Knowledge, attitudes, and behaviors regarding Lyme disease prevention among Connecticut residents, 1999-2004

Barriers to the Uptake of Tickborne Disease Prevention Measures: Connecticut, Maryland 2016-2017

CONTEXT

Public health programs promote numerous tickborne disease (TBD) prevention measures. However, measures are not frequently or consistently performed.

OBJECTIVE

Describe barriers to consistent use of 4 commonly promoted TBD prevention measures.

DESIGN

We conducted an online survey (n = 1883) evaluating behaviors regarding TBD prevention measures including conducting tick checks, applying insect repellents, showering/bathing, and applying chemical or natural pesticides to residential yards. Respondents could select reasons for never, rarely, or sometimes performing these measures. Descriptive analysis and logistic regression modeling evaluated associations between the 3 most cited barriers for each measure and select demographic variables.

SETTING

The survey was administered to residents in high Lyme disease incidence counties of Connecticut and Maryland, 2016-2017.

RESULTS

For tick checks (n = 800), the most cited barriers were forgetting (63%), not spending time in tick habitat (28%), and too much trouble (11%). For applying insect repellents (n = 1303), the most cited barriers were forgetting (38%), personal safety concerns (24%), and too much trouble (19%). For showering/bathing 2 hours after outdoor activity in tick habitat (n = 1080), the most cited barriers were being unaware of the prevention measure (51%), too much trouble (18%), and forgetting (18%). For applying chemical pesticides to yards (n = 1320), the most cited barriers were having environmental (45%), pet safety (31%), and personal safety concerns (28%). Lastly, for applying natural pesticides to yards (n = 1357), the most cited barriers were being unaware of natural pesticides (31%), having cost concerns (23%), and not being concerned about ticks on property (16%).

CONCLUSIONS

Forgetting, too much trouble, unawareness, and safety concerns were primary barriers to using several TBD prevention measures. Education regarding effectiveness, safety, and timing may increase uptake of certain measures. These challenges can be difficult to address, highlighting the need for passive TBD prevention measures, such as a Lyme disease vaccine.

A scoping review of applied tick control research in North America: funding, implementation, and advancement

Geographic ranges of ticks and tick-borne pathogens within North America are shifting due to environmental changes and human-driven activities, with species of public health concern presenting a multifaceted risk to human health. Innovative strategies and continued collaboration to control tick populations are needed to combat this growing threat. We conducted a scoping review of the literature to describe the nature of applied tick control research conducted in North America (Canada, Mexico, and the United States) to date, with the goal of describing key concepts and identifying gaps in this research area. A total of 244 articles met our inclusion criteria and were reviewed for patterns in applied tick control authorship and funding, study location, target species, and control methodology. Most studies (83.6%) were conducted exclusively in the United States and 75% focused on ticks of public health concern, principally Amblyomma americanum (Linnaeus, Acari: Ixodidae), Dermacentor variabilis (Say, Acari: Ixodidae), Ixodes scapularis Say (Acari: Ixodidae), and Rhipicephalus sanguineus (Latreille, Acari: Ixodidae). The majority of funding was provided through US federal agencies, predominantly the Centers for Disease Control and Prevention and the United States Department of Agriculture. Ixodes scapularis was the target of over 50% of identified articles, with the majority of research conducted within 3 states in the Northeast region of the U.S. Only 8.2% of included studies evaluated integrated tick management interventions. We note gaps in tick control research regarding (i) non-Ixodes medically relevant tick species, (ii) endemic range coverage, and (iii) control methodologies evaluated.

Assessing the value and knowledge gains from an online tick identification and tick-borne disease management course for the Southeastern United States

BACKGROUND

Tick-borne diseases are a growing public health threat in the United States. Despite the prevalence and rising burden of tick-borne diseases, there are major gaps in baseline knowledge and surveillance efforts for tick vectors, even among vector control districts and public health agencies. To address this issue, an online tick training course (OTTC) was developed through the Southeastern Center of Excellence in Vector-Borne Diseases (SECOEVBD) to provide a comprehensive knowledge base on ticks, tick-borne diseases, and their management.

METHODS

The OTTC consisted of training modules covering topics including tick biology, tick identification, tick-borne diseases, and public health, personal tick safety, and tick surveillance. The course was largely promoted to vector control specialists and public health employees throughout the Southeastern US. We collected assessment and survey data on participants to gauge learning outcomes, perceptions of the utility of knowledge gained, and barriers and facilitators to applying the knowledge in the field.

RESULTS

The OTTC was successful in increasing participants' baseline knowledge across all course subject areas, with the average score on assessment increasing from 62.6% (pre-course) to 86.7% (post-course). More than half of participants (63.6%) indicated that they would definitely use information from the course in their work. Barriers to using information identified in the delayed assessment included lack of opportunities to apply skills (18.5%) and the need for additional specialized training beyond what the OTTC currently offers (18.5%), while the main facilitator (70.4%) for applying knowledge was having opportunities at work, such as an existing tick surveillance program.

CONCLUSIONS

Overall, this OTTC demonstrated capacity to improve knowledge in a necessary and underserved public health field, and more than half of participants use or plan to use the information in their work. The geographic reach of this online resource was much larger than simply for the Southeastern region for which it was designed, suggesting a much broader need for this resource. Understanding the utility and penetrance of training programs such as these is important for refining materials and assessing optimal targets for training.

Intention to vaccinate for Lyme disease using the Health Belief Model

AIMS

Lyme disease (LD) cases in the United States are estimated to be approaching 500,000 annually. Protective measures, such as repellent use and wearing protective clothing are recommended by public health officials. However, no protective measure has been proven to be consistently effective, partly because they require consistent and persistent behaviour change. While safe and effective vaccines are in development, it is unclear what factors influence the intention to vaccinate against LD. This study uses the Health Belief Model (HBM) framework to determine key drivers associated with vaccine intention. The HBM is widely applied in public health research and uses the following constructs: perceived susceptibility and severity of disease, perceived benefits and barriers to disease prevention, and cues to action for disease prevention to predict health behaviours. To date, the HBM framework has not been applied to vaccination intention for LD.

METHODS AND RESULTS

Data were collected from 874 adults and 834 caregivers of children residing in US states endemic to LD. Sampling adults and caregivers allows us to explore how the intention to vaccinate differs among those at-risk. Estimates from structural equation modelling (SEM) show that the HBM constructs explain much of the variation in intention to vaccinate against LD. Both adult and caregiver intentions to vaccinate are positively influenced by cues to action, perceived susceptibility of LD, and perceived benefits to vaccination. However, there is variation in the influence of constructs across the samples. Caregiver's intention to vaccinate is positively influenced by the perceived severity of LD and negatively influenced by safety concerns about the vaccine, whereas adult intention is negatively influenced by perceived barriers to vaccination.

CONCLUSION

A strong relationship of cues to action on vaccine intention in samples of adults and caregivers suggests the importance of a recommendation from a healthcare provider or the Centers for Disease Control and Prevention (CDC).

Operational Considerations for Using Deer-Targeted 4-Poster Tick Control Devices in a Tick-borne Disease Endemic Community

CONTEXT

In the northeastern United States, recommendations to prevent diseases spread by black-legged ticks ( Ixodes scapularis ) and lone star ticks ( Amblyomma americanum ) often rely on individuals to use personal protection or yard-based strategies. The 4-Poster deer treatment stations (4-Posters) suppress tick populations by treating deer hosts with acaricide, potentially offering a community-wide approach for reducing tick-borne diseases in endemic areas. The 4-Poster deployment logistics in mainland community settings are not well documented but are needed for future public health tick control efforts.

PROGRAM

As part of a public health research effort to design a population-based 4-Poster effectiveness study aimed at reducing tick-borne disease incidence, TickNET researchers partnered with the Town of Ridgefield (Connecticut) to understand the feasibility and operational logistics of deploying 4-Posters on public land within a residential community to inform future public health interventions by municipalities or vector control agencies.

IMPLEMENTATION

We deployed three 4-Posters on a municipal property from July to December 2020 and used motion-activated cameras to record wildlife activity nearby. We documented per-device operational details, costs, materials consumed, and animal activity.

EVALUATION

Operation of 4-Posters was feasible, and device challenges were easily remedied. Deer visitation and heavy nontarget animal use were documented at all devices. Unexpectedly, monthly corn consumption was not correlated with monthly deer-view days. The monthly cost per device was US $1279 or US $305 per hectare with an average 21 minutes of weekly service time.

DISCUSSION

Use of 4-Posters by communities, public health agencies, or vector control programs may be a practicable addition to tick management programs in tick-borne disease endemic areas in the Northeast. Such programs should carefully consider local and state regulations, follow manufacturer and pesticide label guidelines, and include wildlife monitoring. High labor costs incurred in this project could be mitigated by training vector control agency or municipality staff to service 4-Posters.

Efficacy of Unregulated Minimum Risk Products to Kill and Repel Ticks

Human-biting ticks threaten public health in the United States. Registration by the Environmental Protection Agency of products to kill host-seeking ticks or repel ticks contacting humans is indicative of their safety and effectiveness. Unregulated minimum risk products, exempt from Environmental Protection Agency registration and often based on botanical oils, are proliferating in the marketplace, but there is concern about their effectiveness to kill and repel ticks. Evaluations of such products are limited in the published literature. A review showed considerable variability among minimum risk products to kill host-seeking blacklegged ticks, with effectiveness similar to chemical pesticide products for some minimum risk products but minimal impact on the ticks for other products. Evaluations of minimum risk tick repellents have typically focused on individual active ingredients rather than formulated products, which often combine multiple active ingredients. Consumers should be aware that effectiveness to kill and repel ticks can differ among unregulated minimum risk products.

