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Lyme disease in Ontario: Generating and Using Evidence to Inform Decision Making https://www.msu.edu/course/isb/202/ebertmay/images/Deertick%20Female.jpg Nina JainSheehan Enteric, Zoonotic and VectorBorne Diseases

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Page 1: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Lyme disease in Ontario: Generating and  Using Evidence to Inform Decision Making

https://www.msu.edu/course/isb/202/ebertmay/images/Deertick%20Female.jpg

Nina Jain‐Sheehan

Enteric, Zoonotic and Vector‐Borne Diseases

Page 2: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Objectives and Outline

Objectives:

•Describe the emerging epidemiology of Lyme disease in Ontario

•Provide an understanding of Ontario’s existing Lyme disease 

surveillance

•Outline some of Ontario’s plans for improved surveillance and risk 

communication based on our understanding of the emerging 

epidemiology

Outline:

•Human Epidemiology

•Tick Surveillance•Lyme disease Risk Maps

•Lyme disease Initiatives 

2

Page 3: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

The blacklegged tick (Ixodes 

scapularis) is the vector responsible 

for transmitting Lyme disease (LD) in 

Ontario

R. Lindsay PHAC

Page 4: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Tick Habitat

Page 5: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

www.cdc.gov

Page 6: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System
Page 7: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

From: IDSA Guidelines – CID 2006:43 (1 November) 

Page 8: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Ontario Lyme disease History 

• In 1991 only one population of ticks that carry Lyme disease (LD) was known in 

Canada. It was located in Ontario at Long Point Provincial Park.

• Since then the following areas were identified:• Turkey Point Provincial Park• Rondeau Provincial Park• Point Pelee National Park• Prince Edward Point National Wildlife Area

• In 2006 the Ministry of Health and Long‐Term Care participated in tick surveillance 

studies with the Public Health Agency of Canada and discovered an new endemic 

area in St. Lawrence Islands National Park area

• The Ministry started to do active tick surveillance in 2007.    

• Since then the following areas have been identified as endemic:• Wainfleet Bog• Rainy River

Page 9: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Ontario Lyme Disease Endemic  Locations

9

Page 10: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Number of Reported Confirmed and 

Probable Human Lyme Disease Cases and 

Rate (per 100,000 population) by Year, 

Ontario, 2002 to 2013

Data Source:  Ontario Ministry of Health and Long‐Term Care, integrated Public Health Information System (iPHIS) database, extracted by Public Health Ontario [2014/02/04] Population estimates (for rate calculations):  Ontario Ministry of Health and Long‐term Care, IntelliHEALTH Ontario, extracted by Public Health Ontario [2013/09/16]. Notes: Population estimates for 2012 were used to estimate provincial population counts for 2013Data from 2009 onwards includes both confirmed and probable cases.  The Lyme Disease confirmed case definition changed in 2009 such that clinical cases were no longer 

considered confirmed.  Clinical cases are now considered probable cases and case counts for 2009 and subsequent years include both confirmed and probable cases to 

ensure valid comparisons of trends over time. 

10

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Number of Cases and Incidence Rate of 

Lyme Disease by Age and Gender, Ontario, 

2013

11

Case counts include probable and confirmed casesCases: Ontario Ministry of Health and Long‐Term Care, integrated Public Health Information System (iPHIS) database, extracted by Public Health Ontario [2014/02/04].Population estimates (for rate calculations): Ontario Ministry of Health and Long‐term Care, IntelliHEALTH Ontario, extracted by Public Health Ontario [2013/09/16]. 

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Number of Lyme Disease Cases by  Episode Month, Ontario, 2013

12

Note: Episode date is the first of onset date, specimen collection date, or case report date.Case counts include probable and confirmed casesData source: Ontario Ministry of Health and Long‐Term Care, integrated Public Health Information System (iPHIS) database, extracted by Public Health 

Ontario [2014/02/04].

Page 13: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Number and Proportion of Lyme  Disease Cases Reporting Select 

Symptoms, Ontario, 2013.

