via HTD Other tick borne diseases

Q fever, tularemia, TBE complex, bunyaviruses Other infectious causes of symptoms

Anaplasma phagocytophilum semi-automated immunofluorescence test

Finding the organism Sampling & errors Skin best Blood CSF & synovium Biological limitations Culture One time “Gold Standard” New techniques available PCR Real-time PCR based on Fla gene Sensitive within limits above (~50%) Can be combined with culture

Reporting the result B.BURGDORFERI IgG/IgM (C6 EIA)

POSITIVE

Borrelia IgM Lineblot (virastripe) IgM to Borrelia P41 antigen IgM to Borrelia P39 antigen IgM to Borrelia OspC antigen IgM to Borrelia Osp17 antigen IgM to Borrelia VlsE antigen Borrelia IgM Lineblot interpretation

POSITIVE Negative POSITIVE Negative Negative POSITIVE

Borrelia IgG Lineblot (virastripe) IgG to Borrelia P83 antigen IgG to Borrelia P58 antigen IgG to Borrelia P43 antigen IgG to Borrelia P39 antigen IgG to Borrelia P30 antigen IgG to Borrelia OspC antigen IgG to Borrelia p21 antigen IgG to Borrelia Osp17 antigen IgG to Borrelia DBPA antigen IgG to Borrelia P14 antigen IgG to Borrelia VlsE antigen Borrelia IgG Lineblot interpretation

Negative Negative Negative Negative Negative POSITIVE Negative Negative POSITIVE Negative POSITIVE POSITIVE

Compsoite report for early acute Lyme Disease

Interpreting the answers: Duck Test

Looks like a duck

Waddles

Quacks

Looks like a duck

Waddles

No quack

Wrong look

Can’t waddle

Mute

It’s a duck!

Probably a duck

Not a duck…

Test figures 2012-13 Data from 1 June 2012 to 31 May 2013 Total C6 tests 12,742

4,187 tested by Virastripe blot 1569 confirmed positives

Clinical Service RIPL offers helpline for clinicians 01980 612348 Appointed Dr Matt Dryden as Lyme Champion Matt will start a clinic in S. England

Discussing options to support ID physicians in other centres

Patient services Website to be updated Annual Open day Downloadable leaflets to be made available

Why we do not take direct enquiries Patient confidentiality & identification of caller We do not have access to full medical notes We do not have access to haematology, biochemistry and other pathology data We cannot see the patient and hence make any clinical assessment = Bad medicine for a tertiary referral service

Other tests All RIPL and associated lab tests are available if indicated This involves a detailed discussion with the patient's doctor To choose correct tests To ensure we have the right information and history To recommend any other investigations that should be done

Our aim is to help find the cause of the illness by looking for potential infectious origins

Summary RIPL offers a wide service for less common diseases Lyme is part of the array of tests offered Diagnosis is based on C6 and blot Clinical details are part of interpretation We treat credible cases even if they meet only some of the lab criteria if the coat fits

We have a medical help line for physicians ate various levels depending on urgency

Lyme disease conference

9 October 2013

Lyme disease conference Lyme disease in Scotland Roger Evans, Raigmore Hospital, NHS Highland

9 October 2013

Small beginnings • 1988: cases noted by GPs, Immunofluorescence testing on serum samples • 1994: first referrals outside of NHS Highland • 1995: two step testing protocol of EIA and WB. • 2003: established national Lyme borreliosis testing laboratory (SNLBTL) in Inverness.

Number of Highland and referred serum samples for Lyme borreliosis testing from 1988-2012 6000 5000

Introduction of 2-step EIA / WB testing protocol

4000 Number of 3000 samples 2000

Scottish National LB testing laboratory established

Referred

First referrals from outside Highland area

Highland

1000 0 1988

1991

1994

1997

2000 Year

2003

2006

2009

2012

LB epidemiology

Number of cases

Number of seropositive LB cases diagnosed by SNBTL from 1999-2012 500

10.00

450

9.00

400

8.00

350

7.00

Total cases

300

6.00

Females

250

5.00

200

4.00

150

3.00

100

2.00

50

1.00

0

0.00 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year

Males Incidence/100,000

Reporting new cases • In Scotland, Lyme borreliosis is not a notifiable disease but Borrelia burgdorferi is a notifiable organism (Public Health Act 2006) • Current data: all first time Western blot positive cases reported • Current practice to send a questionnaire from these patients to all clinicians

Are the data correct? • LB is a clinical diagnosis supported by laboratory results – Does WB positive = active LB?