Acceptability of 4-poster deer treatment devices for community-wide tick control among residents of high Lyme disease incidence counties in Connecticut and New York, USA

The 4-Poster Tick Control Deer Feeder (4-poster) device applies acaricide to white-tailed deer (Odocoileus virginianus) and can reduce populations of the blacklegged tick (Ixodes scapularis), which transmits the agents of Lyme disease, anaplasmosis, babesiosis, and Powassan virus disease in the Northeastern United States. While 4-poster devices have the potential to provide community-wide management of blacklegged ticks in Lyme disease endemic areas, no recent study has assessed their acceptability among residents. We conducted a survey of residents from 16 counties with high annual average Lyme disease incidence (≥ 10 cases per 100,000 persons between 2013 and 2017) in Connecticut and New York to understand perceptions and experiences related to tickborne diseases, support or concerns for placement of 4-poster devices in their community, and opinions on which entities should be responsible for tick control on private properties. Overall, 37% of 1652 respondents (5.5% response rate) would support placement of a 4-poster device on their own property, 71% would support placement on other private land in their community, and 90% would support placement on public land. Respondents who were male, rented their property, resided on larger properties, or were very or extremely concerned about encountering ticks on their property were each more likely to support placement of 4-poster devices on their own property. The primary reason for not supporting placement of a 4-poster device on one's own property was the need for weekly service visits from pest control professionals, whereas the top reason for not supporting placement on other land (private or public) was safety concerns. Most respondents (61%) felt property owners should be responsible for tick control on private properties. Communities considering 4-poster devices as part of a tick management strategy should consider targeting owners of larger properties and placing devices on public lands.

Relative efficacy of high-pressure versus backpack sprayer applications of 2 natural product-based acaricides for control of host-seeking Ixodes Scapularis and Amblyomma americanum nymphs

We evaluated the relative effectiveness of the natural product acaricide Essentria IC3 and the entomopathogenic fungal acaricide BotaniGard ES to suppress host-seeking Ixodes scapularis Say and Amblyomma americanum (L.) nymphs when applied with low-pressure backpack and high-pressure sprayers. Essentria IC3 applied by backpack sprayer out-performed high-pressure applications, while the opposite was true for treatments with BotaniGard ES. We were unable to demonstrate consistently greater efficacy using high-pressure applications, and neither of the acaricides or application methods provided substantial (>90%) levels of control at 7 days postapplication.

Community-based integrated tick management programs: cost and feasibility scenarios

Numerous studies have assessed the efficacy of environmentally based control methods to suppress populations of the blacklegged tick (Ixodes scapularis Say), but few of these estimated the cost of control. We estimated costs for a range of tick control methods (including habitat management, deer exclusion or population reduction, broadcast of acaricides, and use of host-targeted acaricides) implemented singly or in combination and applied to a model community comprising 320 residential properties and parklands. Using the high end for cost ranges, tick control based on a single method was estimated to have mean annual costs per household in the model community ranging from $132 for treating only forest ecotone with a broadcast synthetic acaricide to kill host-seeking ticks (or $404 for treating all residential forested habitat) to >$2,000 for deployment of bait boxes (SELECT TCS) across all residential tick habitat to treat rodents topically with acaricide to kill infesting ticks. Combining different sets of multiple methods in an integrated tick management program placed the annual cost between $508 and 3,192 annually per household in the model community, underscoring the disconnect between what people in Lyme disease endemic areas say they are willing to pay for tick control (not more than $100-150 annually) and the actual costs for tick control. Additional barriers to implementing community-based tick management programs within residential communities are discussed.

Comparison of in vitro and in vivo repellency bioassay methods for Ixodes scapularis nymphs

BACKGROUND

Numerous bioassay methods have been used to test the efficacy of repellents for ticks, but the comparability of results across different methods has only been evaluated in a single study. Of particular interest are comparisons between bioassays that use artificial containers (in vitro) with those conducted on a human subject (in vivo) for efficacy testing of new potential unregistered active ingredients, which most commonly use in vitro methods.

METHODS

We compared four different bioassay methods and evaluated three ingredients (DEET [N,N-Diethyl-meta-toluamide], peppermint oil and rosemary oil) and a negative control (ethanol) over a 6-h period. Two of the methods tested were in vivo bioassay methods in which the active ingredient was applied to human skin (finger and forearm bioassays), and the other two methods were in vitro methods using artificial containers (jar and petri dish bioassays). All four bioassays were conducted using Ixodes scapularis nymphs. We compared the results using nymphs from two different tick colonies that were derived from I. scapularis collected in the US states of Connecticut and Rhode Island (northern origin) and Oklahoma (southern origin), expecting that ticks of different origin would display differences in host-seeking behavior.

RESULTS

The results between bioassay methods did not differ significantly, even when comparing those that provide the stimulus of human skin with those that do not. We also found that tick colony source can impact the outcome of repellency bioassays due to differences in movement speed; behavioral differences were incorporated into the assay screening. DEET effectively repelled nymphs for the full 6-h duration of the study. Peppermint oil showed a similar repellent efficacy to DEET during the first hour, but it decreased sharply afterwards. Rosemary oil did not effectively repel nymphs across any of the time points.

CONCLUSIONS

The repellency results did not differ significantly between the four bioassay methods tested. The results also highlight the need to consider the geographic origin of ticks used in repellency bioassays in addition to species and life stage. Finally, our results indicate a limited repellent efficacy of the two essential oils tested, which highlights the need for further studies on the duration of repellency for similar botanically derived active ingredients and for evaluation of formulated products.

Rodent-targeted approaches to reduce acarological risk of human exposure to pathogen-infected Ixodes ticks

In the United States, rodents serve as important hosts of medically important Ixodes ticks, including Ixodes scapularis and Ixodes pacificus, as well as reservoirs for human pathogens, including Anaplasma phagocytophilum, Borrelia burgdorferi sensu stricto (s.s.), and Babesia microti. Over the last four decades, different methods to disrupt enzootic transmission of these pathogens between tick vectors and rodent reservoirs have been developed and evaluated. Early work focused on self-application of topical acaricide by rodents to kill infesting ticks; this resulted in two different types of commercial products based on (i) delivery of permethrin to rodents via impregnated cotton offered as nesting material or (ii) application of fipronil to rodents via an impregnated wick as they navigate through a bait box to reach a food source. More recent work has focused on approaches where acaricides, antibiotics, or a vaccine against Bo. burgdorferi s.s. are delivered orally via rodent food baits. Of these, the oral vaccine and oral acaricide are nearest to commercialization. Other approaches in early stages of development include anti-tick vaccines for rodents and use of heritable genome editing to engineer white-footed mice (Peromyscus leucopus) that are refractory to Bo. burgdorferi s.s. In this review, I first outline general benefits and drawbacks of rodent-targeted tick and pathogen control methods, and then describe the empirical evidence for different approaches to impact enzootic pathogen transmission and acarological risk of human exposure to pathogen-infected Ixodes ticks. Rodent-targeted methods remain promising components of integrated tick management approaches but there are concerns about the robustness of the impact of existing rodent-targeted products across habitats and variable tick host communities, and in some cases also for the implementation cost in relation to what homeowners in Lyme disease endemic areas say they are willing to pay for tick control.

Knowledge, Attitudes, and Behaviors Regarding Lyme Borreliosis Prevention in the Endemic Area of Northeastern Poland

(1) Background: The incidence of Lyme borreliosis (LB) is increasing in Europe. The new LB vaccine is still in clinical development, thus the dissemination of knowledge about the disease is essential. We assessed the knowledge, attitudes and preventive practices (KAP) against tick-borne diseases (TBDs) of people living in the endemic area in northeastern Poland. (2) Methods: We surveyed 406 adults using a 37-item anonymous paper survey. The data were analyzed with regression models. (3) Results: The two most popular knowledge sources were the Internet and doctors, selected by 77.8% and 53.4%, respectively. Respondents felt moderately knowledgeable about TBDs and tick bite prophylaxis (median scores 5/10, and 6/10, respectively), considered TBDs to be a significant health threat (median 8/10), attributed high risk to tick mouthparts remaining in the skin after tick removal (median 10/10), and shared multiple misconceptions regarding LB transmission, symptoms, and management. General knowledge scores (GKS) about TBDs and tick protection practices scores (TPS) were moderate (65.0%; IQR, 55.8−71.7%, 63.6%; 54.5−72.7%, respectively). Only 48.0% had a positive attitude towards TBE vaccination. A recent tick-bite was associated with higher GKS (OR, 2.55; 95% CI, 1.27−5.10; p = 0.008), higher TPS (OR 4.76, 95% CI, 2.0−11.1; p < 0.001), and a positive attitude towards TBE vaccine (OR 2.10, 1.07−4.10, p = 0.030). A positive vaccine attitude was also associated with obtaining TBD knowledge from doctors and other verified sources (OR, 2.654, 1.66−4.23; p < 0.001). Age, place of residence, and frequent exposure to ticks in green areas were not associated with GKS, TPS, nor vaccine attitude. (4) Conclusions: Increased risk perceptions are associated with adoption of behaviors preventing TBDs. Medical professionals play an important role in communicating knowledge about TBDs. There is a need to revise current communication strategies with respect to tick bites and prevention of LB and other TBDs.