13

Note: Only select symptoms are shown. Cases can report multiple symptoms.Case counts include probable and confirmed casesData source: Ontario Ministry of Health and Long‐Term Care, integrated Public Health Information System (iPHIS) database, 

extracted by Public Health Ontario [2014/02/04]

Symptom Count (n) Proportion (%)

AV Heart Block 2 0.63

Bells Palsy 25 7.89

Erythema Migrans 178 56.15

Page 14: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Municipalities Identified as the Most Likely Exposure 

Location for Locally Acquired Lyme disease Cases: 

Ontario, 2013 

Data source: Ontario Ministry of Health and Long‐Term Care, integrated Public Health Information System (iPHIS) database, extracted 

by Public Health Ontario [2014/02/19]. Case counts include probable and confirmed cases

14

Page 15: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Health unit Confirmed Probable Total Rate (per 100,000)*

Leeds, Grenville, and Lanark District 24 21 45 26.58

Kingston‐Frontenac and Lennox and Addington 37 14 51 25.75

Eastern Ontario 9 20 29 14.41

Hastings and Prince Edward Counties 10 6 16 9.90

City of Ottawa 12 34 46 5.00

Chatham‐Kent 4 1 5 4.61

Peterborough County‐City 1 4 5 3.58

Haliburton‐Kawartha‐Pine Ridge District 2 4 6 3.34

Haldimand‐Norfolk 3 0 3 2.72

Renfrew County and District 2 0 2 1.93

Durham Regional 7 5 12 1.88

Grey‐Bruce 3 0 3 1.83

Huron County 1 0 1 1.65

York Regional 12 5 17 1.57

Lambton 2 0 2 1.53

Wellington‐Dufferin‐Guelph 2 2 4 1.43

Waterloo 6 1 7 1.30

Perth District 1 0 1 1.30

Halton Regional 3 3 6 1.14

Niagara Regional Area 5 0 5 1.12

City of Toronto 22 7 29 1.04

Ontario 183 134 317 2.35

Number and Incidence Rate of Reported 

Confirmed and Probable Lyme disease Cases 

by Health Unit of Residence, 2013

Data source: Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System (iPHIS) database, extracted by Public Health Ontario [2014/02/04]. Population estimates (for rate calculations): Ontario Ministry of Health and Long‐term Care, IntelliHEALTH Ontario, extracted by Public Health Ontario [2013/09/16]. NOTE: Population counts for 2012are used to 

estimate health unit and provincial population counts for 2013. 

15

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Number and Incidence Rate of Reported 

Confirmed and Probable Lyme disease 

Cases by Health Unit of Residence, 2008

16

Health Unit Confirmed Probable Total Rate (per 100,000)*Leeds, Grenville, and Lanark District 13 0 13 7.73Northwestern 3 2 5 6.08Haldimand‐Norfolk 4 0 4 3.6Brant County 4 0 4 2.87Timiskaming 1 0 1 2.87

Kingston‐Frontenac and Lennox and Addington 2 2 4 2.06Halton Regional 5 4 9 1.82Peterborough County‐City 1 1 2 1.44Perth District 1 0 1 1.29Hastings and Prince Edward Counties 2 0 2 1.23Simcoe Muskoka District 4 1 5 0.97Peel Region 6 6 12 0.92Niagara Regional Area 4 0 4 0.9Algoma District 1 0 1 0.84Hamilton, City of 4 0 4 0.75City of Ottawa 5 1 6 0.68Thunder Bay District 1 0 1 0.64Toronto 11 4 15 0.56Haliburton‐Kawartha‐Pine Ridge District 1 0 1 0.56York Region 3 1 4 0.39Windsor‐Essex County 0 1 1 0.25Middlesex‐London 1 0 1 0.22Waterloo Region 1 0 1 0.19Durham Regional 1 0 1 0.16Ontario 79 23 102 1.63

Data source: Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System (iPHIS) database, extracted by Public Health Ontario [2014/03/10]. Population estimates (for rate calculations): Ontario Ministry of Health and Long‐term Care, IntelliHEALTH Ontario, extracted by Public Health Ontario [2013/09/16].

Page 17: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Standardized Questionnaire

17

• LD cases have increased in Ontario over the past few years.