• Encouraging clinicians not to test for LB if they present with erythema migrans (EM) – Figures need revising: likely to be higher

• GPs do not refer all LB patients for testing – Figures need revising: likely to higher (5-10x)

Current challenges • Investigating avidity WB to identify markers of active / early / past infection – Encouraging results so far

• Revising reporting of LB cases to Health Protection Scotland (HPS) to include those patients with EM (not tested) • GP R&D project: investigate the number of cases not being referred by GPs

Tick collections

Results • 159 ticks collected • 25 isolates • 7 identified so far – B. burgdorferi sensu stricto, B. garinii, B.afzelii

• 7 culture +, PCR • 18 isolates for whole genome sequencing to be performed

Site

No. of ticks

Culture positive

% prevalence

Urchany

115

22

19.1

Culloden

37

2

5.4

1

16.7

Inverness 6

Culture

PCR

Positive

Negative

Positive

18

3

Negative

7

26

Tick comments • Culture positive, PCR negative – Spatial sampling / low numbers (culture became positive within 3-4 days) – Other Borrelia sp.? Not B. miyamotoi as PCR based on flagellin gene which can detect this species

• Ecology value – is the Borrelia genome changing over time?

Conclusions • From small beginnings a competent, LB diagnostic laboratory has been established in Scotland • Addressing the need for active Borrelia infection marker • Revising epidemiology data to give more accurate picture of LB in Scotland • Exploring whether other tick-borne infections are present in Scotland

Lyme disease conference

9 October 2013

Lyme disease conference Lyme as a GP sees it Iain Farmer, Fort Augustus, Highland

9 October 2013

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Lyme disease conference

9 October 2013

Lyme disease conference Complex Lyme cases: the ID physician’s view Alastair Miller, Royal Liverpool University Hospital, Liverpool University and Public Health England

9 October 2013

Complex Lyme cases: the ID physician’s view ALASTAIR MILLER MA FRCP FRCP(Edin) DTM&H Consultant Infectious Disease Physician Royal Liverpool University Hospital Honorary Senior Lecturer University of Liverpool Honorary Consultant Public Health England

Liverpool Clinic O Joint neurological ID/CFS O About 20-30 pa but increasing O Localised Lyme Disease (already covered) O Treat on clinical diagnosis (14 days) O Serology often not positive O Disseminated LD (mainly neurological) O Not LD (mainly CFS)

Presentation of LD O 89% erythema migrans O 5% arthritis O 3% neurological presentation

O 2% lymphocytoma O 1% acrodermatitis O cutoff threshold*

*Band cut-offs are determined on each blot automatically, but are c.80 for all bands except p41 which is around 150.

What else is hidden in the data? 01/2013

08/2012

07/2012

06/2012

p83

-

41

-

-

p58

-

-

-

-

p43

-

-

-

-

p41

-

57

41

66

P39 (BmpA)

-

-

-

-

p30

-

-

-

-

OspC

-

-

-

-

p21

-

-

-

-

Osp17

-

-

-

-

DbpA

40

26

45

86 (POS)

p14

-

-

-

-

VlsE

51

44

-

-

p41

-

65

-

125

p39

-

31

-

-

DATE IgG blots

IgM blots

OspC

C6 ELISA

145 (POS) 128 (POS) 133 (POS)

Osp17 (OspA)

-

-

-

VlsE

-

96 (POS)

-

4.001

4.444

5.338

IgM / IgG combined OD

300 (POS) 53

5.892 (POS)

Patterns of bands and the relative density of bands may reflect, for example: •Disease progression over time – Serial samples

•Disease stage – Single samples

•Species of infecting Borrelia

Data mining Compare band patterns and densities with clinical and diagnostic data

Players in the host immune response to Borrelia Innate Immune Response

Adaptive Immune Response

NK

T Ag

iNKT

Mf PAMP

Ag

Y

B

Ag

Y

PAMP

Non-specific Rapid Recognises common pathogen associated molecular patterns (PAMPs)