Effectiveness of personal protection measures against Lyme disease: A review of epidemiologic studies from the United States

Lyme disease, the most commonly reported vector-borne disease in the United States, is caused by the bacteria Borrelia burgdorferi and is transmitted through the bite of an infected blacklegged tick. In the absence of a licensed vaccine, the prevention of Lyme disease relies heavily on limiting tick exposure. Methods for limiting tick exposure include personal protection measures such as repellent use, wearing protective clothing, avoiding areas where ticks may be present, bathing after exposure to tick habitat and performing regular tick checks. Public health officials typically recommend all these personal protection measures; however, there is limited evidence to promote one behaviour or practice over another. The focus of this article is to review available literature that examines the effectiveness of recommended personal protection measures to prevent Lyme and other Ixodes-transmitted diseases in humans. Articles included in this review were identified through Google Scholar and PubMed searches using specific search terms. We identified over 56,000 articles using Google Scholar and PubMed searches. Of those, 16 studies fit our criteria for inclusion and were reviewed in their entirety. Among the personal protection measures evaluated, no intervention was predominantly or consistently effective across studies, demonstrating that, currently, there is no single best method for primary prevention of Ixodes-transmitted diseases in the United States. Frequently recommended practices such as tick checks, repellent use and protective clothing had mixed results across studies. Study design differences limited comparability among studies, and sample sizes for these studies may have been too small to detect statistically significant results even if a prevention method was effective. Though many of the reviewed personal protection measures are frequently recommended to the public, limited evidence demonstrates their ability to prevent tick-borne disease. Additional standardized studies are needed to evaluate personal protection measures.

Personal protection measures to prevent tick bites in the United States: Knowledge gaps, challenges, and opportunities

Personal protection measures to prevent human tick encounters from resulting in bites are widely recommended as the first line of defense against health impacts associated with ticks. This includes using repellents, wearing untreated or permethrin-treated protective clothing, and conducting tick checks after coming inside, aided by removing outdoor clothing articles and running them in a dryer on high heat (to kill undetected ticks) and taking a shower/bath (to aid in detecting ticks on the skin). These measures have the benefit of incurring no or low cost, but they need to be used consistently to be most effective. In this paper, I review the level of use (acceptability combined with behavior) of the above-mentioned personal protection measures and their effectiveness to prevent tick bites and tick-borne disease. Studies on the level of use of personal protection measures to prevent tick bites have used different recruitment strategies, focused on different types of respondent populations, employed variable phrasings of survey questions relating to a given personal protection measure, and presented results based on variable frequencies of taking action. This complicates the synthesis of the findings, but the studies collectively indicate that members of the public commonly take action to prevent tick bites, most frequently by wearing untreated protective clothing or conducting tick checks (done routinely by 30 to 70% of respondents in most studies of the public), followed by showering/bathing after being outdoors or using repellents on skin/clothing (15 to 40% range), and with permethrin-treated clothing being the least frequently used tick bite prevention method (<5 to 20% range). A suite of experimental studies have shown that applying repellents or permethrin to coveralls or uniform-style clothing can result in decreased numbers of tick bites, but similar studies are lacking for members of the public wearing summer-weight clothing during normal daily activities. Moreover, a set of case-control and cross-sectional studies have explored associations between use of different personal protection measures to prevent tick bites and Lyme disease or other tick-borne infections. The results are mixed for each personal protection measure, with some studies indicating that regular use of the measure is associated with a reduction in tick-borne disease while other studies found no similar protective effect. One possible interpretation is that these personal protection measures can protect against tick-borne infection but the information gathered to date has not been sufficiently detailed to clarify the circumstances under which protection is achieved, especially with regards to frequency of use, parts of the body being protected, and use of combinations of two or more potentially protective measures. In conclusion, personal protection measures to prevent tick bites are used by the public and merit further study to better understand how they need to be used to have the greatest public health impact.

Knowledge, attitudes, and behaviors regarding tick-borne disease prevention in Lyme disease-endemic areas of the Upper Midwest, United States

Lyme disease and other tick-borne diseases are a major public health threat in the Upper Midwestern United States, including Michigan, Minnesota, and Wisconsin. To prevent tick bites and tick-borne diseases, public health officials commonly recommend personal protective measures and property management techniques. Adoption of tick-borne disease prevention behaviors and practices by individuals are, however, highly variable. We aimed to characterize current tick-borne disease knowledge, attitudes, and prevention behaviors (KAB) practiced by the public in these states, as well as their willingness to use specific tick control methods. We conducted a population-based survey in summer 2019 in 48 high-risk counties (those having a five-year average (2013-2017) Lyme disease incidence of ≥ 10 cases per 100,000 persons per year), in Michigan, Minnesota, and Wisconsin. A total of 2713 surveys were analyzed; survey weights were used to account for household selection probability and post-stratified to match county-level joint age and sex population distributions in population-level inference. An estimated 98% of the population had heard of Lyme disease, with most perceiving it as very or extremely serious (91%); however, only an estimated 25% perceived tick-borne diseases as very or extremely common in their community. Among those who spent time in places with ticks from April through October, an estimated 68% check themselves thoroughly for ticks most of the time or always and 43% use bug repellent on skin or clothing most of the time or always. An estimated 13% of the population had ever treated their property with a pesticide to kill ticks, and 3% had ever used devices that apply pesticide to rodents to kill ticks on their property. Willingness to practice tick bite prevention behaviors, however, was estimated to be much higher; with 82% being willing to perform tick checks at least once a day, and more than 60% willing to use bug repellent, tick control products on pets, or to bathe within two hours of being outdoors. We found that residents would likely be willing to support a county-wide tick control program to reduce the risk of tick-borne disease in their community (81%) or to apply tick control products to their property to reduce the risk of tick-borne disease in their household (79%). Tick checks were more likely to be practiced among participants who perceived tick-borne diseases to be highly prevalent in their community, if they or a household member had been previously diagnosed with a tick-borne disease?, or if they perceived tick exposure to be likely around their home, cabin, or vacation home. In addition, property-based tick control methods were associated with perceived risk of encountering ticks around the home, cabin, or vacation home. Participants who had seen information from state health departments were also more likely to practice preventive measures. The most common reported barriers to using any of these methods were forgetfulness, safety concerns, and lack of awareness. Our survey findings shed light on how residents from these Upper Midwest states may adopt tick control and tick bite prevention measures and how public health outreach may be most effective for this population.

A Review of Commercial Metarhizium- and Beauveria-Based Biopesticides for the Biological Control of Ticks in the USA

There is a need for the development of sustainable, nonchemical tick management strategies. Mycoacaricide and mycoinsecticide product development worldwide has focused primarily on fungi in the genera Beauveria (Hypocreales: Cordycipitaceae) and Metarhizium (Hypocreales: Clavicipitaceae). Microbial biopesticides containing entomopathogenic fungi have potential in tick management. However, despite considerable progress in the development of fungal biopesticides over the past 20 years, the establishment of commercial products available for use against ticks continues to be slow. We reviewed published scientific literature and compiled a comprehensive list of reports of the effectiveness of commercial biopesticides based on the fungal genera Metarhizium and Beauveria and registered for use in the USA against ixodid ticks under laboratory and field conditions. We also report on results when these biopesticides were used as a part of integrated tick management. Until efficacious fungus-based products become more available, tick management will rely primarily on synthetic chemical acaricides, with natural-product acaricides as the alternative.

Effects of tick surveillance education on knowledge, attitudes, and practices of local health department employees

BACKGROUND

The number of cases of tick-borne diseases in humans is increasing rapidly within Illinois. The responsibility for increased surveillance of tick-borne disease cases and tick vectors is being placed on local health departments throughout the United States, but they often lack the funding, time, and/or training needed to perform said surveillance. The aims of this study were to develop, deliver, and determine the effectiveness of tick surveillance training workshops for local health department employees within Illinois.

METHODS

We developed and delivered in-person training at local health department offices in each of six Illinois Department of Public Health Environmental Health Regions between April-May of 2019. Pre-, post-, and six-month follow-up questionnaires on knowledge, attitudes, and practices with regards to tick surveillance were administered to training participants. Paired student's t-test or Wilcoxon signed-rank test were used to compare knowledge, attitudes, and practices scores between questionnaires with Cohen's d being used to calculate effect sizes associated with t-tests. McNemar's and McNemar-Bowker tests were used to evaluate individual questions. Spearman's rank correlation was used to evaluate the relationship between knowledge, attitudes, and practices at pre-, post-, and six-month follow-up.

RESULTS

Seventy-six employees from 40 local health departments that represent 44% (45/102) of Illinois counties attended at least one training workshop. Of these attendees, 81.5% (62/76) participated in at least one survey, 79% (60/76) in the in-person pre-training survey, 74% (56/76) in the in-person post-training survey, and 22% (17/76) in the online six-month follow-up survey. The average knowledge score was significantly increased by 8.21 (95% CI:7.28-9.14) points from pre-training to post-training. The average overall attitude score significantly increased by 5.29 (95% CI: 3.91-6.66) points from pre- to post-training. There were no significant differences in practice scores.

CONCLUSIONS

Our study found the training was effective in increasing the knowledge of ticks, tick-borne diseases, and surveillance as well as promoting positive attitudes related to surveillance. While the training, by itself, was not associated with increases in surveillance practices, we were able to empower local public health officials with the knowledge and positive attitudes needed to enact change.

Understanding consumer and clinician perceptions of a potential Lyme disease vaccine

Each year, over 450 000 Lyme disease diagnoses are estimated to occur in the United States, and current preventive measures have been insufficient to stem the rising incidence. An effective human Lyme disease vaccine could be a powerful intervention for population-level impact. In advance of new Lyme disease vaccines coming to market, this study explored barriers to acceptability and motivations for the uptake of a new Lyme disease vaccine. Researchers conducted 9 online focus groups among consumers who may potentially benefit from the vaccine and 30 in-depth interviews among clinician groups who may provide the vaccine. All participants were recruited from three US regions of high Lyme disease incidence. Researchers found that participants shared common motivators to either recommend (clinicians) or accept (consumers) a Lyme disease vaccine, largely driven by perceived benefits of the vaccine, the lack of current effective preventive measures and a greater peace of mind. The concern about the challenges associated with diagnosing and treating Lyme disease is a primary motivator for clinicians to recommend the vaccine, while the concern about getting Lyme disease is a primary motivator for consumers to desire the vaccine.