• Ontario’s 36 Health Units currently use a variety of  questionnaires to interview cases and collect epidemiological 

data 

• To better inform clinical and public health decision making we 

need to collect standardized information from cases.    

• Developing a standardized questionnaire will help to generate  higher quality and more consistent information on LD cases. 

• Main goal is to obtain better exposure location data.

• Exploring ways of standardizing how exposure location data is  collected and reported.

Page 18: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Objectives of Tick Surveillance

• Establish presence/geographic distribution of LD vector, Ixodes  scapularis.

• Differentiate adventitious ticks vs. established populations.

• Size/density of vector populations.

• Prevalence of B. burgdorferi

infection. 

• Infer risk of exposure based on the above factors and intensity of  human use of habitat/opportunity for exposure to infected vectors.

• Implement measures to mitigate risk of exposure & subsequent 

infection and disease.

• The prevalence of B. burgdorferi

and other tick‐borne illnesses will help to 

guide clinical and public health decision making.

Page 19: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Lyme Disease Vector  Surveillance in Ontario 

Passive Surveillance•

Ticks are submitted by the public

Confirmed human cases

Active Surveillance•

Go out into the environment to look for the ticks

Tick dragging

Small mammal trapping

Page 20: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Passive Tick Surveillance

20

• Identification to species• Stage, engorgement, sex• Borrelia and Anaplasma testing

Ixodes scapularis

National Microbiology Laboratory Public Health Ontario Laboratory

Data collection: reporting, analyses, hypotheses testing 

HEALTH UNIT

www.the color.com LRL

Page 21: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Drag Sampling

Page 22: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Small Mammal Trapping

Page 23: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Public Health Ontario Tick Submissions

23

Page 24: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Species Distribution of Submitted  Ticks (2013)

24

Page 25: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

BLT Engorgement and Attachment  Status and B. burgdorferi Positivity (2008‐2012)

Engorgement and 

attachment statusTotal positive pools/total pools tested (%)

Total (avg %)

Adults Nymphs

Engorged + attached146/1,991 (7.3) 18/130 (13.8) 164/2,121 (7.7)

Unengorged + attached718/3,712 (19.3) 14/153 (9.2) 732/3,865 (18.9)

Unengorged + unattached9/60 (15.0) NT† 9/60 (15.0)

Total (average %) 873/5,763 (15.1) 32/283 (11.3)  905/6,046 (15.0)

25

The age of submitters of BLTs that were engorged (45.2 ± 0.80 y) was significantly higher than 

those submitting BLTs that were unengorged (40.5 ±

0.54 y) (F1,2790 

= 24.6; p<0.0001). 

Page 26: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Age distribution of Ixodes scapularis 

submitters (2008–2012).

26

Page 27: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

The Location and Number of I. scapularis Submitted 

to PHO, Based on the Submitter’s Community of 

Residence: Ontario, 2013 

Data source:

Public Health Ontario (PHO), extracted [2014/03/12]27

Page 28: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

The Location and Number of I. scapularis Submitted 

to Public Health Ontario, Based on the Submitter’s 

Community of Residence: Ontario, 2008‐2013

28

Page 29: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Percentage B. burgdorferi‐positivity and 

Total I. scapularis

by Submitter Town of 

Exposure (2008–2012) 

Data source: PHAC, extracted [2014/03/12]29

Page 30: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Atlas of Canada Land Cover

30http://atlas.gc.ca/data/english/maps/forestry/land_cover_map.pdf

Page 31: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Ontario Percent Forest Cover

31https://nfi.nfis.org/forest_themes.php?lang=en

Page 32: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

www.oahpp.ca

Rate of I. scapularis Spread

32

Page 33: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Trends in the Infection Prevalence  of B. burgdorferi 2008–2012

33

*Dotted lines: simple linear regressions for percentage of BLTs 

pools positive for B. burgdorferi. •B.

burgdorferi, y = 2.5x + 5.6;              R²

= 0.96 (F1,3 

= 75.4; p = 

0.003)

Page 34: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

B. Burgdorferi Infection Prevalence  in ticks: Comparisons to Literature

• The overall prevalence of B. burgdorferi infection in 

Ontario BLTs was 15%

• Emerging areas:• Manitoba (10%)• Quebec (13%)• Nova Scotia (15%)