Moderate specificity Rapid Recognises glycolipid antigens

Specific Slow Recognises individual Borrelia-derived antigens

T cells as targets for diagnostic tests (1) Ag

T cell proliferation

T

•T cell activated with its specific Borrelia antigen divides and proliferates

•Measured in vitro by incorporation of labelled nucleotide e.g. 3H-thymidine, into dividing DNA

Ag Ag

T

•Assays typically use PBMCs

T

•Various formats/names:

•Lymphocyte Transformation Test (LTT) •Lymphocyte Transformation Assay (LTA) •T cell proliferation assay •LTT-MELISA

Widely used in Lyme disease research

T

T

T

T

T cell proliferation as a Lyme diagnostic tool? •Investigated as diagnostic tool in over 20 peer-reviewed scientific publications •No consensus on value of LTT as diagnostic test – equivalent levels of proliferation in normal donors and Lyme patients (=poor specificity) – negative LTT/LTA in clinically & serologically positive Lyme patients (=poor sensitivity) – Proposed role for monitoring treatment course and to confirm successful therapy – Proposed role to identify early active disease in seronegative patients i.e. before Ab produced. • Current state-of-the-art: ONLY run LTT/LTA test with other tests. Beware over-interpretation of results.

T cells as targets for diagnostic tests (2) Ag

Ag

Th1

Tc

IFNg

IFNg

T cell cytokine production •T cell activated with its specific Borrelia antigen produces and releases cytokines •Cytokine released depends on type of Borrelia-specific T cell (Tc, Th1, Th2, Th17 etc) •Released cytokine measured in vitro by:

Ag

Ag

Th17

Th2

IL-17

IL-4

• ELISPOT / immunospot / iSpot LymeTM • IFNg-release assay (IGRA) • ELISA • Luminex/ bead-based assay

IFNg ELISPOT as a Lyme diagnostic tool? •Used in Lyme disease research since late 1990s •More rapid (overnight) than LTT (3-5 days) •Investigated as diagnostic tool in few peer-reviewed scientific publications •No consensus on value of IFNg ELISPOT as diagnostic test for Lyme – Not suitable as supplementary diagnostic tool in blood (Forsberg et al 1995) – Not suitable as supplementary diagnostic tool in CSF (Nordberg et al 2012) • Diagnostic value of ELISPOT for other cytokines e.g. IL-17 & IL-4 not tested

Improving LTT & ELISPOT assays Rely on living cells (whole blood or PBMCs) • standardise transport and storage (times, temperature etc) • standardise input cell numbers Source of antigen: whole Borrelia, lysates or single antigens? • glycolipids and lipopeptides in whole Borrelia and lysates induce high background levels of proliferation; batch-to-batch inconsistency of whole Borrelia • Newer assays are using defined Borrelia Ags • Ensure relevant Borrelia species (USA versus Europe) Need for detailed longitudinal clinical studies – compare T cell-based and other diagnostic tests (Ag & Ab)

New diagnostic possibilities •TLR2/TLR1 heterodimers recognise acylated borrelial Osp lipoproteins •diacylated & triacylated

TLR5 Flagellin

TLR2/TLR1 Pam3Cys

Mf

•Basis of SpiroFindTM assay under development and testing by Boulder Diagnostics •Borrelia cocktail used for stimulation

e.g. IL-1b

•Potential for false positives •

Invariant NKT cells recognise low molecular weight glycolipids on Borrelia surface e.g. MGalD • proliferate & release IFNg

•

May be possible to mimic in vitro using synthetic glycolipids

Invariant TCR iNKT

MGalD

IFNg

Summary •New generation, standardised T cell assays need to be developed and applied in longitudinal clinical studies •Diagnostic tests based on the innate and immediate immune response warrant further detailed investigation •Results from new tests need to be compared with current diagnostic tests in the same studies •New diagnostic tests should not be limited to one specialist commercial lab; need external validation and analysis of reproducibility

•Data mining expertise will maximise the predictive power of current and future diagnostic tests

Lyme disease conference

9 October 2013

Ticks, mammals and birds - Ecology of ticks & B. burgdorferi

Jolyon Medlock Head of Medical Entomology & Zoonoses Ecology MRA - ERD Public Health England

Overview of presentation Ticks • Introduction to the British tick fauna • Focus on Ixodes ricinus – the sheep/deer tick • Tick surveillance at a national scale • Tick mapping at a landscape scale – national parks/AONBs • Tick mapping at a habitat scale – impact of woodland management • Tick mapping in urban areas Mammals & birds • Understanding the ecology of Lyme borrelia in ticks and role of wildlife 199 Tick distribution in the UK