Estimating disease vector population size from citizen science data

Citizen science projects have the potential to address hypotheses requiring extremely large datasets that cannot be collected with the financial and labour constraints of most scientific projects. Data collection by the general public could expand the scope of scientific enquiry if these data accurately capture the system under study. However, data collection inconsistencies by the untrained public may result in biased datasets that do not accurately represent the natural world. In this paper, we harness the availability of scientific and public datasets of the Lyme disease tick vector to identify and account for biases in citizen science tick collections. Estimates of tick abundance from the citizen science dataset correspond moderately with estimates from direct surveillance but exhibit consistent biases. These biases can be mitigated by including factors that may impact collector participation or effort in statistical models, which, in turn, result in more accurate estimates of tick population sizes. Accounting for collection biases within large-scale, public participation datasets could update species abundance maps and facilitate using the wealth of citizen science data to answer scientific questions at scales that are not feasible with traditional datasets.

Integrated Tick Management in South Central Wisconsin: Impact of Invasive Vegetation Removal and Host-Targeted Acaricides on the Density of Questing Ixodes scapularis (Acari: Ixodidae) Nymphs

As tick-borne disease incidence increases and pathogens expand into new areas, the need for effective tick management strategies is paramount. In this 5-yr study (2014-2018) conducted in south central Wisconsin, we assessed whether an integrated tick management approach, deployed during peak tick activity (May-August), was more effective at reducing black-legged ticks (Ixodes scapularis Say (Ixodida: Ixodidae)), than individual interventions. Using a factorial design, invasive vegetation removal (Amur honeysuckle, Lonicera maackii Ruprecht (Dipsacales: Caprifoliaceae) and common buckthorn, Rhamnus cathartica Linnaeus (Rosales: Rhamnaceae)) was coupled with deployments of permethrin-treated cotton nesting materials (tick tubes) that target the white-footed mouse (Peromyscus leucopus Rafinesque (Rodentia: Cricetidae)). Results show that the probability of encountering a larval tick by drag sampling was unaffected by treatments at the cumulative 5-yr level. However, vegetation removal significantly reduced larval encounters in 2014, 2015, and 2018, by 33%, 57%, and 61% respectively, and reduced the density of questing nymphal (DON) ticks by 45% in 2015 compared to controls. Despite the limited effect on DON, vegetation removal significantly reduced the cumulative 5-yr density of Borrelia burgdorferi sensu stricto infected nymphs (DIN) (70%) compared to controls as a result of decreased nymphal infection prevalence. Sites treated with tick tubes had lower DIN (66%) and DON (54%) across the study and nymphs were reduced every year following the initial year of deployment compared to controls. Combining treatments did not further reduce DIN or DONs. We conclude that long-term integration of tick tubes with invasive vegetation removal does not provide additional benefit over individual treatments alone.

Prevalence of Risk and Protective Factors for Tick Exposure and Tick-Borne Disease Among Residents of Indiana

OBJECTIVE

To determine the prevalence of risk and protective factors for tick exposure and tick-borne disease (TBD) based on gender and living in urban or rural areas (urbanicity) among a cross section of Indiana adults.

METHODS

Data were collected from 3003 adults (81% response rate) spread across all 92 Indiana counties. Study participants were recruited from existing online panels maintained by Qualtrics. We calculated prevalence ratio (PR) and 95% confidence interval (CI) of 8 primary outcomes for 2 different exposures: (1) gender (male/female) and (2) urbanicity.

RESULTS

Female participants were 10% less likely to find a tick on themselves than male participants (PR = 0.90; 95% CI, 0.74-0.99) and significantly more likely to worry about their health and safety because of ticks, whereas males avoided the outdoors less because of worry about ticks. Female participants were significantly more likely to adopt various personal protective measures, specifically because of concern for ticks. Female participants were also less likely to have been told by a health care provider that they have a TBD (PR = 0.53; 95% CI, 0.38-0.75). Rural participants were significantly more likely to report seeing a tick at their residential property (PR = 2.40; 95% CI, 2.11-2.76), report finding ticks on themselves (PR = 1.90; 95% CI, 1.68-2.23), and report finding a tick on a child at their residential property within the past 6 months than urban dwellers (PR = 1.37; 95% CI, 1.06-1.77). In addition, we found that 62% of participants have very high trust in government sources of information on TBD and tick prevention.

CONCLUSIONS

In Indiana, the area around people's residences may constitute an important source of tick exposure for humans. Being exposed to ticks is most prevalent in those living in rural areas of Indiana. Finally, risk factors for TBD are higher among males than among females.

Recreational behaviour, risk perceptions, and protective practices against ticks: a cross-sectional comparative study before and during the lockdown enforced by the COVID-19 pandemic in Romania

Background

Gaining insight into the risk perceptions and the knowledge evolution of the public about emerging or changing health risks is vital for the improvement of health promotion activities. Currently, scientific evidence regarding the attitudes of the Romanian public towards ticks is scanty. This study aimed to identify how the lockdown enforced by the COVID-19 pandemic in Romania impacted the recreational behaviour, risk perceptions, and protective practices of the Romanian population regarding ticks.

Methods

A cross-sectional, nationwide web-based questionnaire was designed and distributed via social media to evaluate if, and how, the COVID-19 lockdown impacted the behaviour of the Romanian public concerning ticks. The survey was available online from 6 May until 15 May 2020, which marked the last day of the travel ban in Romania. The collected data were processed by applying both uni- and multivariate methods.

Results

Respondents reported a higher frequency of finding ticks on themselves and their dogs during the lockdown. Bathing/showering and checking the body for ticks were the two most used protective behaviours both before and during the lockdown. Nevertheless, an overall lower usage rate of protective measures was registered during the lockdown. Almost all dog owners used a form of ectoparasite control for their dogs, and only three stopped due to lockdown-associated reasons. Respondent characteristics that were found to be positively associated with risk perceptions were being female and living in peri-urban/suburban/rural environments.

Conclusions

Despite spending less time outdoors during the lockdown, more respondents reported finding ticks on themselves or their dogs. Changes in the preferences for recreational locations, rates of protective practices usage, amount of time spent in specific areas, or tick seasonal activity might have contributed to this outcome. Concerning risk groups, men of all ages, senior citizens, and rural inhabitants should be targeted by the relevant Romanian authorities when promoting local or nationwide tick awareness campaigns.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04944-7.

Barriers to Effective Tick Management and Tick-Bite Prevention in the United States (Acari: Ixodidae)

Lyme and other tick-borne diseases are increasing in the United States. Development of tick control tools have focused primarily on the blacklegged tick, Ixodes scapularis Say. Application of acaricides or entomopathogenic fungal agents to kill host-seeking ticks or ticks on rodents can suppress I. scapularis abundance in residential landscapes, but evidence is lacking for impact on human tick bites or tick-borne disease. Similar studies remain limited for the lone star tick, Amblyomma americanum (L.). Other knowledge gaps include how well homeowners and pest control companies perform in the broadcast application of tick-killing products, relative to high efficacy reported in research studies, and the tick-killing potential of natural product formulations exempt from Environmental Protection Agency registration. Area-wide control based on preventing ticks from feeding on their main reproductive host, the white-tailed deer, can suppress populations of both I. scapularis and A. americanum. Some studies also suggest an impact on Lyme disease cases, but this needs to be further validated in larger-scale intervention studies. The effectiveness, scale, cost, and implementation of various tick management strategies are important considerations in efforts to reduce human tick encounters and tick-borne disease. Additional barriers include weak incentives for industry and academia to develop, test, and register new tick and pathogen control technologies, including vaccines targeting humans, tick reproductive hosts, or wildlife pathogen reservoirs. Solutions will need to be 'two-pronged': improving the tick and pathogen control toolbox and strengthening the public health workforce engaging in tick control at local and state levels.

Tick and Tickborne Pathogen Surveillance as a Public Health Tool in the United States

In recent decades, tickborne disease (TBD) cases and established populations of medically important ticks have been reported over expanding geographic areas, and an increasing number of tickborne bacteria, viruses, and protozoans have been recognized as human pathogens, collectively contributing to an increasing burden of TBDs in the United States. The prevention and diagnosis of TBDs depend greatly on an accurate understanding by the public and healthcare providers of when and where persons are at risk for exposure to human-biting ticks and to the pathogens these ticks transmit. However, national maps showing the distributions of medically important ticks and the presence or prevalence of tickborne pathogens are often incomplete, outdated, or lacking entirely. Similar deficiencies exist regarding geographic variability in host-seeking tick abundance. Efforts to accurately depict acarological risk are hampered by lack of systematic and routine surveillance for medically important ticks and their associated human pathogens. In this review, we: 1) outline the public health importance of tick surveillance; 2) identify gaps in knowledge regarding the distributions and abundance of medically important ticks in the United States and the presence and prevalence of their associated pathogens; 3) describe key objectives for tick surveillance and review methods appropriate for addressing those goals; and 4) assess current capacity and barriers to implementation and sustainability of tick surveillance programs.