• Long‐established areas:• Hudson Valley, NY (49–65%)• New Jersey (49%)• Long Point, Ontario (67%) 

34

10% 13% 15%

15%

49%49‐65%

67%

Ogden NH, et al. (2006) Int J Parasitol 36: 63‐70; Ogden NH, et al. (2006)  J Med Entomol 43: 600‐609; Schulze TL, et al.  (2003)  J Med 

Entomol 40: 555‐558; Magnarelli LA, et al. (1986) J Wildl Dis 22: 178‐188; Lindsay LR, et al. (1999) J Med Entomol 36: 243‐254.

Page 35: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Summary of Tick Data

• I. scapularis is now the most abundant tick submitted in ON

• Eastern region reported the highest submission rates for BLTs

• Coincide with higher rates of Lyme disease

• Land use and temperature possible driving factors; increased awareness

• Children 0–9 yo & adults 55–74 yo have highest submission rates for BLTs; 

engorged BLTs more often submitted from older individuals; males

submitted more BLTs

• Due to variable exposure to tick habitats, host behaviors or tick  submission efforts?

• Opportunity for targeted education 

• Proportion of BLTs

infected with B.

burgdorferi

has increased in Ontario 

(2008‐2012)

• Continued increase expected for next few years until equilibrium established

Page 36: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Implications of Data

• Utility of passive surveillance limited to regions of the 

province with a high population density• Sparsely populated Northern areas will rely on human case detection, 

small mammal trapping, and tick dragging

• Better to concentrate efforts on active tick dragging in known  risk areas and passive from low risk/unknown areas

36

Page 37: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Three tiers of Tick Submissions1.Active surveillance only for endemic/high 

submission areas

2.Passive outside of endemic areas

3.Continue passive submissions in the rest of the 

province

Proposed Changes for tick  surveillance activities

37

Page 38: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Preliminary Lyme disease Risk Maps

38

Data Elements:•Endemic Locations•Human Cases (most 

likely exposure•Tick submissions (most 

likely acquisition)•Tick positivity•Active Drag Sites

Page 39: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Ecological Factors Facilitating Tick  Expansion

• Conducting a literature review identifying the abiotic and  biotic factors required for tick establishment

• Focusing on evidence from North America, particularly 

northcentral and northeastern United States, and 

Ontario/Quebec

• Primary risk to ticks is desiccation 

• Future steps:• Identify distribution of these requirements in Ontario

• Map out likely environments for tick establishment

39

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Literature Review Preliminary  Results

40

• Factors influencing distribution and expansion of I. scapularis:

Presenter
Presentation Notes
Other habitat factors identified include: drainage, gradient slope, soil type, elevation, distance to water, latitude, acorn abundance, and canopy cover.
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Page 42: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Provincial Lyme disease  Awareness Campaign (Ministry of 

Health and Long‐Term Care)

www.ontario.ca/lyme

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Conclusions

• Lyme disease epidemiology continues to evolve in Ontario

• Our understanding of current and future risk is improving

• Based on existing evidence we are undertaking several initiatives to  further improve our understanding and risk communication related

to Lyme disease in Ontario. Specifically:• Standardized case questionnaires• Refinements to Ontario’s tick surveillance• Production of risk maps for use by physicians and public health partners• Reviewing evidence on tick expansion to inform future plans and activities

• We will continue to adjust and improve our approaches to provide

the most relevant scientific and technical support possible given the 

available and emerging evidence.

43

Page 44: Lyme disease in Ontario: Generating and Evidence to Inform ... · Lyme disease cases: Ontario Ministry of Health and Long‐term Care, integrated Public Health Information System

Acknowledgments

• Ontario’s 36 Public Health Units• Public Health Ontario:

• Curtis Russell• Mark Nelder• Leigh Hobbs• Samir

Patel• Filip

Ralevski• Stephen Moore• Doug Sider• Vaneet

Rakhra• Steven Johnson 

• Public Health Agency of Canada• Robbin

Lindsay• Nick Ogden

44