The British tick fauna Ixodes ricinus

Dermacentor reticulatus

22 species recorded 19 Hard ticks (Ixodid) • 15 Ixodes species • Dermacentor reticulatus • Haemaphysalis punctata • Hyalomma marginatum – (imported by migrant birds) • Rhipicephalus sanguineus (imported by pets, not native) 3 Soft ticks (Argasid) • 2 Argas/Carios • 1 Ornithodoros – rarely imported on seabirds

200

Carios vespertilionis

Hard ticks (Ixodid ticks) •Live outdoors, some are nidiculous (i.e. nest-dwelling); arduous lifestyle, require a chance meeting with animals. •Once attached, they engorge slowly, dispersed by their hosts long distances on migratory birds

•Spend most of their time ‘questing’ for blood hosts and attached to their hosts - high mortality rates due to host grooming, predation and environmental factors •Hard sclerotised plate (scutum), forward-projecting capitulum.

•Except in male, all stages have a small scutum to allow them to engorge •In the male the scutum completely covers its body. It does not engorge. It has armoured plates, to retain moisture levels.

201

Ixodes – specialist parasites of wildlife 7 species are principally bird ticks: Ixodes arboricola Tree-hole nesting birds

Ixodes caledonicus Cliff nesting birds

Ixodes rothschildi Burrow nesting birds

202

Ixodes frontalis Passerine birds

Ixodes unicavatus Coastal birds

Ixodes lividus Sand martins

Ixodes uriae Cliff colony birds

Humans are rarely bitten, only as accidental hosts

Ixodes – specialist parasites of wildlife 6 species are principally mammal ticks: Ixodes acuminatus Small mammals

Ixodes ventalloi Rabbit tick

203

Ixodes apronophorus Wetland mammals

Ixodes trianguliceps Burrowing small mammals

Ixodes canisuga Fox tick

Ixodes vespertilionis Horseshoe bats

Humans are rarely bitten, only as accidental hosts

Ixodes – parasites of humans 2 species are mammal ticks but do bite humans:

Ixodes ricinus Deer/Sheep/Pasture/Caster bean tick Ixodes hexagonus Hedgehog tick

Humans are occasional hosts

204

Humans are frequent hosts

Hedgehog tick, Ixodes hexagonus

Unusual & Imported ticks

Hyalomma marginatum

Unusual 206 & Imported ticks

Ixodes ricinus (Deer/sheep tick)

Larva

Nymph 1.4 mm

Adult male

Larva – 3 pairs of legs

Male – scutum covers entire body Nymph and Female are similar – female much larger with genital aperture and porose area 207 Ixodes ricinus

Adult female 3.3mm long

Nationwide tick surveillance

Number of submissions of ticks to TRS ~8000 ticks since 2005 from TRS (2005-2012) Public, GPs, Vets, Wildlife charities – 1400 submissions

Further 10,000 ticks from field studies

80

70 60 50

Advice to public on tick bites Advice on managing ticks in gardens Tick awareness material Tick identification to public, GPs and Vets

40 30 20 10 0

0 9 0 3 6 9 12 4 7 10 0 3 6 9 12 2 5 8 11 4 7 10 3 6 9 12 3 6 9 2005

2006

2007

208 Tick distribution in the UK

2008

2009

2010

2011

2012

[email protected]

Raising public awareness of ticks

209 Tick awareness leaflets

Ixodes ricinus distribution (2005-2009)

(1880-2004)

2010-2013

210 BRC Tick surveillance

Nationwide geo-spatial mapping

211 Vector risk mapping

Mapping Ixodes ricinus at a landscape scale, e.g. national park / AONB Surveying publicly accessible sites

Mapping ticks in an AONB/National Park

Eco/environ variables

Refining risk

Predictor variables (landscape) - W, SW, SE and E aspects - Calcareous & neutral grassland; heathland - Impermeable soils - Impermeable bedrock & superficial geologies - Presence of cattle & sheep grazing - Reduced slope - High soil moisture - Lower midday temperatures

Identifying risk factors 212 Mapping ticks at a regional scale

Medlock et al. 2008

Mapping Ixodes ricinus at a habitat scale - implications for woodland management

213 Managing ticks at a habitat scale

Medlock et al. 2012

Impact of habitat corridors on Ixodes ricinus - the role of field margins as habitats for ticks