Stemming the Rising Tide of Human-Biting Ticks and Tickborne Diseases, United States

Ticks and tickborne diseases are increasingly problematic. There have been positive developments that should result in improved strategies and better tools to suppress ticks, reduce human tick bites, and roll back tickborne diseases. However, we equally need to address the question of who is responsible for implementing the solutions. The current model of individual responsibility for tick control evolved from a scenario in the 1990s focusing strongly on exposure to blacklegged ticks and Lyme disease spirochetes in peridomestic settings of the northeastern United States. Today, the threat posed by human-biting ticks is more widespread across the eastern United States, increasingly complex (multiple tick species and >10 notable tickborne pathogens), and, across tick species, more spatially diffuse (including backyards, neighborhood green spaces, and public recreation areas). To mitigate tick-associated negative societal effects, we must consider shifting the responsibility for tick control to include both individual persons and professionally staffed tick-management programs.

Tick trails: the role of online recreational trail reviews in identifying risk factors and behavioral recommendations associated with tick encounters in Indiana

BACKGROUND

Recreational trails abound across the United States and represent high risk areas for tick exposure. Although online reviews represent a rich source of user information, they have rarely been used in determining the risk of tick exposure during recreational trail use. Based on online user reviews and comments, the purpose of this study was to determine risk factors and behavioral recommendations associated with tick encounters (Tick Presence) on recreational trails in the state of Indiana, U.S.

METHODS

We reviewed 26,016 user comments left on AllTrails.com for 697 Indiana trails. Reviews were evaluated to determine Tick Presence/Absence, the total number of Tick Presence Reviews per trail, and multiple trail and user behavioral characteristics. We used hot spot (Getis-Ord Gi*) analysis to test the hypothesis of whether there are clusters in the number of Tick Presence Reviews. Pearson chi-square tests of independence evaluated whether tick presence was associated with several trail characteristics. Finally, negative binomial regression evaluated the strength of the association between the number of Tick Presence Reviews and several trail characteristics.

RESULTS

Tick Presence was recorded at 10% (n = 65) of trails and occurred most frequently in May. Hot spot analysis revealed statistically significant clusters of Tick Presence Reviews on trails in the Southern Indiana State Region. Results of χ2 tests indicated significant associations between Tick Presence Reviews and (a) State Region and (b) Land Management Type; Mann-Whitney U tests detected significant differences in Tick Presence Reviews based on Trail Length and Elevation Gain. Subsequent results of a negative binomial regression model indicated that Southern Indiana State Region, Federal and Private Land Management Type, and Elevation Gain were factors significantly associated with Tick Presence Reviews. Content of user reviews indicated several behaviors employed to prevent tick encounters, particularly Repellent Application and Recreational Deterrence; 25% included a behavior Recommendation to others.

CONCLUSIONS

Online, user-generated trail reviews have the potential to serve as rich data sources for identifying recreational trails, where 1) the risk of tick exposure is great, 2) more robust active tick and tick-borne pathogen surveillance may be warranted, and 3) tailored prevention interventions are needed.

Do-It-Yourself Tick Control: Granular Gamma-Cyhalothrin Reduces Ixodes scapularis (Acari: Ixodidae) Nymphs in Residential Backyards

Lyme disease is the most common vector-borne disease in the United States with hotspots in the Northeast and Midwest. Integrated vector control for mosquito-borne disease prevention is often organized at the community level, but tick control is primarily coordinated at the household and individual level. Management of the blacklegged tick, Ixodes scapularis (Say), the vector of the causative agent of Lyme disease in the Midwest and eastern United States in peridomestic environments may be critical as many tick encounters are reported to occur in the yard. Therefore, we assessed the effectiveness of a widely available and low-cost pesticide that targets common lawn pests and is labeled for use against ticks. In June 2019, we evaluated a granular form of gamma-cyhalothrin in a placebo-controlled residential backyard study (n = 90) in two communities in Wisconsin. The product applied by the research team reduced nymphal blacklegged ticks in plots established in the lawn part of the ecotone by 97% one week after application at both communities and by 89-97% three to four weeks postapplication. The proportion of homes with at least one nymphal tick postapplication was significantly lower at acaricide-treated homes and ranged from 4.2 to 29.2% compared with placebo homes where at least one nymphal tick was found at 50-81.5% of homes. These results support the efficacy of a low-cost do-it-yourself strategy for homeowners seeking to reduce blacklegged ticks in the yard.

Willingness to Pay for Select Tick-Borne Disease Prevention Measures in Endemic Areas

Tick-borne diseases (TBDs) are increasing despite prevention recommendations. We explored whether cost is a barrier to prevention use in Connecticut and Maryland, using a cross-sectional survey. Respondents were queried regarding their willingness to pay for chemical, natural, and rodent-targeted yard pesticide treatments and permethrin-treated clothing. We evaluated associations between demographics, TBD knowledge and attitudes, and willingness to pay for prevention methods. Most respondents would pay for yard treatments (85%); 95% preferring natural pesticide, and 82% would pay for permethrin-treated clothing. Most did not want to pay more than $99 for any of the yard treatments. Having a household income of $100 000 was associated with willingness to pay $100 or more for chemical, natural, or rodent-targeted treatments and $25 or more for permethrin self-treated and pretreated clothing. Yard treatments, especially natural pesticides, were acceptable for TBD prevention; however, current pricing may be cost-prohibitive. Permethrin-treated clothing may be an affordable and acceptable prevention method.

Assessing Public Tick Identification Ability and Tick Bite Riskiness Using Passive Photograph-Based Crowdsourced Tick Surveillance

Tick identification is critical for assessing disease risk from a tick bite and for determining requisite treatment. Data from the University of Rhode Island's TickEncounter Resource Center's photo-based surveillance system, TickSpotters, indicate that users incorrectly identified their submitted specimen 83% of the time. Of the top four most commonly submitted tick species, western blacklegged ticks (Ixodes pacificus Cooley & Kohls [Ixodida: Ixodidae]) had the largest proportion of unidentified or misidentified submissions (87.7% incorrectly identified to species), followed by lone star ticks (Amblyomma americanum Linneaus [Ixodida: Ixodidae]; 86.8% incorrect), American dog ticks (Dermacentor variabilis Say [Ixodida: Ixodidae]; 80.7% incorrect), and blacklegged ticks (Ixodes scapularis Say [Ixodida: Ixodidae]; 77.1% incorrect). More than one quarter of participants (26.3%) submitted photographs of ticks that had been feeding for at least 2.5 d, suggesting heightened risk. Logistic regression generalized linear models suggested that participants were significantly more likely to misidentify nymph-stage ticks than adult ticks (odds ratio [OR] = 0.40, 95% confidence interval [CI]: 0.23, 0.68, P < 0.001). Ticks reported on pets were more likely to be identified correctly than those found on humans (OR = 1.07, 95% CI: 1.01-2.04, P < 0.001), and ticks feeding for 2.5 d or longer were more likely to be misidentified than those having fed for one day or less (OR = 0.43, 95% CI: 0.29-0.65, P < 0.001). State and region of residence and season of submission did not contribute significantly to the optimal model. These findings provide targets for future educational efforts and underscore the value of photograph-based tick surveillance to elucidate these knowledge gaps.

Synthetic Pyrethroid, Natural Product, and Entomopathogenic Fungal Acaricide Product Formulations for Sustained Early Season Suppression of Host-Seeking Ixodes scapularis (Acari: Ixodidae) and Amblyomma americanum Nymphs

We compared the ability of product formulations representing a synthetic pyrethroid acaricide (Talstar P Professional Insecticide), a natural product-based acaricide (Essentria IC3), and an entomopathogenic fungal acaricide (Met52 EC Bioinsecticide) to suppress Ixodes scapularis Say and Amblyomma americanum (L.) nymphs when applied following USEPA approved manufacturers' label recommendations for tick control using hand-pumped knapsack sprayers before the beginning of their seasonal activity period in the spring. We applied Met52 EC Bioinsecticide (11% Metarhizium anisopliae Strain F52) to five 100 m2 plots (10.6 ml AI/plot) in mid-April 2020. Two weeks later at the end of April 2020, we treated an additional five 100 m2 plots each with either Talstar P Professional Insecticide (7.9% bifenthrin @ 2.5 ml AI/plot) or Essentria IC3 (10% rosemary oil, 5% geraniol, and 2% peppermint oil @ 86.6 ml AI/plot). Weekly sampling of all plots through the end of June 2020 showed that both Met52 EC Bioinsecticide and Essentria IC3 failed to maintain a 90% suppression threshold for I. scapularis, compared to control plots, and required two additional applications over the course of the trial. In contrast, Talstar P Professional Insecticide suppressed 100% of I. scapularis nymphs and ≥96 and 100% of A. americanum nymphs and adults, respectively. Such pre-season applications of synthetic pyrethroids significantly reduce the early season acarological risk for exposure to host-seeking ticks as well as the frequency of acaricide applications.

Spray Safe, Play Safe: Story-Based Films Increase Homeowner Confidence About Backyard Tick Management

Lyme disease incidence is increasing in the United States despite myriad efforts to educate individuals about effective prevention practices to reduce exposure to nymphal Ixodes scapularis Say (Acari: Ixodidae) (blacklegged tick), the primary vector of the pathogen causing Lyme disease. Furthermore, Lyme prevention educational needs currently exceed the ability of public health professionals to deliver the information in person. Past work has shown there is especially high confusion regarding the use of acaricides for tick management by homeowners. Story-based education is known to engage individuals and change behaviors. To increase the reach and engagement regarding Lyme disease prevention practices, especially residential acaricide use, we created short, story-based educational films (Spray Safe, Play Safe) and evaluated their educational benefit with a survey pre- and post-viewing. We determined that after viewing the films, a significantly higher percentage of respondents reported increased confidence in identifying the riskiest areas in their yards for ticks, using personal protective measures to prevent tick bites, using tick-safe landscaping, and using tick control products. This study also suggests that using short, engaging films that can be posted to popular websites and social media outlets could be employed more frequently for successful and engaging Lyme disease education, as creative and up-to-date educational methods are needed.

Epidemiology and cost of Lyme disease-related hospitalizations among patients with employer-sponsored health insurance-United States, 2005-2014

An estimated 300,000 cases of Lyme disease occur in the United States annually. Disseminated Lyme disease may result in carditis, arthritis, facial palsy or meningitis, sometimes requiring hospitalization. We describe the epidemiology and cost of Lyme disease-related hospitalizations. We analysed 2005-2014 data from the Truven Health Analytics MarketScan Commercial Claims and Encounters Databases to identify inpatient records associated with Lyme disease based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. We estimated the annual number and median cost of Lyme disease-related hospitalizations in the United States in persons under 65 years of age. Costs were adjusted to reflect 2016 dollars. Of 20,983,165 admission records contained in the inpatient databases during the study period, 2,823 (0.01%) met inclusion criteria for Lyme disease-related hospitalizations. Over half of the identified records contained an ICD-9-CM code for meningitis (n = 614), carditis (n = 429), facial palsy (n = 400) or arthritis (n = 377). Nearly 60% of hospitalized patients were male. The median cost per Lyme disease-related hospitalization was $11,688 (range: $140-$323,613). The manifestation with the highest median cost per stay was carditis ($17,461), followed by meningitis ($15,177), arthritis ($13,012) and facial palsy ($10,491). Median cost was highest among the 15- to 19-year-old age group ($12,991). Admissions occurring in January had the highest median cost ($13,777) for all study years. Based on extrapolation to the U.S. population, we estimate that 2,196 Lyme disease-related hospitalizations in persons under 65 years of age occur annually with an estimated annual cost of $25,826,237. Lyme disease is usually treated in an outpatient setting; however, some patients with Lyme disease require hospitalization, underscoring the need for effective prevention methods to mitigate these serious cases. Information from this analysis can aid economic evaluations of interventions that prevent infection and advances in disease detection.

Control of ixodid ticks and prevention of tick-borne diseases in the United States: The prospect of a new Lyme disease vaccine and the continuing problem with tick exposure on residential properties

In the United States, exposure to human-biting ixodid ticks can occur while spending time on residential properties or in neighborhood green spaces as well as during recreational or occupational activities on public lands. Human-biting tick species collectively transmit >15 species of pathogenic microorganisms and the national burden of tick-borne diseases is increasing. The prospect of a new Lyme disease vaccine for use in humans provides hope for substantial reduction in the >450,000 estimated annual cases of Lyme disease but this breakthrough would not reduce cases of other tick-borne diseases, such as anaplasmosis, babesiosis, ehrlichiosis, spotted fever group rickettsiosis, and Powassan encephalitis. One intriguing question is to what extent a new Lyme disease vaccine would impact the use of personal protection measures acting broadly against tick-bites. The main tick vector for Lyme disease spirochetes in the eastern United States, Ixodes scapularis, also transmits causative agents of anaplasmosis, babesiosis, and Powassan encephalitis; and this tick species co-occurs with other human-biting vectors such as Amblyomma americanum and Dermacentor variabilis. It therefore is important that a new Lyme disease vaccine does not result in reduced use of tick-bite prevention measures, such as tick repellents, permethrin-treated clothing, and frequent tick checks. Another key issue is the continuing problem with tick exposure on residential properties, which represents a heavily used outdoor environment the residents cannot reasonably avoid and where they tend to spend large amounts of time outside. As it may not be realistic to keep up daily vigilance with personal protective measures against tick-bites on residential properties during many months of every year, homeowners may also consider the option to suppress host-seeking ticks by means of deer fencing, landscaping, vegetation management, and use of products to kill host-seeking ticks or ticks infesting rodents. When considering the full range of options for actions that can be taken to suppress host-seeking ticks on residential properties, it is clear that individual homeowners face a difficult and bewildering task in deciding what to do based on very general guidance from public health agencies (developed without the benefit of a strong evidence base) and often without ready access to local public health professionals experienced in tick control. This situation is not satisfactory but cannot be corrected without first addressing knowledge gaps regarding the impact of peridomestic tick control measures on host-seeking ticks, human tick-bites, and tick-borne diseases. In parallel with this effort, there also is a need to increase the local public health workforce with knowledge of and experience with tick control to provide better access for homeowners to sound and objective advice regarding tick control on their properties based on key characteristics of the landscaping, habitat composition, and use patterns by wild animal tick hosts as well as the residents.

Evaluating the Effects of Minimal Risk Natural Products for Control of the Tick, Ixodes scapularis (Acari: Ixodidae)

Knockdown and residual activity of 10 minimal risk natural products (MRNPs), one experimental formulation of nootkatone, and two bifenthrin labels were evaluated against host-seeking nymphal Ixodes scapularis Say using a novel micro-plot product screening system placed in a landscape setting similar to a wooded residential property. The MRNPs evaluated included Tick Stop, EcoPCO EC-X, Met52 EC, CedarCide PCO Choice, EcoEXEMPT IC2, EcoSMART Organic Insecticide, Essentria IC3, privately labeled products 1 and 2 (based on EcoEXEMPT IC2 and sold as a professional pest control application), and Tick Killz. Just the nootkatone and 4 of these 10 products tested (EcoPCO EC-X, Met52 EC, EcoEXEMPT IC2, and Essentria IC3) had statistically significant (P < 0.05) knockdown effects (killed ticks while active in the arenas) when compared to water-only controls, but only 2 of these, EcoPCO EC-X and nootkatone, displayed significant residual tick-killing activity after weathering naturally in the landscape for 2 wk prior to tick application/testing. Moreover, botanical oil-based products with the same active ingredients provided inconsistent results when tested multiple times across study years.

Preventing tick-bites among children in Indiana, USA: An analysis of factors associated with parental protective behaviors

Despite evidence to the effect that there is low parental adoption of tick-bite personal protective behavior (PPB) for their children - a population at high risk for tick exposure, very limited information is available on factors associated with parental adoption of PPB. The objective of this study was to identify the most significant factors associated with parental adoption of tick-bite PPB on behalf of a child or children at risk of tick encounters. A cross-section of parents in Indiana, USA whose child had spent time outdoors in tick habitat during the summer were recruited from representative online panels maintained by Qualtrics. Binary logistic regression was used to model determinants of five tick-bite PPBs. Our results revealed that the application of tick repellent (89 %, n = 718) followed by conducting a tick check of the child's body soon after returning from the outdoors (84 %, n = 676) were the PPBs most frequently adopted by parents. Conversely, tucking one's shirt into pants and pants into socks was the least frequently adopted PPB (48 %, n = 386). Compared to other factors evaluated in logistic regression models, parents who reported implementing one or more residential tick control practices were significantly more likely to adopt nearly all five tick-bite PPBs for their children. Additionally, parents who were more worried about their health due to ticks and reported being more likely to avoid the outdoors because of ticks were more likely to adopt at least three PPBs on behalf of their children. To ensure children can most safely engage in outdoor activity, identifying the factors associated with parental adoption of tick-bite preventive behaviors represents an important mechanism in the prevention of tick-borne diseases.

Experiences with tick exposure, Lyme disease, and use of personal prevention methods for tick bites among members of the U.S. population, 2013-2015

Consistent and effective use of personal prevention methods for tickborne diseases, including Lyme disease (LD), is dependent on risk awareness. To improve our understanding of the general U.S. population's experiences with tick exposure and use of personal prevention methods, we used data from ConsumerStyles, a web-based, nationally representative questionnaire on health-related topics. Questions addressed tick bites and LD diagnosis in the last year, use of personal prevention methods to prevent tick bites, and willingness to receive a theoretical LD vaccine. Of 10,551 participants surveyed over three years, 12.3 % reported a tick bite for themselves or a household member in the last year, including 15.4 % of participants in high LD incidence (LDI) states, 16.3 % in states neighboring high LDI states, and 9.4 % in low LDI states. Participants in high LDI states and neighboring states were most likely to use personal prevention methods, though 46.6 % of participants in high LDI states and 53.9 % in neighboring states reported not using any method. Participants in low LDI states, adults ≥ 75 years of age, those with higher incomes, and those living in urban housing tended to be less likely to practice personal prevention methods. Likeliness to receive a theoretical LD vaccine was high in high LDI (64.5 %), neighboring (52.5 %), and low LDI (49.7 %) states. Targeted educational efforts are needed to ensure those in high LDI and neighboring states, particularly older adults, are aware of their risk of LD and recommended personal prevention methods.

Development and validation of a behavioral index for adaptation to lyme disease

Background

Recent evidence suggests that climate change and other factors are leading to the emergence of Lyme disease in the province of Quebec, where it previously did not exist. As risk areas expand further north, the population can adopt specific preventive behaviors to limit chances of infection. The objectives of this study were to (1) create an index of Lyme disease prevention behaviors (LDPB), and (2) use the theory of planned behavior (TPB) to explain the decision-making process of people who choose to adopt LDPB.

Methods

A sample of 1959 adults living in a Lyme disease risk area completed a questionnaire by phone (n = 1003) or on the Web (n = 956). The questionnaire measured whether they did or did not adopt the LDPB proposed by public health officials. It also measured some TPB variables, including their attitude or perceived social norms regarding LDPB.

Results

Our findings led to the creation of a Lyme disease prevention index consisting of 10 behaviors, down from the 19 behaviors initially considered for inclusion in the index. Rates of adoption of each behavior varied tremendously, from 4.30 to 83.80%. All variables of the TPB model (attitude, social norms, and perceived control) were significantly associated with intention to adopt preventive behaviors. Intention itself was significantly associated with adoption of LDPB. Likewise, risk perception was positively correlated with the adoption of LDPB.

Conclusions

This study led to the creation of a Lyme disease prevention index that can be used by public health agencies, researchers, and professionals to monitor the evolution over time of individuals’ LDPB adoption rates. It also showed the usefulness of the TPB in understanding the adoption of LDPB and how intention to adopt such behaviors is formed.

Context matters: Contrasting behavioral and residential risk factors for Lyme disease between high-incidence states in the Northeastern and Midwestern United States

The dynamics of zoonotic vector-borne diseases are determined by a complex set of parameters including human behavior that may vary with socio-ecological contexts. Lyme disease is the most common vector-borne disease in the United States. The Northeast and upper Midwest are the regions most affected - two areas with differing levels of urbanization and differing sociocultural settings. The probability of being infected with Lyme disease is related to the risk of encounters with Ixodes scapularis ticks infected with Borrelia burgdorferi sensu lato, which reflects both the environmental tick hazard and human behaviors. Herein, we compare behavioral and peridomestic risk factors perceived to influence the risk for human-tick encounters between two high-incidence states in the Northeast (New York and New Jersey) and one high-incidence state in the Midwest (Wisconsin). We used a smartphone application, The Tick App, as a novel survey tool, during spring and summer of 2018. Adaptive human behavior was identified in the relationship between outdoor activities and the use of methods to prevent tick bites. More frequent recreational outdoor activities and gardening (a peridomestic activity) were associated with a 1.4-2.3 times increased likelihood of using personal protective measures to prevent tick bites, when accounting for demographics and previous Lyme diagnosis. Most outdoor activities were more frequently reported by participants from the Midwest (n = 697), representing an older demographic, than the Northeast (n = 396). Participants from the Northeast were less likely to report use of personal protective measures to prevent tick bites, but a larger proportion of participants from the Northeast reported application of environmental pesticides targeting ticks or mosquitoes or other insects on their property (34 % of 279 versus 22 % of 616 participants) and interventions to reduce the presence of peridomestic deer compared to participants from the Midwest (e.g. 20 % of 278 versus 7% of 615 participants reported having a deer proof fence). Participants from the Midwest were more likely to kill rodents on their property (28 % versus 13 %). These differences illustrate the need for further assessment of personal behavior and tick exposure in these two Lyme disease-endemic regions to aid in targeted public health messaging to reduce tick-borne diseases.

Artificial Accumulation of Leaf Litter in Forest Edges on Residential Properties via Leaf Blowing Is Associated with Increased Numbers of Host-Seeking Ixodes scapularis (Acari: Ixodidae) Nymphs

We examined whether routine fall yard maintenance, specifically depositing leaves removed from lawns and landscaping along forest margins, may increase densities of nymphal Ixodes scapularis Say and Amblyomma americanum (L.) ticks within these managed areas. Leaf blowing activities in fall 2017 and 2018 on residential properties in New Jersey, United States, significantly increased leaf litter depth in managed edge areas (range = 259.8-352.8 mm) compared to unmanaged edges (77.6-188.0 mm) and adjacent forest (39.4-166.2 mm). Drag sampling conducted on 20 and 30 dates in spring 2018 and 2019, respectively, yielded ≥3-fold more I. scapularis nymphs in managed edge plots compared to natural edge and forest plots in both years. In 2018, we collected more A. americanum nymphs from forest plots than from either natural or managed edge plots, but 2019 natural edge plots yielded the greatest number of the ticks. Nearly half of A. americanum adults were collected in forest plots in both years. Our data suggest that the acarological risk of human encounters with I. scapularis nymphs may be significantly greater in areas receiving an accumulation of leaves from leaf blowing or raking compared to adjacent unmanaged forest edges. This artificially elevated acarological risk can be mitigated if homeowners avail themselves of curbside leaf pickup or composting services offered by many municipalities or request that lawn/landscaping contractors remove collected leaves offsite, or at least to areas of less frequent use, rather than concentrating them along the lawn-forest edge.

Availability and Nature of Commercial Tick Control Services in Three Lyme Disease Endemic States

In an update of earlier surveys conducted in Connecticut and New Jersey in the mid-1990s, an online survey of private commercial pest control firms engaged in residential tick control showed that the application of synthetic acaricides continues to be the primary method of control used. The carbamate and organophospate acaricides, previously the most commonly used against ticks, have given way to synthetic pyrethroids and, to a lesser extent, the use of natural product/organic acaricides. Typical costs for a single acaricide application today ($100-$200 for a 1 acre [0.4 ha] property) remain similar to those reported from the earlier surveys, although the frequency of applications and, therefore, also the overall annual cost has increased. The application habitats within residential properties, life stages targeted, and application equipment used have not changed appreciably since the mid-1990s. While most survey respondents expressed knowledge of natural product acaricides and Damminix Tick Tubes, many reported that they either did not employ or knew very little about other alternative tick control methods (including entomopathogenic fungus and topical application of acaricides to tick hosts via 4-Poster deer treatment stations or Select TCS rodent bait boxes). This suggests either a failure to adequately inform the pest management industry and their potential client base of the availability of alternate methods, and/or industry concerns about cost and effectiveness of the alternatives.

Woodchip borders at the forest ecotone as an environmental control measure to reduce questing tick density along recreational trails in Ottawa, Canada

Recent studies have highlighted the occurrence and distribution of Ixodes scapularis ticks infected with Borrelia burgdorferi sensu stricto (s.s.) around the city of Ottawa, Ontario, Canada, and the need for strategies to mitigate the risk of human exposure and infection. We conducted a field study from July to October 2018 to examine the effectiveness of ecotonal woodchip borders as an environmental control method to suppress the density of host-seeking ticks along recreational trails in Ottawa. We used an experimental design with ten 100-m trail replicates randomized to intervention or control groups, and monitored questing tick density at weekly intervals in mid-summer and early fall. We compared questing tick density between woodchip-treated and untreated trails using a mixed-effects Poisson regression model. Of the 138 I. scapularis ticks collected, there were 86 adult and nymphal ticks, 37 (43 %) of which were positive for B. burgdorferi s.s. A total of 58 Haemaphysalis leporispalustris were also collected. Mean combined adult and nymphal I. scapularis density was 1.15 (1.40 standard deviation; SD) per 100 m in the control group compared to 0.28 (0.56 SD) per 100 m in the intervention group, reflecting a 75 % reduction in questing tick density on trail replicates treated with woodchip borders (p < 0.001). An effect of the intervention was observed in both sampling periods. This study indicates that woodchip borders may be an effective strategy to suppress questing tick density along trail margins where recreational trail users are more active, thereby reducing the likelihood of tick encounters.

Systematic review and meta-analysis of tick-borne disease risk factors in residential yards, neighborhoods, and beyond

BACKGROUND

Exposure to blacklegged ticks Ixodes scapularis that transmit pathogens is thought to occur peri-domestically. However, the locations where people most frequently encounter infected ticks are not well characterized, leading to mixed messages from public health officials about where risk is highest.

METHODS

We conducted a systematic review and meta-analysis on spatial risk factors for tick-borne disease and tick bites in eastern North America. We examined three scales: the residential yard, the neighborhood surrounding (but not including) the yard, and outside the neighborhood. Nineteen eligible studies represented 2741 cases of tick-borne illness and 1447 tick bites. Using random effects models, we derived pooled odds ratio (OR) estimates.

RESULTS

The meta-analysis revealed significant disease risk factors at the scale of the yard (OR 2.60 95% CI 1.96 - 3.46), the neighborhood (OR 4.08 95% CI 2.49 - 6.68), and outside the neighborhood (OR 2.03 95% CI 1.59 - 2.59). Although significant risk exists at each scale, neighborhood scale risk factors best explained disease exposure. Analysis of variance revealed risk at the neighborhood scale was 57% greater than risk at the yard scale and 101% greater than risk outside the neighborhood.

CONCLUSIONS

This analysis emphasizes the importance of understanding and reducing tick-borne disease risk at the neighborhood scale. Risk-reducing interventions applied at each scale could be effective, but interventions applied at the neighborhood scale are most likely to protect human health.

TRIAL REGISTRATION

The study was registered with PROSPERO: CRD42017079169 .

Knowledge, attitudes, and behaviors regarding tick-borne disease prevention in endemic areas

As part of a TickNET collaboration we evaluated the knowledge, attitudes, and behaviors related to tick-borne disease (TBD) prevention among persons living in endemic areas of Connecticut (CT) and Maryland (MD). Up-to-date information on the use of various prevention methods, as well as attitudes toward available and potential prevention options, is critical for effective promotion of recommended behaviors. During 2016-2017, printed invitations were mailed via the post office to 27,029 households requesting participation in an online survey regarding knowledge of TBD, risk perceptions, and prevention behaviors. Prevention behaviors included tick checks, showering/bathing, insect repellents, pet tick control, and chemical or natural pesticide use on residential properties. Associations of sociodemographic characteristics and knowledge and attitude variables with prevention behaviors were assessed in unadjusted analyses and multivariable models to calculate adjusted odds ratios (aOR). Participants were also asked if they would be willing to get a Lyme disease (LD) vaccine, if one becomes available. Overall, 1883 (7%) persons completed the survey. Participants reported using preventive behaviors most of the time or always as follows: pet tick control (83%), tick checks (58%), showering/bathing (42%), insect repellent (31%), and chemical (23%) or natural (15%) pesticides on property. Self-rated knowledge of LD, perceived prevalence of LD, perceived severity of LD, and perceived likelihood of contracting LD or another TBD were significantly (p < 0.05) associated with performing a tick check [aOR 2.5, aOR 1.71, aOR 1.36, aOR 1.83, respectively]. Female gender and perceived prevalence of LD were significantly associated with applying insect repellent [aOR 1.56, aOR 1.64, respectively]. Perceived prevalence of LD was significantly associated with showering or bathing, insect repellents, and pet tick control [aOR 1.42, aOR 1.64, aOR 1.92, respectively]. Income > $100,000 was significantly associated with applying a chemical or natural pesticide to one's property [aOR 1.29, aOR 1.40, respectively]. A majority of respondents (84%) reported that they were very likely or somewhat likely to get a LD vaccine if one were available. Few behaviors (tick checks and pet tick control) were reported to be practiced by more than half of the respondents living in LD endemic areas. Perceived prevalence of LD was the only factor associated with performing most of the prevention behaviors (tick checks, showering/bathing, use of insect repellents, and pet tick control). Use of chemical or natural pesticides appears to be driven by income. Greater efforts are needed to encourage use of prevention behaviors in endemic areas, and this may be facilitated by increasing awareness of local prevalence.