214 Understanding impact of habitat connectivity on ticks across landscapes

215 Ticks in urban green space

Locations Churchill Gardens

Wyndham Park

Sports Centre

Avon Valley

Church Road

Laverstock Down

Burrough's Hill

Bishopdown Railway

Bishopdown Park

Bemerton Water Meadows

Quidhampton Wood

Bemerton Riverside

Bemerton Heath

Hampton Park

Britford Farm

Harnham Steps

Harnham Slope

Harnham Riverside

Harnham Chalk

Castle Hill

Hudson's Field

Stratford Mill

Sarum track

Sarum Down

Tick abundance

Building in urban green space Salisbury City tick abundance

40

9% prevalence of B. burgdorferi

Potential conflicts between infectious disease health risk and biodiversity goals:  Need to include “vector risk assessment” in Environmental Impact 10 Example of peri-urban tick & Borrelia area Assessments

0

20 Mar 27 Mar 04 Apr 10 Apr 19 Apr 26 Apr 01 May 09 May 22 May 30 May 03 Jun 11 Jun 21 Jun 28 Jun 05 Jul 10 Jul 19 Jul 24 Jul 30 Jul 09 Aug 14 Aug 23 Aug 30 Aug 05 Sep 11 Sep 20 Sep 27 Sep 04 Oct

Tick abundance 14

12 Ticks/10m Temp Vegetation

8 15

6

2

0

Date

216 Tick seasonality

Temperature

10 30

60

25

50

20

40

30

4 10

20

5

10

0

0

Vegetation height

Early warning of increased tick activity Tick activity for seasonal forecasting

Large mammals: - Deer species Blood host - Sheep Not generally involved in transmission cycles; localised transmission through coFeed feeding in sheep reported; both important tick hosts

Lyme borreliosis Transmission cycle ADULT FEMALE

Feed & infect

Trans-stadial transmission

Source of infection, More conspicuous Low no. lower risk

Woodland birds: Source of infection, - T. merula moult Less conspicuous Acquire infection - E. rubecula What ecological factors are driving high Borrelia High no., High risk HUMAN - P. colchicus prevalence rates inNYMPHS ticks? Medium-sized mammals: Feed & infect -Deer numbers - Sc. carolinensis Trans-stadial - Habitat - Le. europaeus Low probability transmission Small mammals: - Ap. sylvestris - Ap. flavicollis - My. glareolus - S. araneus - M. agrestis

- Game bird releases - Seasonality moult Urban v rural Acquire -infection LARVAE Feed

- Host seasonal dynamics - Seasonal changes in tick infestation rates - Seasonal changes in tick infection rates - Differences in Borrelia genospecies cycles Trans-ovarial transmission very low: develop higher infection rates: possibly more important in transmission cycles, however engorged ticks develop less well

-

Strong association between small mammal rodents with B. afzelii

-

Studies in Slovakia on infection rates -

Engorged nymphs from small mammals: 47% infected

-

Questing nymphs: 7% infected

219 Small mammals and Borrelia

Role of other small/medium sized mammals -

-

Shrews (Sorex araneus, S. minutus) -

Efficient tick predators

-

European studies: 80% infestation rates; mean 40-60 larvae/shrew; 18% infect

Dormice -

Hazel dormouse (Muscardinus avellanarius) – arboreal, winter hibernation

-

Fat dormouse (Glis glis) – Germany: L infest 2-3x, N infest 20x -

-

-

-

9 yrs, synanthropic, 70% infected, 95% derived N

Grey squirrel (Sciurus carolinensis)

-

Norfolk studies: mean L 8-19 compared to mouse L 1-4: upto 100 larvae

-

More important in spring/early summer – more arboreal in autumn

Red squirrel (Sciurus vulgaris) -

Switzerland study: 370L (64%), 380N (69%), 1 F on 1 animal cf. QL 3%, Qn 34%

-

70% infection rates (Bbss, Ba)

Siberian chipmunk (in France) -

potential new host and reservoir

220 Other mammals

Role of other animals -

-

-

Hedgehog (Erinaceous europaeus) -

Highly infested with ticks: Ireland study - >400L, 60N on 1 adult

-

Also infested with I. hexagonus: -

In Switzerland – means 50L, 11N, 2.5 F I. ricinus

-

Co-infested in woodlands, mono-infested (IH) in urban areas: IH 24%

-

Silent cycle of transmission

Lizards -

Important dilution hosts in North America

-

Intensity of LD transmission negatively associated with Sand lizard dist in Ger.