Factors Leading Municipal Authorities to Implement Preventive Interventions for Lyme Disease

The aim of this study is to document climate change adaptation interventions targeting Lyme disease at the municipal level in the province of Quebec (Canada). This exploratory study relies on the theory of planned behavior and certain constructs from the health belief model to identify the factors leading municipal authorities to implement preventive interventions for Lyme disease (PILD). Data were obtained from an online survey sent, during the summer of 2018, to municipal officers in 820 municipalities in Quebec, in all health regions where the population is at risk of contracting Lyme disease (response rate = 36%). The questionnaire was used to measure the implementation of PILD, the intention to implement these interventions, attitudes, perceived social pressure, perceived control (levers and barriers) over interventions, perceived effectiveness of preventive measures, risk, and perceived vulnerability. Results of structural equation analyses showed that attitudes were significantly associated with municipal authorities' intention to implement PILD, while the intention to implement PILD was a significant predictor of the implementation of PILD. Additional analyses showed that perceived barriers added a moderating effect in the intention-implementation relationship. The prediction of behaviors or practices that municipal authorities could implement to prevent Lyme disease will enable the evaluation over time of the evolution of Quebec municipalities' adaptation to Lyme disease. Moreover, the examination of the associations of specific psychosocial factors revealed important implications for the design of effective behavior-change interventions, which would allow health officials doing awareness work to create personalized interventions better suited to municipal officers and their specific contexts.

Implementation of preventive measures against tick-borne infections in a non-endemic area for tick-borne encephalitis-Results from a population-based survey in Lower Saxony, Germany

Lyme borreliosis (LB) and tick-borne encephalitis (TBE) are the most common tick-borne diseases in Germany. While for LB only non-specific prevention strategies exist, TBE can be additionally prevented by vaccination. It is unclear to which extent non-specific prevention strategies are applied by individuals living in non-endemic areas for TBE in Germany, and whether TBE vaccination status affects their implementation. Participants of the HaBIDS panel (Hygiene and Behavior Infectious Diseases Study) from four counties of Lower Saxony were invited to fill out a questionnaire on their TBE vaccination status, their LB diagnoses as well as their knowledge, attitudes, and practice related to prevention measures for tick-borne diseases. Based on self-reported data we estimated cumulative lifetime incidence (CUM) and incidence of LB as well as TBE vaccination coverage. One year later, participants received a supplementary questionnaire focusing on reasons for vaccination against TBE and compliance with the vaccination schedule. 1,573 (74.2% of those invited) panel members aged 18-69 years participated in this study. Of these, 22.8% reported to have ever been vaccinated against TBE. The estimated CUM of LB was 5.1% (95%-CI: 4.1%-6.4%), and the incidence was 1.09 per 1,000 person years (95%-CI: 0.87-1.36). 98% of participants knew that LB is transmitted by the bite of an infected tick, but about 50% didn't know that TBE vaccination does not protect against LB. Even though about 80% of study participants were convinced that recommended non-specific prevention strategies were indeed protective, a much lower proportion implemented them. TBE-vaccinated participants were better informed about tick-borne diseases compared to non-vaccinated participants, whereby being vaccinated did not negatively affect implementation of non-specific prevention strategies. Based on data from the supplementary questionnaire, traveling to endemic areas (75.3%) was the main reason for TBE vaccination; 33.0% of those vaccinated had a complete vaccination schedule with three doses. Our study in a TBE non-endemic area revealed deficits in knowledge about which pathogens are covered by TBE vaccination, and a lack in the implementation of non-specific prevention measures. TBE vaccination was not associated with a reduced uptake of non-specific prevention measures.

A scoping review of Lyme disease research relevant to public health

Lyme disease (LD) is an emerging infectious disease in Canada associated with expansion of the geographic range of the tick vector Ixodes scapularis in eastern and central Canada. A scoping review of published research was prioritized to identify and characterize the scientific evidence concerning key aspects of LD to support public health efforts. Prior to initiation of this review, an expert advisory group was surveyed to solicit insight on priority topics and scope. A pre-tested search strategy implemented in eight databases (updated September 2016) captured relevant research. Pre-tested screening and data characterization forms were completed by two independent reviewers and descriptive analysis was conducted to identify topic areas with solid evidence and knowledge gaps. Of 19,353 records screened, 2,258 relevant articles were included in the review under the following six public health focus areas: a) surveillance/monitoring in North America (n=809); b) evaluation of diagnostic tests (n=736); c) risk factors (n=545); d) public health interventions (n=205); e) public knowledge, attitudes and/or perceptions in North America (n=202); and f) the economic burden of LD or cost-benefit of interventions (n=32). The majority of research investigated Borrelia burgdorferi (n=1,664), humans (n=1,154) and Ixodes scapularis (n=459). Sufficient research was identified for potential systematic reviews in four topic areas: a) accuracy of diagnostic tests; b) risk factors for human illness; c) efficacy of LD intervention strategies; and d) prevalence and/or incidence of LD in humans or B. burgdorferi sensu stricto in vertebrate reservoirs or ticks in North America. Future primary research could focus on closing knowledge gaps, such as the role of less studied vertebrate reservoirs in the transmission cycle. Results of this scoping review can be used to quickly identify and summarize relevant research pertaining to specific questions about LD or B. burgdorferi sensu lato in humans, vertebrate hosts or vectors, providing evidence-informed information within timelines that are conducive for public health decision-making.

Learning to live with ticks? The role of exposure and risk perceptions in protective behaviour against tick-borne diseases

The purpose of this study is to analyse the role of risk perceptions and exposure for protective behaviour against tick bites and the related diseases Lyme borreliosis (LB) and tick-borne encephalitis (TBE), both of which are growing health concerns. We use data from a national survey in Sweden with respondents in geographical areas with substantial differences in both abundance of ticks and incidence of LB and TBE. We find that the share of respondents who frequently use protective clothing (64%), perform tick checks (63%) or avoid tall grass while in areas with ticks (48%) is relatively high. However, the use of protective measures is uneven and a considerably lower share tuck their trousers into their socks (18%), use repellent against ticks (16%) or use a combination of protective measures. Thirty-one per cent of the respondents report one or more tick bites in the last year and 68% report one or more lifetime tick bites, indicating that it is difficult to protect oneself from tick bites. There is a strong positive association between exposure and checking the skin for ticks, but exposure is only weakly associated with other protective measures. Tick bites are perceived as a serious health risk by as many as 43% of the respondents. The perception that a single tick bite is serious is negatively associated with actual exposure to ticks, while the opposite is true for the perception that tick bites constitute a serious lifetime health risk. This indicates a learning effect in relation to risk perceptions and the performance of tick checks, but not in relation to other protective measures. Recommendations include informing people of the risks associated with tick bites, the efficacy of various protective measures and the importance of combining multiple types of protection. Given the high exposure to tick bites, the growing incidence of TBE and LB, and the difficulties in preventing tick bites, other preventive measures should be further discussed, including vaccination programmes.

Integrated control of juvenile Ixodes scapularis parasitizing Peromyscus leucopus in residential settings in Connecticut, United States

Lyme disease continues to be the most common vector-borne disease in the United States with an estimated 330,000 human cases annually. In the eastern United States, the blacklegged tick, Ixodes scapularis, is the primary vector of the Lyme disease spirochete, Borrelia burgdorferi, and the white-footed mouse, Peromyscus leucopus, is a primary reservoir host. In four residential neighborhoods in Connecticut over three years, we tested the effectiveness of different low-toxicity integrated tick management approaches to control larval and nymphal I. scapularis parasitizing P. leucopus. Combinations of white-tailed deer, Odocoileus virginianus, reduction, broadcast application of the entomopathogenic fungus Metarhizium anisopliae, and distribution of fipronil-based rodent-targeted bait boxes were evaluated against an experimental control. Deer reduction with no other intervention likely forced juvenile I. scapularis to obtain blood meals from available reservoir hosts, resulting in increased exposure of P. leucopus to B. burgdorferi compared to control sites. The M. anisopliae/bait box and the deer reduction/M. anisopliae/bait box treatment combinations resulted in 94% and 85% reductions in larvae parasitizing P. leucopus that tested positive for B. burgdorferi, respectively, compared to control. Deer reduction alone resulted in only a 3% reduction, likely because parasitizing juvenile I. scapularis were not targeted by bait box-delivered fipronil. Unless there is community support to reduce and maintain deer at very low densities (<5 deer/km²), it is clear that a combination of M. anisopliae/fipronil-based bait boxes offers an effective, localized, low-toxicity option for reducing I. scapularis parasitizing P. leucopus without complications from host switching.