Migratory birds (Swedish study) -

23000 migrant birds surveyed, 2% infest, mean 2ticks/bird, 98% IR

-

30% of ticks in spring infected

-

>6.8m ticks enter Sweden each spring, 4.7m leave in autumn; 1.3m infected

-

Redwing – migratory restlessness reactivating latent infections

221 Other animals

Role of woodland birds -

Ground feeding passerines are very important in Bb transmission

-

Most important species (83% infested) are (Czech studies): -

Robin (Erithacus rubecula)

-

Blackbird (Turdus merula)

-

Song thrush (Turdus philomelos)

-

Robin fed 51% of all larvae feeding on birds

-

Blackbird fed 54% of all nymphs (highest infestations 50 L and 20N/bird)

-

Infection rates: 6-16% in larvae; 12-22% in nymphs

-

Turdus sp. and E. rubecula very important amplifiers for B. garinii and B. valaisiana

222 Woodland birds

Role of pheasant -

~20 million pheasant (Phasianus colchicus) released in UK each year

-

Densities in Dorset/Wiltshire studies: 500-1200 birds/km2

-

Feed large numbers of nymphs: -

43n/bird in April; 23n/bird in June

-

Most important host nymphal host

-

Male birds 4x infestation rates – testosterone and immunosuppression

-

Infection rates in ticks from pheasant (Dorset): -

22% infected, cf. 0% questing population

-

Mostly B. garinii (neuroborreliosis) and B. valaisiana – important amplifiers – no evidence of B, afzelii : possibly eliminated

-

Feed large numbers of questing nymphs -> exposure; infected adult ticks

-

Reduction in B. afzelii – zooprophylactic role 223 Pheasant

Role of deer -

Very important host for all stages

-

Irish studies on Fallow deer:

Deer

L/50m

N/30s

A/30s

Inf qN

Inf qA

22-118

33-34

5-6.6

1.7%

3.1%

1.6-12.5

0.1-1.2 12.4%

No deer 1.5-5.5

-

-

17.9%

Dilution hosts for Bb - Swedish studies - Compared moulted ticks from deer (0%) to questing N (7-11%) - 20% n infection rates: need 300,000 nymphs for infection - Typical infestation immunity, low infection rates Role of deer: increase tick numbers; dilute infection rates -> sustain tick pop 224 Deer

Role of livestock -

Sheep -

Upland sheep – feed 80% of all larvae, >95% all N and A

-

No systemic infection in sheep

-

Studies in Scotland confirm co-feeding transmission -

-

N:A 9cms; transmission during max. peaks of infestation

Cattle -

Zooprophylactic role on transmission

-

French studies: infection rates in questing ticks inside/outside cattle enclosures

-

-

4x lower infection rates in Nymphs inside enclosures

-

6x lower in Adults

Could we use cattle to dilute infection rates, and mop up ticks?

225 Livestock

Large mammals: - Deer species Blood host - Sheep Not generally involved in transmission cycles; localised transmission through coFeed feeding in sheep reported; both important tick hosts

Lyme borreliosis Transmission cycle ADULT FEMALE

Feed & infect

Trans-stadial transmission

Source of infection, More conspicuous Low no. lower risk

Woodland birds: Source of infection, - T. merula moult Less conspicuous Acquire infection - E. rubecula High no., High risk HUMAN Could understanding the ecology ofNYMPHS Borrelia burgdorferi - P. colchicus be employed understanding: Medium-sized mammals: Feed &in infect - Sc. carolinensis 1. Rates of exposure Trans-stadial - Le. europaeus Low probability transmission 2. Determinants for high risk areas

3. mammals: Targeted Small - Ap. sylvestris - Ap. flavicollis - My. glareolus - S. araneus - M. agrestis

of infection

management/grazing regimes to minimise moult ticks and Borrelia Acquire infection Feed

- Host seasonal dynamics - Seasonal changes in tick infestation rates - Seasonal changes in tick infection rates - Differences in Borrelia genospecies cycles Trans-ovarial transmission very low: