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Report of the Other Tick-Borne Diseases and Co-Infections Subcommittee to the Tick-Borne Disease Working Group








  
  
    

  
      





Background: Why other tick-borne diseases and co-infections are importantMethodsPriority #1: Improving the detection and diagnosis of other tick-borne diseases and co-infectionsPriority #2: Treatment of Other Tick-Borne Diseases and CoinfectionsPriority #3: Alpha-gal Meat AllergyReferencesAppendix 1: Subcommittee Agendas and Top-Line SummariesAppendix 2: Complete List of Issues that Could Be Addressed in the First Report to CongressAppendix 3: Gabby’s Story: The Importance of Proper Diagnosis and Treatment

*Information and opinions in this report do not necessarily reflect the opinions of the working group, the U.S. Department of Health and Human Services, or any other component of the federal government.*

*Readers should not consider the report or any part of it to be guidance or instruction regarding the diagnosis, care, or treatment of tick-borne diseases or to supersede in any way existing guidance.*

*All subcommittee members actively participat**ed**in the development of this report. Members voted to approve submission of the report to the Working Group and on the wording of each of the possible actions contained in the report. The vote to submit the report indicates general agreement with the content of the docum**ent**, but it does not necessarily indicate complete agreement with each and every statement in the full report.*

Background: Why other tick-borne diseases and co-infections are important

Co-infection of ticks with human and animal pathogens is more widespread than is commonly recognized by both medical professionals and the public. Ticks contain multiple tick-borne pathogens, which can be transmitted with a single tick bite. Some tick-borne pathogens can be transmitted within a short period of time after a tick bite (i.e., *Borrelia hermsii*and Powassan virus), although other tick-borne pathogens such as *Anaplasma, Ehrlichia, Babesia,* *Rickettsia* and other borrelia species take longer. Transmission for some tick-borne diseases is also possible by blood transfusion (*Babesia, Anaplasma, Bartonella,* tick-borne relapsing fever), solid organ transplantation (*Babesia*), and through maternal-fetal transmission (*Babesia, Bartonella,* relapsing fever borreliae, certain arthropod borne flaviviruses). Increased awareness with appropriate testing and treatment is therefore important to help decrease morbidity and mortality from other tick-borne diseases and co-infections.

Current microbiologic science suggests that some tick-borne pathogens and co-infections can infect humans both acutely and chronically. These pathogens can persist in an indolent manner and reactivate periodically causing relapsing and remitting illness. Clinical observation of health care providers who see tick-borne disease patients observe that in persistently symptomatic patients more than one tick-borne disease is often present. It should be kept in mind that these co-infections may have been acquired sequentially, not necessarily with one single tick bite. Peer reviewed literature suggest coinfection of a patient with *Babesia* and *Borrelia* or with *Ehrlichia*, *Anaplasma,* and *Borrelia* result in increased symptoms and a longer duration of illness. The burden of borreliosis alone is documented, and society suffers in terms of lost productivity and patients requiring more care and support. Given that preliminary peer-reviewed data and clinical expert opinion notes increased morbidity when a patient has more than one tick-borne infection, the burden of coinfection is likely higher than that of borreliosis alone. Identifying the incidence of coinfection among chronically ill patients, while establishing effective diagnostic and treatment regimens, will help decrease the burden of illness and associated suffering.

Methods

**Table 1: Members of the Other Tick-borne Diseases and Co-infections**

Subcommittee Members
			Type
			Stakeholder Group
			Expertise(Co-Chair)**Richard Horowitz, MD,**Hyde Park, NY
			Public
			Health Care Provider
			Internist with 30 years’ experience diagnosing and treating patients with individual tick-borne diseases and co-infections(Co-Chair)**Allen L. Richards, PhD, MS,**Naval Medical Research Center, Silver Spring, MD
			Federal DoD
			Scientist
			Rickettsiology with emphasis in diagnostic assay and vaccine development, immunopathogenesis, treatment, and surveillance**Megan DuLaney, MS,**DoD Center for Global Health Engagement, Alexandria, VA
			Public
			Patient
			Patient perspective**Marna E. Ericson, PhD,** Dermatology Imaging Center, University of Minnesota Academic Health Center, Minneapolis, MS
			Public
			Scientist and Family Member
			Uses cutting-edge microscopy in the detection, diagnosis, biofilms, and pathophysiology of *Bartonella* diseases**Christine Green, MD,**Green Oaks Medical Center, Mountain View, CA
			Public
			Health Care Provider
			Diagnosis, treatment, and education of Lyme Disease**Charles Lubelczyk, MPH,**Maine Medical Center Research Institute, Scarborough, ME
			Public
			Public Health
			Vector ecologist and entomologist with special interests in tick-associated *Borrelia miyamotoi*, Powassan virus, and *Babesia* species**Ulrike Munderloh, DVM,** **PhD,** Department of Entomoloy, University of Minnesota, St. Paul, MN
			Public
			Scientist
			Specializes in *Anaplasma,* *Ehrlichia,* and *Rickettsia***Garth L. Nicolson, PhD, MD** **(H)**, Institute of Molecular Medicine, South Laguna Beach, CA
			Public
			Scientist
			Biochemist. Studies molecular pathology of *Mycoplasma, Chlamydia*andviral infections, and their role in chronic neurodegenerative and neurobehavioral diseases**Christopher Paddock, MD,** MPHTM, Rickettsial Zoonoses Branch, CDC, Atlanta, GA
			Federal CDC
			Pathologist
			Entomologist and Pathologist with an interest in rickettsiology, tick-borne diseases, pathology, and surveillance**Samuel S. Perdue, PhD,** Bacteriology and Mycology Branch, DMID/NIAID/NIH, Bethesda, MD
			Federal NIH
			Scientist
			Arthropod diseases with interested in Lyme disease, rickettsial diseases (including those caused by: *Anaplasma, Bartonella, Coxiella, Ehrichia, Neorickettsia*, *Orientia* and*Rickettsia*species)**Sam R. Telford III, ScD, MS,** Cummins School of Veterinarian Medicine, Tufts University
			Public
			Scientist
			Vector Ecologist/Epidemiologist with emphasis on tick-borne diseases: Babesiosis, Lyme disease and Tularemia**Table 2: Overview of Other Tick-borne Diseases and Co-infections Meetings, 2018**

Meeting No.
			Date
			Present
			Topics Addressed1
			February 23, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Charles Lubelczyk, Ulrike Munderloh, Garth Nicolson, Samuel Perdue, Sam Telford

			John Aucott (WG Chair), Debbie Seem, Cat Thomson (Writer) Richard Wolitski (DFO)
			Introduction of members to each other; clarification of the purpose and process of the subcommittee; discussion of topics to focus on in the group’s report to the working group2
			March 2, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Charles Lubelczyk, Ulrike Munderloh, Garth Nicolson, Christopher Paddock, Sam Telford

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			Discussion of the format of future meetings, creating the report to the working group, obtaining references, and inviting presenters; continued development of the list of the subcommittee’s priorities.3
			March 9, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Ulrike Munderloh, Garth Nicolson, Samuel Perdue, Allen Richards (Co-Chair), Sam Telford

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			Discussion on background and list of issues for the report to the TBDWG. The subcommittee considered the background information needed and developing a list of issues and subsequently a prioritized list for the subcommittee to address in reference to Other Tick-borne Diseases and Co-infections. The subcommittee also discussed the development of a list of presenters for the next 8 weekly meetings.4
			March 16, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Charles Lubelczyk, Ulrike Munderloh, Garth Nicolson, Christopher Paddock, Samuel Perdue, Allen Richards (Co-Chair), Sam Telford

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			Three presenters provided PowerPoint presentations and answered questions by the subcommittee members. The presenters and their topics included in order of presentation: Sam Telford III, ScD, *Babesia:*Gaps in knowledge and the role of*Babesia*in the overall burden of deer tick infections*;* Edward B. Breitschwerdt, DVM: Ticks, Bartonella species, and bartonellosis*;* and Marna Ericson, PhD: Detection of immunoreactive *Bartonella*species in mammalian tissues using advanced imaging techniques5
			March 23, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Charles Lubelczyk, Ulrike Munderloh, Garth Nicolson, Samuel Perdue, Allen Richards (Co-Chair), Sam Telford

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			Steven Schutzer, MD and Erin McGintee, MD presented on the topic of mast cell activation and alpha-gal allergy and answered questions from the subcommittee members. Subcommittee members also discussed and voted on their Issues and Priorities document and divided into subgroups to begin writing.6
			March 30, 2018
			Megan DuLaney, Christine Green, Richard Horowitz (Co-Chair), Ulrike Munderloh, Garth Nicolson, Sam Telford

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			Konstance Knox, PhD presented on the role of Powassan virus as an emerging tick-borne infection and answered questions from the subcommittee members. Members also reviewed and discussed their workplan and report to the Tick-Borne Disease Working Group.7
			April 6, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Charles Lubelczyk, Ulrike Munderloh, Garth Nicolson, Samuel Perdue, Sam Telford

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			Sin Hang Lee, MD, FRCP(C), FACP presented on diagnosing tick-borne borrelial spirochetemia by partial 16S rRNA gene sequencing and answered questions from the subcommittee members. Members also reviewed and discussed their report to the Tick-Borne Disease Working Group.8
			April 13, 2018
			Megan DuLaney, Christine Green, Charles Lubelczyk, Ulrike Munderloh, Christopher Paddock, Samuel Perdue, Allen Richards (Co-Chair), Sam Telford

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			Three presenters provided PowerPoint presentations and answered questions by the subcommittee members. The presenters and their topics included in order of presentation: Jyotsna Shah, PhD: Diagnosis of tick-borne diseases other than Lyme disease; Linda K. Bockenstedt, MD: Update on *Borrelia miyamotoi*, the agent of hard-tick relapsing fever; Michael Kosoy, PhD: Bartonella: Bacteria, hosts, vectors9
			April 20, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Charles Lubelczyk, Ulrike Munderloh, Garth Nicolson, Christopher Paddock, Samuel Perdue, Allen Richards (Co-Chair)

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			Three presenters provided PowerPoint presentations and answered questions by the subcommittee members. The presenters and their topics included in order of presentation: Garth Ehrlich, PhD: Lyme disease complicating factors: Biofilms, polymicrobial infections, and genetic heterogeneity in relation to diagnosis; Richard Horowitz, MD: Diagnosis and treatment of Lyme and other tick-borne diseases and coinfections; Chris Green, MD: Clinician’s perspective on coinfection10
			April 27, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Charles Lubelczyk, Ulrike Munderloh, Christopher Paddock, Samuel Perdue, Allen Richards (Co-Chair)

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			The subcommittee spent the duration of their meeting discussing and voting on the Diagnosis section of their report to the Tick-Borne Disease Working Group.11
			May 3, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Charles Lubelczyk, Ulrike Munderloh, Christopher Paddock, Samuel Perdue, Allen Richards (Co-Chair), Sam Telford

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			The subcommittee spent the duration of their meeting discussing and voting on the Treatment and Alpha-gal allergy sections of their report to the Tick-Borne Disease Working Group.12
			May 4, 2018
			Megan DuLaney, Marna Ericson, Christine Green, Richard Horowitz (Co-Chair), Charles Lubelczyk, Ulrike Munderloh, Samuel Perdue, Sam Telford

			John Aucott (WG Chair), Cat Thomson (Writer) Richard Wolitski (DFO)
			The subcommittee finished voting on the Treatment section and reviewed their final report to the Tick-Borne Disease Working Group. They also reviewed and discussed the Powerpoint presentation that would be used to present their findings to the Tick-Borne Disease Working Group at the May10, 2018 meeting.**Table 3: Presenters to the Other Tick-borne Diseases and Co-infections**

Meeting No.
			Presenter
			Topics Discussed#4
			Sam Telford III ScD; Edward B Breitschwerdt DVM; Marna Ericson, PhD, UMN
			*Babesia:*Gaps in knowledge and the role of*Babesia*in the overall burden of deer tick infections*;* Ticks, Bartonella species, and bartonellosis*;* Detection of immunoreactive *Bartonella*species in mammalian tissues using advanced imaging techniques#5
			Steven Schutzer, MD and Erin McGintee, MD
			Mast cell activation and alpha gal#6
			Konstance Knox, PhD
			The role of Powassan virus as an emerging tick-borne infection#7
			Sin Hang Lee, MD, FRCP(C), FACP
			Diagnosing tick-borne borrelial spirochetemia by partial 16S rRNA gene sequencing#8
			Jyotsna Shah, PhD: Linda K. Bockenstedt, MD; Michael Kosoy, PhD
			Diagnosis of tick-borne diseases other than Lyme disease; Update on *Borrelia miyamotoi*, the agent of hard-tick relapsing fever; Bartonella: Bacteria, hosts, vectors#9
			Garth Ehrlich, PhD; Richard Horowitz, MD; Chris Green, MD
			Lyme disease complicating factors: Biofilms, polymicrobial infections, and genetic heterogeneity in relation to diagnosis; Diagnosis and treatment of Lyme and other tick-borne diseases and coinfections; Clinician’s perspective on coinfection**Table 4: Votes Taken by the Other Tick-borne Diseases and Co-infections subcommittee**

Meeting No.
			Motion
			Results
			Minority Response2
			The motion to accept the current draft of the list of issues the subcommittee was going to address.
			Outcome: Passed—all present in favor; none opposed; none abstained; two members were not present (9/0/0/2)
			No3
			To approve issues and priorities section of the report for submission to the Working Group
			Passed: all in favor; none opposed; none abstained; none absent

			11/0/0/0
			No10
			Results>Diagnosis> Improved education about taking proper history, reviewing symptomatology, performing a physical examination, the importance of detection assays, the types of assays available, and how to use laboratory assay results> **Vote on Potential Action One:**Conduct studies to answer important questions about the natural history of other tick-borne diseases and coinfections as well as the human immune response to the infections.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No10
			Results>Diagnosis> Issue 1. Improved education about the importance of detection assays, the types of assays available, and how to use them> **Vote on Potential Action Two:**Educate health care providers, clinical testing laboratories, patients, and the general public to be conducted by medical agencies (e.g. HHS), private organizations, knowledgeable clinicians and scientists.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No10
			Results>Diagnosis> Issue 1. Improved education about the importance of detection assays, the types of assays available, and how to use them>**Vote on** **Potential Action Three**: Create a tick-borne diseases and coinfections multi-site working group to have a collaborative, standardized approach to data collection and conduct longitudinal cohort natural history studies of sequelae or complications of treated infections.
			Outcome: Passed—all present in favor; none opposed; one abstained; one member was not present (10/0/1/1)
			No10
			Results>Diagnosis>Issue 2.Improve diagnostic methods for clinical diagnosis>**Vote on** **Potential Action One:** Develop flow charts/algorithms for clinical diagnosis of other tick-borne disease and coinfections.
			Outcome: Passed; two opposed; none abstained; one member was not present (8/2/0/1)
			Two members did not vote in favor of this action. They did not believe that recommending flow charts for diagnosis fell within the subcommittee’s charge to identify gaps.10
			Results>Diagnosis>Issue 3. Improved laboratory testing for other tick-borne diseases and coinfections to provide laboratory confirmation of clinical diagnosis and to detect agents in tick vectors during surveillance of other tick-borne diseases and coinfections.>**Vote on** **Potential Action One:**Develop flow charts or algorithms for clinical diagnosis and laboratory testing. These would include algorithms for acute and chronic illness.
			Outcome: Passed; two opposed; none abstained; one member was not present (8/2/0/1)
			Two members did not vote in favor of this action. They did not believe that recommending flow charts for diagnosis fell within the subcommittee’s charge to identify gaps.10
			Results>Diagnosis>Issue 3. Improved laboratory testing for other tick-borne diseases and coinfections to provide laboratory confirmation of clinical diagnosis and to detect agents in tick vectors during surveillance of other tick-borne diseases and coinfections.>**Vote on** **Potential Action Two:** Promote independent validation of laboratory developed tests utilizing panels of control samples that are assessed blindly.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No10
			Results>Diagnosis>Issue 3. Improved laboratory testing for other tick-borne diseases and coinfections to provide laboratory confirmation of clinical diagnosis and to detect agents in tick vectors during surveillance of other tick-borne diseases and coinfections.>**Vote on** **Potential Action Three:** Establish realistic goals for new tests; in other words, there is no such thing as 100% sensitive and specific assays.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No10
			Results>Diagnosis>Issue 3. Improved laboratory testing for other tick-borne diseases and coinfections to provide laboratory confirmation of clinical diagnosis and to detect agents in tick vectors during surveillance of other tick-borne diseases and coinfections.>**Vote on** **Potential Action Four:** Examine ways to optimize sampling (skin for *B. burgdorferi, Rickettsia* spp., *Bartonella*spp.)
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No10
			Results>Diagnosis>Issue 3. Improved laboratory testing for other tick-borne diseases and coinfections to provide laboratory confirmation of clinical diagnosis and to detect agents in tick vectors during surveillance of other tick-borne diseases and coinfections.> **Vote on** **Potential Action Five:** Develop new and better tests for other tick-borne diseases and coinfections in both acute and chronic presentations based on the needs identified from systematic review.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No10
			Results>Diagnosis>Issue 3. Improved laboratory testing for other tick-borne diseases and coinfections to provide laboratory confirmation of clinical diagnosis and to detect agents in tick vectors during surveillance of other tick-borne diseases and coinfections.> **Vote on** **Potential Action Six:** Expand the number of externally validated assays to provide complete coverage of other tick-borne diseases and coinfections.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No10
			Results>Diagnosis> Issue 4. Improve Surveillance for other tick-borne diseases and co-infections.

			Questions: How to improve other tick-borne diseases and coinfections surveillance so that risk of disease is better understood leading to better mitigation strategies.> Vote on **Potential Action One:** Increase resources available for surveillance including collaborative projects centering on surveillance or recognition of tick-borne diseases at the state level.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No11
			Results>Alpha-gal allergy>**Vote on** **Possible Action One:** Increase education and awareness pre-diagnosis, and counseling after diagnosis.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No11
			Results>Alpha-gal allergy>**Vote on** **Possible Action Two:**Increase research and educational efforts regarding food or food-based products that contain meat allergens that pose a risk to the public following a tick bite.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No11
			Results>Alpha-gal allergy>**Vote on** **Possible Action Three:**Increase resources for surveillance of alpha-gal allergy in human populations within the expanding range of *Amblyomma americanum*.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No11
			Results>Alpha-gal allergy>**Vote on** **Possible Action Four:**Dedicate additional resources for surveillance and control of *Amblyomma americanum* across its expanding range.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No11
			Results>Alpha-gal allergy>**Vote on** **Possible Action Five:**Increase resources for immunologic and animal model research to identify and better understand the tick allergens that cause alpha-gal meat allergy.
			Outcome: Passed—all present in favor; none opposed; none abstained; one member was not present (10/0/0/1)
			No11
			Results>Treatment> Issue 1. Anaplasma> **Vote on Potential Action One: Educate**health care providers on the use of doxycycline: To decrease morbidity and mortality, doxycycline should be used as a first line treatment for all diseases resulting from tick bites when patients present with clinical symptoms suggestive of HGA or HME. It is the drug of choice for all groups, including children under the age of eight, and in pregnancy (short courses). Rifampin is another choice in pregnancy for HGA, depending on the clinician’s judgement. Dissemination of this information to all health care providers is important (standardized training modules, brochures, e-prescribing information).
			Outcome: Passed—all present in favor; none opposed; none abstained; two members were not present (9/0/0/2)
			No11
			Results>Treatment> Issue 1. Anaplasma>**Vote on Potential Action Two:** Increase resources to determine mechanisms of immune suppression by Ap and Ech, and how best to address pro-inflammatory mechanisms post infection.
			Outcome: Passed—all present in favor; none opposed; none abstained; two members were not present (9/0/0/2)
			No11
			Results>Treatment> Issue 2. Babesia>**Vote on Potential Action One**: Increase research to improve diagnostics, developing broader *Babesia* testing panels, secondary to genetic diversity/multiple Babesia species.
			Outcome: Passed—one opposed; none abstained; two members were not present (8/1/0/2)
			“New” assays are less of a priority than implementing the existing ones or determining their predictive values. There are many PCR assays that have been used in multiple peer-reviewed publications that could be used (or are being used by select CLTs); all have sufficient sensitivity for clinical diagnostic use and have the capacity to detect all piroplasms. Independent validation (using well characterized clinical samples) of LTDs currently used could resolve discprencies between clinical diagnoses and expectations based on the known epidemiology of *Babesia*species such as *B. duncani.*11
			Results>Treatment> Issue 2. Babesia>**Vote onPotential Action Two**: Provide health care education among not only family practice/internal medicine physicians, but also subspecialists (including but not limited to hospitalists, OB/GYN, infectious disease doctors), regarding the signs/symptoms/risks/laboratory evaluation/treatment challenges of Babesiosis.
			Outcome: Passed—all present in favor; none opposed; none abstained; two members were not present (9/0/0/2)11
			Results>Treatment> Issue 2. Babesia>**Vote onPotential Action Three**: Conduct laboratory research and clinical trials to evaluate new treatment regimens for babesiosis. Resistance to standard babesiosisregimens has been reported (medications, alternative medicine protocols), and patients who are immunosuppressed and/or with co-morbid conditions often fail treatment, leading to increased morbidity and mortality. These can be tested in animal models prior to clinical evaluation and human trials.
			Outcome: Passed—all present in favor; none opposed; none abstained; two members were not present (9/0/0/2)
			No11
			Results>Treatment> Issue 2. Babesia>**Vote on Potential Action Four**: Conduct research on immunotherapy (e.g., human monoclonal antibodies) to control parasitemia while on drug treatment. Host factors are important, and more research is needed for determining the best therapeutic regimen in conditions where chronic parasitemia can exist.
			Outcome: Passed—all present in favor; none opposed; none abstained; two members were not present (9/0/0/2)
			No11
			Results>Treatment> Issue 3. Other Borrelia species: *Borrelia miyamotoi* (and relapsing fever borrelia), *Borrelia burgdorferi* sensu lato species>**Vote on Potential Action One**: Education: Improve public education on prevention of tick bites and education of health care providers regarding modes of transmission (tick bites, transfusion, maternal-fetal route) as well as the signs/symptoms of non-Lyme disease borrelioses.
			Outcome: Passed—all present in favor; none opposed; none abstained; two members were not present (9/0/0/2)
			No11
			Results>Treatment> Issue 3. Other Borrelia species: *Borrelia miyamotoi* (and relapsing fever borrelia), *Borrelia burgdorferi* sensu lato species>**Vote on Potential Action Two**: Diagnostics: Expand routine testing panels to include other Borrelia species apart from *Borrelia burgdorferi*, since non-Lyme disease borreliosis may be more common than appreciated. These syndromes overlap symptoms seen in Lyme disease as well as other borrelia infections (fatigue, pain, sleep disorders, cognitive difficulties) and standard Lyme testing will not detect varied borrelia species. Adding the variable major protein (vmp) as a recombinant antigen for EIA along with GlpQ protein will help to identify both early and convalescent illness with B. miyamotoi disease (BMD).
			Outcome: Passed—all present in favor; none opposed; none abstained; two members were not present (9/0/0/2)
			No11
			Results>Treatment> Issue 3. Other Borrelia species: *Borrelia miyamotoi* (and relapsing fever borrelia), *Borrelia burgdorferi* sensu lato species>**Vote on Potential Action Three:** Treatment: Evaluate efficacy of treatment regimens against diverse borreliosestransmitted by soft/hard ticks, especially when different co-infections are present, as persistent infection has been reported.
			Outcome: Passed—all present in favor; none opposed; none abstained; two members were not present (9/0/0/2)
			No12
			Results>Treatment> Issue 4. Deer Tick Virus (DTV)/Powassan virus (POWV)>**Vote on Potential Action One:**Allocate resources for research into effective treatment: There is a need to develop effective treatment regimens in cases of POWV encephalitis with neuroinvasive disease. Approximately half of survivors with neuroinvasive disease have severe permanent neurological symptoms and 10% of POWV encephalitis cases are fatal.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment> Issue 4. Deer Tick Virus (DTV)/Powassan virus (POWV)>**Vote on Potential Action Two:** Conduct research (animal models) to determine modes of transmission and whether persistence exists after an acute infection. Since other flaviviruses, such as TBEV, West Nile virus and Zika virus, share many biological characteristics to POWV, it is possible that POWV can establish a persistent infection in humans and/or be responsible for birth defects.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment> Issue 5. Rickettsia (Rocky Mountain Spotted Fever - RMSF)>**Vote on Potential Action One**: Education of all primary care providers and pharmacists regarding non-specific signs and symptoms of early infection with RMSF, where epidemiological clues and basic awareness of the disease is imperative. Education is also needed that doxycycline is indicated as first-line therapy for Rocky Mountain spotted fever in both children and pregnant women.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment> Issue 5. Rickettsia (Rocky Mountain Spotted Fever - RMSF)>**Vote on Potential Action Two**: Education ofclinicians regarding the importance of treating Rocky Mountain spotted fever presumptively. Clinicians should never delay or stop therapy while waiting for the results of a confirmatory test, or on the basis of an initially negative test result.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment>Issue 6. Bartonella spp.>**Vote on Potential Action One:** Allocate resources to improve and expand diagnostic assays to include a broad range of species of *Bartonella*.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment>Issue 6. Bartonella spp.>**Vote on Potential Action Two:** Allocate resources to improve and expand research into modes of transmission and epidemiology.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment>**Issue 6. Bartonella spp.>Vote on Potential Action Three:** Allocate resources to improve and expand research into the interaction between simultaneous infecting pathogens and the effect on the immune response of two or more pathogens. This is not unique to *Bartonella*, but applies to many vector-borne infections.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment>**Issue 6. Bartonella spp.>Vote on Potential Action Four:**Conduct animal and human clinical trials to evaluate more effective treatment protocols, as *Bartonella*has been shown to persist despite single or combination therapy.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment>**Issue 6. Bartonella spp.>Vote on Potential Action Five:**Allocate resources to conduct research to determine the risk of transmitting multiple tick-borne pathogens via the blood supply.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment>Issue 7. Evidence of Chronic coinfection states/Other Pathogens>**Vote on Potential Action One:** Review the role of overlapping causes of inflammation, such as associated Mycoplasma infections, environmental toxins, food allergies and leaky gut, as well as imbalances in the microbiome. Some of these are not directly related to tick-borne disease, but may be contributing to autoimmunity and ongoing chronic symptomatology in PTLDS leading to increased health care costs and disability.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			No12
			Results>Treatment>Issue 7. Evidence of Chronic coinfection states/Other Pathogens>**Vote on Potential Action Two:** Conduct research on the role of free radical oxidative stress and cytokine production during tick-borne infection. Downstream effects of inflammation may result in disabling symptoms. More research is needed in this area to improve therapeutic outcomes. Allocate resources to conduct clinical trials to identify contributing causes and confounding factors.
			Outcome: Passed—all present in favor; none opposed; none abstained; three members were not present (8/0/0/3)
			NoMethods Discussion

The Chair and Vice-Chair of the Working Group selected two members for each subcommittee to serve as co-chairs (Table 1). One was a federal employee (Allen Richards, PhD) and the other was a member of the public (Richard Horowitz, MD).

Subcommittee members were selected from a total of 220 nominations that were received from people who had nominated themselves to either one of the requests that were published in the Federal Register to serve on the Working Group or on a subcommittee. Of these, a total of 71 persons expressed interest in the **Other Tick-borne Diseases and Co-infections** subcommittee. These nominees were considered using a two-stage process. First, the co-chairs reviewed all of the nominations and identified the people who have experience related to helping patients with tick-borne diseases, as well as some knowledge of the specific content of the subcommittee(s) of their choice. In addition, the co-chairs ensured that the perspectives of patients and other key stakeholders outlined in the 21st Century Cures Act were identified during the first round of review. Subsequently, the co-chairs discussed the identified individuals to select the best well-rounded and diverse candidates for the subcommittee. This list was sent to the TBDWG and the individuals selected were contacted and determined if they would participate in the **Other Tick-borne Diseases and Co-infections**subcommittee. Nine individuals consented to working on the subcommittee and thus became members of the subcommittee. The total composition of the subcommittee is shown in Table 1.

The key characteristics of subcommittee co-chairs and members (e.g., professional expertise, past experience addressing these issues, patient, family member, etc.) are outlined in Table 1. Table 1 also demonstrates that four of the eleven members of the subcommittee represented a federal partner (DoD, CDC and NIH) while seven of the eleven members represented a non-federal perspective. From February 23 to May 4, 2018, the subcommittee meetings were held each Friday from approximately 2:00pm to 4:00pm EST by teleconference/webinar (Table 2).

During initial discussions, the group identified the most pressing priorities and issues affecting patients with “other” tick-borne diseases and grouped them into five key themes. The members then decided on two methods for gathering information about those themes: 1) collecting relevant peer-reviewed medical and scientific publications related to OTBD&C; and 2) scheduling presentations to the group by experts with insights into the different issues and priorities. All relevant articles and presentations were made available on Sharepoint for the subcommittee members to read and consider.

At the outset, the subcommittee also developed a process for voting on various issues and actions and developing its report to the Tick-Borne Disease Working Group. It began with work on the background, development of the the list of prioritized issues during the first two meetings (Table 2). These working meetings were augmented by e-mails for members to review and discuss working/draft documents. Subsequently, the third to eighth meetings were dedicated to obtaining knowledge and references (medical and scientific publications) on **Other Tick-borne Diseases and Co-infections** by leading experts in the field (three to four experts per meeting) presenting orally with their PowerPoint presentations by teleconference/webinar (Table 3). Speakers were selected by the subcommittee to include subcommittee members, outside clinicians, scientists, and stakeholders. As the presentations were attended and the references read, the subcommittee continue to develop their working document to give to the TBDWG. When gaps in the presenters and/or the references were obtained during this process, then new presenters were invited to speak and documents read. During the process of development of the working document, votes were taken to ensure that the direction of the subcommittee was following a course agreeable to all or a majority of the subcommittee members (Table 4).

The speakers selected, and the published literature utilized by the subcommittee was used to identify the most significant issues of **Other Tick-borne Diseases and Co-infections** and to determine what was known and what was not known or missing in the control/mitigation of other tick-borne diseases and co-infections. The subcommittee strategy was to collect information that was not monolithic but diverse in its opinions and data. The diverse makeup of the subcommittee facilitated the selection of a diverse list of presenters and publications. During the subcommittee’s meetings, gaps in the presented material and references were identified and new presenters and references were included. This insured that information that might disconfirm the conclusions of the studies referenced were identified.

Public commentary on alpha gal allergy was obtained from written and oral public testimony. These informed the group as to the importance of addressing alpha gal allergy as one of our initial priorities.

The report to the working group was developed during discussions within meetings and by phone calls and e-mails between meetings. The co-chairs wrote initial drafts and then the subcommittee into groups to write sections related to their expertise. The co-chairs then finalized each subsection and resent them to the members for their vote (buy-in). They recorded the votes for and against each product and also tracked how many abstained from voting or did not respond (NR). If a minority against the product was identified, they were allowed to write a rebuttal. Due to the diverse nature of our subcommittee and the topics discussed, a wide area of interests were identified. This led to much discussion until a consensus was agreed upon or a majority response was made on the main points and recommendations.

Disagreement in the group and recognizing differences in opinions and why they exist was addressed by giving every member a chance to express their opinion on the weekly conference calls, commenting on all of the priorities and issues identified in the working group document. The document integrated all the diverse opinions into the “Complete List of Issues that Could Be Addressed in the First Report to Congress” (Appendix 2). Minority opinions, such as the importance of certain co-infections (*Bartonella, Mycoplasma,*and *Chlamydia*species) and whether they were tick transmitted were included in the report as gaps in knowledge and the importance of other tick-borne diseases present as single infections, such as Rocky Mountain spotted fever and human granulocytic anaplasmosis.

The PowerPoint briefing for the Other Tick-Borne Diseases and Coinfections subcommittee was based on questions needing to be addressed in the three key themes of our document, including the diagnosis and treatment of tick-borne diseases and coinfections, including alpha-gal allergy.

Priority #1: Improving the detection and diagnosis of other tick-borne diseases and co-infections

**Note:**References for the in-text citations can be found at the end of the document under “Key Theme 1: Improving the detection and diagnosis of other tick-borne diseases and co-infections”****

The diagnosis of other tick-borne diseases & co-infections (OTBD&C) is dependent on the clinical context, which includes taking a proper history (risk of potential tick exposure), reviewing symptomatology, performing a physical examination, and establishing a differential diagnosis augmented by laboratory diagnosis and detection. The following issues are essential to the accurate detection and proper diagnosis of other tick-borne illnesses and their coinfections.

Improved education about taking proper history, reviewing symptomatology, performing a physical examination, the importance of detection assays, the types of assays available, and how to use laboratory assay results
	Improved clinical diagnosis
	Improved laboratory testing
	Improved surveillance**Target groups:**health care providers; clinical testing laboratories; patients; and the general public.

Issue 1. Improved education about taking proper history, reviewing symptomatology, performing a physical examination, the importance of detection assays, the types of assays available, and how to use laboratory assay results

Question: What can be accomplished through improved education about detection assays?

(a) Health care providers will select the best available tests; they will know how to utilize the results; and they will understand the limitations of the assays used.

(b) Clinical testing laboratories will select appropriate, validated, sensitive, and specific assays to detect and diagnose other tick-borne diseases and coinfections.

(c) Patients will better understand the importance and limitations of assays available for the detection and diagnosis of other tick-borne diseases and coinfections.

(d) The general population will know what tests are available and understand their use and limitations.

Of vital importance, all four target groups should be made aware that single pathogen infections can occur from a tick bite, and that multiple infections may be transmitted by one tick or independently or sequentially by numerous tick bites (Telford and Goethert 2008; Paddock and Telford 2010).

Background:

Ticks, like any other living organism, contain a diverse microbiome (Clay and Fuqua 2010). Some of the members of this microbiome are recognized to infect people and cause disease. Other members of the microbiome are related to known pathogens but have not been incriminated as agents of human disease. Nonetheless, a large diversity of known zoonotic agents is transmitted by common human-biting ticks in the United States. Some of the more important human biting ticks include deer or blacklegged ticks (*Ixodes scapularis)*; western blacklegged ticks (*Ixodes pacificus*); Lone Star ticks (*Amblyomma americanum*); Gulf Coast ticks (*Amblyomma maculatum*); American dog ticks (*Dermacentor variabilis*); Rocky Mountain wood ticks (*Dermacentor andersoni*); brown dog ticks (*Rhipicephalus sanguineus*); and soft-bodied ticks (Argasidae).

Given the risk of infection from a tick bite, the educational message to health care providers and the general population should be, **“no tick bite is a good tick bite,”** and that tick bites may lead to illness from other tick-borne diseases and coinfections, also known as concurrent or polymicrobial infections. Providers and clinical testing laboratories might not be aware of or consider the possibility of coinfections and, therefore, they may not order the appropriate tests. In addition, patients and the general population may not understand the possibility of the many different diseases and the difficulty of diagnosing them. Moreover, all target populations may be unaware that tick-borne infections can exacerbate comorbidities.

What needs to be done?

Health care providers need to be made aware of the host-pathogen interaction and how to update their clinical information by way of current epidemiologic and pathophysiologic data available on tick-borne diseases (Brownsson et al., 2017). For example, they should receive education about how some tick-borne infections are characterized by their capacity for chronic infection. *Babesia microti* has been documented to persist in the blood of both treated and untreated patients for nine months (Krause PJ et al., 1998; Allred DR. 2003; Krause PJ et al. 2008; Horowitz & Freeman, 2016). Bovine babesiosis is well known to be characterized by premunition, a low level parasitemia for the duration of the animal’s life, kept controlled by immunity which is in turn stimulated by low level antigen production by the parasite (Calder et al., 1996).

Although it is unlikely that *Rickettsia rickettsii* or *Francisella tularensis* will chronically persist, except in the case of ulcero-glandular or glandular forms of tularemia or potentially in immunosuppressed individuals (WHO Guidelines on Tularaemia. 2007. ISBN 978 92 4 154737 6), RNA and typical pathology of tick-borne encephalitis virus (TBEV) have been detected from autopsy brain tissue 55 years after the initial infection (Pogodina 1996).**** Such chronic infection states can, but not always, be difficult to prove by direct detection of the infectious agent. As discussed in the Treatment section (Theme 2), *Bartonella* species can be extremely difficult to diagnose by clinicians. There is evidence that they hide in the intracellular compartment, and without broad-based sensitive serology, testing can be negative (Horowitz & Freeman, 2016; Nicolson et al., 2000; Eskow, Adelson, Raja-Venkitesh, Rao, & Mordechai, 2003; Horowitz, 2003).

Health care providers should be educated in the development of the immune response to other tick-borne diseases and coinfections and how that relates to treatment and diagnosis. Seronegativity can and does occur in patients with active disease, and a proper diagnostic and treatment approach relies on understanding the risk of potential tick exposure; the varied clinical presentations of other tick-borne diseases and coinfections; timing of antibody production; sensitivity and specificity of tests; and using the full range of assays available for confirming a clinical diagnosis (i.e., dermatological testing/biopsies, blood smears, antibody tests, PCR, RNA (FISH), etc.).

One of the most significant immune responses for diagnosis is the appearance or enhanced production of agent-specific antibodies. A specific detectable antibody response to other tick-borne diseases and coinfections is normally developed over a period of weeks during acute infection (Thomm AM et al., 2018). However, patients with acute early infection do not often have specific antibodies at diagnostically detectable titers, and physicians should initiate treatment based on a history of potential tick exposure. This is especially true for suspected Rocky Mountain spotted fever given the increased mortality risk associated with delayed initiation of therapy. (Holman et al., 2001) Antibody titers against *B. burgdorferi* take on average 4-6 weeks to rise to diagnostic levels and administration of antibiotics at an early disease stage can dampen the development of a specific immune response and lead to a negative test using a 2-tier testing protocol developed for Lyme disease surveillance (Aguero-Rosenfeld et al., 1996). Seronegativity can also result from *Borrelia*’s ability to form immune complexes (along with other mechanisms to avoid immune recognition), and/or from exposure to other *Borrelia* species like the relapsing fever borrelia, *Borrelia miyamotoi*, which is not detected on standard two-tiered testing for Lyme disease. Delay in antibody production can also take place with human anaplasmosis, which is serologically detectable only 1 week or more after illness onset (https://www.cdc.gov/lyme/faq/index.html), and in the case of infections with other agents, this period may be much longer. For example, *Rickettsia* *africae* specific antibodies may take a median of 25 and 28 days to reach detectable levels of IgM and IgG, respectively (Fournier PE et al., 2002); whereas other rickettsia-specific antibodies may take less time than those against *R. africae,*but will still take a week or more to reach detectable levels (Fournier PE, et al. 2002; Luce-Fedrow et al., 2015). The prompt treatment with appropriate antibiotics will delay the antibody level reaching detectable levels (Fournier PE, et al. 2002; Luce-Fedrow et al., 2015). The absence of an antibody response in a patient with signs and symptoms of a tick-borne illness should prompt analysis for both tick-borne pathogens as well as known factors for immune suppression (e.g. malignancy, HIV, splenectomy, immunosuppressive drugs), or consideration of another disease that is not tick-borne.

Health care providers should also be educated about the appropriate use and interpretation of testing. For example, serology is insensitive for confirming exposure when a patient has acutely presented, but often demonstrates seroconversion if a convalescent serum sample is obtained 3-4 weeks later (Fournier, et al., 2002; Branda et al., 2018). Thus, a seroconversion is a very sensitive means of confirming exposure, but waiting for a convalescent serum sample is an inappropriate reason for delaying treatment. This is the especially the case for Rocky Mountain spotted fever, where withholding treatment with doxycycline could lead to significant morbidity and mortality.

Acute blood samples are the source for direct detection of the agent (blood smear, PCR) and can provide a definitive diagnosis in some tick-borne diseases (Fournier, et al. 2002; Luce-Fedrow et al., 2015). It should be noted that an agent directly detected is very informative when validated assays are used; however, a negative test does not rule out the infection. A negative test can result from many reasons such as the limited window of detection (e.g. bacteremia detectable by qPCR peaked at 9-12 days post disease presentation in scrub typhus patients from Vietnam) (Kramme S et al., 2009) or CLT assay sensitivity (Telford SR personal communication); however, the sensitivity of confirming a diagnosis by direct detection continues to be an area that needs improvement in other tick-borne diseases and coinfections (Akoolo, et al., 2017; Harms & Dehio, 2012; Finlay & McFadden, 2006; Minnick & Battisti, 2009).

The insensitivity of serology for acute patient samples has contributed to the perception that such tests are poorly sensitive for later use in confirming the diagnosis of diverse infections. Serology is poorly sensitive when the antibody response has not expanded to detectable levels, but the failure to seroconvert in untreated patients (as demonstrated by a comparison of acute and convalescent serum samples separated by at least two weeks between collections) suggests a reconsideration of the diagnosis, and/or mechanisms of immune evasion and immune suppression. It is also possible that early treatment may blunt the antibody response and reduce the presence of antibody or the likelihood of seroconversion. In this case, evidence for past exposure to a tick-borne disease may be lacking. Also, presence of cross-reactive antibodies in a single acute sample or the lack of a seroconversion may suggest a diagnosis that is incorrect. For example, about 10% of people in the United States (and worldwide) have pre-existing spotted fever group rickettsiae (SFGR)-specific antibodies. Thus, a health care provider may treat a patient with a positive reaction to a Rocky Mountain spotted fever (RMSF) serological test for RMSF when they should be looking at another cause of the patients’ disease (Hechemy et al., 1989; Luce-Fedrow et al. 2015). This illustrates the power and limitations of serology and the need for paired tests, which cannot definitively confirm or rule out the presence of infection.

Laboratory Developed Tests (LDT) are available that offer testing to confirm the diagnosis of other tick-borne diseases and coinfections. Some of those tests have not been independently evaluated, even though the laboratories may be CLIA certified. We need further studies regarding the sensitivity and specificity of other tick-borne diseases and coinfections testing. Validation of LDTs can be costly and difficult to do. The evaluation can be an arduous, if not impossible task, if the samples required for validation are simply not available. For example, although clinicians across the United States are finding evidence of *Babesia duncani* using testing from national-based commercial laboratories (Horowitz, 2016), there have only been 13 *Babesia duncani* (WA1 babesiosis) cases for which incontrovertible evidence of the disease etiology (direct detection of the agent by blood smear or PCR; hamster inoculation; in vitro culture) has been reported and accepted by the Centers for Disease Control and Prevention (Bloch et al., 2012). The case reports have been published previously (Thomford et al., 1994).

Clinical testing laboratories need to be educated about the importance of and the need to utilize well characterized control samples, which are crucial to developing testing panels that could be sent to them blinded to their infection status. Best practices in laboratory testing depends on independent replication of results and validation of tests should be based on the best available science. Even well validated tests, such as the indirect fluorescent antibody test (IFAT) for detecting specific antibody to *B. microti*(Krause et al., 1994), have not been adequately analyzed for estimating positive and negative predictive values under conditions of low endemic population risk (low pretest probability) (Van Stralen et al., 2009). That is why obtaining a travel history with potential tick exposure is so important, since ultimately the diagnosis and decision to treat must be based on risk, clinical and laboratory findings, and evaluation of antibody titers and symptomatology pre- and post-treatment.

The main educational point is that even if a test is offered by a CLIA certified laboratory, however respected that laboratory may be, its positive predictive value may be unknown. This is particularly true for other tick-borne diseases and coinfections that are considered rare (e.g., *B. duncani*) either empirically from case reports or expected from ecological data. Since migratory birds are carrying ticks across large geographical areas, although certain *Babesia*species and other co-infections may be rare in a region based on prior clinical and surveillance studies, the possibility of expansion and tracking these potential moving targets is important. This suggests the need for coordination between local health departments and governmental agencies with multidisciplinary clinical networks (i.e., state work groups) that can also serve as centers of excellence for rare tick-borne diseases.

Validated assays are perhaps the best guide to treatment decisions for the reasons outlined above. Non-validated assays can provide additional results and possibly clarification, thereby strengthening the diagnosis based on a validated test. However, as physicians struggle to help their patients with complicated severe illness, they are often placed in a position of not having the tools they need to diagnose and effectively manage their patients. This gap in diagnostics is seen as a major need for urgent research and development.

Health care providers should encourage patients to seek additional medical care if a treatment regimen (particularly for acute febrile disease) does not resolve symptoms. For example, a failure to defervesce after 2-3 days of oral doxycycline (provided for presumptive treatment of human granulocytic anaplasmosis, ehrlichiosis, and rickettsioses) may indicate the presence of tick-borne pathogens unresponsive to doxycycline such as babesiosis, or non-tick associated conditions, and further testing should be initiated with haste. The provider should also educate the patient on ways to prevent future tick bites and to implement such practices for their entire family.

Health care providers should be educated in obtaining the best clinical samples to assist in making an accurate diagnosis. For example, taking skin biopsies, a more invasive procedure than venipuncture, is usually well-tolerated and may be the specimen of choice for many other tick-borne diseases and coinfections. However, a potential barrier to this is the lack of credentialing for general practitioners in skin biopsy and the incompatibility of the time it takes to fit the procedure in to a busy practitioner’s schedule. This is another reason why the creation of tick-borne disease centers of excellence, gathering and evaluating big data, would help to improve the clinical diagnosis and treatment of tick-borne disorders.

Clinical treatment laboratories need to be educated that tissue samples require modified DNA-extraction protocols to effectively harvest pathogen DNA, and take longer to complete, thus delaying results. Also, as in the case of the erythema migrans (EM) lesion, skin should be sampled at the expanding edge, not the center where spirochetes may have been cleared. Health care providers will need additional training to know how to obtain appropriate skin samples. Additional education is not necessary for venipuncture.

The general population should be made aware that the threat of other tick-borne diseases and coinfections is present anywhere ticks can be found: in their backyard and in other outdoor activity areas, such as parks, outdoor sports fields, and hiking trails.

Good natural history studies (longitudinal cohort) of sequelae or complications of treated infections need to control for additional tick exposure and have sufficient sample sizes. Ethical considerations prevent enrolling symptomatic subjects that remain untreated; however, natural history of untreated, asymptomatic infection may provide data on the dynamic nature of disease. (Does someone with positive serology, but no signs or symptoms, later develop disease in the absence of new exposure?)

Possible opportunities

Identifying the “best, most effective” agency(ies) to provide education for health care providers. This could be done by engaging both traditional and tick-borne disease community provider organizations (clinical testing laboratories [e.g. ASCP], patient and health care provider tick-borne disease organizations, public health agencies like HHS and the CDC, and university-based researchers) to ensure a comprehensive and balanced approach.Are there threats or challenges to educating the target populations for implementing change?

Although educating healthcare providers about OTBD&C is a top priority, the challenge in implementing a new initiative is to identify the appropriate agency to do this with respect to authority (national standing; expertise) and capacity to reach all health care providers. It is unlikely that just one agency could serve the purposes outlined by our subcommittee. In addition, the majority of community-based physicians are not part of or engaged with some medical groups tasked with the diagnosis and treatment of tick-borne diseases. Almost all continuity of care for this patient group is delivered by non-subspecialists, including primary care physicians and “Lyme literate” physicians, who have organized their own group of peers and sought out alternative approaches to care for their patients. Bringing diverse groups together to discuss the emerging science of tick-borne diseases and co-infections and develop best practice guidelines is therefore a huge gap that needs to be addressed. Another challenge is to avoid burdening such any one agency with a non-funded education mandate for fear that it would be a low priority for implementation.

Gaps in the education of the target populations:

Education of health care providers is needed to ensure they know when and how to use diagnostic tests and how to interpret the results.
	Clinical testing laboratories need to be educated in the use of well characterized samples for all other tick-borne diseases and coinfections in order to develop testing panels. Samples could be sent to them blinded to their infection status to ensure accuracy.
	Education of patients, patient family members, and the general population about other tick-borne diseases and coinfections needs to be improved and prioritized.
	Few studies exist examining the capacity for concurrent tick-borne infections to modify the typical antibody response of the component infections.
	The natural history of untreated tick-borne diseases and coinfections (other than Lyme disease), and what circumstances contribute to persistence of tick-borne infection(s), such as *Borrelia burgdorferi* sensu lato species and *Babesia,*have yet to be described. In addition, further studies are needed of the potential role and impact of other agents such as *Bartonella*, *Mycoplasma* and certain flaviviruses, which have the potential to cause chronic infection.Potential Actions for working group to consider for recommendations

Conduct studies to answer important questions about the natural history of other tick-borne diseases and coinfections as well as the human immune response to the infections.
	Educate health care providers, clinical testing laboratories, patients, and the general public—to be conducted by medical agencies (e.g. HHS), private organizations, knowledgeable clinicians and scientists.
	Create a tick-borne diseases and coinfections multi-site working group to have a collaborative, standardized approach to data collection and conduct longitudinal cohort natural history studies of sequelae or complications of treated infections.Votes of Subcommittee Members

Potential actions were presented and discussed by subcommittee members. The wording of Potential actions here were voted on by subcommittee members and results are presented here.

Conduct studies to answer important questions about the natural history of other tick-borne diseases and coinfections as well as the human immune response to the infections.**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**10
			0
			0
			1Educate health care providers, clinical testing laboratories, patients, and the general public—to be conducted by medical agencies (e.g. HHS), private organizations, knowledgeable clinicians and scientists.**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**10
			0
			0
			1Create a tick-borne diseases and coinfections multi-site working group to have a collaborative, standardized approach to data collection and conduct longitudinal cohort natural history studies of sequelae or complications of treated infections.**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**9
			0
			1
			1Issue 2. Improve diagnostic methods for clinical diagnosis

**Questions: Under what circumstances do we need to improve clinical diagnosis?**

In order for a health care provider to consider a diagnosis and therefore pick a test, a clinical suspicion of the illness is required. The suspicion is generated by the clinical symptoms and course of development of illness described by the patient or patient representative. Multiple simultaneous infection is a fact in tickborne disease – in ticks and in humans. The infections are often tick borne, and other vector borne or opportunistic infections have been documented at times to be coinfecting a single individual patient. There are a few case reports and fewer series documenting some symptoms in some simultaneous infections. Severity of symptoms is noted to be increased in coinfection with *Babesia* and *Borrelia,*and infectious potential, particularly into the central nervous system, may be augmented by *Ehrlichia* (Grab et al. 2007). This would suggest a possible worse neurological picture with *Borellia*-*Ehrlichia* coinfection.

The incidence of two or more infections in Lyme disease is unknown. Johnson (PeerJ 2014) published a survey of 5,357 subjects with clinically diagnosed Lyme disease (3,090 were selected for the study). Results revealed that tickborne coinfections confirmed by serological testing were reported by 53.3% of respondents: 23.5% reported at least one co-infection and 29.8% reported two or more co-infections. More specifically, 32.3% of respondents reported laboratory confirmed diagnosis with *Babesia*, 28.3% with *Bartonella*, 14.5% with *Ehrlichia*, 4.8% with *Anaplasma*, 15.1% with *Mycoplasma*, 5.6% with Rocky Mountain spotted fever, and 0.8% with tularemia. (Studies regarding Lyme coinfections with *Babesia*, *Ehrlichia-Anaplasma*, *Bartonella*, and *Anaplasma-Bartonella-Mycoplasma*can be found at the end of this document in the Additional References by Topic section.)

A tick bite frequently results in two or more infections. Community health care providers need a method of reporting patients who are chronically ill. This can allow us to create case definitions and clinical descriptions of the different multiple infections thus guiding our choice of testing as well as testing development—creating a cohort to study.

**Background**

An accurate diagnosis is the foundation for successful treatment. The history and initial examination taken by the attending physician usually provides a guide for how to proceed. Health care providers need to consider a **syndromic approach** to tick-exposed patients; as opposed to diagnosis focused on a specific infection, the set of signs and symptoms is evaluated in the context of a differential diagnosis (Citera M et al. 2017; Horowitz, 2013; Horowitz, 2017). The nonspecific “flu-like illness,” for example, may be caused by any of the known tick-transmitted agents or may not be due to a tick-borne disease. In the northeastern, upper Midwestern and coastal Pacific states, the “most common” tick-transmitted infection (Paddock and Telford 2011) is usually Lyme disease. However, infection with the less common pathogens should also be considered in patients with flu-like symptoms and exposure or a history of recent exposure to ticks. Concurrent infection with more than one agent (also known as “coinfection”) may complicate patient management (Krause PJ et al. 1994; Sexton, 1998; Maggi, 2013). For example, on Nantucket Island, the treatment of a patient with fever and EM with a standard course of doxycycline not uncommonly leads to the return of that patient a week or more later with signs and symptoms of babesiosis due to *B. microti* (TJ Lepore MD, personal communication), a pathogen not susceptible to the tetracyclines. Analysis of an acute blood sample (taken when the patient presented with EM) for DNA of *B. microti* and *A. phagocytophilum* might provide direct evidence that one or more other infections may be contributing to the apparent signs and symptoms. Reflex testing for those infections known to be companion agents to that of Lyme disease might reduce the probability of an undetected coinfection when the patient presented with signs and symptoms of Lyme disease. Moreover, infection with *A. phagocytophilum*, an *I. scapalaris*-transmitted pathogen, may cause immunosuppression in animals (Woldenhiwet 2006), and therefore clinicians should be mindful of this issue.

A syndromic approach could be used by clinical laboratories that test samples from tick-exposed patients. For example, if an acute blood sample is received for confirmation of a diagnosis of *B. miyamotoi* infection, molecular detection assays for *B. microti* and *A. phagocytophilum* should also be performed (Molloy et al., 2015). Some CTLs offer a tick-borne disease panel, including multiplex serological platforms, which may reduce the costs for added testing (Tokarz et al., 2018). A microarray, multiplex PCR, or next generation sequencing (NGS) targeting 16S rDNA, or a transcriptome analysis that has the potential to identify all tick-borne agents including viruses, could fill a gap that would replace a panel of individual assays and potentially test for more agents at a lower cost.

Moreover, the CDC might establish a format for community, university, and medical center health care providers to register suspected tick-borne disease and coinfection clinical cases. With the help of current expert system techniques and computer science, reporting can be streamlined and more user-friendly. Additionally, the CDC might also require reporting of both suspected acute and chronic tick-borne diseases; the data to be gathered should be decided by clinical and laboratory experts.

**What needs to be done**

**1. Develop a general algorithm or flow chart for clinical diagnosis of other tick-borne diseases and coinfections to be** **displayed in the offices of health care professionals**

The main diagnostic tools for clinical diagnosis are, as for any other infectious disease: timing of symptoms, current signs and symptoms, history of exposure, comorbidities, routine labs; differential diagnosis; and presumptive diagnosis and treatment. Specifically, in the case of tick-borne disease, the history of exposure, including the geographic location and month of the year, comorbidity, specific labs (LFTs, CBC) and differential diagnosis are key tools.Patient history would direct the examination: Although ticks might be found in Central Park or parks in Staten Island, a life-long resident of Manhattan who has never spent time outside the City would not commonly be considered at risk for a tick-borne disease and thus those candidates would be low on the differential diagnosis. Other environmental infections (not transmitted by ticks) should be considered: cat ownership and individuals working with other animals, for example, should prompt suspicion of cat scratch disease, which can have signs and symptoms that overlap greatly with many of the tick-borne diseases.
	Comorbidity (for example, immunosuppression) may enhance susceptibility and predispose a patient to severe disease or complicated management, and thus ruling out tick-borne disease becomes urgent.
	Elevated liver function tests (LFT) and leukopenia (primarily left shift) are usually present in human granulocytic anaplasmosis (HGA) and are occasionally seen in *B. microti* infected patients as well as in patients with acute Lyme disease (Horowitz et al, 1996). HGA patients usually have thrombocytopenia and leukopenia, and such findings may also accompany babesiosis. Spotted fever group (SFG) rickettsiosis usually demonstrates thrombocytopenia, elevated LFT, and hyponatremia.
	Differential diagnosis: There are a limited number of likely tick-borne infections in the United States. Most have typical geographic distributions as defined by peer reviewed literature (documentation of an ecological cycle and/or case reports) or by national surveillance. However, the geographic distributions are expanding and “real time” data is not always readily available for states on the border of known endemic regions (for example Ohio, Tennessee, and Kentucky).
	While it is true that common tick-borne infections will be commonly seen whereas rare tick-borne infections will be rarely seen, it is also true that rare illnesses do occur and that common illness occur without their usual characteristics. For example, *B. burgdorferi-*infected ticks do occur in the southern United States, and even though they are much less efficient in transmitting Lyme disease, there is a potential gap in our knowledge of *B. burgdorferi* infection in the South (Rudenko, Golovchenkoa, Grubhoffera, & Oliver, 2011; Rudenko et al., 2016; Stromdahl & Hickling, 2012; Herman-Giddens & Herman-Giddens, 2017; Wormser, et al., 2005; Herman-Giddens, 2018).**Possible opportunities**

Development of new and more inclusive clinical diagnosis algorithms.

**Are there threats or challenges to educating the target populations for implementing change?**

Agendas or perceived agendas by different groups and the environment of mistrust that exists between groups impede collaboration and information sharing among them.

**Gaps in clinical diagnosis**

There is a lack of clinical algorithms and guidance for health care providers who want to establish the diagnosis of other tick-borne diseases and coinfections. A comprehensive list of symptoms, differential diagnoses, and laboratory tests for each of the different infections (which help to confirm or rule out the diagnosis) would be helpful.

**Votes of Subcommittee Members**

Potential actions were presented and discussed by subcommittee members. The wording of Potential actions here were voted on by subcommittee members and results are presented here.

**Potential Action One:** Develop flow charts/algorithms for clinical diagnosis of other tick-borne disease and coinfections.

**Vote on Potential Action One:** Develop flow charts/algorithms for clinical diagnosis of other tick-borne disease and coinfections.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**8
			2
			0
			1**Minority Response**

Two members did not vote in favor of this action. They did not believe that recommending flow charts for diagnosis fell within the subcommittee’s charge to identify gaps.

Issue 3. Improved laboratory testing for other tick-borne diseases and coinfections to provide laboratory confirmation of clinical diagnosis and to detect agents in tick vectors during surveillance of other tick-borne diseases and coinfections.

**Questions about the state of the art of other tick-borne diseases and coinfections:**

What are the most accurate (sensitive, specific, reproducible, etc.) and cost effective clinical diagnostic modalities for other tick-borne diseases and coinfections?
		What is the evidence that we need better diagnostic algorithms?
		What new direction should laboratory testing go; what new methods of sample collection preparation are needed to enhance the sensitivity and specificity of diagnostic tests; and what improvement to validation of assays need to be implemented?**Background**

**Laboratory detection and diagnosis.**Most acute tick-borne diseases comprise a presumptive clinical diagnosis. Laboratory methods to support the clinical diagnosis include direct detection of the agent (visualization, culture, antigen detection or nucleic acid amplification) or indirect methods (detecting specific antibody, metabolomics, etc.).

Direct detection
	Giemsa stained blood smears: when another tick-borne diseases and coinfection patient presents with fever, a Giemsa stained blood smear may provide definitive evidence of babesiosis (intraerythrocytic parasites); human anaplasmosis or *Ehrlichia ewingii* ehrlichiosis (inclusions in granulocytes); and borreliosis due to *B. mayonii* or the classical relapsing fever agents (extracellular spirochetes). Monocytic ehrlichioses (*E. chaffeensis*, *E. muris*) are rarely confirmed by blood smear due to the scarcity of circulating monocytes. Spirochetes are only rarely detected in blood smears from *Borrelia miyamotoi*infection (BMI) patients. Intra-erythrocytic inclusions may be seen in blood smears from Colorado tick fever patients. Blood smears cannot be used to confirm rickettsiosis, tularemia, or the arboviral infections (Powassan/deer tick virus; Heartland and Bourbon virus).
		FISH staining of blood smears has also proven effective and new tests with new fluorescent RNA probes can detect single cells and is quantitative of agents of other tick-borne diseases and coinfections.
		Nucleic acid amplification tests (NAAT). This modality is now preferred for direct detection of a pathogen from clinical samples. The great sensitivity of PCR and reverse transcriptase PCR (RT-PCR) means that laboratories must operate with stringent contamination control procedures during extraction and reaction setup; PCR can theoretically detect even a single contaminating target sequence, and thus false positives can occur. Quantitative real-time PCR (qPCR), in particular, provides enhanced sensitivity, specificity and is more rapid than standard PCR (Luce-Fedrow et al., 2015). Primer sets are available for all tick-borne infections; some are better validated than others.
	Blood culture is currently of limited clinical value and remains primarily the province of research laboratories for tick-borne infections. *B. microti* cannot be cultivated in vitro. *Ehrlichia* species and *A. phagocytophilum* may be readily cultivated in diverse leukocyte lines (e.g., DH82 canine macrophages; HL60 promyelocytes) in research laboratories. *Rickettsia* species may be cultivated from blood by centrifugation of plasma or buffy coats onto monolayers of epithelial cells (e.g. Vero) but may be hazardous and culture is much less sensitive than PCR (Luce-Fedrow et al., 2015). Tularemia is rarely confirmed by culture of blood and is likewise hazardous. Like many other flaviviruses, Powassan/deer tick virus has a transient viremia and is thus not commonly cultivated from blood. Heartland and Bourbon virus were identified by cultivation on cells (incidental findings from attempting to confirm rickettsial or ehrlichial infection) but too few cases have been identified to determine sensitivity. All arboviral cultivation requires enhanced caution.
	Combining culture, PCR and serology tests at 3 time points is improving detection of *Bartonella*spp. (Duncan et al., 2007) and should be considered for detection of other OTBD&C pathogens.
	Serology is one of the most common tests for the laboratory diagnosis of other tick-borne diseases and coinfections.ELISA/IFA: They include the well-known enzyme-linked immunosorbent assays (ELISAs) and indirect fluorescence antibody assays (IFAs) used to detect species- and group-specific antibodies (IgM, IgA, and/or IgG) against infectious agents. One of the major limitations with acute serology is lack of sensitivity in diagnosing acute infection (Luce-Fedrow 2015). Diagnostic strategies using acute and convalescent serum samples (collected at least two weeks apart) have greater sensitivity, but this may be diminished by early treatment as is known in the case of Lyme disease. The use of serology for chronic illness is confounded by multiple variables, including potential co-infections, immune evasion, immune suppression, and the lack of specificity given the background seroreactivity in the general population from remote asymptomatic or symptomatic exposure (Akoolo et al., 2017; Liang, Brown, Wang, Iozzo, & Fikrig, 2004; Girshick, Huppertz, Reussmann, Krenn, & Karch, 1996; Hastey, Eisner, Barthold, & Baumgarth, 2012; Breitschwerdt et al., 2014; Finlay & McFadden, 2006).
	Point-of-care assays: have limited sensitivity and specificity. Thus, the development of a new point of care rapid diagnostic serological tests that addresses the lack of sensitivity and specific are rare and very desirable (GAP). In veterinary medicine, hand-held cartridge format tests using immobilized antigen or antibody, or immobilized DNA capture probes have been developed that yield results in minutes, requires only a few microliters of blood and has better sensitivity due to the use of DNA capture probes (e.g., Idexx). While they must be interpreted with care, they can be a useful diagnostic aid. Similar devices using immobilized probes to capture antibody, antigen or DNA/RNA are being developed in research labs across the globe, however, due to a variety of reasons (funding, slow process for regulatory approval, cost to patient), progress in this area has been slow. Hand-held, field-deployable diagnostic devices would be tremendously useful, especially in outlying regions where access to specialist testing labs is restricted or requires much time. Currently available tests such as those utilizing membrane-immobilized capture probes (spot blots, etc.) could be adapted, and could be combined in different arrays to provide panels for diagnosis of multiple agents.Possible opportunities

New technology will greatly improve the direct detection of an infecting agent. Excellent nucleic acid amplification tests (NAAT) exist for the known tick-borne infections, but there is no agreement on adopting a consensus test; each clinical testing laboratory might use a different one, often a laboratory developed test. As with serology, validation and estimation of positive and negative predictive values have not been undertaken for most of these tests. Other modalities such as RNA testing, transcriptome analysis, NGS, and others such as “omics” and chemokine assays, and metabolic biosignatures may be increasingly used as costs diminish. In anticipation of their use, guidance should be provided to proactively ensure that validation is done.
	Selecting the right samples for specific infections is an area that requires additional research. Ticks deliver pathogens to and ingest them from a feeding lesion created in the dermal niche and thus skin biopsy should be considered for sampling to enhance confirmatory testing. Rickettsiosis can be definitively diagnosed at acute presentation by detecting *Rickettsia* spp. by fluorescent antibody, immunohistochemistry, or NAAT within samples of exanthemata. Combinations of methods (serology, PCR and culture) of such samples along with blood may provide more sensitivity than just testing blood, particularly for individuals with persistent infection. Animal models can be also used to improve diagnostics; the gold standard for diagnosis of human babesiosis due to *B. microti*, prior to PCR, was hamster inoculation (Telford et al., 1993). Skin and other tissues, as well as blood can also be analyzed using advanced imaging techniques coupled with new probe technologies which would help fill the detection and diagnostic gap. These new diagnostic approaches could facilitate early detection, clinically relevant cell and tissue context information as well as spatial variation and relation of co-infections. Imaging technologies include single- and multi-photon laser scanning microscopy, Second Harmonic Generation (SHG), Correlative Light and Electron Microscopy (CLEM) and super-resolution microscopy; all of which offer unprecedented information on pathogenesis (Ericson et al., 2017; Donovan et al., 2017). These imaging technologies can be coupled with immunostaining, fluorescence in situ hybridization, and new in situ RNA fluorescence probes for information on the etiology and pathogenesis of tick-borne disease as seen in HIV detection (Vasquez et al., 2018).
	Timelines for testing need to be developed that take into consideration which tissue compartments the pathogen colonizes in the host, and how the dynamics of spread are affected by antibiotic treatment. Rickettsiae may take up to 10 days to reach levels in the blood that are detectable using NAAT, but the agent is present and detectable in eschars before onset of symptoms (Luce-Fedrow et al., 2015). The characteristic rash where rickettsial DNA can be found appears approximately 3-7 days after onset of symptoms. In addition, presence and duration of the rickettsial DNA in eschar and rash is not affected by prior treatment with doxycycline whereas rickettsial DNA drops below detectable levels in blood quickly after administration of the first dose (Whitman et al. 2007). Multiple blood samples taken over time as used in detecting the causative agents of malaria, typhoid fever diagnosis, bartonelliosis, should be considered for detecting tick-borne pathogens (Duncan et al., 2007).Are there threats or challenges to implementation or change?

Independent validation of laboratory developed tests need to be done for all clinical labs performing tick-borne testing.Possible conflict of interest for those pushing specific new technology.
	It is recognized that most tick-borne disease testing is performed using non-FDA approved laboratory developed tests or "in-house" tests performed in a Clinical Laboratory Improvement Amendments (CLIA) approved lab. It is unclear what level of test validation is routine in the field or even possible in cases of rare diseases and how this information is conveyed to patients and providers.
	With mounting evidence for increasing prevalence of tick-borne co-infections (IOM https://www.ncbi.nlm.nih.gov/books/NBK57020/), it must be considered as one possibility that lingering signs and symptoms possibly are due to ongoing infection with another agent that is not sensitive to doxycycline or that the symptoms are the result of other mechanisms due to ongoing inflammation that may be dependent or independent on persistent pathogens or antigens. Since persistence of *Borrelia* species and co-infections have been reported in the scientific literature after “standard” courses of antibiotics, it is dependent on the clinician to establish a differential diagnosis regarding ongoing signs and symptoms and the possible need for additional diagnostic tests and treatment. Persistent infection may require longer courses of anti-infective agents. If persistent infection has been ruled out (which is difficult to do with the current state of diagnostics), then in that case, continued antibiotic treatment is not without risk given the possible induction of dysbiosis with establishment of harmful, resistant bacteria, as well as direct organ damage. Both undertreatment and overtreatment also poses a significant financial burden to the patient. (Studies regarding persistence and antibiotics can be found in the Additional References by Topic section at the end of the document.)
	Laboratory developed tests may indeed be based on good science, but their predictive value is not known unless there is independent evaluation of their predictive value. This comprises a major gap in the confirmation of a clinical diagnosis of other tick-borne diseases and coinfections. On the one hand, the unified validated protocols and reagents of the Laboratory Response Network (LRN) have greatly enhanced the nation’s confidence in confirming or rejecting whether a sample contains an agent of biodefense interest. On the other hand, rigid adherence to protocols and the restricted availability of test reagents stifles innovation. The greatest confidence of a laboratory test is associated with those that have been used by many peer reviewed publications and have undergone interlaboratory comparisons using a defined sample panel developed by an independent agency with well characterized samples of known provenance. For virtually all other tick-borne diseases, such panels do not exist and indeed for most, known positive samples are small in number. This is a major gap for diagnosis of other tick-borne diseases and coinfections.
	One challenge for independent evaluation is that the laboratories’ methods may not be fully disclosed, and independent evaluations may affect the economic value of the LDT to a company or a patented technologies value to the inventor/researcher. Related to this issue is the possibility of conflicts of interests among those promoting “new and better tests,” particularly if they are LDTs proprietary to a for-profit company.
	Another challenge is the nature of “known positive” samples: Who should acquire such samples and designate their status? The best option would be to leverage the expertise of the Council of State and Territorial Epidemiologists (CSTE; https://cste.site-ym.com/?page=About_CSTE) and the Association of Public Health Laboratories (https://www.aphl.org/programs/infectious_disease/Pages/default.aspx), although their missions are directed solely at the nation’s public health programs. Nonetheless, the principles and procedures for validating tests to be used in our state health laboratories, and the development and adoption of surveillance case definitions could be used to apply to the clinical setting.Gaps

An easy-to-read, understandable, and complete flow chart or algorithm is needed to diagnose other tick-borne diseases and coinfections.
	Control samples available to laboratories (blinded) are needed to validate assays.
	New, more sensitive assays need to be available on site.Potential Actions for working group to consider for recommendations?

**Potential Action One:** Develop flow charts or algorithms for clinical diagnosis and laboratory testing. These would include algorithms for acute and chronic illness.

**Potential Action Two:** Promote independent validation of laboratory developed tests utilizing panels of control samples that are assessed blindly.

**Potential Action Three:** Establish realistic goals for new tests; in other words, there is no such thing as 100% sensitive and specific assays.

**Potential Action Four:** Examine ways to optimize sampling (skin for *B. burgdorferi, Rickettsia* spp., *Bartonella*spp.)

**Potential Action Five:** Develop new and better tests for other tick-borne diseases and coinfections in both acute and chronic presentations based on the needs identified from systematic review.

**Potential Action Six:** Expand the number of externally validated assays to provide complete coverage of other tick-borne diseases and coinfections.

**Votes of Subcommittee Members**

Potential actions were presented and discussed by subcommittee members. The wording of Potential actions here were voted on by subcommittee members and results are presented here.

**Vote on Potential Action One:** Develop flow charts or algorithms for clinical diagnosis and laboratory testing. These would include algorithms for acute and chronic illness.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**8
			2
			0
			1**Minority Response**

Two members did not vote in favor of this action. They did not believe that recommending flow charts for diagnosis fell within the subcommittee’s charge to identify gaps.

**Vote on Potential Action Two:** Promote independent validation of laboratory developed tests utilizing panels of control samples that are assessed blindly.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**10
			0
			0
			1**Vote on Potential Action Three:** Establish realistic goals for new tests; in other words, there is no such thing as 100% sensitive and specific assay.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**10
			0
			0
			1**Vote on Potential Action Four:** Examine strategies to improve appropriate diagnostic sampling (skin for *B. burgdorferi, Rickettsia* spp., *Bartonella*spp.)

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**10
			0
			0
			1**Vote Potential Action Five:** Develop new and better tests for other tick-borne diseases and coinfections in both acute and chronic presentations based on the needs identified from systematic review.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**10
			0
			0
			1**Vote on Potential Action Six:**Expand the number of externally validated assays to provide complete coverage of other tick-borne diseases and coinfections.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**10
			0
			0
			1Issue 4. Improve Surveillance for other tick-borne diseases and co-infections.

Questions: How to improve other tick-borne diseases and coinfections surveillance so that risk of disease is better understood leading to better mitigation strategies.

Background

The prevalence of agents causing OTBD&C has been changing, with regional, even county to county differences. Overall, they have increased significantly, often causing co-infections with agents transmitted by the same tick, or sequential infections transmitted by different ticks, including different species (Hutchinson et al., 2015). The clinical presentation of mixed infections can either be dominated by one of the co-infecting agents, or it can be different than either alone. Often, co-infections are reported to result in more severe disease, as is the case for co-infections with *A. phagocytophilum*, *Babesia,* and *Bartonella* species attributed to the remarkable capacity of these bacteria to infect neutrophil granulocytes, first line defenders of the innate immune system. Additionally, patients suffering from co-infections may need different treatment regimes, if the pathogens are not susceptible to the same drug, e.g., in mixed babesiosis-borreliosis cases or co-infection with an arbovirus (Frost et al. 2017). If only one of the agents is targeted, the other may become dominant, possibly resulting in fulminant, life-threatening infections.

Under-recognition of disease in patients who have inapparent symptoms, as in the case of Powassan/DTV, may occur, and may only be discovered when other pathogens have been screened for (i.e. West Nile virus or Jamestown Canyon virus) (Hinten et al. 2008). In these cases, knowledge of epidemiologic conditions, such as the presence of infected ticks, may be useful in potential diagnosis of disease (Diuk-Wasser et al. 2016; El-Khoury et al. 2016). It is also possible, perhaps common in “chronic Lyme disease,” that if the infection is not caught early, persistence is possible, and that an unrecognized second infectious agent or agent(s) may also persist and continue to cause illness, prompting continued doses of the inappropriate drug, with poor results. This problem emphasizes the need for including multiple OTBIs in diagnostic approaches. Certainly, existing single-target diagnostics can be implemented together, and some multi-target diagnostic serologic tests are available. Although these would cost more up front, the cost-savings and increased well-being to patients are potentially significant.

Why is it important?

There is currently a trend among states to re-evaluate surveillance programs, which may be seen as labor –intensive and costly (Cartter et al. 2018). As many state surveillance systems go from tracking individual cases of Lyme disease (because of the sheer volume), reporting of other tick-borne illnesses will, in most cases, continue (Dahlgren et al. 2015). This data provides important information, especially as questions arise on seasonality and geographic distribution of risk in states where these conditions are emerging or are newly recognized (Hinten et al. 2008).

What needs to be done?

Within state infrastructure, the presence of multi-disciplinary work groups tackling vector-borne diseases provides an opportunity for data and idea exchange on human, veterinary, and epidemiologic issues. Although generally held at state levels, they frequently, although not always, include public, private, university and NGO partners (such as medical institutions) in quarterly or bi-monthly meetings. In addition to the exchange of data presented at meetings, there may also develop the potential for collaborative projects centering on surveillance or recognition of tick-borne diseases at the state level (Nadolny et al., 2015)

Are there threats or challenges to implementation or change?

As cases of reported OTBD&C number far below Lyme disease nationally (Hook et al. 2015), one challenge is education among health care providers that other, less common tick-borne pathogens are cycling within their areas. For this reason, there is a strong incentive for communication among physicians and public health officials with other disciplines, such as wildlife agencies and veterinarians, who may be encountering ticks and their related pathogens in scenarios (such as field surveillance) not normally seen by clinicians (Kahn 2006). It is also possible that other tick-borne illnesses and coinfections are underreported and often mistaken for other chronic illnesses such as fibromyalgia or chronic fatigue.

Gaps: Improve surveillance for other tick-borne diseases and co-infections.

Potential Actions for working group to consider for recommendations?

**Potential Action One:** Increase resources available for surveillance including collaborative projects centering on surveillance or recognition of tick-borne diseases at the state level

**Votes of Subcommittee Members**

Potential actions were presented and discussed by subcommittee members. The wording of Potential actions here were voted on by subcommittee members and results are presented here.

**Vote on Potential Action One:** Increase resources available for surveillance including collaborative projects centering on surveillance or recognition of tick-borne diseases at the state level

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**9
			0
			1
			1Summary of Potential Actions:

Conduct good longitudinal cohort natural history studies of sequelae or complications of treated infections, as well as the human immune response to the infections; there is a need to control for additional tick exposure and have sufficient sample sizes. Ethical considerations prevent enrolling symptomatic subjects that remain untreated, but the natural history of untreated asymptomatic infection may provide data on the dynamic nature of the disease process (Does someone with positive serology but no signs or symptoms later develop disease in the absence of new exposure?).
	Educate health care providers, clinical testing laboratories, patients, and the general public about the broad range of tick-borne diseases and the role of tests vs. clinical diagnosis through a collaborative effort among medical agencies, private medical and patient organizations as well as knowledgeable clinicians and scientists.
	Create a tick-borne disease multi-site working group with a collaborative/standardized approach to data collection and studies. Increase resources available for surveillance or recognition of tick-borne diseases at the state level.
	Develop flow charts/algorithms for clinical diagnosis of other tick-borne disease and coinfections. These would include algorithms for acute and chronic illness.
	Expand the number of externally validated assays to provide complete coverage of other tick-borne diseases and coinfections. Perform independent validation of laboratory developed tests utilizing panels of control samples that are assessed blindly.
	Establish realistic goals for new tests (there is no such thing as a 100% sensitive and specific test)
	Examine strategies to improve and optimize appropriate diagnostic sampling (skin for *B. burgdorferi*, *Rickettsia* species, *Bartonella* species). Because it is not easy to predict what samples will be needed, an approach to specimen collection should be based on 1) a history of tick bite, tick exposure (many cases of tick-borne disease do not record a record of a tick bite), or visiting areas of known risk, and 2) thorough examination of the patient’s skin for suspected tick-bites and presence of rash. If an eschar and/or rash is found, such lesions should be sampled, in addition to obtaining blood. Such an approach is already taken by physicians in areas endemic for scrub typhus.Establish clinical definitions for other tick-borne diseases and coinfections so that a syndromic approach can be applied to a patient and lead to reflex testing for other tick-borne diseases and coinfections known to tick-endemic areas.
	Develop new and better tests for other tick-borne diseases and coinfections in both acute and chronic presentations based on the needs identified from systematic review.
	Determine what are the most accurate and cost-effective modalities. Due to the concern patients and patient advocates have for wanting to know the cause of illnesses associated with ticks, cost savings is not high on their list of priorities. Thus, we should consider cost savings and accessibility for accurate diagnostics, but a higher priority is to develop diagnostic modalities that accurately identify the cause(s) of other tick-borne diseases and coinfections.
	Finally, increase awareness of other tick-borne diseases and coinfections among health care providers and provide ongoing educational opportunities. An experienced individual who practices in an endemic region should be highly alert to the possibility of a tick-borne infection, look for additional evidence (e.g., rash, neurological impairment), and order appropriate laboratory tests (differential blood cell counts, IFA/Western blot, serum amino transferases, others) to support the suspected diagnosis. A rise in antibody titer is only helpful in paired serum samples taken weeks apart and cannot be used to guide immediate treatment decisions. NAAT, if positive, can be fast and specific, as well as sensitive, but are often not done in a physician’s office, rather are submitted to specialist testing labs. Some of the new advanced imaging diagnostics have proven to be very accurate. This again requires additional time. Through educating health care providers about the signs and symptoms of other tick-borne diseases and coinfections and the need to provide prompt treatment for suspected infections like Rocky Mountain spotted fever (using doxycycline in children and pregnancy) we will be able to decrease long term complications and lives will be saved.Priority #2: Treatment of Other Tick-Borne Diseases and Coinfections

**Note:**References are presented by topic at the end of the document in the “References by Topic” section.

Issue 1. Anaplasma

Clinical Picture/Syndromic Surveillance

Human granulocytic anaplasmosis (HGA) is caused by *Anaplasma phagocytophilum* (Ap) transmitted by *Ixodes scapularis* in the eastern and midwestern states, *Ixodes pacificus* in western coastal states, and *Ixodes ricinus* in Europe. Ap is found in *Ixodes spinipalpis* in mountain areas, but no human infections have been documented. The *Ixodes* species ticks that transmit HGA are also vectors for other human disease agents, and coinfection by *Anaplasma phagocytophilum* with *Borrelia burgdorferi* (Lyme disease), *Babesia microti* (babesiosis) and tick-borne encephalitis virus has been confirmed in both humans and laboratory animals. Transfusion risk has also been documented for HGA (as for other tick-borne pathogens including *Babesia*, *Bartonella* and relapsing fever borrelia such as *Borrelia miyamotoi*). Reservoirs include small mammals (white footed mouse), white tailed deer, and coyotes (northern California). In 1997, the presence of Ap in nymphal ticks was high (>25%).

HGA ranges in severity from asymptomatic seroconversion to a mild or severe febrile illness, and in rare instances, severe disease can result in organ failure or death. Symptoms typically begin a median of nine days following the tick bite, with most patients seeking medical attention within the first four days of illness. Nonspecific signs and symptoms include acute onset of fever, headache, malaise, arthralgias, myalgias, and occasionally gastrointestinal symptoms, including nausea, abdominal pain, and diarrhea. Rash is uncommon, noted in less than 10% of patients. Cough has also rarely been reported, as has central nervous system involvement, with meningoencephalitis occurring in approximately 1% of cases. Different peripheral nervous system manifestations have also been described, including brachial plexopathy, cranial nerve palsies (including bilateral facial nerve palsy), and demyelinating polyneuropathy, where recovery of neurologic function may be delayed over several months. The higher incidence of peripheral nervous system manifestations may be due to co-infection with *Borrelia burgdorferi* or a complicating opportunistic infection. Testing for co-infections is therefore advised, especially in cases of HGA with associated central or peripheral nervous system symptoms.

Fatalities associated with HGA occur in less than 1% of infections and are usually due to opportunistic infections, whereas 3% of human monocytotropic ehrlichiosis (HME) cases are fatal with the deaths occurring most commonly in immunosuppressed individuals who develop acute respiratory distress syndrome (ARDS), hepatitis, or opportunistic nosocomial infections.

Pathology/Pathophysiology

After a tick bite, *Anaplasma* *phagocytophilum* enters the circulation and multiplies within polymorphonucelar leukocytes and within endosomes, reprograming host cell defense mechanisms, which facilitate their survival. It is a gram negative obligate intracellular bacterium with two morphologic intracellular forms (DC [dense core] and RC [replicative, bigger]). The DC is necessary for adhesion and infection, and then the RC undergoes binary fusion, with new bacteria maturing into DC, then repeating the cycle. During infection, *A. phagocytophilum*upregulates the production of chemokine IL-8 as well as pro-inflammatory cytokines, contributing to its pathophysiological effects. Pathologic findings in patients with HGA and in animal models include normocellular or hypercellular bone marrow, hepatic apoptosis and focal splenic necrosis, and mild interstitial pneumonitis and pulmonary hemorrhage.

*A. phagocytophilum* uses multiple evasion strategies to inhibit neutrophil anti-microbial functions. One mechanism is its ability to inhibit the fusion of the lysosomes with the cytoplasmic vacuoles and arresting or inhibiting signaling pathways. Leukopenia and impaired function of neutrophils in patients with HGA can promote susceptibility to secondary and opportunistic infections, especially in those hospitalized with underlying diseases. Although the immune mechanisms that account for severe and fatal HGA are not completely understood, there is some evidence of immunosuppression in patients with HGA.

*Ehrlichia chaffeensis* (Ech), the agent of human monocytotropic ehrlichiosis (HME), is a bacterium of the family Anaplasmataceae and transmitted by the Lone Star tick, *Amblyomma americanum,*an aggressive human-biting species originally present in the southeastern, south central, and mid-Atlantic states. This tick species has progressively expanded its range northwards, and is now established in New York State and Iowa. In the United States, it is also the main species associated with alpha-gal allergy, and has been identified as a vector of Rocky Mountain Spotted fever rickettsiae (*Rickettsia rickettsii*) in its range. White-tailed deer and canids are reservoirs of *E. chaffeensis*, and deer also are an important host for the ticks. HME is an acute, pro-inflammatory syndrome similar to HGA, but usually more severe, and with a higher mortality rate. Unlike *A.* *phagocytophilum,* *E. chaffeensis*targets cells of the monocytic lineage, and is only rarely detected in peripheral blood smears. Similar to HGA, HME is more severe in older patients. *Ehrlichia ewingii* is more benign than either Ap or *E. chaffeensis,* and morulae have been confirmed only blood smears from in immune-compromised patients.

Evidence for Treatment

Human granulocytic anaplasmosis (HGA), caused by *Anaplasma phagocytophilum*; human monocytic ehrlichiosis (HME), caused by *Ehrlichia chaffeensis*; and human ewingii ehrlichiosis, (HEE) caused by *Ehrlichia ewingii* are the most frequent causes of human anaplasmosis and ehrlichioses. Their prevalence and incidence are increasing, and generally present as undifferentiated fever, with associated leukopenia, thrombocytopenia, and increased serum transaminases (also seen in rickettsiosis like Rocky Mountain spotted fever (RMSF), Heartland and Bourbon viral infections, and *B. miyamotoi* infection). Once an anaplasmosis or ehrlichiosis is suspected on historical and clinical grounds, doxycycline treatment should be initiated immediately with attempts at etiologic confirmation using laboratory methods including serology (IFA, or immunofluorescence antibody assay), PCR (or polymerase chain reaction, the most sensitive test for early infection), and culture. Blood smear examination (looking for morulae) can also be performed, but a negative result should not delay treatment. Blood samples must be taken prior to administering doxycycline therapy since morulae disappear from the blood within 24–72 hours after treatment, and prolonged examination is often required to accurately detect *A. phagocytophilum* morulae, as they can be present in less than 0.1% of neutrophils. Antibody formation does not usually develop during the time a patient presents with active disease, so treatment with doxycycline is required early in the course of a suspected illness, in order to decrease potential morbidity and mortality.

Obtaining a thorough clinical history is important to determine the probability of infection and the need for treatment. Clinical historical features include: recent tick bite or exposure; travel to endemic areas for tick-borne diseases; outdoor activities in areas likely to be tick-infested (tall grass, low brush, or grassy yards in endemic areas) or areas that border roads, trails, yards, or fields between the months of April to September. Certain recreational activities, such as golf, or military exercises have also shown to have a higher incidence of exposure. The presentation of a similar illness in family members, coworkers, or pet dogs also increases the probability of exposure. Since most patients will not recall a tick bite (nymphal ticks are small, and may be attached at areas not visible), the absence of confirmed tick exposure should not exclude the diagnosis.

If laboratory testing of a patient with a history of probable exposure to ticks in a region endemic for a human ehrlichiosis agent reveals leukopenia, thrombocytopenia, and/or elevated liver enzymes, the clinician should consider obtaining PCR and blood cultures, with appropriate serologic testing, and immediately initiate antibiotic therapy with doxycycline. Antibiotic therapy should be started as soon as infection is suspected, even before laboratory diagnosis has been confirmed.

Patients can be treated as outpatients with oral medication, if a reliable caregiver is available, and the patient is compliant with follow-up assessment and treatment. Hospitalization may be necessary to rule out life threatening disease and complications, especially in those with comorbid illnesses or who are immunosuppressed. Complications include respiratory failure, toxic shock-like syndrome, rhabdomyolysis, pancreatitis, acute renal failure, and opportunistic viral or fungal pathogen infections. Advanced age and delays in diagnosis and initiation of antibiotic therapy often lead to more severe clinical outcomes for HGA.

The current recommended therapeutic regimen for HGA is doxycycline twice a day for 5-14 days (oral/intravenous). Tetracyclines can also be used four times a day (QID), but due to frequent dosing schedules, doxycycline is the treatment of choice. The intravenous (IV) route is available in those with severe infection or gastrointestinal intolerance. Children under the age of eight should be given doxycycline since the illness can be life threatening (there is a minimal risk of teeth staining with short term use). A small number of pediatric-age and pregnant HGA patients have been successfully treated with rifampin, as it has good in vitro MICs (minimal inhibitory concentrations) necessary to kill the bacteria, but it is only recommended if there is a history of allergy to tetracycline antibiotics, pregnancy, or if the patient is under eight years old (and not with co-morbid conditions). The dosage for rifampin is twice daily for adults. Other antibiotics have not been proven to have adequate efficacy, including quinolones, chloramphenicol, cephalosporins, macrolides and gentamycin. Treatment should continue for at least three days until the patient is afebrile. Treatment with a tetracycline usually results in defervescence and improvement in the clinical picture within 24-48 hours. Lack of response suggests an alternative diagnosis such as a different tick-borne disease-causing leukopenia, thrombocytopenia, and/or a transaminitis which is not responsive to tetracyclines (Heartland and Bourbon viruses, Babesiosis) or a different secondary infection. Acute respiratory distress syndrome (ARDS), which is a rare complication of HGA, can also be seen with relapsing fever borrelia (responsive to tetracyclines), as well as in severe cases of Babesiosis and malarial infections (unresponsive to tetracyclines).

Evidence for persistent infection/chronic symptomatology/chronic co-infection

Persistent infection leading to chronic symptomatology has been reported in the scientific literature. See the “References by Topic” section at the end of this document.

Gaps in Knowledge/data

The true prevalence of human granulocytic anaplasmosis (HGA) infection and ehrlichioses is unknown, due to multiple species and lack of a case definition and proper testing among health care providers. Improved education among medical professionals regarding the signs, symptoms and laboratory abnormalities associated with HGA and obtaining a travel history can help decrease associated morbidity and mortality. The mechanism by which immune suppression occurs in HGA is not completely understood.

Opportunities/Recommendations Going Forward

Improved education among health care providers regarding the signs, symptoms, and laboratory abnormalities associated with HGA and HME can help decrease associated morbidity and mortality. Education on the appropriate use of laboratory testing and the need to immediately treat suspected clinical cases will help improve outcomes, especially in the young and elderly, who are most susceptible. Lives will be saved by broader awareness of this established recommendation, particularly among primary care providers, many of whom still consider the use of doxycycline in young children as contraindicated.

Investigations are needed to determine the mechanism by which immune suppression occurs (including animal studies), and to determine the true prevalence of HGA and other ehrlichiosis in the general population. This should be coordinated with other tick-borne diseases.

Potential Actions for Working Group to Consider

The subcommittee identified two potential actions that the federal government could take to improve treatment of tick-borne diseases and coinfections.

**Potential Action One:** Educate health care providers on the use of doxycycline: To decrease morbidity and mortality, doxycycline should be used as a first line treatment for all diseases resulting from tick bites when patients present with clinical symptoms suggestive of HGA or HME. It is the drug of choice for all groups, including children under the age of eight, and in pregnancy (short courses). Rifampin is another choice in pregnancy for HGA, depending on the clinician’s judgement. Dissemination of this information to all health care providers is important (standardized training modules, brochures, e-prescribing information).

**Potential Action Two:** Increase resources to determine mechanisms of immune suppression by Ap and Ech, and how best to address pro-inflammatory mechanisms post infection.

Votes of Subcommittee Members

Potential actions were presented and discussed by subcommittee members. The wording of potential actions here were voted on by subcommittee members and results are presented here.

**Vote on Potential Action One:** Educate health care providers on the use of doxycycline: To decrease morbidity and mortality, doxycycline should be used as a first line treatment for all diseases resulting from tick bites when patients present with clinical symptoms suggestive of HGA or HME. It is the drug of choice for all groups, including children under the age of eight, and in pregnancy (short courses). Rifampin is another choice in pregnancy for HGA, depending on the clinician’s judgement. Dissemination of this information to all health care providers is important (standardized training modules, brochures, e-prescribing information).

**Number in Favor**
			**Number Opposed**
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			**Number Absent**9
			0
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			2**Vote on Potential Action Two:** Dedicate research moniesIncrease research on mechanisms of immune suppression by Ap and Ech, and how best to address pro-inflammatory mechanisms post infection.

**Number in Favor**
			**Number Opposed**
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			**Number Absent**9
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			2Issue 2. Babesia

Clinical Picture/Syndromic Surveillance

The genus Babesia comprises over 100 species of tick-transmitted protozoal pathogens (piroplasms), which include the most common human pathogens: *Babesia microti*and B. duncani (WA-1) in the United States; Rarely: *Babesia*MO-1, KO-1; as well as B. divergens, B. venatorum (EU-1). Co-infection with *B. burgdorferi* increases the frequency of *B. microti* in infected ticks and Lyme disease is frequently transmitted at the same time as Babesiosis. A screening questionnaire to establish pre-test probability of exposure to *Babesia*would therefore be helpful. A recently validated Lyme disease questionnaire found two questions relate to symptoms of Babesiosis. “Any patient who complains of unexplained fevers, day and night sweats, chills, flushing, an unexplained cough, and shortness of breath (“air hunger”), which are questions number 1 and number 22 (Section 1 of the questionnaire), may have a concomitant infection with babesiosis. A *Babesia* panel approach with a Giemsa stain, *Babesia* titers (IFA) for multiple species of *Babesia* (*B.microti*, *B.duncani* [WA-1], *B.divergens,* and *B. sp. EU1*], with PCR and FISH (fluorescence in situ hybridization) testing, may help to establish the diagnosis in the United States and Europe while ruling out other causes of these symptoms.”

Clinicians should evaluate for the sudden onset of Babesiosis symptoms, such as fevers, sweats, shaking chills, fatigue, headaches, and so forth. Respiratory symptoms including an unexplained cough, and shortness of breath (“air hunger”) can also be seen. Five factors consistent with co-infection with Lyme disease were seen on the validated questionnaire: fatigue, flu like symptoms, joint stiffness, tingling, and concentration problems. Migratory joint/muscle/nerve pain was found to be highly correlated with exposure to Lyme disease, once other etiologies were ruled out. The Lyme questionnaire demonstrated convergent and divergent construct validity, as well as predictive validity. A score > 63 on the questionnaire confers a high probability of Lyme disease; Between 45-62 (probable), 25-44 (possible). Healthy individuals scored below 24. A high score on the validated questionnaire along with positive responses to questions 1 and 22 of section 1 of the questionnaire would therefore increase the pretest probability of exposure to Babesiosis, apart from exposure to Lyme disease.

Laboratory Evaluation

Malarial-like symptoms can be seen with or without associated laboratory abnormalities, including leucopenia, thrombocytopenia, transaminitis and hemolytic anemia (*B. divergens* increases the risk); Patients who are co-infected and/or with low levels of parasitemia may therefore not present with the classical symptoms of Babesiosis (i.e., anemia, leucopenia, thrombocytopenia, transaminitis). **Gap:** What is the mechanism/pathophysiology to explain differences in clinical symptoms and laboratory testing? Splenectomy and immunosuppression leads to severe illness. Severe disease is also usually seen in hospitalized patients with concurrent illnesses, including chronic conditions such as congestive heart failure (CHF) and renal failure.

*Babesia* are increasingly appreciated as a cause of transfusion-transmitted infection. Babesiosis is now the most commonly reported transfusion-transmitted protozoal infection in the U.S. (Chagas disease and malaria are others). 0.38% of 1,661,281 donations contained evidence of infection. Of this 0.38%, 20% contained *B. microti* DNA, suggesting viable parasites that comprise a transfusion hazard.

**Untreated individuals may be persistently parasitemic for months**
	**Most infections are subclinical or milder in younger individuals**
	**Screening of blood units is not done everywhere**Sensitive methods are therefore needed to screen blood products. Researchers have found that *B. microti* 18S rRNA is over 1,000-fold more abundant than its coding genes, making reverse transcription PCR (RT-PCR) much more sensitive than PCR. Babesia 18S rRNA may therefore be useful for screening the blood supply, apart from using standard antibody/PCR testing. Novel qPCR assays may also detect *Babesia* not found by IFA/FISH in asymptomatic patients (38%). Multiple species of *Babesia* (*B. duncani*, *B. divergens*) also increase the potential risk of transmission.

Pathology/Pathophysiology

Apart from causing a hemolytic anemia, atypical symptoms include an unexplained cough, air hunger, rarely ARDS (avoid steroids) and warm autoimmune hemolytic anemia. Although advanced age, immunosuppression, and splenectomy increase the risk of critical outcomes, severe hemolytic anemia as a presenting complaint has been reported in immunocompetent patients with intact spleens.

Pathophysiology of *babesiosis* includes potentially adverse effects on treatment of Lyme disease. Effective control of *B. burgdorferi* infection depends on a Th2 CD4+ T cell response within regional lymph nodes, and co-infection with *B. microti* may influence T cells toward a TH1 response. Suppressed immune responses can also be seen with parasites. There are immunosuppressive effects of *B. microti* infections on maintenance of co-infecting agents, and Infection with *Babesia*impairs other parasite clearance (nematodes like Trichuris, trypanosomes).

**Regimen Patient Dosing**

Adults and children: Atovaquone and azithromycin (oral) twice a day; or Clindamycin (oral or IV) every eight hours with Quinine (oral) every six hours. Dosing is dependent on body weight.

Adding high dose trimethoprim/sulfamethoxazole to Clindamycin and Quinine or Atovaquone and azithromycin may be a useful adjunct to combination therapy in treatment resistant babesiosis. Other antimalarial drugs such as mefloquine with artemisinin-based drugs also have some efficacy in treating resistant Babesiosis, although attention is needed to avoid drug interactions affecting QT intervals on the electrocardiogram. Newer treatment protocols for Babesia have also been recently published. Mycobacterial drugs like Dapsone with antimalarial activity have been demonstrated to be helpful in those failing classical therapy for Lyme disease with associated Babesiosis:

Newer combinations of endochin-like quinolones and atovaquone have been shown to be effective in animal models but have yet to be tested in human clinical trials.

Evidence for persistent infection/chronic symptomatology/chronic co-infection

Persistent infection leading to chronic symptomatology has been reported in the scientific literature. See the “References by Topic” section at the end of the document. See the “References by Topic” section at the end of this document.

Gaps in Knowledge/Data

There are two main species of Babesiosis responsible for clinical illness in the United States, which are *Babesia microti* and *Babesia duncani*. Rarely MO-1 or KO-1 will cause symptomatic disease, and patients may therefore not be diagnosed if only tested for one species. There is also genetic diversity (VNTR markers) among human babesiosis samples, which could lead to chronic illness. Some of the different Babesia species include:

*B. divergens* and *B. divergens*-like infections (including EU-1, MO-1) in the U.S., Europe, Russia and China
	*B. duncani* babesiosis, primarily in the western U.S. (clinicians have also been finding it in the eastern U.S., which requires further confirmation)
	Ruminant babesiosis (KO-1, *B. crassa*, others) in China and Korea
	*B. microti* babesiosis (Germany, Japan, Taiwan, Australia, Ecuador?)
	Babesiosis, no agent identified (South Africa, India, Brazil)
	Spurious (?) babesiosis: Bolivia, China, Nigeria, Egypt, Sudan, ColombiaObtaining a travel history is therefore important in order to determine the risk of exposure, as multiple species of Babesia (such as *B. duncani, B. divergens*) increase the potential risk of transmission.

The species of Babesia and comorbid conditions may also affect treatment decisions. Treatment failures across the northeast have been noted where there is *B. microti* babesiosis, primarily in people with associated comorbidity or immunosuppression. Lemieux et al. found mutations in the cytb and rpl4 genes of *B. microti* from patients with resistant infections (these genes in plasmodia are known to encode proteins with as sites where atovaquone and azithromycin bind). Resistance to atovaquone and azithromycin is now commonly seen in clinical practice, and research is therefore needed for more effective treatment protocols. Ineffective treatment can increase inflammation by increasing nitric oxide, resulting in more inflammatory cytokine production and a worsening clinical picture. Nitric oxide (NO) can be stimulated by infections (as well as toxins, and trauma), leading to increased levels of peroxynitrite. The oxidative stress that results stimulates NF-κB, subsequently increasing inflammatory cytokines, such as IL-1, IL-6, IL-8, TNF-α, IFNγ. These contribute to increased signs and symptoms seen with tick-borne illness.

Opportunities/Recommendations Going Forward

Certain groups are particularly at risk and more prone to the effects of Babesiosis. Transmission of *Babesia* takes place primarily through tick bites, but is also possible by blood transfusion, solid organ transplantation, as well as maternal-fetal transmission. High risk groups therefore include:

Very young and elderly individuals. Age-related pathology is seen in babesiosis, similar to Anaplasmosis, with a worsening of the clinical picture if a patient is splenectomized, immuncompromised, or has a co-infection. Physician education is therefore needed to identify the risk of Babesia in specific age groups with these medical conditions. This includes the judicious use of steroids, as death due to reactivation of latent babesia infections with high-dose corticosteroid therapy has been reported in the medical literature.
	Red Cross screened blood for Babesiosis should be considered in those requiring a transfusion, especially in those with comorbid conditions and/or those who are immunosuppressed. Babesia has also been reported to be transmitted by solid organ transplantation. Physician education is needed to help stratify risk and identify symptoms and potential risk factors post transfusion/transplantation.
	OB-GYN: Babesia is a risk among pregnant patients and requires education among obstetrician/gynecologists and midwives. HELLP Syndrome (hemolysis, elevated liver enzymes, low platelet count) can be confused with babesiosis, and mothers with pre-partum Lyme disease and subclinical babesiosis can still transmit the infection resulting in the fetuses requiring a transfusion. Physician education is therefore needed to establish the proper diagnosis and to understand risks and benefits of various drug treatments during pregnancy. Treatment in pregnancy includes Clindamycin plus Quinine for 7 days, which has been shown to be effective/safe in the 3rd trimester (high dose quinine can cause abortion in the 1st trimester). Clindamycin plus Mepron and Zithromax has also safely been used in the 3rd trimester, resulting in two consecutive healthy babies.
	Animal models and a defined clinical case definition creating a cohort is needed in order to study pathophysiology and mechanism of disease.Potential Actions for Working Group to Consider

The subcommittee identified four potential actions that the federal government could take to improve treatment of tick-borne diseases and coinfections.

**Potential Action One**: Increase research to improve diagnostics, developing broader *Babesia* testing panels, secondary to genetic diversity/multiple Babesia species.

**Potential Action Two**: Provide health care education among not only family practice/internal medicine physicians, but also subspecialists (including but not limited to hospitalists, OB/GYN, infectious disease doctors), regarding the signs/symptoms/risks/laboratory evaluation/treatment challenges of Babesiosis.

**Potential Action Three:** Conduct laboratory research and clinical trials to evaluate new treatment regimens for babesiosis. Resistance to standard babesiosis**regimens has been reported (medications, alternative medicine protocols), and patients who are immunosuppressed and/or with co-morbid conditions often fail treatment, leading to increased morbidity and mortality. These can be tested in animal models prior to clinical evaluation and human trials.

**Potential Action Four:** Conduct research on immunotherapy (e.g., human monoclonal antibodies) to control parasitemia while on drug treatment. Host factors are important, and more research is needed for determining the best therapeutic regimen in conditions where chronic parasitemia can exist.

Votes of Subcommittee Members

Potential actions were presented and discussed by subcommittee members. The wording of potential actions here were voted on by subcommittee members and results are presented here.

**Vote on Potential Action One**: Increase research to improve diagnostics, developing broader *Babesia* testing panels, secondary to genetic diversity/multiple Babesia species.

**Number in Favor**
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			2Minority Response

One member did not vote in favor of this action. Their position is that, “new” assays are less of a priority than implementing the existing ones or determining their predictive values. There are many PCR assays that have been used in multiple peer-reviewed publications that could be used (or are being used by select CLTs); all have sufficient sensitivity for clinical diagnostic use and have the capacity to detect all piroplasms. Independent validation (using well characterized clinical samples) of LTDs currently used could resolve discprencies between clinical diagnoses and expectations based on the known epidemiology of *Babesia*species such as *B. duncani”.*

**Vote on Potential Action Two**: Provide health care education among not only family practice/internal medicine physicians, but also subspecialists (including but not limited to hospitalists, OB/GYN, infectious disease doctors), regarding the signs/symptoms/risks/laboratory evaluation/treatment challenges of Babesiosis.

**Number in Favor**
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			2**Vote on Potential Action Three:** Conduct laboratory research and clinical trials to evaluate new treatment regimens for babesiosis. Resistance to standard babesiosis**regimens has been reported (medications, alternative medicine protocols), and patients who are immunosuppressed and/or with co-morbid conditions often fail treatment, leading to increased morbidity and mortality. These can be tested in animal models prior to clinical evaluation and human trials.

**Number in Favor**
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			**Number Abstained**
			**Number Absent**9
			0
			0
			2**Vote on Potential Action Four:** Conduct research on immunotherapy (e.g., human monoclonal antibodies) to control parasitemia while on drug treatment. Host factors are important, and more research is needed for determining the best therapeutic regimen in conditions where chronic parasitemia can exist.

**Number in Favor**
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			**Number Absent**9
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			0
			2Issue 3. Other Borrelia species: Borrelia miyamotoi (and relapsing fever borrelia), Borrelia burgdorferi sensu lato species

Clinical Picture/Syndromic Surveillance

*Borrelia miyamotoi* is spreading across the United States and is becoming increasingly recognized as a common tick-borne disease. For example, in adult *Ixodes pacificus* ticks in the San Francisco Bay area, *B. miyamotoi* is as abundant as *B. burgdorferi*. Increasing abundance of *B. miyamotoi* may be due in part to transovarial transmission of the bacteria, seen in 6-73% of the ticks. Recent figures showed that 4% of people living in southern New England had evidence of previous *B. miyamotoi* infection, and 2%-10% of all ticks that transmit Lyme disease contain *B. miyamotoi*. The frequency of *B. miyamotoi* infection was therefore comparable to that of other infections transmitted by *Ixodes scapularis*, such as anaplasmosis and babesiosis, and may be responsible for those with Lyme-like syndromes.

Antibody tests lack adequate sensitivity for early infection, leading to improper diagnoses, and some pathogenic strains belonging to the *B. burgdorferi* sensu lato complex have a worldwide distribution, yet they are rarely considered or tested for during a diagnosis workshop. Examples include recently discovered strains like *B. bissetti* and *B. mayonii*, and *B. burgdorferi* sensu lato species transmitted from *Amyblomma americanum* ticks causing STARI (Southern tick-associated rash illness).

The rising incidence of *Borrelia*infections includes more than 16 new species discovered between 1990-2017, increasing the worldwide threat of borreliosis. Not all of them have been implicated as human pathogens. Species that have been implicated in human disease to date include:

USA: *B. burgdorferi*sensu lato*, Borrelia*sensu stricto (B31) (297), *B. mayonii, B. bissettii, B. lanei.*These last two species were recently implicated as human pathogens in California.

Europe: *Borrelia afzelii* (Acrodermatitis chronica atrophicans [ACA]), *Borrelia garinii* (neuroborreliosis), *B. spielmani* (early skin disease), *B. valaisana*, *B. lusitanea*, *B. bavariensis*

The lack of a gold standard for diagnosis of different *Borrelia* species makes producing accurate statistics difficult. Since *B. miyamotoi* disease (BMD) does not usually cross react with *B. burgdorferi* tests, antibody testing for Lyme is not an effective tool for discovering BMD, and antibodies to the GlpQ protein will not identify early disease but can instead be used in convalescent illness. A new approach by Koetsveld et al. (2018) increases sensitivity in early infection by adding the variable major protein (vmp) as a recombinant antigen for EIA.

Clinical Picture/Syndromic Surveillance

The incubation period for relapsing fever borrelia transmitted by soft ticks is usually five to fifteen days. Symptoms typically last two to nine days and then recur. Acute onset can include non-specific symptoms, including:

Fever – up to 104 degrees (Differential diagnosis: babesiosis, brucellosis, Q-fever) with chills and sweats (which can be drenching)

Headaches (Differential diagnosis of other tick-borne diseases: Lyme, Ehrlichia, Q-fever...)

Myalgias and arthralgias (Differential diagnosis of other TBD’s: Lyme, Ehrlichia, Rocky Mountain spotted fever, Q-fever...)

Occasional conjuctivitis, cough

Atypical Symptoms: Relapsing fever can present as a “Great Imitator”

Gastrointestinal: nausea, vomiting, abdominal pain; diarrhea, hepatitis w/ hepatosplenomegaly (HSM) and jaundice (Differential diagnosis: Lyme, Ehrlichia, tularemia (typhoidal form), *Rickettsia*)

Cardiac: myocarditis, arrhythmias (Differential diagnosis: Lyme, *Bartonella*)

Pulmonary: acute respiratory distress syndrome (ARDS) (Differential diagnosis: *Babesia*, malaria, *Anaplasma*, Rocky Mountain spotted fever)

Hematology: Disseminated Intravascular Coagulation (DIC)

Central nervous system: facial nerve palsy, hearing loss, iritis, peripheral neuropathy, psychiatric symptoms, cerebrovascular accident, meningo-encephalitis

Pathology/Pathophysiology

*B. burgdorferi*, through gene recombination, can modify its surface antigen VlsE, and non-expressed vls, creating different outer surface antigens, helping to avoid immune recognition. *B. miyamotoi* and other relapsing fever spirochetes have the same pathogenic mechanism, explaining the relapsing/remitting aspect of the disease.

Transplacental infection of the human fetus has been recognized for relapsing fever borreliosis, as well as Lyme disease, babesiosis and bartonellosis, so active prevention and screening practices are needed to protect the fetus. *Borrelia miyamotoi* has also been shown to be able to survive in human blood components, so active screening of the blood supply is needed to decrease transfusion risk.

Evidence for Treatment

In vitro data: Tick-borne relapsing fever *Borrelia*(such as*B. hermsii)*are susceptible to doxycycline, azithromycin, and ceftriaxone (Rocephin) as well as amoxicillin; however, *B. miyamotoi* are resistant to amoxicillin in vitro.

Treatment: Central nervous system (CNS) involvement: Tetracyclines QID for 10 days; IV Rocephin once a day (cephalosporins like ceftriaxone are primarily used for CNS involvement), or alternatively use IV Pen G Q 4 hours.

Most cases are usually managed with penicillin, doxycycline, or tetracycline treatment if there is no CNS symptomatology. Some prefer penicillin as it is believed that this makes Jarisch–Herxheimer reactions (JHR) less likely. Less frequently, cephalosporins, erythromycin, and chloramphenicol have been used.

Ceftriaxone, Tetracycline, Erythromycin, and Chloramphenicol are medications with demonstrated efficacy in treating relapsing fever borreliosis.

**Evidence for persistent infection/chronic symptomatology/chronic co-infection**

Persistent infection leading to chronic symptomatology has been reported in the scientific literature. See the “References by Topic” section at the end of this document.

Gaps in Knowledge/data

True incidence of *B. miyamotoi* disease (BMD) and the role of *B. burgdorferi*sensu lato species in other diseases with a chronic fatiguing, musculoskeletal component (e.g., chronic fatigue syndrome, fibromyalgia) is unknown. *B. miyamotoi* is present in all tick species that transmit Lyme disease, and in 2013, NIAID-supported investigators showed evidence of *B. miyamotoi* infection in the United States. One of these preliminary studies showed patients with acute Lyme disease were more likely to be co-infected with *B. miyamotoi* than people who did not have Lyme disease, but how co-infection affects disease transmission and progression of illness is not known.

Opportunities/Recommendations Going Forward

Vector control and personal protection to prevent tick bites is essential. There is a significant risk of contracting relapsing fever bacteria like *Borrelia hermsii* since it can be transmitted within five minutes of a tick bite. Other species like *Borrelia miyamotoi* carry a risk of larval transmission, and larvae are too small for most people to detect.

To improve the quality of health care in the United States and lower costs, consider expanding testing panels to include other *Borrelia* species apart from *Borrelia burgdorferi*. Individuals across the United States with Lyme-like syndromes (chronic fatiguing, musculoskeletal illness) may also have been exposed to *B. burgdorferi* sensu lato species, and standard Lyme testing is not sensitive enough to detect all these varied species.

Threats or Challenges

Spirochetosis is being found by PCR in patients with Lyme disease during winter months, after conventional antibiotic regimens, and the ratio of *B. burgdorferi* to *B. miyamotoi* infections was found to be as high as 3:1. We need to consider *B. miyamotoi* and other *Borrelia*in “unexplained medical conditions” even after seemingly “adequate” therapy. *Borrelia miyamotoi* can also be transmitted by blood transfusion and relapsing fever borrelia are able to be transmitted from mother to fetus.

Potential Actions for Working Group to Consider

The subcommittee identified three potential actions that the federal government could take to improve treatment of tick-borne diseases and coinfections.

**Potential Action One**: Education: Improve public education on prevention of tick bites and education of health care providers regarding modes of transmission (tick bites, transfusion, maternal-fetal route) as well as the signs/symptoms of non-Lyme disease borrelioses.

**Potential Action Two**: Diagnostics: Expand routine testing panels to include other Borrelia species apart from *Borrelia burgdorferi*, since non-Lyme disease borreliosis may be more common than appreciated. These syndromes overlap symptoms seen in Lyme disease as well as other borrelia infections (fatigue, pain, sleep disorders, cognitive difficulties) and standard Lyme testing will not detect varied borrelia species. Adding the variable major protein (vmp) as a recombinant antigen for EIA along with GlpQ protein will help to identify both early and convalescent illness with B. miyamotoi disease (BMD).

**Potential Action Three**: Treatment: Evaluate efficacy of treatment regimens against diverse borrelioses**transmitted by soft/hard ticks, especially when different co-infections are present, as persistent infection has been reported.

Votes of Subcommittee Members

Potential actions were presented and discussed by subcommittee members. The wording of potential actions here were voted on by subcommittee members and results are presented here.

**Vote on Potential Action One:**Education: Improve public education on prevention of tick bites and education of health care providers regarding modes of transmission (tick bites, transfusion, maternal-fetal route) as well as the signs/symptoms of non-Lyme diseases borrelioses.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**9
			0
			0
			2**Vote on Potential Action Two**: Diagnostics: Expand routine testing panels to include other Borrelia species apart from *Borrelia burgdorferi*, since non-Lyme disease borreliosis may be more common than appreciated. These syndromes overlap symptoms seen in Lyme disease as well as other borrelia infections (fatigue, pain, sleep disorders, cognitive difficulties) and standard Lyme testing will not detect varied borrelia species. Adding the variable major protein (vmp) as a recombinant antigen for EIA along with GlpQ protein will help to identify both early and convalescent illness with B. miyamotoi disease (BMD).

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**9
			0
			0
			2**Vote on Potential Action Three**: Treatment: Evaluate efficacy of treatment regimens against diverse borrelioses**transmitted by soft/hard ticks, especially when different co-infections are present, as persistent infection has been reported.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**9
			0
			0
			2Patients study group

In July–August, 2013, 34 samples were collected from 24 residents of the southeastern USA for microbiological testing as part of ongoing studies of tick-borne diseases in the southern USA (University of North Florida IRB approval #468310-3). Written informed consent was obtained from each patient before enrolment in the study. The group consisted of three samples from North Carolina, eleven samples from Georgia and ten from Florida. Five residents provided serum and plasma samples, the rest contributed either serum (eight samples) or plasma (15 samples). The major symptoms observed in patients included severe headache, nausea, muscle and joint pain, numbness and tingling sensations in extremities, neck pain, back pain, panic attacks, depression, dizziness, vision problems, sleep problems and shortness of breath. Tick bite was recalled by 17 patients (71%), six patients were uncertain and one reported no tick bite. Lesions at the tick bite sites that resembled erythema migrans were observed in 12 patients (50%) and were highly variable in size, from a few centimetres in diameter to 9–12 cm in some cases. Six patients did not report a history of erythema migrans and the last six patients were uncertain. All 12 patients that had a history of erythema migrans were suspected of having Lyme borreliosis (LB) and were treated to some degree with antibiotics. All patients were tested for multiple tick-borne pathogens, including *Babesia microti*, *Rickettsia rickettsii*, *Ehrlichia chaffeensis* and *Borrelia burgdorferi*, using commercially available kits: tests for *Babesia microti*, *R. rickettsii* and *E. chaffeensis* (Focus Diagnostics, Cypress, CA, USA), Lyme IgM/IgG antibody ELISA and Lyme IgM and IgG Western blot (Quest Diagnostics, Madison, NJ, USA; Labcorp, Burlington, NC, USA, respectively). All patients had already undergone antibiotic treatments, some of extended duration, up to 9 months, that involved oral treatments with 100 mg doxycycline twice a day, as they were suspected of having LB.

Results: After 11 weeks of cultivation, atypically shaped microorganisms were observed in five out of 34 initial MKP cultures, i.e. one serum sample from North Carolina, two plasma samples from Georgia and two plasma samples from Florida. However, after 14 weeks of cultivation one serum sample from North Carolina and one plasma sample from Florida did not develop into growing cultures and did not show the presence of viable cells. PCR analysis of residual culture with B. burgdorferi s.l.-specific PCR primers confirmed the presence of Borrelia-related DNA in both of them. The remaining three plasma samples, M6p and M11p from Georgia, and M7p from Florida, developed into well-established cultures that confirmed their viability in two subsequent passages in MKP medium. Initially, all samples were seeded in duplicate into homemade complete MKP and BSK-H media under identical conditions. We do not present any data regarding the BSK-H part of the project as all BSK-H seeded samples were culture negative after 14 weeks of cultivation. M6p and M11p strains were isolated from a married couple, both 48-years old, currently living in Georgia, USA. The male patient (M6p) grew up in Tampa, Florida and was an airline pilot. Although travelling internationally for several years, he denied being exposed to tick habitat outside the USA. During the past few years he had flown only within the USA. The patient recalled tick bites in several areas of Georgia and Florida; however, the vast majority of bites were encountered at the site of his current residence. No information is available regarding the tick species. In 2010 he began experiencing muscle and joint pain, especially in his hips. He sought clinical evaluation in August 2011. Tests for *Babesia microti* and R. rickettsii (Focus Diagnostics, USA) were negative. Tests for E. chaffeensis IgM were positive at 1:40 (reference range <1:20) and IgG was positive at 1:256 (reference range <1:64). Lyme IgM/IgG antibody ELISA (Quest Diagnostics) was positive at 2.56 (diagnostic cut off is >1.19), whereas Lyme IgM and IgG Western blots were negative (Quest Diagnostics). The patient completed 9 continuous months of oral doxycycline treatment (100 mg twice per day) with resolution of most symptoms for the following year. However, by June 2013 his previous symptoms had re-emerged. The female patient (sample M11p), the spouse of the male patient described above, grew up in Alabama, and also lives at their residence in Georgia, USA. Over the years she experienced multiple tick bites (tick species is unknown) in her current neighbourhood. Only bites in June 2010 resulted in a noticeable rash on her abdomen and thigh. The patient experienced headache, nausea, muscle and joint pain, predominantly in her hands and arms. In August 2011 she was tested for the presence of multiple tick-borne pathogens. The Lyme IgM/IgG ELISA test gave borderline results at 1.18. Lyme IgM Western blot was negative. The presence of a single p41 band was observed on the Lyme IgG Western blot. Test results for all other tick-borne infections were negative. This patient also completed 9 months of continuous oral doxycycline treatment, with improvement of symptoms. Yet, her symptoms also returned approximately 1 year after the treatment.

The patient from Florida (sample M7p) was a 58-year-old female who grew up in New Jersey, moved to Georgia in 1983 and then to Tallahassee, Florida in 2006. In May 2013, she detected an attached tick, and experienced a rash at the tick bite site. She had not travelled from the site of her residence in the days before the tick bite. No information is available concerning the tick species. The patient’s primary-care physician suspected Lyme borreliosis. However, a Lyme IgM/IgG ELISA test was negative. She was prescribed 10 days of oral doxycycline (100 mg, twice per day), with an additional 30 days of doxycycline after that. After 40 days of continuous antibiotic treatment, the patient’s blood was collected for analysis. At that time, the patient experienced headache, neck pain, back pain, panic attacks, depression, dizziness, vision problems and numbness or tingling in the extremities, sleep problems, tinnitus and shortness of breath. Lyme IgM and IgG Western blot (Labcorp) tests conducted on the same blood samples were negative. The three patients presented were all seronegative according to the current CDC surveillance definition of LB, yet B. burgdorferi s.l. was isolated from each of them. Laboratory studies on multiple immunocompetent hosts involving highly sensitive and specific molecular tools for pathogen detection revealed the presence of persistent spirochaetes in host tissues months after antibiotic treatments.

Issue 4. Deer Tick Virus (DTV) / Powassan virus (POWV)

Clinical Picture/Syndromic Surveillance

Powassan virus (POWV) is transmitted to small- and medium-sized mammals by *Ixodes scapularis*, *Ixodes cookei*, and several other *Ixodes* tick species. The virus is transmitted by transovarian and transstadial passage in ticks. Tick prevention is essential due to potential severe complications from this disease. The virus was isolated from 4.9% of questing adults collected in four counties in NY (2012) and the Powassan virus can be transmitted within 15 minutes of tick attachment.

Two Powassan lineages are present: lineage I (prototype POWV) and lineage II (deer tick virus [DTV]). POWV lineage II, also known as deer tick virus, is the strain of the virus most frequently found in *Ixodes scapularis* ticks and is implicated in most cases of POWV encephalitis in the United States. Cases have been detected in New York, Connecticut, Massachusetts, Wisconsin, Minnesota, Colorado, West Virginia, and Ontario, Canada. The Centers for Disease Control and Prevention (CDC) previously reported over seventy cases of Powassan virus confirmed in the U.S., with five cases in Massachusetts (2015), and four cases recently in NY (Saratoga and Dutchess Counties, 2017). Incidence is highest in Minnesota where with the exception of 2014 and 2015, cases have been reported every year since 2008, with a peak of 11 in 2011 (range, 1 to 11), and 5 cases in 2016. However, the incidence of exposure is higher based on newly published literature. Thomm et al. (2018) recently reported that on samples collected from regions where Lyme disease is endemic, and seroprevalence for POWV in TBD samples was 9.4% (10 of 106) versus 2% when tested with non-tick borne disease samples (2 of 100, P = 0.034). No evidence of POWV infection was seen in samples collected from a region where Lyme disease was not endemic (0 of 22).

According to the CDC, many people who become infected with POWV do not develop any symptoms. The incubation period (time from tick bite to onset of illness) ranges from about one week to one month. POWV can infect the central nervous system and cause encephalitis and meningitis, leading to symptoms which can include fever, headache, nausea, vomiting, a stiff neck, weakness, confusion, loss of coordination, speech difficulties, and seizures. The majority of symptomatic POWV cases typically involve an initial febrile illness, where during the prodromal phase, sore throat, drowsiness, headache, and disorientation are commonly present. In more severe cases that progress to neurological involvement, the most common clinical presentations of disease are encephalitis (which can be hemmorhagic) with confusion, meningoencephalitis, and aseptic meningitis. The encephalitic phase is characterized by vomiting, prolonged fever, respiratory distress, loss of coordination, difficulty speaking, and seizures. Ocular symptoms, including ophthalmoplegia and direction-changing nystagmus, have been reported in some cases of POWV encephalitis. Throughout the encephalitic phase of disease, lethargy and some degree of paralysis are typical. Reports of both spastic and flaccid paralyses as well as coma in human infections have been reported.

Testing includes an indirect enzyme immunoassay (EIA) to screen for POWV, with EIA-positive samples reflexed to a laboratory-developed, POWV specific immunofluorescence assay (IFA).

A clinically compatible case of POWV neuroinvasive disease is defined as having a fever of greater than thirty-eight degrees centigrade, any signs of peripheral or central nervous system dysfunction documented by a physician, and the absence of a more likely clinical explanation. In addition to meeting the clinical disease criteria, one or more of the following laboratory criteria must be met for POWV diagnosis: POWV isolation; or detection of specific nucleic acid/ viral antigen in blood, CSF (cerebrospinal fluid), tissue, or other body fluids; or a four-fold change in POWV-specific quantitative antibody titers in paired serum; or POWV specific IgM antibodies in CSF with a negative result for other IgM antibodies in CSF for arboviruses endemic to the region where exposure occurred; or POWV-specific IgM antibodies in serum with confirmatory POWV-specific neutralizing antibodies in the same or a later specimen.

Sequelae

Approximately half of survivors with neuroinvasive disease have severe permanent neurological symptoms, such as recurrent headaches, muscle wasting, generalized weakness, and memory problems. Approximately 10% of POWV encephalitis cases are fatal.

Pathology/Pathophysiology

Neurons and glial cells are the preferential targets of infection. POWV encephalitis cases are typically characterized by perivascular and focal parenchymal infiltration composed largely of lymphocytes and monocytes. Occasional brain necrosis is associated with areas of more intense inflammatory infiltrates. The widespread destruction of neuronal cells has been detected in the large motor neurons of the brainstem, spinal anterior horns, cerebellum, basal ganglia, and thalamus. As with tick-borne encephalitis virus (TBEV) cases in Europe, magnetic resonance imaging (MRI) abnormalities for POWV cases are nonspecific and not diagnostic; The majority of the reported MRI findings for patients diagnosed with POWV describe T2/fluid-attenuation inversion recovery (FLAIR) hyperintensities within the brainstem, extending to the cortex and deep gray structures.

Evidence for Treatment

Persons with severe POWV illness often need to be hospitalized. Treatment is supportive, and may include respiratory support, intravenous fluids, and medications to reduce swelling in the brain. No effective treatment exists for severe disease, with a 10-15% mortality rate. There are several reports of high-dose corticosteroids used to treat patients with severe, neuroinvasive POWV disease, and all the treated patients survived, although the potential role of corticosteroids has not been clearly defined. Intravenous immunoglobulin (IVIG) for treatment of POWV encephalitis has also been tried. Both patients treated with IVIG survived the POWV infection, although one patient displayed significant neurological sequelae after discharge. The role of antiviral therapy in treating POWV disease is unknown.

Evidence for persistent infection/chronic symptomatology/chronic co-infection

Some flaviviruses, such as West Nile virus and Zika virus, share many biological characteristics to POWV, and have been shown to able to persist after acute infection. It is possible that POWV can establish a persistent infection in humans and/or be responsible for birth defects, but more research is required to answer these questions.

See the “References by Topic” section at the end of this document.

Gaps in Knowledge/Data

No effective treatment exists for severe neurological complications and sequelae. Increasing rates of exposure to POWV in highly Lyme endemic areas, with the potential for severe morbidity and mortality, requires more research into a cure and evaluating vaccines for prevention (TBEV in Europe has an effective vaccine). Due to some fundamental flaws in licensing and deployment of vaccines in the U.S., this is presently impractical, as companies attempting to bring a vaccine to market would likely not recover their monies, with a poor return on investment.

Transmission of TBEV has also been shown to be by consumption of raw milk from infected goat, cows and sheep, however it is currently unknown whether POWV can be transmitted by unpasteurized dairy products.

There is a lack of data regarding POWV infection in North America and little data regarding clinical presentations apart from cases of encephalitis. The clinical consequences of concurrent infection of POWV and Lyme bacteria are unknown. Long term outcomes of patients concurrently infected with POWV and Lyme bacteria are also unknown. Neurotropic tick-borne flaviviruses such as West Nile virus (WNV), Zika virus (ZIKV), and POWV share many biological characteristics, and more research is needed to determine whether POWV can establish persistent infection in humans as well as contribute to birth defects.

Opportunities/Recommendations Going Forward

The increasing numbers of individuals exposed to POWV in highly endemic areas, combined with the risk of contracting a potentially fatal illness with no cure, increases the opportunity to launch an effective educational campaign. The public needs to understand the necessity of instituting effective tick prevention. The best way to protect against Powassan and other tick-borne diseases is to avoid tick bites. This requires staying out of wooded or grassy areas whenever possible; spraying all areas of bare skin with an insect repellent containing at least 20% DEET (deep woods) or IR3535/picardin which repel ticks, keeping in mind that repellants only last for a few hours. Permethrin-treated clothing and gear will also decrease the risk of a bite. Once indoors, checking clothing and pets for ticks, along with a full body check is essential, especially in areas that might escape recognition, such as the scalp, behind the knees, axilla (armpit), and groin/perirectal area. Taking a bath or shower to find and wash off any ticks on the skin can also be helpful, while placing clothes in a dryer on high heat for 15 minutes which will kill ticks.

Potential Actions for Working Group to Consider

The subcommittee identified two potential actions that the federal government could take to improve treatment of tick-borne diseases and coinfections.

**Potential Action One:** Allocate resources for research into effective treatment: There is a need to develop effective treatment regimens in cases of POWV encephalitis with neuroinvasive disease. Approximately half of survivors with neuroinvasive disease have severe permanent neurological symptoms and 10% of POWV encephalitis cases are fatal.

**Potential Action Two:** Conduct research (animal models) to determine modes of transmission and whether persistence exists after an acute infection. Since other flaviviruses, such as TBEV, West Nile virus and Zika virus, share many biological characteristics to POWV, it is possible that POWV can establish a persistent infection in humans and/or be responsible for birth defects.

Votes of Subcommittee Members

**Vote on Potential Action One:** Allocate resources for research into effective treatment: There is a need to develop effective treatment regimens in cases of POWV encephalitis with neuroinvasive disease. Approximately half of survivors with neuroinvasive disease have severe permanent neurological symptoms and 10% of POWV encephalitis cases are fatal.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**8
			0
			0
			3**Vote on Potential Action Two:** Conduct research (animal models) to determine modes of transmission and whether persistence exists after an acute infection. Since other flaviviruses, such as TBEV, West Nile virus and Zika virus, share many biological characteristics to POWV, it is possible that POWV can establish a persistent infection in humans and/or be responsible for birth defects.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**8
			0
			0
			3Issue 5. Rickettsia (Rocky Mountain Spotted Fever - RMSF)

Rocky Mountain spotted fever (RMSF) is a life-threatening illness that has fallen under the radar of many health care providers because it is considered “rare.” However, given that patients who contract it fail precipitously and often die within just a few days, the spotlight needs to be directed at this dangerous disease. Gabby Galbo was just five years old when she was admitted to the emergency room with fever and chest pains. She tested negative for strep throat, and the doctors sent her home. After just two days and several more visits to the emergency room, Gabby died of sepsis. Her parents watched helplessly as their child deteriorated and ultimately succumbed. Only after they had ruled out many more common diagnostic possibilities did her providers begin to consider tick exposure and tick-borne diseases.

Gabby’s story is not unusual. Those who die from Rocky Mountain spotted fever, often children, experience the same precipitous decline that she did. However, it is a treatable disease, but only if detected early. Inadequate education about tick-borne diseases (at the clinical and state level), lack of proper testing, and delay in treatment resulted in Gabby’s death. This was in part due her providers taking an inadequate history and their lack of knowledge about tick-borne diseases like RMSF, tick seasonality, and timing of disease. They may also have been unaware that doxycycline is safe for all ages in the treatment of tick-borne diseases, and is the only effective treatment for RMSF. It can decrease the risks of life threatening complications, but only if given within the first five days of illness when it is most effective.

To read Gabby’s story, which is no different than the stories of hundreds of other children each year, refer to Appendix 3 at the end of this document.

Epidemiology

Rocky Mountain spotted fever (RMSF) is a nationally notifiable disease in the United States, and the reported incidence of RMSF and other tickborne spotted fever group (SFG) rickettsioses, including *Rickettsia parkeri* rickettsiosis and *Rickettsia*364D rickettsiosis, has increased markedly during the last 15 years. During 2000 through 2007, reported incidence rose from 1.7 to more than 7 cases cases per million persons. During 2008-2012, the estimated average annual incidence incidence of all SFG rickettsioses was 8.9 cases per million persons, with 63% of all reports originating from Arkansas, Missouri, North Carolina, Oklahoma, and Tennessee. The disease has emerged recently among several tribal lands in the southwestern United States, where the incidence rate is approximately 150 times higher than U.S. average in the most severely impacted communities. RMSF has also emerged as an important public health concern in states of Mexico, such as Baja California and Sonora, that border the United States.

Case fatality rates are disproportionately higher among young children as compared to adults. During 1983-2007, approximately 15% of all reported fatal cases of RMSF were in children under the age of 10, and from 2008-2012, case-fatality rates in this cohort were approximately five times greater than all other age groups combined. RMSF occurs throughout most of the Western Hemisphere.

The disease is almost always caused by the bite from an infected tick, although transmission via blood transfusion has been described. Throughout much of the United States, *Dermacentor variabilis*(the American dog tick) and*Dermacentor andersoni*(the Rocky Mountain wood tick) are considered primary tick vectors; however, *Rhipicephalus sanguineus* (the brown dog tick) is recognized increasing as the vector species responsible for perpetuating hyperendemic levels of this disease in the southwestern United States and northern Mexico.

Clinical Picture/Syndromic Surveillance

RMSF can be a difficult disease to diagnose clinically in its early stages, even by experienced physicians. While most patients seek care within the first three days after onset of fever, the prodromal signs and symptoms are nonspecific, and even in areas where awareness of the disease is high, most patients with RMSF are not diagnosed correctly on their first visit for medical care. Because the early signs, symptoms, and laboratory features of RMSF are often insufficient to differentiate this disease from other, more commonly encountered viral or bacterial illnesses that can present as an acute sepsis syndrome, epidemiological clues and basic awareness of the disease is imperative. Most deaths are attributable to delayed diagnosis and failure to initiate specific antimicrobial therapy within the first five to six days of illness. Timely administration of appropriate therapy is critical because at least one-half of all deaths occur within the first eight days of illness.

The disease begins with an abrupt onset of fever often accompanied by severe frontal headache, nausea or vomiting, and generalized myalgia. Other findings recorded with varying frequency in pediatric case series include calf tenderness, abdominal pain, irritability, splenomegaly, conjunctivitis, periorbital edema and peripheral edema, particularly involving the dorsum of the hands. A generalized maculopapular rash, consisting of discrete, 1 to 5 mm blanching macules, appears two to five days after fever onset. In most cases, the rash begins on the wrists, ankles, and forearms then spreads centrally to involve the legs, buttocks, trunk, and face. In more advanced cases of disease, the rash frequently involves the palms and soles. With progression of disease, the rash becomes more petechial, and individual lesions often enlarge and coalesce to form ecchymoses. In approximately 10% of patients, the rash is evanescent, atypical in distribution, or entirely absent, and RMSF can progress rapidly to life-threatening disease involving multiple organ systems. Manifestations of severe disease can include acute respiratory distress syndrome, first-degree atrioventricular block, cardiac failure, disseminated intravascular coagulopathy, gangrene, acute renal failure, seizure, coma, or tonsillar herniation.

Long-term neurological sequelae including hearing loss, speech dysfunction, hypertonia, paresis, parethesias, bladder and bowel dysfunction, vestibular and swallowing disorders can occur in people who survive severe disease. In children, behavioral disturbances and learning disabilities are among the most frequently described sequelae and generally occur in patients in whom severe alterations in consciousness occurred during the acute illness. Gangrene and extensive skin necrosis are relatively uncommon manifestations that occur in patients recovering from severe disease, and may involve digits, hands, feet, ears, nose, scrotum, or entire limbs**.**

Before the introduction and generalized use of effective antibiotic therapy for RMSF, approximately one in five patients infected with *R. rickettsii* died from the illness. With advances in treatment and medical care, U.S. deaths attributable to RMSF declined considerably; nonetheless, one well-characterized U.S. outbreak of this disease during 2002-2011, involving approximately 200 patients, revealed a case-fatality rate of 7%.

Pathology/Pathophysiology

*Rickettsia rickettsii* bacteria are inoculated into the skin of the host at the feeding site of the tick. Transmission generally occurs within a few hours after tick attachment but may occur as quickly as ten minutes depending on the species of tick and its prior feeding status. Unlike most other tickborne spotted fevers, an eschar rarely occurs at the inoculation site. The incubation period of disease onset ranges from four to eight days in most patients and reflects the interval during which the bacteria have disseminated to establish infection at distant sites within the systemic microvasculature of the host. Although *R. rickettsii*can infect several different cell types, its primary targets of infection in mammalian hosts are the endothelial cells lining capillaries, arterioles, and venules of all major tissues and organ systems. Damage to endothelium of the dermis, skeletal muscle, and vital organs such as brain, heart, lungs, kidneys, and gastrointestinal tract results in the systemic manifestations characteristically observed in people with RMSF.

Evidence for Treatment

RMSF is a life-threatening illness and appropriate antimicrobial therapy must be initiated quickly and empirically on the basis of clinical and epidemiologic findings. Clinicians must treat presumptively and should never delay or stop therapy while waiting for the results of a confirmatory test, or on the basis of an initially negative test result. Tetracycline-class antibiotics, most often doxycycline, are the treatment of choice. Patients treated with tetracycylines within the first five days of symptoms are significantly less likely to be hospitalized, require admission to an intensive care unit, or die than people treated later in the course of disease, or those treated with antibiotics with no efficacy against *R. rickettsii*.

For adults and children of all ages, doxycycline is the drug of choice for RMSF and all other rickettsial infections. Most patients with uncomplicated RMSF who receive doxycycline will become afebrile within 24 to 48 hours after initiation of therapy. The resolution of symptoms typically occurs more slowly in patients with severe illness, particularly in people with damage to multiple organ systems. Therapy should be continued for at least three days after unequivocal evidence of clinical improvement is seen. The usual duration of treatment is seven to 10 days. Previous studies of children who received older tetracycline-class antibiotics (e.g., tetracycline, oxytetracycline, and chlortetracycline) during tooth crown calcification linked these drugs with enamel hypoplasia and discoloration of permanent teeth. However, these observations have not been associated with the use of doxycycline, and multiple series examining the permanent teeth of children who received multiple courses of doxycycline while under eight years-of-age have demonstrated the absence of tooth staining, enamel hypoplasia, or tooth color differences attributable to this antibiotic.

Chloramphenicol is the only other antimicrobial agent with demonstrated clinical efficacy against *R. rickettsii*, but it is no longer available in the oral form in the United States. In addition, epidemiological data suggest that RMSF patients treated with chloramphenicol have a higher risk for severe illness and death than children treated with a tetracycline. In vitro evidence also suggests that chloramphenicol may also not be effective treatment of infections caused by *Ehrlichia*and *Anaplasma*species which can commonly present with similar clinical syndromes to RMSF. Penicillins, cephalosporins, macrolides, aminoglycosides, and sulfa-containing antibiotics are ineffective in treating RMSF. Sulfonamides have no activity against *R. rickettsii*and may exacerbate the disease. Some *Rickettsia* species are susceptible to rifampin, and a few case reports describe its successful use in patients with doxycycline intolerance. However, there currently are no clinical data to support its use as first-line therapy in patients with RMSF.

Evidence for persistent infection/chronic symptomatology/chronic co-infection

Severe multisystemic effects have been reported with delays in treatment. See the “References by Topic” section at the end of this document.

Gaps in Knowledge/Data

Despite recommendations by the U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics Committee on Infectious Diseases that advocate the use of doxycycline as primary therapy for RMSF in children of all ages, recent surveys indicate that many U.S. healthcare providers are still reluctant to prescribe doxycycline to children under 8 year-of-age, even in areas where RMSF is endemic. Improved clinical education of primary care providers and pharmacists is urgently needed to disseminate this life-saving information.

Opportunities/Path Going Forward

Clinical awareness of doxycycline as first-line therapy in children of all ages is crucial and needs to be articulated clearly to all primary care providers and pharmacists. A fundamental and effective approach to provide this information could be at the level of medical and pharmacy school education. By including this information in medical and pharmacy school curricula, and by informing future health care providers of the safety of this antibiotic in this patient cohort (as well as removing misinformation regarding its absolute contraindication in young children), lives will be saved.

Potential Actions for Working Group to Consider

The subcommittee identified two potential actions that the federal government could take to improve treatment of tick-borne diseases and coinfections.

**Potential Action One:** Education of all primary care providers and pharmacists regarding non-specific signs and symptoms of early infection with RMSF, where epidemiological clues and basic awareness of the disease is imperative. Education is also needed that doxycycline is indicated as first-line therapy for Rocky Mountain spotted fever in both children and pregnant women.

**Potential Action Two:**Education of****clinicians regarding the importance of treating Rocky Mountain spotted fever presumptively. Clinicians should never delay or stop therapy while waiting for the results of a confirmatory test, or on the basis of an initially negative test result.

Votes of Subcommittee Members

Potential actions were presented and discussed by subcommittee members. The wording of potential actions here were voted on by subcommittee members and results are presented here.

**Vote on Potential Action One:** Education of all primary care providers and pharmacists regarding non-specific signs and symptoms of early infection with RMSF, where epidemiological clues and basic awareness of the disease is imperative. Education is also needed that doxycycline is indicated as first-line therapy for Rocky Mountain spotted fever in both children and pregnant women.

**Number in Favor**
			**Number Opposed**
			**Number Abstained**
			**Number Absent**8
			0
			0
			3**Vote on Potential Action Two:**Education of****clinicians regarding the importance of treating Rocky Mountain spotted fever presumptively. Clinicians should never delay or stop therapy while waiting for the results of a confirmatory test, or on the basis of an initially negative test result.

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			3Issue 6. Bartonella species

Clinical Picture/Syndromic Surveillance:

Bartonella species infections complicate tick-borne infections in humans. Bacteria of the genus Bartonella are responsible for emerging and re-emerging diseases worldwide and can present with illnesses ranging from benign and self-limited diseases to severe and life-threatening diseases.

Example: A young woman experiencing depression, anxiety, mood swings, severe headaches, muscle spasms, interphalangeal joint stiffness, decreased peripheral vision, diminished tactile sensation, and hallucinations was persistently Bartonella koehlerae seroreactive and bacteremic. Following antibiotic treatment, B. koehlerae antibodies and DNA were not detected and all symptoms resolved.

Bartonella Case Report

“An 18-year-old female was sequentially examined by a neurologist, psychiatrist, neuro-ophthalmologist, and infectious disease physician because of a 4-year history of slowly progressive neurological and neurocognitive abnormalities. Celiac disease was diagnosed in December 2004, following complaints of frequent stomach cramps. Despite dietary control of gastrointestinal symptoms, she developed intermittent joint pain, primarily involving the ankles. During 2005, the patient reported reduced tactile sensation in her hands and by 2007 frequent severe headaches, back pain, generalized muscle spasms, and an inability to extend her fingers due to stiffness in her proximal and distal interphalangeal joints. In 2008, she was referred to a neurologist for evaluation of depression, anxiety, mood swings, dizziness, auditory and visual hallucinations, and a progressive decrease in peripheral vision. No abnormalities were observed on a noncontract magnetic resonance image (MRI) of the brain or an electroencephalogram.

The hallucinations were initially infrequent; however, by fall 2008, the hallucinations became frequent, more intense and at times were accompanied by 1- to 2-min dissociative episodes. The patient’s psychiatrist addressed her anxiety with cognitive behavioral therapy and anti-epileptic medication, which reduced hallucination frequency to less than once daily.

In January 2009, at the request of the patient’s parents, we performed PCR on aseptically obtained EDTA-anticoagulated blood and serum, inoculated EDTA blood into Bartonella- Alphaproteobacteria growth medium (BAPGM), and tested serum for immunofluorescent antibodies using cell culture grown *Bartonella vinsonii subsp. berkhoffii* genotypes I, II, and III and *Bartonella henselae* antigens, as previously described (2,5, 6, 11). (...) A PCR amplicon was obtained from the 14-day BAPGM enrichment culture, suggesting Bartonella sp. growth following incubation for 14 days.(....). Repeat testing generated no additional serological or molecular evidence to support previous or current infection with a Bartonella sp.

In March 2009, the patient was referred to a neuro-ophthalmologist because of decreased peripheral vision. The ophthalmologic examination was normal, with 20/20 visual acuity and no eye pain or redness. By formal perimetry, peripheral vision was reduced to the central 5 degrees bilaterally. The patient was advised to avoid driving a car and to repeat perimetry testing in a few weeks; however, the patient was noncompliant and was not reexamined until 20 months later.

In June 2009, her infectious-disease clinician initiated an 8-week course of doxycycline (100 mg twice daily) and rifampin (300 mg twice daily), due to ongoing symptoms and the January 2009 Bartonella genus PCR result in the 14-day enrichment culture. After starting antibiotics and while continuing cognitive behavioral therapy, and antiseizure medication, the patient reported a further decrease (from daily to one episode every 2 weeks) in hallucination frequency. When the patient was reexamined at the conclusion of the antibiotic course, treatment duration was extended for an additional 6 weeks due to the patient’s maladherence. Following completion of antibiotics, the patient regained the ability to extend her fingers and described improved tactile sensation. Her psychiatrist documented a further improvement, with her hallucinations changing from disturbing visual and auditory sensations, to non-disturbing episodes of hearing her name called, to simply a “white noise.” At the patient’s request, the dose of oxcarbazepine was reduced.

Microbiology

Bartonella is a fastidious chemotrophic gram-negative rod or cocci-rod. Bartonella infects erythrocytes or red cells, pericytes, vascular endothelium, dermis, prostate, brain, heart myocardium bone, etc, . In 2017 there were 36 species or subspecies, 14 of which cause human disease. Modern laboratory techniques and normal bacterial evolution result in new species or subspecies described each year.

Epidemiology

The primary reservoir of *Bartonella henselae* is feline: domestic cats, wild cats and feral cats. Other reservoirs include dogs and humans, which are reservoirs for *Bartonella quintana* and *bacilliformis*, *Bartonella*bacteremia in felines is estimated between 11 and 90 percent depending on location, and whether the animal is wild or domestic or feral.

The primary vector is the cat flea. Other vectors include sandflies, *Ixodes ricinus* ticks and body lice. Tick transmission is confirmed in dogs and Bartonella is present in ticks in different percentages depending on location (Regier 2016 Paras and Vect). However, the incidence of Bartonella bacteremia in felines, the widespread incidence of cat fleas as well as the documented incidence of persistent bacteremia and recurrent bacteremia after clearing of Bartonella from the blood makes confirming tick transmission difficult. However, there have been 45 field studies of Bartonella in both soft and hard ticks, worldwide. Bartonella incidence is 14-fold higher in nymphal ticks than in adult ticks in one study.

Rapid emergence of Bartonella species infection is likely due:

Weakened immune system, organ transplant and cancer with immunosuppressive therapies
	Increased outdoor activities, increased poverty-homelessness, rat exposure, increased international travel
	Coinfection with other organisms. See coinfection case (Breitschwerdt)
	More transport to many geo locations of zoo and domestic animals
	Diagnostic advances, PCR and advanced imaging of tissues
	better understanding of Bartonellae-vector-host interactionsMaternal-Fetal Transmission and Transfusion Risk

Maternal fetal transmission during pregnancy have been noted in case reports. Studies have also shown transfuction transmission risk. See the “References by Topic” section at the end of this document.

**Pathophysiology**—how does this bacterium cause all those symptoms?

While Bartonella species ultimately infect the red blood cell, upon introduction into the body, the red cell is not immediately invaded. The dermis, the site of inoculation, has been proposed as a primary niche for Bartonella (Hong et al. 2017, Maggi Et Al 2013, Eicher and Dehio 2012,). In some case the incubation period for RBC invasion can be 60 days. Additionally, Bartonella can reside in the endothelium (blood vessel wall), immune cells such as monocytes or lymphocytes, or in some cases the bone marrow in the proto-erythrocyte or lymph node. It is thought that the bacterium disseminates during this time, as eradication of the bacteremia often is impermanent and recurrence is common. Additionally, advanced imaging and PCR of tissues from Bartonella bacteremic subjects, revealed immunoreactive Bartonella spp. not only in the endothelial and red-blood cells but in the dermis, heart, teeth, bone and brain. The wide-spread distribution of these bacterium, often in patients with persistent Bartonellosis, may explain the vast array of symptoms seen with Bartonella infection. Additionally, these bacteria can form biofilms (heart, dermal collagen, PICC line) which confers resistant to immune surveillance and traditional antibiotic therapy.

Bacteremia and Disease Persistence

Harms et al. notes that Bartonella acts as a stealth pathogen in that it can manipulate and evade both the cellular and humoral immune response and foils both the innate and adaptive immune system.

Some biologic changes are similar to those known for *Borrelia burgdorferi*. Both cellular and humoral immunity are necessary for complete eradication of *Bartonella* from reservoir hosts. *Bartonella* actively alters host immune response resulting in persistent bacteremia. Antibody to *Bartonella* is able to remove it from blood but not from the intracellular niche resulting in persistent relapsing bacteremia. Studies in dogs and knockout mice indicated that both cellular and humoral responses are manipulated leading to increase in complex class II (MHC-II)-negative B cells and an increase in CD4+ T cells with abortive proliferation. CD8 cells are functionally handicapped. In addition *Bartonella* can upregulate genes towards proangiogenesis activation increasing IL-8 and activating NF-kappa B and VEGF. Bartonella live in and survive on endothelium and blood product and by upregulation provide their own “home” or niche in the host.

Interaction between simultaneous infecting pathogens and the effect on immune response of two or more pathogens needs to be explored in order to inform practitioners regarding diagnosis and effective treatment.

It is noted in Dehio that diagnosis of Bartonella is most often made on tissue specimens not via serology. PCR positive tissue, negative culture is frequent in studies. Negative serology and positive PCR is also frequently seen. Clinical signs of *Bartonella*include tracks formally referred to as striae. Recently linear lesions/striations have been described in a case report of a patient with Bartonella. Immunoreactive Bartonella henselae was found in a biopsy of this lesion. These linear Bartonella tracks may indicate disruption of the collagen in the dermis. (Ericson personal communication). Infection with Bartonella spp.can cause a variety of skin manifestations including bacillary angiomatosis, papules and nodules.

Symptoms of Bartonellosis

Symptoms: Bartonella can and does invade many if not all organs and tissues in the body. (private communication Edward Breitschwerdt) Symptoms confirmed from Bartonella infection include: Chest pain, Fatigue, Visual blurring and paralysis in upward gaze, Eye pain, Nystagmus, Pneumonia, Pain, Headache, Migraine type headache, change in consciousness, coma, arthralgia, fibromyalgia, photophobia, phonophobia, anxiety, seizures, pain syndromes including complex regional pain syndrome, and depersonalization

Diagnoses confirmed due to Bartonella

Cardiac: Pericarditis, endocarditis, and myocarditis

Pulmonary: pneumonia

Opthalmologic: Parinaud’s oculoglandular syndrome, retinitis

CNS: Encephalitis, encephalopathy, coma, seizures, Epilepsia partialis continua, status epilepticus, hallucinations, peripheral facial nerve paralysis, hemiplegia

Hematologic: hemolytic anemia, relapsing bacteremia,

G.I.: hepatosplenomegaly, hepatitis

Renal: Glomerulonephritis,

Orthopedic: Osteomyelitis

Skin: verruga peruna, bacillary angiomatosis, linear scarring from collagen malformation

Lymphatics: lymph node enlargement

Coinfection

In a rheumatologic practice in the Maryland DC area, 296 patients were investigated for infection with 3 *Bartonella*species. 41% were infected with one of the 3 species of *Bartonella. 62.5 % were seroreative to*Bartonella antigen. Only half of the patients with PCR positivity were seropositive for *Bartonella.* 65% of those who were PCR positive for *Bartonella* had previously been diagnosed with Lyme disease.

In California dogs with endocarditis were infected with *Anaplasma phagocytophilum*as well as Bartonella*.*This is probably important in terms of thinking of human tick-borne disease. There are case reports of *Anaplasma platys*, *Bartonella henselae* and *Candidatus Mycoplasma haematoparvum.*

Evidence for Treatment

In human cases of Bartonella**endocarditis, effective antibiotic therapy should include an aminoglycoside prescribed for a minimum of two weeks [190]. In immunocompromised patients with bacillary angiomatosis or bacillary peliosis, the effectiveness of treatments with various antimicrobial substances has been evaluated [127]. Over- all, tetracyclines, erythromycin, rifampin, azithromycin, doxycycline or a combination of these antibiotics are effective and should be administered in these patients for at least six weeks and be continued for 4 to 6 months.

Endocarditis

**Suspected Bartonella, culture negative**: Gentamicin and ceftriaxone with or without doxycycline.

**Documented Bartonella, culture positiv**e: Doxycycline and gentamicin.

Various antibiotic regimens have been used to treat patients with complicated CSD (retinitis, encephalopathy, and visceral forms). The combination of doxycycline with rifampin has been successful in treating patient with retinitis. If treatment is chosen for patients with central nervous system (CNS) disease, the combination of doxycycline and rifampin is preferred. The optimum duration of antibiotic therapy for immunocompetent patients with complicated CSD has not been determined.

Lesions of bacillary angiomatosis (BA) and Pelliosis resolved in several patients treated with ceftriaxone or fluoroquinolone compounds, but the progression of BA lesions in patients has been observed during treatment with ciprofloxacin. Additionally, a Bartonella species has been isolated from the blood or BA lesions of patients being treated with narrow-spectrum cephalosporins, nafcillin, gentamicin, and trimethoprim-sulfamethoxazole (but never from patients being treated with a macrolide, rifamycin, or a tetracycline).

Bartonella infections present a unique treatment challenge because they are persistent and often relapse and they involve an intraerythrocytic phase that apparently provides a protective niche for the bartonellae. For serious Bartonella infections, it is critical to use two antibiotics, each of which has good in vivo efficacy against Bartonella. This is particularly important if gentamicin is one of the drugs in the regimen, because the gentamicin protection assay with red blood cells infected in vivo, as well as the in vitro erythrocyte cell culture model, document that bartonellae residing within erythrocytes are protected from gentamicin.”

Recent clinical treatment updates has found that two intracellular drugs with good activity against *Bartonella*spp can result in clinical improvement and resolution in eliminating bacteremia. A recent case report describes a 31 year old female patient (presentation in 2010) who could no longer perform daily living or employment activities, with symptoms of muscle and joint pain, muscle weakness, headaches, tingling and fatigue. She had a fracture of her sesmoid bone in 2009 that was a non healing bone. The patent was diagnosed with Ehlers Danlos Type III and hypermobility. She had positive blood cultures for *Bartonella koehlerae* with positive PCR. Serology to five Bartonella species was negative.

Treatment: Azithromycin, Rifampin and Minocycline were started and four weeks later, joint pain was decreased and a non-healing sesmoid bone healed. The patient improved but remained bacteremic and antibiotic therapy was changed to Clarithromycin and Rifampin. This therapy was discontinued in August 2012 for pregnancy. Culture remained negative in 2016. The patient has remained free of rheumatologic symptoms through April of 2018 at the time of publication.

Treatment of symptomatic bacteremic Bartonella patients should include two intracellular antibiotics for 6 months. In a small series presented at a medical conference in 2014, Rifampin and Clarithromycin proved the most efficacious.

Gaps in Knowledge/data

The challenge for clinicians is establishing whether a patient with Lyme disease with ongoing, serious clinical manifestations despite classical therapy has a Bartonella infection. Issues with seronegativity, multiple species and persistence complicate the clinical setting.

Opportunities/Path Going Forward

The etiology of PTLDS has yet to be fully elucidated. Stealth infections like Bartonella may be playing a role according to certain clinicians, but more research is needed regarding tick transmission. We also need to expand diagnostic assays to include a broader range of species and evaluate more effective treatment protocols for persistent infection. Further animal models and human clinical trials are needed

Potential Actions for Working Group to Consider

The subcommittee identified five potential actions that the federal government could take to improve treatment of tick-borne diseases and coinfections.

**Vote on Potential Action One:** Allocate resources to improve and expand diagnostic assays to include a broad range of species of *Bartonella*.

**Vote on Potential Action Two:** Allocate resources to improve and expand research into modes of transmission and epidemiology.

**Vote on Potential Action Three:** Allocate resources to improve and expand research into the interaction between simultaneous infecting pathogens and the effect on the immune response of two or more pathogens. This is not unique to *Bartonella*, but applies to many vector-borne infections.

**Vote on Potential Action Four:** Conduct animal and human clinical trials to evaluate more effective treatment protocols, as *Bartonella*has been shown to persist despite single or combination therapy.

**Vote on Potential Action Five:** Allocate resources to conduct research to determine the risk of transmitting multiple tick-borne pathogens via the blood supply.

Votes of Subcommittee Members

Potential actions were presented and discussed by subcommittee members. The wording of potential actions here were voted on by subcommittee members and results are presented here.

**Vote on Potential Action One:** Allocate resources to improve and expand diagnostic assays to include a broad range of species of *Bartonella*.

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			3**Vote on Potential Action Two:** Allocate resources to improve and expand research into modes of transmission and epidemiology.

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			3**Vote on Potential Action Three:** Allocate resources to improve and expand research into the interaction between simultaneous infecting pathogens and the effect on the immune response of two or more pathogens. This is not unique to *Bartonella*, but applies to many vector-borne infections.

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			3**Vote on Potential Action Four:** Conduct animal and human clinical trials to evaluate more effective treatment protocols, as *Bartonella*has been shown to persist despite single or combination therapy.

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			3**Vote on Potential Action Five:** Allocate resources to conduct research to determine the risk of transmitting multiple tick-borne pathogens via the blood supply.

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			3Issue 7. Evidence of Chronic coinfection states/Other Pathogens

Mycoplasma Infections in Lyme disease patients

**Clinical Picture/Syndromic Surveillance.**In some clinical studies, approximately 70% of chronic Lyme patients were found to have systemic Mycoplasma species infections, and the species predominantly found in Lyme patients was M. fermentans. That is not the species found in other chronic conditions, such as fibromyalgia, chronic fatigue syndrome, rheumatoid arthritis and autism sectrum disorders where M. pneumoniae is the most common Mycoplasma species found. The overall incidence of Mycoplasma infections in non-Lyme patients is about 50%. Although these findings implicate the potential role of Mycoplasma as a co-infecton in those suffering with Lyme and tick-borne illness, this needs to be confirmed in larger clinical studies.

*M. fermentans* has been found in ticks in Northern California, New York and New Jersey, but there is much less evidence of *M. pneumoniae* in ticks. This may be why Lyme patients usually have more *M. fermentans* than *M. pneumonia* infections, suggesting that *M. fermentans* is transmitted by ticks and is not simply a bystander infection waiting to proliferate in immune-suppressed hosts. More research is needed in this area.

In other chronic conditions *M. pneumoniae,* not *M. fermentans*, is the most common *Mycoplasma*infection found. The fact that patients with Lyme disease have this systemic infection at much higher rates than many other common Lyme bacterial and viral co-infections suggests that this is an important co-infection in Lyme patients. There are problems with testing for *Mycoplasma* as with other intracellular bacterial infections, and this needs to be addressed in future research studies. Similarly, treatment strategies have not progressed beyond long-term doxycycline with dietary supplements.

Gaps in knowledge/Opportunities for Expanded Treatment Options

A potential opportunistic infection that is postulated to also be vector borne may simultaneously infect hosts with known tick-borne pathogens.

While pathophysiology of *Borrelia burgdorferi* and *Borrelia burgdorferi* sensu lato is well delineated and described both in vitro, in animal models and in humans, the pathophysiology of *Babesia*, *Ehrlichia*, and *Anaplasma* are less well explored.

Multiple overlapping sources of inflammation have been reported in patients with other tick-borne diseases and co-infections, increasing inflammatory cytokine formation, confounding and worsening symptomatology. These can include factors not directly related to tick bites and associated pathogens yet worsening the clinical picture. These can include: leaky gut/food allergies, dysglycemia and insulin resistance, imbalances in the microbiome, mineral deficiencies (zinc), sleep disorders (increasing IL-6) and exposure to environmental toxins (heavy metals, pesticides, volatile organic solvents (VOS), small particle pollution, and mold) with associated detoxification problems. Some environmental toxins (mold gliotoxins) are also known to be immunosuppressive or associated with autoimmune reactions (mercury, small particle pollution, asbestos, BPA).

Free radical accumulation and the resulting oxidative stress from Lyme and tick-borne infections along with environmental toxins may also damage mitochondrial membranes, leading to mitochondrial dysfunction, and/or cause nerve dysfunction with associated neuropathy and postural orthostatic tachycardia syndrome (POTS)/dysautonomia. These symptoms will not respond to anti-infective therapies but require instead a targeted therapeutic approach.

Potential Actions for Working Group to Consider

The subcommittee identified two potential actions that the federal government could take to improve treatment of tick-borne diseases and coinfections.

**Potential Action One:** Review the role of overlapping causes of inflammation, such as associated Mycoplasma infections, environmental toxins, food allergies and leaky gut, as well as imbalances in the microbiome. Some of these are not directly related to tick-borne disease, but may be contributing to autoimmunity and ongoing chronic symptomatology in PTLDS leading to increased health care costs and disability.

**Potential Action Two:** Conduct research on the role of free radical oxidative stress and cytokine production during tick-borne infection. Downstream effects of inflammation may result in disabling symptoms. More research is needed in this area to improve therapeutic outcomes. Allocate resources to conduct clinical trials to identify contributing causes and confounding factors.

Votes of Subcommittee Members

Potential actions were presented and discussed by subcommittee members. The wording of potential actions here were voted on by subcommittee members and results are presented here.

**Vote on Potential Action One:**Review the role of overlapping causes of inflammation, such as associated Mycoplasma infections, environmental toxins, food allergies and leaky gut, as well as imbalances in the microbiome. Some of these are not directly related to tick-borne disease, but may be contributing to autoimmunity and ongoing chronic symptomatology in PTLDS leading to increased health care costs and disability.

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			3**Vote on Potential Action Two:**Conduct research on the role of free radical oxidative stress and cytokine production during tick-borne infection. Downstream effects of inflammation may result in disabling symptoms. More research is needed in this area to improve therapeutic outcomes. Allocate resources to conduct clinical trials to identify contributing causes and confounding factors.

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			3General Treatment Resources

For general treatment resources, refer to the References by Topic section at the end of this document.

Priority #3: Alpha-gal Meat Allergy

Background

In the United States, meat allergy caused by alpha-gal sensitization occurs in individuals who have experienced prior bites from a lone star tick, *Amblyomma americanum*. Unlike other tick-borne diseases, this illness is not thought to be due to an infection, but to the development of immunoglobulin (Ig) E against the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal) which has been found to be present in the gastrointestinal tract of at least one species of tick. This alpha-gal meat allergy was only recently reported (in the early 2000s), first in the southeastern United States where *Amblyomma americanum* is common. There is no evidence for other tick species causing the allergy in North America. Since then however, the alpha-gal allergy meat has been reported in other areas of the world where it is due to other tick species including *Ixodes ricinus, Ixodes holocyclus, Amblyomma cajennense, Amblyomma sculptum, and Haemaphysalis longicornis*. *H. longicornis* has recently been identified as an imported tick species in New Jersey raising the possibility of alpha-gal sensitization by this invasive tick species.

The magnitude of the problem and the true number of cases is unknown, as there is very little awareness of alpha-gal allergy. Alpha-gal allergy it is not a reportable disease. Endemic regions in the United States correspond to the distribution of lone star ticks and range from Long Island to the Southeastern states.

The lone star tick is also the principal vector of several potentially life-threatening and debilitating infectious diseases, including ehrlichiosis, Heartland virus infection, and Bourbon virus infection, and its range has expanded rapidly and extensively across much of the eastern United States during the last 50 years. Established populations of *A. americanum*now extend from the Gulf of Mexico as far north as Minnesota in the north central states, as well as throughout Pennsylvania and New York, and parts of Connecticut. In the Midwestern US populations of lone star ticks are now described from Nebraska and South Dakota. Collectively, these data suggest that an increasing percentage of the US population is at risk to the multitude of disease caused by this tick, including alpha gal meat allergy. Anecdotal reports from allergists in endemic areas suggest that the number of cases is at least in the thousands and possibly higher. Some authorities have suggested that the number of cases of alpha-gal meat allergy may be as high as the number of other tick-borne infections. The number of cases is likely increasing as the geographic range of lone star ticks expands.

Prevention. Prevention of alpha-gal meat allergy rests on established principals of tick bite prevention in general. However, increased awareness and public health education programs specifically about alpha-gal allergy and targeted towards both the general public and clinicians in endemic areas are also needed.

The clinical spectrum and pathogenesis. The alpha-gal meat allergy is a vector-induced, mast-cell and IgE mediated allergy. Although most food allergies present with immediate symptoms such as mouth tingling, in patients with convincing evidence of IgE-mediated alpha-gal allergy the reaction began as quickly as several minutes or was as delayed as three to six hours after ingestion. Patients may also develop symptoms in the middle of the night after eating meat for dinner. This variability in time to symptom onset may be explained by the nature of the carbohydrate allergen (in contrast to typical protein allergens). It can present with urticarial, gastrointestinal symptoms, and airway angioedema. Fatalities are rarely seen, but it can be life-threatening with anaphylaxis. Patients react to a carbohydrate antigen in all non-primate mammalian meats, gelatin (highly sensitive individuals may react to BSA in a drink or gelatin in a capsule), or very rarely, dairy. Personal care products, certain medical products and nutritional supplements are not typically implicated in alpha-gal meat allergy although anecdotal cases have been discussed.

The cross-reactive carbohydrate determinant, alpha-gal, which is present on a range of mammalian meats, has been shown to be a potent allergen. Patients who have IgE to alpha-gal can develop severe hypersensitivity reactions to the monoclonal antibody cetuximab, (epidermal growth factor receptor inhibitor), which also contains alpha-gal. This association was made after a group of patients experienced anaphylaxis upon their initial exposure to cetuximab, indicating that they had been previously sensitized to some component of the drug. A subset of these patients living in the southeastern United States also described delayed anaphylaxis to beef, pork, lamb or other non-primate mammalian meat, despite having tolerated these meats previously. These reactions are atypical for other IgE-mediated allergies in that they do not start until several hours after meat ingestion and are associated with negative or very weak wheal responses to prick tests with meat extracts.

In central Virginia, the alpha-gal meat allergy is now the most common cause of anaphylaxis in adults. Among city dwellers the syndrome is rare, but nonetheless needs to be on the list of possible causes of otherwise unexplained anaphylaxis.

The diagnosis. Many of the patients described in the literature have reported that allergic symptoms to meat ingestion began after a series of tick bites from *Amblyomma americanum*. Alpha-gal meat allergy should be part of the differential diagnosis of idiopathic anaphylaxis. IgE antibody levels to alpha-gal is diagnostic. A positive test for alpha gal can be subclinical, or “false +”. IgE immunoassays to galactose-alpha-1,3-galactose (alpha-gal), are commercially available

Differential Diagnosis

The differential diagnosis of alpha-gal allergies includes other forms of anaphylaxis and IgE mediated allergies. In addition, Mast Cell Activation Syndrome (MCAS), Systemic Mastocytosis (SM), and Mast cell Leukemia [MCL]) could be in the differential diagnosis.

**The treatment.** Treatment of alpha gal allergy begins with avoidance of exposure to mammalian meat products, most importantly in food products. Unfortunately, the allergic response cannot be avoided by cooking the meat, as it is a due to a carbohydrate antigen. Antihistamines can be taken before eating as prophylaxis. Management largely consists of avoidance of the causative meat and patient education about how to self-inject epinephrine if needed for accidental exposures. Over time following the initial tick bite, the intensity of the allergic response has become less severe in many affected individuals.

Gaps in knowledge/data

There are several major gaps in the alpha-gal field including

There is no surveillance for the number of cases of alpha-gal allergy and the trends over time of geographic expansion of the disease.
	The exact nature of the allergen in lone star ticks is unknown.
	Insufficient education and awareness. Education is needed regarding the range of potential triggers. Alpha-gal sugar is found not only in beef, but also pork, lamb, venison, goat, and bison, and the alpha gal allergy can also can be triggered by animal-based products containing gelatin
	The role of other triggers such as personal care products (select perfumes, colognes), and medical products (select IV bags contain gelatin), nutritional supplements (i.e., magnesium stearate can be mammal/animal derived), as well as "natural flavorings" which often contain mammal/animal ingredients, and adhesives (stamps, tape, band-aides) needs further investigation
	Effective measures to prevent lone star tick bites.
	Effective measures to prevent exposure to alpha-gal containing substances through proper labeling of foods/beverages/personal care products/medical products/nutritional supplements.
	Inform patients on the need to carry an EPI-PEN, Medrol dose pack, and Benadryl for anaphylactic reactions
	Treatment/Evaluating the magnitude of the problem: Gaps exist in both treatment and evaluating the magnitude of the problem as well as the mechanisms of action that drive pathogenesis causing anaphylaxis.
	There is currently no plan for an organized approach to education and awareness for alpha-gal allergy. There are no HSS/NIH sponsored programs for Centers of Excellence or Collaborative Networks for Tick-borne diseases, including alpha-gal allergy. Research funding for tick-borne diseases, and alpha-gal specifically, is limited and not commensurate with the ever-increasing number of cases in the US.
	There are CDC-sponsored centers of excellence for vector-borne diseases, which include tick-borne diseases, e.g., the ones at the U of WI - Madison, KSU - ManhattanPotential Actions for the Working Group to Consider

**Potential Action One:** Increase education and awareness pre-diagnosis, and counseling after diagnosis.

**Potential Action Two:** Increase research and educational efforts regarding food or food-based products that contain meat allergens that pose a risk to the public following a tick bite.

**Potential Action Three:** Increase resources for surveillance of alpha-gal allergy in human populations within the expanding range of *Amblyomma americanum*.

**Potential Action Four:** Dedicate additional resources for surveillance and control of *Amblyomma americanum* across its expanding range.

**Potential Action Five:** Increase resources for immunologic and animal model research to identify and better understand the tick allergens that cause alpha-gal meat allergy.

Votes of Subcommittee Members

Possible actions were presented and discussed by subcommittee members. The wording of possible actions here were voted on by subcommittee members and results are presented here.

**Vote: Potential Action One:** Increase education and awareness pre-diagnosis, and counseling after diagnosis.

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			1**Vote: Potential Action Two:** Increase research and educational efforts regarding food or food-based products that contain meat allergens that pose a risk to the public following a tick bite.

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			1**Vote: Potential Action Three:**Increase resources for surveillance of alpha-gal allergy in human populations within the expanding range of *Amblyomma americanum*.****

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			1**Vote: Potential Action Four:** Dedicate additional resources for surveillance and control of *Amblyomma americanum* across its expanding range.

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			1**Vote: Potential Action Five:** Increase resources for immunologic and animal model research to identify and better understand the tick allergens that cause alpha-gal meat allergy.

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			1References

Priority #1 Improving the detection and diagnosis of other tick-borne diseases and co-infections

Aguero-Rosenfeld, M., Nowakowski, J., Bittker, S., Cooper, D., B Nadelman, R., & P Wormser, G. (1996). Evolution of the serologic response to Borrelia burgdorferi in treated patients with culture-confirmed erythema migrans. *Journal of Clinical Microbiology*, *34*, 1–9.

Akoolo, L., Schlachter, S., Khan, R., Alter, L., Rojtman, A. D., Gedroic, K., ... Parveen, N. (2017). A novel quantitative PCR detects Babesia infection in patients not identified by currently available non-nucleic acid amplification tests. *BMC Microbiology*, *17*. https://doi.org/10.1186/s12866-017-0929-2

Allred, D. R. (2003). Babesiosis: persistence in the face of adversity. *Trends in Parasitology*, *19*(2), 51–55. https://doi.org/10.1016/S1471-4922(02)00065-X

Beaman, M. H. (2016). Lyme disease: why the controversy? *Internal Medicine Journal*, *46*(12), 1370–1375. https://doi.org/10.1111/imj.13278

Bloch, E. M., Herwaldt, B. L., Leiby, D. A., Shaieb, A., Herron, R. M., Chervenak, M., ... Kjemtrup, A. M. (2012). The third described case of transfusion-transmitted Babesia duncani. *Transfusion*, *52*(7), 1517–1522. https://doi.org/10.1111/j.1537-2995.2011.03467.x

Branda, J. A., Body, B. A., :, J., Branson, B. M., Dattwyler, R. J., Fikrig, E., ... Schutzer, S. E. (2018). Advances in Serodiagnostic Testing for Lyme Disease Are at Hand. *Clinical Infectious Diseases*, *66*(7), 1133–1139. https://doi.org/10.1093/cid/cix943

Breitschwerdt, E. B., Hegarty, B. C., Qurollo, B. A., Saito, T. B., Maggi, R. G., Blanton, L. S., & Bouyer, D. H. (2014). Intravascular persistence of Anaplasma platys, Ehrlichia chaffeensis, and Ehrlichia ewingii DNA in the blood of a dog and two family members. *Parasites & Vectors*, *7*, 298. https://doi.org/10.1186/1756-3305-7-298

Brownson, R. C., Colditz, G. A., & Proctor, E. K. (Eds.). (2017). Dissemination and implementation research in health: translating science to practice. Oxford University Press.

Calder, J. A., Reddy, G. R., Chieves, L., Courtney, C. H., Littell, R., Livengood, J. R., ... Dame, J. B. (1996). Monitoring Babesia bovis infections in cattle by using PCR-based tests. *Journal of Clinical Microbiology*, *34*(11), 2748–2755.

Cartter, M. L., Lynfield, R., Feldman, K. A., Hook, S. A., & Hinckley, A. F. (2018). Lyme disease surveillance in the United States: Looking for ways to cut the Gordian knot. *Zoonoses and Public Health*, *65*(2), 227–229. https://doi.org/10.1111/zph.12448

Centers for Disease Control and Prevention. (2015). *Lyme Disease Frequently Asked Questions (FAQ).* Retrieved from https://www.cdc.gov/lyme/faq/index.html

Citera, M., Freeman, P. R., & Horowitz, R. I. (2017). Empirical validation of the Horowitz Multiple Systemic Infectious Disease Syndrome Questionnaire for suspected Lyme disease. *International Journal of General Medicine*, *10*, 249–273. https://doi.org/10.2147/IJGM.S140224

Clay K., Fuqua C. (2010). The tick microbiome: diversity, distribution and influence of the internal microbial community for a blood-feeding disease vector. Critical needs and gaps in understanding prevention, amelioration, and resolution of Lyme and other tick-borne diseases: the short-term and long-term outcomes [Workshop]. Washington, D. C.: Institute of Medicine Committee on Lyme Disease and Other Tick-Borne Diseases: The State of the Science. Available: iom.edu/∼/media/Files/Activity%20Files/Disease/TickBorne/08-The-Tick-Microbiome.pdf

Dahlgren, F. S., Heitman, K. N., Drexler, N. A., Massung, R. F., & Behravesh, C. B. (2015). Human granulocytic anaplasmosis in the United States from 2008 to 2012: a summary of national surveillance data. *The American Journal of Tropical Medicine and Hygiene*, *93*(1), 66–72. https://doi.org/10.4269/ajtmh.15-0122

Diuk-Wasser, M. A., Vannier, E., & Krause, P. J. (2016). Coinfection by Ixodes Tick-Borne Pathogens: Ecological, Epidemiological, and Clinical Consequences. *Trends in Parasitology*, *32*(1), 30–42. https://doi.org/10.1016/j.pt.2015.09.008

Donovan, T. A., Fox, P. R., Balakrishnan, N., Ericson, M., Hooker, V., & Breitschwerdt, E. B. (2017). Pyogranulomatous pancarditis with intramyocardial Bartonella henselae San Antonio 2 (BhSA2) in a dog. *Journal of Veterinary Internal Medicine*, *31*(1), 142–148. https://doi.org/10.1111/jvim.14609

Duncan, A. W., Maggi, R. G., & Breitschwerdt, E. B. (2007). A combined approach for the enhanced detection and isolation of Bartonella species in dog blood samples: pre-enrichment liquid culture followed by PCR and subculture onto agar plates. *Journal of Microbiological Methods*, *69*(2), 273–281. https://doi.org/10.1016/j.mimet.2007.01.010

Dunn, J. M., Krause, P. J., Davis, S., Vannier, E. G., Fitzpatrick, M. C., Rollend, L., ... Diuk-Wasser, M. A. (2014). Borrelia burgdorferi promotes the establishment of Babesia microti in the Northeastern United States. *PLOS ONE*, *9*(12), e115494. https://doi.org/10.1371/journal.pone.0115494

El Khoury, M. Y., Camargo, J. F., White, J. L., Backenson, B. P., Dupuis, A. P., Escuyer, K. L., ... Wong, S. J. (2013). Potential role of deer tick virus in Powassan encephalitis cases in Lyme disease-endemic areas of New York, U.S.A. *Emerging Infectious Diseases*, *19*(12), 1926–1933. https://doi.org/10.3201/eid1912.130903

Ericson, M., Balakrishnan, N., Mozayeni, B. R., Woods, C. W., Dencklau, J., Kelly, S., & Breitschwerdt, E. B. (2017). Culture, PCR, DNA sequencing, and second harmonic generation (SHG) visualization of *Bartonella henselae* from a surgically excised human femoral head. *Clinical Rheumatology*, *36*(7), 1669–1675. https://doi.org/10.1007/s10067-016-3524-2

Eskow, E., Adelson, M. E., Rao, R.-V. S., & Mordechai, E. (2003). Evidence for disseminated *Mycoplasma fermentans* in New Jersey residents with antecedent tick attachment and subsequent musculoskeletal symptoms. *Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Diseases*, *9*(2), 77–87. https://doi.org/10.1097/01.RHU.0000062510.04724.07

Ettestad, P. J., Campbell, G. L., Welbel, S. F., Genese, C. A., Spitalny, K. C., Marchetti, C. M., & Dennis, D. T. (1995). Biliary complications in the treatment of unsubstantiated Lyme disease. *The Journal of Infectious Diseases*, *171*(2), 356–361. https://doi.org/10.1093/infdis/171.2.356

Finlay, B. B., & McFadden, G. (2006). Anti-immunology: evasion of the host immune system by bacterial and viral pathogens. *Cell*, *124*(4), 767–782. https://doi.org/10.1016/j.cell.2006.01.034

Fournier PE, Jensenius M, Laferl H, Vene S, Raoult D. Kinetics of antibody responses in *Rickettsia africae* and *Rickettsia conorii* infections. Clin Diagn Lab Immunol 2002;9:324-8. Doi: 10.1128/CDLI.9.2.324-328.2002.

Fournier, P.-E., Fujita, H., Takada, N., & Raoult, D. (2002). Genetic identification of rickettsiae isolated from ticks in Japan. *Journal of Clinical Microbiology*, *40*(6), 2176–2181.

Frost, H. M., Schotthoefer, A. M., Thomm, A. M., Dupuis, A. P., Kehl, S. C., Kramer, L. D....Knox, K. K. (2017). Serologic evidence of Powassan virus infection in patients with suspected Lyme disease. *Emerging Infectious Diseases*, *23*(8), 1384–1388. https://dx.doi.org/10.3201/eid2308.161971.

Girschick, H. J., Huppertz, H. I., Rüssmann, H., Krenn, V., & Karch, H. (1996). Intracellular persistence of Borrelia burgdorferi in human synovial cells. *Rheumatology International*, *16*(3), 125–132.

Grab DJ, Nyarko E, Barat NC, Nikolskaia OV, Dumler JS. *Anaplasma phagocytophilum*-*Borrelia burgdorferi* coinfection enhances chemokine, cytokine, and matrix metalloprotease expression by human brain microvascular endothelial cells. *Clinical Vaccine Immunol: CVI*. 2007;14(11):1420-1424. doi:10.1128/CVI.00308-07.

Harms, A., & Dehio, C. (2012). Intruders below the radar: molecular pathogenesis of Bartonella spp. *Clinical Microbiology Reviews*, *25*(1), 42–78. https://doi.org/10.1128/CMR.05009-11

Hastey, C. J., Elsner, R. A., Barthold, S. W., & Baumgarth, N. (2012). Delays and diversions mark the development of B cell responses to Borrelia burgdorferi infection. *Journal of Immunology (Baltimore, Md.: 1950)*, *188*(11), 5612–5622. https://doi.org/10.4049/jimmunol.1103735

Hechemy, K. E., Raoult, D., Fox, J., Han, Y., Elliott, L. B., & Rawlings, J. (1989). Cross-reaction of immune sera from patients with rickettsial diseases. *Journal of Medical Microbiology*, *29*(3), 199–202. https://doi.org/10.1099/00222615-29-3-199

Herman-Giddens, M. E., & Herman-Giddens, D. M. (2017). Retrospective Case Reports of Two Central North Carolina Residents: Frequency of Tick Bites and Associated Illnesses, 2001-2014. *North Carolina Medical Journal*, *78*(3), 156–163. https://doi.org/10.18043/ncm.78.3.156

Herman-Giddens, M. E. (2018). Relative risk for ehrlichiosis and Lyme disease where vectors for both are sympatric, Southeastern United States. *Emerging Infectious Diseases*, *24*(2), 404–405. https://dx.doi.org/10.3201/eid2402.170962

Hinckley, A. F., Connally, N. P., Meek, J. I., Johnson, B. J., Kemperman, M. M., Feldman, K. A., ... Mead, P. S. (2014). Lyme disease testing by large commercial laboratories in the United States. *Clinical Infectious Diseases* *59*(5), 676–681. https://doi.org/10.1093/cid/ciu397

Hinten, S. R., Beckett, G. A., Gensheimer, K. F., Pritchard, E., Courtney, T. M., Sears, S. D., ... Marfin, A. A. (2008). Increased recognition of Powassan encephalitis in the United States, 1999-2005. *Vector Borne and Zoonotic Diseases*, *8*(6), 733–740. https://doi.org/10.1089/vbz.2008.0022

Holman, R. C., Paddock, C. D., Curns, A. T., Krebs, J. W., McQuiston, J. H., & Childs, J. E. (2001). Analysis of risk factors for fatal Rocky Mountain Spotted Fever: evidence for superiority of tetracyclines for therapy. *The Journal of Infectious Diseases*, *184*(11), 1437–1444. https://doi.org/10.1086/324372

Homer, M. J., Aguilar-Delfin, I., Telford, S. R., Krause, P. J., & Persing, D. H. (2000). Babesiosis. *Clinical Microbiology Reviews*, *13*(3), 451–469. https://doi.org/10.1128/CMR.13.3.451-469.2000

Hook, S. A., Nelson, C. A., & Mead, P. S. (2015). U.S. public’s experience with ticks and tick-borne diseases: Results from national Health Styles surveys. *Ticks and Tick-Borne Diseases*, *6*(4), 483–488. https://doi.org/10.1016/j.ttbdis.2015.03.017

Horowitz, H. W., B. Dworkin, G. Forseter, R. B. Nadelman, C. Connolly, B. B. Luciano, J. Nowakowski, T. A. O’Brien, M. Calmann, and G. P. Wormser. “Liver Function in Early Lyme Disease.” *Hepatology (Baltimore, Md.)* 23, no. 6 (June 1996): 1412–17. https://doi.org/10.1002/hep.510230617.

Horowitz R.I., M.D. et.al. (2003). Mycoplasma Infections in Chronic Lyme Disease: A Retrospective Analysis of Co-Infection and Persistence Demonstrated by PCR Analysis Despite Long Term Antibiotic Treatment [Abstract]. 16th International Scientific Conference on Lyme Disease & Other Tick-Borne Disorders. Hartford, Connecticut, June.

Horowitz, R.I. (2013). *Why Can’t I Get Better? Solving the Mystery of Lyme and Chronic Disease*. NYC: St Martin’s Press.

Horowitz, R. I., & Freeman, P. R. (2016). Are mycobacterium drugs effective for treatment resistant Lyme disease, tick-borne co-infections, and autoimmune disease? *JSM Arthritis, 1*(2), 1008.

Horowitz, R., & Freeman, P. R. (2016). The use of dapsone as a novel “persister” drug in the treatment of chronic Lyme disease/post treatment Lyme Disease Syndrome. *Journal of Clinical and Experimental Dermatology Research*, *07*. https://doi.org/10.4172/2155-9554.1000345

Horowitz, R.I. (2017). *How Can I Get Better? An Action Plan for Treating Resistant Lyme and Chronic Disease.* NYC: St Martin’s Press.

Hutchinson, M. L., Strohecker, M. D., Simmons, T. W., Kyle, A. D., & Helwig, M. W. (2015). Prevalence Rates of *Borrelia burgdorferi* (Spirochaetales: Spirochaetaceae), *Anaplasma phagocytophilum* (Rickettsiales: Anaplasmataceae), and *Babesia microti* (Piroplasmida: Babesiidae) in Host-Seeking *Ixodes scapularis* (Acari: Ixodidae) from Pennsylvania. *Journal of Medical Entomology*, *52*(4), 693–698. https://doi.org/10.1093/jme/tjv037

Institute of Medicine (US) Committee. Lyme Disease and Other Tick-borne Diseases: The State of the Science [Workshop]. National Academies Press. Washington DC. 2011.

Johnson, L., Aylward, A., & Stricker, R. B. (2011). Healthcare access and burden of care for patients with Lyme disease: a large United States survey. *Health Policy (Amsterdam, Netherlands)*, *102*(1), 64–71. https://doi.org/10.1016/j.healthpol.2011.05.007

Kahn, L. H. (2006). Confronting zoonoses, linking human and veterinary medicine. *Emerging Infectious Diseases*, *12*(4), 556–561. https://doi.org/10.3201/eid1204.050956

Kramme, S., Van An, L., Khoa, N. D., Van Trin, L., Tannich, E., Rybniker, J., ... Panning, M. (2009). *Orientia tsutsugamushi* bacteremia and cytokine levels in Vietnamese scrub typhus Patients. *Journal of Clinical Microbiology*, *47*(3), 586–589. https://doi.org/10.1128/JCM.00997-08

Krause, P. J., Telford, S. R., Ryan, R., Conrad, P. A., Wilson, M., Thomford, J. W., & Spielman, A. (1994). Diagnosis of babesiosis: evaluation of a serologic test for the detection of *Babesia microti* antibody. *The Journal of Infectious Diseases*, *169*(4), 923–926.

Krause, P. J., Telford, S. R., Spielman, A., Sikand, V., Ryan, R., Christianson, D., ... Persing, D. H. (1996). Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness. *JAMA*, *275*(21), 1657–1660.

Krause, P. J., Spielman, A., Telford, S. R., Sikand, V. K., McKay, K., Christianson, D., ... Persing, D. H. (1998). Persistent parasitemia after acute babesiosis. *New England Journal of Medicine*, *339*(3), 160–165. https://doi.org/10.1056/NEJM199807163390304

Krause, P. J., Gewurz, B. E., Hill, D., Marty, F. M., Vannier, E., Foppa, I. M., ... Spielman, A. (2008). Persistent and relapsing babesiosis in immunocompromised patients. *Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America*, *46*(3), 370–376. https://doi.org/10.1086/525852

Liang, F. T., Brown, E. L., Wang, T., Iozzo, R. V., & Fikrig, E. (2004). Protective niche for *Borrelia burgdorferi* to evade humoral immunity. *The American Journal of Pathology*, *165*(3), 977–985.

Luce-Fedrow, A., Mullins, K., Kostik, A. P., St John, H. K., Jiang, J., & Richards, A. L. (2015). Strategies for detecting rickettsiae and diagnosing rickettsial diseases. *Future Microbiology*, *10*(4), 537–564. https://doi.org/10.2217/fmb.14.141

Maggi, R. G., Mozayeni, B., Pultorak, E. L., Hegarty, B. C., Bradley, J. M., Correa, M. ... Breitschwerdt, E. B. (2012). *Bartonella*spp. bacteremia and rheumatic symptoms in patients from Lyme disease-endemic region. *Emerging Infectious Diseases*, *18*(5), 783–791. https://dx.doi.org/10.3201/eid1805.111366.

Maggi, R. G., Mascarelli, P. E., Havenga, L. N., Naidoo, V., & Breitschwerdt, E. B. (2013). Co-infection with Anaplasma platys, Bartonella henselae and Candidatus Mycoplasma haematoparvum in a veterinarian. *Parasites & Vectors*, *6*, 103. https://doi.org/10.1186/1756-3305-6-103

Marzec, N. S., Nelson C., Waldron P. R., Blackburn B. G., Hosain S., Greenhow T., Green G. M., Lomen-Hoerth C., Golden M., Mead P. S. (2017). Serious Bacterial Infections Acquired During Treatment of Patients Given a Diagnosis of Chronic Lyme Disease—United States. *MMWR. Morbidity and Mortality Weekly Report*, *66*, 607–9. https://doi.org/10.15585/mmwr.mm6623a3

Minnick, M. F., & Battisti, J. M. (2009). Pestilence, persistence and pathogenicity: infection strategies of Bartonella. *Future Microbiology*, *4*(6), 743–758. https://doi.org/10.2217/fmb.09.41

Molloy, P. J., Telford, S. R., Chowdri, H. R., Lepore, T. J., Gugliotta, J. L., Weeks, K. E., ... Berardi, V. P. (2015). Borrelia miyamotoi Disease in the Northeastern United States: A Case Series. *Annals of Internal Medicine*, *163*(2), 91–98. https://doi.org/10.7326/M15-0333

Nadolny, R. M., Feldman, K. A., Pagac, B., Stromdahl, E. Y., Rutz, H., Wee, S.-B., ... Gaff, H. D. (2015). Review of the Mid-Atlantic Tick Summit III: A model for regional information sharing. *Ticks and Tick-Borne Diseases*, *6*(4), 435–438. https://doi.org/10.1016/j.ttbdis.2015.04.001

Nicolson G. L., Nasralla M., Franco A. R., Nicolson N. L., Erwin R., Ngwenya R., Berns P. A. (2000). Diagnosis and integrative treatment of intracellular bacterial infections in Chronic Fatigue and Fibromyalgia Syndromes, Gulf War Illness, Rheumatoid Arthritis and other chronic illnesses. *Clinical Practice of Alternative Medicine, 1*(2): 92–102. http://www.immed.org/infectious%20disease%20reports/06.16.12%20pdf%20updates/CPAM-GLNetal.-00.1.21.pdf

Paddock, C. D., & Telford, S. R. (2010). *Through a glass, darkly: the global incidence of tick-borne diseases.* Report of the Institute of Medicine Committee on Lyme Disease and Other Tick-Borne Diseases: The State of the Science. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK57015/

Pogodina VV. MPChumakov: Posthumous contribution into investigations of chronic tick-borne encephalitis. International Scientific Conference “Tick-borne viral, rickettsial, and bacterial infections”, 24–26 September 1996, Listvyanka, Irkutsk, Russia.

Ramsey, A. H., Belongia, E. A., Chyou, P.-H., & Davis, J. P. (2004). Appropriateness of Lyme disease serologic testing. *Annals of Family Medicine*, *2*(4), 341–344. https://doi.org/10.1370/afm.117

Rudenko, N., Golovchenko, M., Grubhoffer, L., & Oliver, J. H. (2011). Updates on Borrelia burgdorferi sensu lato complex with respect to public health. *Ticks and Tick-Borne Diseases*, *2*(3), 123–128. https://doi.org/10.1016/j.ttbdis.2011.04.002

Rudenko, N., Golovchenko, M., Vancova, M., Clark, K., Grubhoffer, L., & Oliver, J. H. (2016). Isolation of live Borrelia burgdorferi sensu lato spirochaetes from patients with undefined disorders and symptoms not typical for Lyme borreliosis. *Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases*, *22*(3), 267.e9-15. https://doi.org/10.1016/j.cmi.2015.11.009

Sexton, D. J., Corey, G. R., Carpenter, C., Kong, L. Q., Gandhi, T., Breitschwerdt, E., ... Dumler, S. J. (1998). Dual infection with Ehrlichia chaffeensis and a spotted fever group rickettsia: A case report. *Emerging Infectious Diseases*, *4*(2), 311–316. https://doi.org/10.3201/eid0402.980222

Stralen, K. J. van, Stel, V. S., Reitsma, J. B., Dekker, F. W., Zoccali, C., & Jager, K. J. (2009). Diagnostic methods I: sensitivity, specificity, and other measures of accuracy. *Kidney International*, *75*(12), 1257–1263. https://doi.org/10.1038/ki.2009.92

Stromdahl, E. Y., & Hickling, G. J. (2012). Beyond Lyme: Aetiology of tick-borne human diseases with emphasis on the south-eastern United States. *Zoonoses and Public Health*, *59 Suppl 2*, 48–64. https://doi.org/10.1111/j.1863-2378.2012.01475.x

Telford III, S. R., Gorenflot A., Brasseur P., & Spielman A. (1993). *Babesial infections in humans and wildlife*. In J. P. Kreier (Ed.),*Parasitic Protozoa*, (2nd ed., Vol. 5, 1–47). San Diego: Academic Press.

Telford III, S. R., & Goethert, H. K. (2008). Emerging and emergent tick-borne infections. In A. S. Bowman & P. A. Nuttall (Eds.), *Ticks: Biology, Disease and Control*, 344–376. Cambridge: Cambridge University Press. https://doi.org/10.1017/CBO9780511551802.017

Telford S.R., Personal communication

Thomford, J. W., Conrad, P. A., Telford, S. R., Mathiesen, D., Bowman, B. H., Spielman, A., ... Persing, D. H. (1994). Cultivation and phylogenetic characterization of a newly recognized human pathogenic protozoan. *The Journal of Infectious Diseases*, *169*(5), 1050–1056.

Thomm, A. M., Schotthoefer, A. M., Dupuis, A. P., Kramer, L. D., Frost, H. M., Fritsche, T. R., ... Kehl, S. C. (2018). Development and validation of a serologic test panel for detection of Powassan virus infection in U.S. patients residing in regions where Lyme disease is endemic. *The American Society for Microbiology*, *3*(1), e00467-17. https://doi.org/10.1128/mSphere.00467-17

Vasquez, J. J., Hussien, R., Aguilar-Rodriguez, B., Junger, H., Dobi, D., Henrich, T. J., ... Laszik, Z. G. (2018). Elucidating the burden of HIV in tissues using multiplexed immunofluorescence and in situ hybridization: Methods for the single-cell phenotypic characterization of cells harboring HIV in situ. *The Journal of Histochemistry and Cytochemistry: Official Journal of the Histochemistry Society*, 22155418756848. https://doi.org/10.1369/0022155418756848

Whitman, T. J., Richards, A. L., Paddock, C. D., Tamminga, C. L., Sniezek, P. J., Jiang, J., ... Sanders, J. W. (2007). Rickettsia parkeri infection after tick bite, Virginia. *Emerging Infectious Diseases*, *13*(2), 334–336. https://doi.org/10.3201/eid1302.061295

World Health Organization. (2007). *Guidelines on tularemia: epidemic and pandemic alert and response*. Geneva: World Health Organization. Retrieved from http://www.who.int/csr/resources/publications/deliberate/WHO_CDS_EPR_2007_7/en/

Woldehiwet Zerai. (2006). Anaplasma phagocytophilum in ruminants in Europe. *Annals of the New York Academy of Sciences*, *1078*(1), 446–460. https://doi.org/10.1196/annals.1374.084

Wormser, G. P., Masters, E., Nowakowski, J., McKenna, D., Holmgren, D., Ma, K., ... Nadelman, R. B. (2005). Prospective clinical evaluation of patients from Missouri and New York with erythema migrans-like skin lesions. *Clinical Infectious Diseases*, *41*(7), 958–965. https://doi.org/10.1086/432935

Zhang, X., I Meltzer, M., A Peña, C., B Hopkins, A., Wroth, L., & Fix, A. (2006). Economic impact of Lyme disease. *Emerging Infectious Diseases*, *12*, 653–660. https://doi.org/10.3201/eid1204.050602

Addition References by Topic

**Immune Response and Cytokine Response.**Soloski and Aucott et al. have identified protein expression changes and cytokine arrays that can predict which acute Lyme patients are more likely to have persistent symptoms or relapse of symptoms after initial treatment. *Ehrlichia*, *Anaplasma*, *Babesia* and *Bartonella* alter cytokine expression via effects on protein expression. Each organism essentially manipulates protein expression resulting in increased likelihood of successful infection and avoidance of successful immune eradication of the particular pathogen. The effect of different pathogens on cytokine and immune response in the case of multiple tick-borne disease infection is an area to investigate. This could lead to better diagnostics and inform therapeutics. Proteomics and metabolomics currently provide the emerging techniques to investigate protein expression.

**Borrelia**

Soloski Mark J., Lauren A. Crowder, Lauren J. Lahey, Catriona A. Wagner, William H. Robinson, John N. Aucott. Serum Inflammatory Mediators as Markers of Human Lyme disease Activity. 2014 PLoS ONE 9(4): e93243. doi:10.1371/journal.pone.0093243

Aucott John N., Mark J. Soloski, Alison W. Rebman, Lauren A. Crowder, Lauren J.Lahey, Catriona A. Wagner, William H. Robinson, Kathleen T. Bechtold. CCL19 as a Chemokine Risk Factor for Post-Treatment Lyme Disease Syndrome: A Prospective 2 Clinical Cohort Study. June 2016 Clin. Vaccine Immunol. doi:10.1128/CVI.00071-16.

Rebman , Alison W , MJ Soloski and JN Aucott. Ch12 Sex and Gender Impact Lyme disease Immunology, Diagnosis and Treatment. In SL Klein and CW Roberts (ed) Sex and Gender differences in infection and treatments for infectious disease. 2015 OI 10.1007/978-3-319-16438-0_12

**Ehrlichia / Anaplasma**

Olano JP and DH Walker. Human Ehrlichiosis. Medical Clinics of NA. 2002. 86(2):375392.

Grab DJ, Nyarko E, Barat NC, Nikolskaia OV, Dumler JS. Anaplasma phagocytophilum-Borrelia burgdorferi co-infection enhances chemokine, cytokine, and matrix metalloprotease expression by human brain microvascular endothelial cells. Clin Vaccine Immunol 2007; 14(11): 1420-4.

**Babesia**

Krause Peter J., Johanna Daily, Sam R. Telford, Edouard Vannier, Paul Lantos and Andrew Spielman. Shared features in the pathobiology of babesiosis and malaria. Trends in Parasitology Vol.xxx No.x doi:10.1016/j.pt.2007.09.005

**Bartonella**

Harms, Alexander and Christoph Dehio. Intruders below the radar: molecular pathogenesis of Bartonella spp. Clin. Microbiol. Rev. 2012, 25(1):42. DOI: 10.1128/CMR.05009-11.

Allison D. Tuttle, DVM; Adam J. Birkenheuer, DVM; Tarja Juopperi, DVM; Michael G. Levy, PhD; Edward B. Breitschwerdt, DVM. Concurrent bartonellosis and babesiosis in a dog with persistent thrombocytopenia. 2003. JAVMA, Vol 223, No. 9, November 1, 2003

**Evidence of Coinfections with Lyme disease**

**Babesia-Lyme disease**

Krause, P. J., Telford, S. R., Spielman, A., Sikand, V., Ryan, R., Christianson, D., ... Persing, D. H. (1996). Concurrent Lyme disease and babesiosis: evidence for increased severity and duration of illness. *JAMA*, *275*(21), 1657–1660. https://doi.org/10.1001/jama.1996.03530450047031

***Ehrlichia-Anaplasma-*Lyme disease**

Mitchell, P D, K D Reed, and J M Hofkes. “Immunoserologic Evidence of Coinfection with Borrelia Burgdorferi, Babesia Microti, and Human Granulocytic Ehrlichia Species in Residents of Wisconsin and Minnesota.” *Journal of Clinical Microbiology* 34, no. 3 (March 1996): 724–27.

**Bartonella-Lyme disease**

Maggi, R. G., Mozayeni, B., Pultorak, E. L., Hegarty, B. C., Bradley, J. M., Correa, M....Breitschwerdt, E. B. (2012). Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease-endemic region. *Emerging Infectious Diseases*, *18*(5), 783-791. https://dx.doi.org/10.3201/eid1805.111366.

***Anaplasma-Bartonella-Mycoplasma***

Maggi, RG and PE Mascarelli, LN Havenga, V Naidoo and EB Breitschwerdt. Co-infection with Anaplasma platys, Bartonella henselae and Candidatus Mycoplasma haematoparvum in a veterinarian. 2013. Parasites & Vectors . 6:103

http://www.parasitesandvectors.com/content/6/1/103

**Multiple coinfection with seronegativity Dog Kennel**

Kordick, S. K., Breitschwerdt, E. B., Hegarty, B. C., Southwick, K. L., Colitz, C. M., Hancock, S. I., ... MacCormack, J. N. (1999). Coinfection with multiple tick-borne pathogens in a Walker Hound kennel in North Carolina. *Journal of Clinical Microbiology*, *37*(8), 2631–2638.

**Chronic Infection despite intensive antibiotics**

Bradley JF,et al, The Persistence of Spirochetal Nucleic Acids in Active Lyme Arthritis. Ann Int Med 1994;487-9

Bayer ME, Zhang L, Bayer MH. Borrelia burgdorferi DNA in the urine of treated patients with chronic Lyme Disease symptoms. A PCR study of 97 cases. Infection 1996. Sept-Oct;24(5):347-53

Diringer MN, et al, Lyme meningoencephalitis- report of a severe, penicillin resistant case. Arthritis & Rheum, 1987;30:705-708

Donta, ST, Tetracycline therapy in chronic Lyme disease. Chronic Infectious Diseases, 1997; 25 (Suppl 1): 552-56

Fitzpatrick JE, et al. Chronic septic arthritis caused by Borrelia burgdorferi. Clin Ortho 1993 Dec;(297):238-41

Georgilis K, Peacocke M, & Klempner MS. Fibroblasts protect the Lyme disease spirochete, Borrelia burgdorferi, from ceftriaxone in vitro. J Infect Dis 1992;166: 440-444

Fallon BA, et al. Repeated antibiotic treatment in chronic Lyme disease, Journal of Spirochetal and Tick-borne Diseases, 1999; 6 (Fall/Winter):94-101

Fraser DD, et al. Molecular detection of persistent Borrelia burgdorferi in a man with dermatomyositis. Clinical and Exper Rheum. 1992;10:387-390

Fried MD et al, Borrelia burdorferi persists in the gastrointestinal tract of children and adolescents with Lyme Disease, JNL of Spirochetal and Tick-borne Diseases, Spring/Summer 2002; 9:11-15

Girschick HJ, et al. Intracellular persistence of Borrelia burgdorferi in human synovial cells. Rheumatol Int 1996;16(3):125-132

Hassler D, et al. Pulsed high-dose cefotaxime therapy in refractory Lyme Borreliosis (letter). Lancet 1991;338:193

Horowitz RI. Chronic Persistent Lyme Borreliosis: PCR evidence of chronic infection despite extended antibiotic therapy: A Retrospective Review. Abstract XIII Intl Sci Conf on Lyme Disease. Mar 24-26, 2000.

Haupl T, et al. Persistence of Borrelia burgdorferi in ligamentous tissue from a patient with chronic Lyme borreliosis. Arthritis Rheum 1993;36:1621-1626

Karma A, et al. Long term follow-up of chronic Lyme neuroretinitis. Retina 1996;16:505-509

Keller TL, et al. PCR detection of Borrelia burgdorferi DNA in cerebrospinal fluid of Lyme neuroborreliosis patients. Neurology 1992;43:32-42

Masters EJ, et al. Spirochetemia after continuous high-dose oral amoxicillin therapy. Infect Dis Clin Practice 1994;3:207-208

Ma Y, et al. Intracellular localization of Borrelia burgdorferi within human endothelial cells. Infect Immun 1991;59:671-678

Meier P, et al. Pars plana vitrectomy in Borrelia burgdorferi endophthalmitis. Klin Monatsbl Augenheilkd 1998 Dec;213(6):351-4

Preac-Mursic V, et al. Survival of Borrelia burgdorferi in antibiotically treated patients with Lyme borreliosis. Infection 1989;17:355-359.

Preac-Mursic V, et al. Persistence of Borrelia burdorferi and Histopathological Alterations in Experimentally Infected Animals. A comparison with Histopathological Findings in Human Lyme Disease. Infection 1990;18(6):332-341

Straubinger RK, et al. Persistence of Borrelia burgdorferi in Experimentally Infected Dogs after Antibiotic Treatment. J Clin Microbiol 1997;35(1):111-116

Embers, M. et al. Persistence of Borrelia burgdorferi in Rhesus Macaques following Antibiotic treatment of Disseminated Infection. PLoS ONE 7(1): e29914. doi:10.1371/journal.pone

Embers ME, Hasenkampf NR, et al. (2017) Variable manifestations, diverse seroreactivity and post-treatment persistence in non-human primates exposed to Borrelia burgdorferi by tick feeding. PLoS ONE 12(12): e0189071. https://doi.org/10.1371/journal.pone.0189071

Priority #2: Treatment of Other Tick-Borne Diseases and Coinfections

References by Topic

**Gabby’s Story: The Importance of Properly Diagnosing and Treating Other Tick-borne Diseases**

Zientek, Jillian, F. Scott Dahlgren, Jennifer H. McQuiston, and Joanna (2014, February) Regan. Self-Reported Treatment Practices by Healthcare Providers Could Lead to Death from Rocky Mountain Spotted Fever. *The Journal of Pediatrics, (164)*2, 2014): 416–18. https://doi.org/10.1016/j.jpeds.2013.10.008.

**Background: Why other tick-borne diseases and co-infections are important**

Aliota, M. T., Dupuis, A. P., Wilczek, M. P., Peters, R. J., Ostfeld, R. S., & Kramer, L. D. (2014). The prevalence of zoonotic tick-borne pathogens in Ixodes scapularis collected in the Hudson Valley, New York State. *Vector Borne and Zoonotic Diseases*, *14*(4), 245–250. https://doi.org/10.1089/vbz.2013.1475

Egizi A., Fefferman N. H., & Jordan R. A. (2017). Relative risk for ehrlichiosis and Lyme disease in an area where vectors for both are sympatric, New Jersey, U.S.A. *Emerging Infectious Diseases*, *23*(6):939–945. doi:10.3201/eid2306.160528

Swanson, S. J., Neitzel, D., Reed, K. D., & Belongia, E. A. (2006). Coinfections acquired from ixodes ticks. *Clinical Microbiology Reviews*, *19*(4), 708–727. https://doi.org/10.1128/CMR.00011-06

Wroblewski, D., Gebhardt, L., Prusinski, M.A., Meehan, L.J., Halse, T.A., & Musser, K.A. (2017). Detection of Borrelia miyamotoi and other tick-borne pathogens in human clinical specimens and Ixodes scapularis ticks in New York State, 2012–2015. *Ticks and Tick-Borne Diseases*, *8*(3), 407–411. https://doi.org/10.1016/j.ttbdis.2017.01.004

**Cost to Society**

Adrion, E. R., Aucott, J., Lemke, K. W., & Weiner, J. P. (2015). Health care costs, utilization and patterns of care following Lyme disease. *PLOS ONE*, *10*(2), e0116767. https://doi.org/10.1371/journal.pone.0116767

Maes, E., Lecomte, P., & Ray, N. (1998). A cost-of-illness study of Lyme disease in the United States. *Clinical Therapeutics*, *20*(5), 993–1008. https://doi.org/10.1016/S0149-2918(98)80081-7

Vanderhoof I. T., Vanderhoof-Forschner K. (1993, Jan/Feb). Lyme disease: Cost to society. *Contingencies*, 42–48.

Zhang X., Meltzer M. I., Pena C. A., Hopkins A. B., Wroth L., & Fix A. D. (2006). Economic impact of Lyme disease. *Emerging Infectious Diseases*, *12*(4): 653–660. www.cdc.gov/eid.

**Anaplasma**

**Clinical Picture/Syndromic Surveillance**

Breitschwerdt, E. B., Mascarelli, P. E., Schweickert, L. A., Maggi, R. G., Hegarty, B. C., Bradley, J. M., & Woods, C. W. (2011). Hallucinations, sensory neuropathy, and peripheral visual deficits in a young woman infected with Bartonella koehlerae. *Journal of Clinical Microbiology*, *49*(9), 3415–3417. https://doi.org/10.1128/JCM.00833-11

Olano, J. P. & Walker, D. H. (2002). Human ehrlichioses. *Medical Clinics of North America*, *86*(2), 375–392. https://doi.org/10.1016/S0025-7125(03)00093-2

**Pathology/Pathophysiology**

Dumler, J. S., Madigan, J. E., Pusterla, N., & Bakken, J. S. (2007). Ehrlichioses in humans: epidemiology, clinical presentation, diagnosis, and treatment. *Clinical Infectious Diseases*, *45*(Supplement_1), S45–S51. https://doi.org/10.1086/518146

Ismail, N., Bloch, K. C., & McBride, J. W. (2010). Human ehrlichiosis and anaplasmosis. *Clinics in Laboratory Medicine*, *30*(1), 261–292. https://doi.org/10.1016/j.cll.2009.10.004

Klein, M. B., Nelson, C. M., & Goodman, J. L. (1997). Antibiotic susceptibility of the newly cultivated agent of human granulocytic ehrlichiosis: promising activity of quinolones and rifamycins. *Antimicrobial Agents and Chemotherapy, Antimicrobial Agents and Chemotherapy*, *41*(1), 76–79.

Olano, J. P., & Walker, D. H. (2002). Human ehrlichioses. *Medical Clinics of North America*, *86*(2), 375–392. https://doi.org/10.1016/S0025-7125(03)00093-2

Parola, P., & Raoult, D. (2001). Ticks and tickborne bacterial diseases in humans: an emerging infectious threat. *Clinical Infectious Diseases*, *32*(6), 897–928. https://doi.org/10.1086/319347

Regunath, H., Rojas-Moreno, C., Olano, J. P., Hammer, R. D., & Salzer, W. (2017). Early diagnosis of Ehrlichia ewingii infection in a lung transplant recipient by peripheral blood smear. *Transplant Infectious Disease*, *19*(2), e12652. https://doi.org/10.1111/tid.12652

**Evidence of acute infection and support for treatment of acute infection**

Cross, R., Ling, C., Day, N. P. J., McGready, R., & Paris, D. H. (2016). Revisiting doxycycline in pregnancy and early childhood--time to rebuild its reputation? *Expert Opinion on Drug Safety*, *15*(3), 367–382. https://doi.org/10.1517/14740338.2016.1133584

Dumler, J. S., Madigan, J. E., Pusterla, N., & Bakken, J. S. (2007). Ehrlichioses in humans: epidemiology, clinical presentation, diagnosis, and treatment. *Clinical Infectious Diseases*, *45*(Supplement_1), S45–S51. https://doi.org/10.1086/518146

Pöyhönen, H., Nurmi, M., Peltola, V., Alaluusua, S., Ruuskanen, O., & Lähdesmäki, T. (2017). Dental staining after doxycycline use in children. *Journal of Antimicrobial Chemotherapy*, *72*(10), 2887–2890. https://doi.org/10.1093/jac/dkx245

Thomas, R. J., Dumler, J. S., & Carlyon, J. A. (2009). Current management of human granulocytic anaplasmosis, human monocytic ehrlichiosis and Ehrlichia ewingii ehrlichiosis. *Expert Review of Anti-Infective Therapy*, *7*(6), 709–722. https://doi.org/10.1586/eri.09.44

Volovitz, B., Shkap, R., Amir, J., Calderon, S., Varsano, I., & Nussinovitch, M. (2007). Absence of tooth staining with doxycycline treatment in young children. *Clinical Pediatrics*, *46*(2), 121–126. https://doi.org/10.1177/0009922806290026

Evidence for persistent infection/chronic symptomatology/chronic co-infection

**Human**

Breitschwerdt, E. B., Hegarty, B. C., Qurollo, B. A., Saito, T. B., Maggi, R. G., Blanton, L. S., & Bouyer, D. H. (2014). Intravascular persistence of Anaplasma platys, Ehrlichia chaffeensis, and Ehrlichia ewingii DNA in the blood of a dog and two family members. *Parasites & Vectors*, *7*, 298. https://doi.org/10.1186/1756-3305-7-298

Maggi, R. G., Mascarelli, P. E., Havenga, L. N., Naidoo, V., & Breitschwerdt, E. B. (2013). Co-infection with Anaplasma platys, Bartonella henselae and Candidatus Mycoplasma haematoparvum in a veterinarian. *Parasites & Vectors*, *6*, 103. https://doi.org/10.1186/1756-3305-6-103

**Animal**

Breitschwerdt, E. B., Hegarty, B. C., Qurollo, B. A., Saito, T. B., Maggi, R. G., Blanton, L. S., & Bouyer, D. H. (2014). Intravascular persistence of Anaplasma platys, Ehrlichia chaffeensis, and Ehrlichia ewingii DNA in the blood of a dog and two family members. *Parasites & Vectors*, *7*, 298. https://doi.org/10.1186/1756-3305-7-298

Kordick, S. K., Breitschwerdt, E. B., Hegarty, B. C., Southwick, K. L., Colitz, C. M., Hancock S. I., Bradley J. M., Rumbough L. R., Mcpherson J. T., & MacCormack, J. N. (1999). Coinfection with multiple tick-borne pathogens in a Walker Hound Kennel in North Carolina. *Journal of Clinical Microbiology*, *37*(8), 2631–2638.

**Transfusion**

Annen, K., Friedman, K., Eshoa, C., Horowitz, M., Gottschall, J., & Straus, T. (2012). Two cases of transfusion-transmitted Anaplasma phagocytophilum. *American Journal of Clinical Pathology*, *137*(4), 562–565. https://doi.org/10.1309/AJCP4E4VQQQOZIAQ

Centers for Disease Control and Prevention (CDC). (2008). Anaplasma phagocytophilum transmitted through blood transfusion―Minnesota, 2007. *MMWR. Morbidity and Mortality Weekly Report*, *57*(42), 1145–1148.

Regan, J., Matthias, J., Green-Murphy, A., Stanek, D., Bertholf, M., Pritt, B. S., Sloan L. M., Kelly A. J., Singleton J., McQuiston J. H., Hocevar S. N., & Whittle, J. P. (2013). A confirmed Ehrlichia ewingii infection likely acquired through platelet transfusion. *Clinical Infectious Diseases*, *56*(12), e105-107. https://doi.org/10.1093/cid/cit177

Townsend, R. L., Moritz, E. D., Fialkow, L. B., Berardi, V., & Stramer, S. L. (2014). Probable transfusion-transmission of Anaplasma phagocytophilum by leukoreduced platelets. *Transfusion*, *54*(11), 2828–2832. https://doi.org/10.1111/trf.12675

**Clinical Case(s) illustrating how co-infection affects diagnosis and treatment**

Krause, P. J., McKay, K., Thompson, C. A., Sikand, V. K., Lentz, R., Lepore, T., ... Spielman, A. (2002). Disease-specific diagnosis of coinfecting tickborne zoonoses: babesiosis, human granulocytic ehrlichiosis, and Lyme disease. *Clinical Infectious Diseases*, *34*(9), 1184–1191. https://doi.org/10.1086/339813

**Babesia**

**Clinical Picture/Syndromic Surveillance**

Citera, M., Freeman, P. R., & Horowitz, R. I. (2017). Empirical validation of the Horowitz Multiple Systemic Infectious Disease Syndrome Questionnaire for suspected Lyme disease. *International Journal of General Medicine*, *10*, 249–273. https://doi.org/10.2147/IJGM.S140224

Curcio, S. R., Tria, L. P., & Gucwa, A. L. (2016). Seroprevalence of Babesia microti in individuals with Lyme disease. *Vector Borne and Zoonotic Diseases (Larchmont, N.Y.)*, *16*(12), 737–743. https://doi.org/10.1089/vbz.2016.2020

Dunn, J. M., Krause, P. J., Davis, S., Vannier, E. G., Fitzpatrick, M. C., Rollend, L., ... Diuk-Wasser, M. A. (2014). Borrelia burgdorferi promotes the establishment of Babesia microti in the Northeastern United States. *PLOS ONE*, *9*(12), e115494. https://doi.org/10.1371/journal.pone.0115494

Hersh, M. H., Ostfeld, R. S., McHenry, D. J., Tibbetts, M., Brunner, J. L., Killilea, M. E., ... Keesing, F. (2014). Co-infection of blacklegged ticks with Babesia microti and Borrelia burgdorferi is higher than expected and acquired from small mammal hosts. *PloS One*, *9*(6), e99348. https://doi.org/10.1371/journal.pone.0099348

Horowitz, R.I., M.D. (1999). Babesiosis in Upstate New York: PCR and RNA evidence of co-infection with Babesia Microti among Ixodidae ticks in Dutchess County, NY. [Abstract]. 12th International Conference on Lyme Disease and Other Spirochetal and Tick-Borne Disorders. New York, New York, April 9−10.

Horowitz, M. L., Coletta, F., & Fein, A. M. (1994). Delayed onset adult respiratory distress syndrome in Babesiosis. *CHEST*, *106*(4), 1299–1301. https://doi.org/10.1378/chest.106.4.1299

Knapp, K. L., & Rice, N. A. (2015). Human Coinfection with Borrelia burgdorferi and Babesia microti in the United States. *Journal of Parasitology Research, 2015*, 1–11. https://doi.org/10.1155/2015/587131

Lempereur, L., Shiels, B., Heyman, P., Moreau, E., Saegerman, C., Losson, B., & Malandrin, L. (2015). A retrospective serological survey on human babesiosis in Belgium. *Clinical Microbiology and Infection*, *21*(1), 96.e1-96.e7. https://doi.org/10.1016/j.cmi.2014.07.004

Mylonakis, E. (2001). When to suspect and how to monitor babesiosis. *American Family Physician*, *63*(10), 1969.

Laboratory Evaluation

Akoolo, L., Schlachter, S., Khan, R., Alter, L., Rojtman, A. D., Gedroic, K., ... Parveen, N. (2017). A novel quantitative PCR detects Babesia infection in patients not identified by currently available non-nucleic acid amplification tests. *BMC Microbiology*, *17*. https://doi.org/10.1186/s12866-017-0929-2

Hamer, S. A., Hickling, G. J., Walker, E. D., & Tsao, J. I. (2014). Increased diversity of zoonotic pathogens and Borrelia burgdorferi strains in established versus incipient Ixodes scapularis populations across the Midwestern United States. *Infection, Genetics and Evolution*, *27*, 531–542. https://doi.org/10.1016/j.meegid.2014.06.003

Hanron, A. E., Billman, Z. P., Seilie, A. M., Chang, M., & Murphy, S. C. (2017). Detection of Babesia microti parasites by highly sensitive 18S rRNA reverse transcription PCR. *Diagnostic Microbiology and Infectious Disease*, *87*(3), 226–228. https://doi.org/10.1016/j.diagmicrobio.2016.11.021

Millan, J., Proboste, T., Fernandez de Mera, I. G., Chirife, A. D., de la Fuente, J., & Altet, L. (2016). Molecular detection of vector-borne pathogens in wild and domestic carnivores and their ticks at the human-wildlife interface. *Ticks and Tick-Borne Diseases*, *7*(2), 284–290. https://doi.org/10.1016/j.ttbdis.2015.11.003

Shah, J., Horowitz, R. (Spring, 2012). Human babesiosis and ehrlichiosis-current status. European Journal of Infectious Disease *6*(1).

Thomford, J. W., Conrad, P. A., Telford, S. R., Mathiesen, D., Bowman, B. H., Spielman, A., ... Persing, D. H. (1994). Cultivation and phylogenetic characterization of a newly recognized human pathogenic protozoan. *The Journal of Infectious Diseases*, *169*(5), 1050–1056. https://doi.org/10.1093/infdis/169.5.1050

Pathology/Pathophysiology

Gordon, S., Cordon, R. A., Mazdzer, E. J., Valigorsky, J. M., Blagg, N. A., & Barnes, S. J. (1984). Adult respiratory distress syndrome in babesiosis. *CHEST*, *86*(4), 633–634. https://doi.org/10.1378/chest.86.4.633

Iacopino, V., & Earnhart, T. (1990). Life-threatening babesiosis in a woman from Wisconsin. *Archives of Internal Medicine*, *150*(7), 1527–1528. https://doi.org/10.1001/archinte.1990.00390190159027

Matyniak, J. E., & Reiner, S. L. (1995). T helper phenotype and genetic susceptibility in experimental Lyme disease. *Journal of Experimental Medicine,181*(3), 1251–1254. doi:10.1084/jem.181.3.1251

Murray, P. K., Jennings, F. W., Murray, M., & Urquhart, G. M. (1974). The nature of immunosuppression in Trypanosoma brucei infections in mice. II. The role of the T and B lymphocytes. *Immunology*, *27*(5), 825–840.

Woolley, A. E., Montgomery, M. W., Savage, W. J., Achebe, M. O., Dunford, K., Villeda, S., ... Marty, F. M. (2017). Post-babesiosis warm autoimmune hemolytic anemia. *New England Journal of Medicine*, *376*(10), 939–946. https://doi.org/10.1056/NEJMoa1612165

Evidence for Treatment

Goethert, H. K., Molloy, P., Berardi, V., Weeks, K., & Telford, S. III. (2018). Zoonotic Babesia microti in the Northeastern U.S.: Evidence for the expansion of a specific parasite lineage. *PLOS ONE*, *13*(3), e0193837. https://doi.org/10.1371/journal.pone.0193837

Horowitz, R., & Freeman, P. R. (2016). The use of dapsone as a novel “persister” drug in the treatment of chronic Lyme disease/Post treatment Lyme Disease Syndrome. *Journal of Clinical and Experimental Dermatology Research*, *07*. https://doi.org/10.4172/2155-9554.1000345

Horowitz, R.I., M.D. (1999). High Dose Trimethoprim-Sulfamethoxatole Therapy: A Useful Adjunct to Combination Therapy in the Treatment of Resistant Babesiosis [Abstract]. 12th International Conference on Lyme Disease and Other Spirochetal and Tick-Borne Disorders. New York, New York, April 9−10.

Horowitz, R.I., M.D. (1998). Atovaquone and Azithromycin Therapy: A New Treatment Protocol for Babesiosis in Co-Infected Lyme Patients [Abstract]. 11th International Conference on Lyme Disease and Other Spirochetal and Tick-Borne Disorders. New York, New York, April 25−26.

Horowitz R.I., M.D. (2000). Mefloquinine and Artemesia: A Prospective Trial of Combination Therapy in Chronic Babesiosis [Abstract], 13th Annual International Scientific Conference on Lyme Disease and other Tick-Borne Disorders. Hartford, Connecticut, March 25−26.

Horowitz, R. (1999). Chronic Persistent Babesiosis after Clindamycin and Quinine/ Mepron and Zithromax. [Abstract]. 12th International Conference on Lyme Borreliosis. New York, New York, April

Kletsova, E. A., Spitzer, E. D., Fries, B. C., & Marcos, L. A. (2017). Babesiosis in Long Island: review of 62 cases focusing on treatment with Azithromycin and Atovaquone. *Annals of Clinical Microbiology and Antimicrobials*, *16*, 26. https://doi.org/10.1186/s12941-017-0198-9

Wormser, G., Prasad, A., Neuhaus, E., Joshi, S., Nowakowski, J., Nelson, J., ... Krause, P. (2010). Emergence of resistance to Azithromycin-Atovaquone in immunocompromised patients with Babesia microti infection. *Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America*, *50*, 381–386. https://doi.org/10.1086/649859

Krause, P. J., Spielman, A., Telford, S. R., Sikand, V. K., McKay, K., Christianson, D., ... Persing, D. H. (1998). Persistent parasitemia after acute babesiosis. *New England Journal of Medicine*, *339*(3), 160–165. https://doi.org/10.1056/NEJM199807163390304

Krause, P., Gewurz, B., Hill, D., M Marty, F., Vannier, E., Foppa, I., ... Spielman, A. (2008). Persistent and relapsing babesiosis in immunocompromised patients. *Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America*, *46*, 370–376. https://doi.org/10.1086/525852

Lawres, L., Garg, A., Kumar, V., Bruzual, I., P. Forquer, I., Renard, I., ... Ben Mamoun, C. (2016). Radical cure of experimental babesiosis in immunodeficient mice using a combination of an endochin-like quinolone and atovaquone. *The Journal of Experimental Medicine*, *213*, jem.20151519. https://doi.org/10.1084/jem.20151519

Lemieux, J. E., D. Tran, A., Freimark, L., Schaffner, S., Goethert, H., G. Andersen, K., ... Sabeti, P. (2016). A global map of genetic diversity in Babesia microti reveals strong population structure and identifies variants associated with clinical relapse. *Nature Microbiology*, *1*, 16079. https://doi.org/10.1038/nmicrobiol.2016.79

Stich, R. W., Shoda, L. K. M., Dreewes, M., Adler, B., Jungi, T. W., & Brown, W. C. (1998). Stimulation of nitric oxide production in macrophages by babesia bovis. *Infection and Immunity*, *66*(9), 4130–4136.

Vannier, E., Gewurz, B. E., & Krause, P. J. (2008). Human babesiosis. *Infectious Disease Clinics of North America*, *22*(3), 469–ix. https://doi.org/10.1016/j.idc.2008.03.010

Opportunities/Recommendations Going Forward

Feder, H. M. J., Lawlor, M., & Krause, P. J. (2003). Babesiosis in pregnancy. *New England Journal of Medicine*, *349*(2), 195–196. https://doi.org/10.1056/NEJM200307103490221

Gulersen, M., Brost, B. C., Bobrovnikov, V., & Bornstein, E. (2016). Acute babesiosis in pregnancy: a novel imitator of hemolysis, elevated liver enzymes, and low platelet count syndrome. *Obstetrics and Gynecology*, *128*(1), 197–200. https://doi.org/10.1097/AOG.0000000000001445

Herwaldt, B. L., Springs, F. E., Roberts, P. P., Eberhard, M. L., Case, K., Persing, D. H., & Agger, W. A. (1995). Babesiosis in Wisconsin: A potentially fatal disease. *The American Journal of Tropical Medicine and Hygiene*, *53*(2), 146–151. https://doi.org/10.4269/ajtmh.1995.53.146

Horowitz, R. Relapsing babesiosis in two consecutive pregnancies despite standard antimalarial treatment. Unpublished Study.

Saetre, K., Godhwani, N., Maria, M., Patel, D., Wang, G., Li, K. I., ... Nolan, S. M. (2018). Congenital babesiosis after maternal infection with Borrelia burgdorferi and Babesia microti. *Journal of the Pediatric Infectious Diseases Society*, *7*(1), e1–e5. https://doi.org/10.1093/jpids/pix074

**Evidence of acute infection and support for treatment of acute infection**

Eskow, E. S., Krause, P. J., Spielman, A., Freeman, K., & Aslanzadeh, J. (1999). Southern extension of the range of human babesiosis in the Eastern United States. *Journal of Clinical Microbiology*, *37*(6), 2051–2052.

Vannier, E., Krause, P. J. (n.d.) Babesia species (Babesiosis). *Infectious Disease and Antimicrobial Agents.*Retrieved from http://www.antimicrobe.org/b51.asp

Vannier, E., Gewurz, B. E., & Krause, P. J. (2008). Human babesiosis. *Infectious Disease Clinics of North America*, *22*(3), 469–ix. https://doi.org/10.1016/j.idc.2008.03.010

**Evidence for persistent infection/chronic symptomatology/chronic co-infection**

**Human**

Allred, D. (2003). Babesiosis: Persistence in the face of adversity. *Trends in Parasitology*, *19*, 51–55. https://doi.org/10.1016/S1471-4922(02)00065-X

Bonnet, S., Jouglin, M., Malandrin, L., Becker, C., Agoulon, A., L’hostis, M., & Chauvin, A. (2007). Transstadial and transovarial persistence of Babesia divergens DNA in Ixodes ricinus ticks fed on infected blood in a new skin-feeding technique. *Parasitology*, *134*, 197–207. https://doi.org/10.1017/S0031182006001545

Djokic, V., Akoolo, L., & Parveen, N. (2018). Babesia microti infection changes host spleen architecture and is cleared by a Th1 immune response. *Frontiers in Microbiology*, *9*, 85. https://doi.org/10.3389/fmicb.2018.00085

Herwaldt, B. L., Neitzel, D. F., Gorlin, J., A Jensen, K., H Perry, E., R Peglow, W., ... Wilson, M. (2002). Transmission of Babesia microti in Minnesota through four blood donations from the same donor over a 6-month period. *Transfusion*, *42*, 1154–1158. https://doi.org/10.1046/j.1537-2995.2002.00189.x

Horowitz, R. (1999). Chronic Persistent Babesiosis after C+Q/ M+Z [Abstract]. 12th International Conference on Lyme Borreliosis. New York, New York, April.

Krause, P. J., Telford, S. R., Spielman, A., Sikand, V., Ryan, R., Christianson, D., ... Persing, D. H. (1996). Concurrent Lyme disease and babesiosis: evidence for increased severity and duration of illness. *JAMA*, *275*(21), 1657–1660. https://doi.org/10.1001/jama.1996.03530450047031

Krause, P., Gewurz, B., Hill, D., M Marty, F., Vannier, E., Foppa, I., ... Spielman, A. (2008). Persistent and relapsing babesiosis in immunocompromised patients. *Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America*, *46*, 370–376. https://doi.org/10.1086/525852

Krause, P. J., Spielman, A., Telford, S. R., Sikand, V. K., McKay, K., Christianson, D., ... Persing, D. H. (1998). Persistent parasitemia after acute babesiosis. *New England Journal of Medicine*, *339*(3), 160–165. https://doi.org/10.1056/NEJM199807163390304

Lebech et al. Serologic evidence of granulocytic Ehrlichiosis and piroplasma WA 1 in European patients with Lyme neuroborreliosis. Seventh International Congress on Lyme Borreliosis 1996:390.

Lemieux, J. E., D. Tran, A., Freimark, L., Schaffner, S., Goethert, H., G. Andersen, K., ... Sabeti, P. (2016). A global map of genetic diversity in Babesia microti reveals strong population structure and identifies variants associated with clinical relapse. *Nature Microbiology*, *1*, 16079. https://doi.org/10.1038/nmicrobiol.2016.79

Marcus, L. C., Steere, A. C., Duray, P. H., Anderson, A. E., & Mahoney, E. B. (1985). Fatal pancarditis in a patient with coexistent Lyme disease and babesiosis. Demonstration of spirochetes in the myocardium. *Annals of Internal Medicine*, *103*(3), 374–376.

Stricker, R. B., Burrascano, J. J., Harris, N. S., Horowitz, R., Johnson, L., Smith, P. V., & Phillips, S. E. (2006). Coinfection with Borrelia burgdorferi and Babesia microti: bad or worse? *The Journal of Infectious Diseases*, *193*(6), 901–902; author reply 902. https://doi.org/10.1086/500473

Umemiya-Shirafuji, R., Hatta, T., Okubo, K., Sato, M., Maeda, H., Kume, A., ... Suzuki, H. (2017). Transovarial persistence of Babesia ovata DNA in a hard tick, Haemaphysalis longicornis, in a semi-artificial mouse skin membrane feeding system. *Acta Parasitologica*, *62*(4):836–841. https://doi.org/10.1515/ap-2017-0100

Wormser, G. P., Prasad, A., Neuhaus, E., Joshi, S., Nowakowski, J., Nelson, J., ... Krause, P. (2010). Emergence of resistance to Azithromycin-Atovaquone in immunocompromised patients with Babesia microti infection. *Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America*, *50*, 381–386. https://doi.org/10.1086/649859

**Animal**

K Goethert, H., & R Telford, S. (2003). Enzootic transmission of Babesia divergens among cottontail rabbits on Nantucket Island, Massachusetts. *The American Journal of Tropical Medicine and Hygiene*, *69*, 455–460.

Holman, P. J., Spencer, A. M., Droleskey, R. E., Goethert, H. K., & Telford, S. R. (2005). In vitro cultivation of a zoonotic babesia sp. isolated from Eastern cottontail rabbits (Sylvilagus floridanus) on Nantucket Island, Massachusetts. *Journal of Clinical Microbiology*, *43*(8), 3995–4001. https://doi.org/10.1128/JCM.43.8.3995-4001.2005

**Maternal-Fetal Transmission**

Sethi, S., Alcid, D., Kesarwala, H., & Tolan, R. W. (2009). Probable congenital babesiosis in infant, New Jersey, USA. *Emerging Infectious Diseases*, *15*(5), 788–791. https://doi.org/10.3201/eid1505.070808

Tołkacz, K., Bednarska, M., Alsarraf, M., Dwużnik, D., Grzybek, M., Welc-Falęciak, R., ... Bajer, A. (2017). Prevalence, genetic identity and vertical transmission of Babesia microti in three naturally infected species of vole, Microtus spp. (Cricetidae). *Parasites & Vectors*, *10*, 66. https://doi.org/10.1186/s13071-017-2007-x

**Transfusion**

Asad, S., Sweeney, J., & A Mermel, L. (2009). Tranfusion-transmitted babesiosis in Rhode Island. *Transfusion*, *49*, 2564–2573. https://doi.org/10.1111/j.1537-2995.2009.02380.x

Bloch, E. M., Herwaldt, B. L., Leiby, D. A., Shaieb, A., Herron, R. M., Chervenak, M., ... Kjemtrup, A. M. (2012). The third described case of transfusion-transmitted Babesia duncani. *Transfusion*, *52*(7), 1517–1522. https://doi.org/10.1111/j.1537-2995.2011.03467.x

Blue, D., Graves, V., McCarthy, L., Cruz, J., Gregurek, S., & Smith, D. (2009). Fatal transfusion-transmitted Babesia microti in the Midwest. *Transfusion*, *49*(1), 8. https://doi.org/10.1111/j.1537-2995.2008.01883.x

Burgess, M. J., Rosenbaum, E. R., Pritt, B. S., Haselow, D. T., Ferren, K. M., Alzghoul, B. N., ... Bradsher, R. W. (2017). Possiblet transfusion-transmitted Babesia divergens-like/MO-1 infection in an Arkansas patient. *Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America*, *64*(11), 1622–1625. https://doi.org/10.1093/cid/cix216

Cangelosi, J. J., Sarvat, B., Sarria, J. C., Herwaldt, B. L., & Indrikovs, A. J. (2008). Transmission of Babesia microti by blood transfusion in Texas. *Vox Sanguinis*, *95*(4), 331–334. https://doi.org/10.1111/j.1423-0410.2008.01094.x

Cirino, C. M., Leitman, S. F., Williams, E., Fedorko, D., Palmore, T. N., Klion, A., ... Hsieh, M. M. (2008). Transfusion-associated babesiosis with an atypical time course after nonmyeloablative transplantation for sickle cell disease. *Annals of Internal Medicine*, *148*(10), 794–795.

Gubernot, D. M., Nakhasi, H. L., Mied, P. A., Asher, D. M., Epstein, J. S., & Kumar, S. (2009). Transfusion-transmitted babesiosis in the United States: summary of a workshop. *Transfusion*, *49*(12), 2759–2771. https://doi.org/10.1111/j.1537-2995.2009.02429.x

Gubernot, D. M., Lucey, C. T., Lee, K. C., Conley, G. B., Holness, L. G., & Wise, R. P. (2009). Babesia infection through blood transfusions: reports received by the US Food and Drug Administration, 1997–2007. *Clinical Infectious Diseases*, *48*(1), 25–30. https://doi.org/10.1086/595010

Herwaldt, B. L., Neitzel, D. F., Gorlin, J. B., Jensen, K. A., Perry, E. H., Peglow, W. R., ... Wilson, M. (2002). Transmission of Babesia microti in Minnesota through four blood donations from the same donor over a 6-month period. *Transfusion*, *42*(9), 1154–1158.

Herwaldt, B. L., Linden, J. V., Bosserman, E., Young, C., Olkowska, D., & Wilson, M. (2011). Transfusion-associated babesiosis in the United States: a description of cases. *Annals of Internal Medicine*, *155*(8), 509–519. https://doi.org/10.7326/0003-4819-155-8-201110180-00362

Herwaldt, B. L., Kjemtrup, A. M., Conrad, P. A., Barnes, R. C., Wilson, M., McCarthy, M. G., ... Eberhard, M. L. (1997). Transfusion-transmitted babesiosis in Washington State: first reported case caused by a WA1-type parasite. *The Journal of Infectious Diseases*, *175*(5), 1259–1262.

Kjemtrup, A. M., Lee, B., Fritz, C. L., Evans, C., Chervenak, M., & Conrad, P. A. (2002). Investigation of transfusion transmission of a WA1-type babesial parasite to a premature infant in California. *Transfusion*, *42*(11), 1482–1487.

Leiby, D. A. (2006). Babesiosis and blood transfusion: flying under the radar. *Vox Sanguinis*, *90*(3), 157–165. https://doi.org/10.1111/j.1423-0410.2006.00740.x

Ngo, V., & Civen, R. (2009). Babesiosis acquired through blood transfusion, California, USA. *Emerging Infectious Diseases*, *15*(5), 785–787. https://doi.org/10.3201/eid1505.081562

Pantanowitz, L., & Cannon, M. E. (2001). Extracellular Babesia microti parasites. *Transfusion*, *41*(4), 440.

Tonnetti, L., Eder, A. F., Dy, B., Kennedy, J., Pisciotto, P., Benjamin, R. J., & Leiby, D. A. (2009). Transfusion-transmitted Babesia microti identified through hemovigilance. *Transfusion*, *49*(12), 2557–2563. https://doi.org/10.1111/j.1537-2995.2009.02317.x

Zhao, Y., Love, K. R., Hall, S. W., & Beardell, F. V. (2009). A fatal case of transfusion-transmitted babesiosis in the State of Delaware. *Transfusion*, *49*(12), 2583–2587. https://doi.org/10.1111/j.1537-2995.2009.02454.x

**Solid Organ Transplantation**

Brennan, M. B., Herwaldt, B. L., Kazmierczak, J. J., Weiss, J. W., Klein, C. L., Leith, C. P., ... Gauthier, G. M. (2016). Transmission of Babesia microti Parasites by Solid Organ Transplantation. *Emerging Infectious Diseases*, *22*(11). https://doi.org/10.3201/eid2211.151028

**Other Borrelia species:** ***Borrelia miyamotoi*** **(and relapsing fever borrelia), *Borrelia burgdorferi* sensu lato species**

**Clinical Picture/Syndromic Surveillance**

Branda, J. A., & Rosenberg, E. S. (2013). Borrelia miyamotoi: a lesson in disease discovery. *Annals of Internal Medicine*, *159*(1), 61–62. https://doi.org/10.7326/0003-4819-159-1-201307020-00009

Clark, K. L., Leydet, B., & Hartman, S. (2013). Lyme borreliosis in human patients in Florida and Georgia, USA. *International Journal of Medical Sciences*, *10*(7), 915–931. https://doi.org/10.7150/ijms.6273

Girard, Y. A., Fedorova, N., & Lane, R. S. (2011). Genetic diversity of Borrelia burgdorferi and detection of B. bissettii-like DNA in serum of North-Coastal California Residents. *Journal of Clinical Microbiology*, *49*(3), 945–954. https://doi.org/10.1128/JCM.01689-10

Gugliotta, J. L., Goethert, H. K., Berardi, V. P., & Telford, S. R. (2013). Meningoencephalitis from Borrelia miyamotoi in an immunocompromised patient. *The New England Journal of Medicine*, *368*, 240–245. https://doi.org/10.1056/NEJMoa1209039

Hojgaard, A., Lukacik, G., & Piesman, J. (2014). Detection of Borrelia burgdorferi, Anaplasma phagocytophilum and Babesia microti, with two different multiplex PCR assays. *Ticks and Tick-Borne Diseases*, *5*(3), 349–351. https://doi.org/10.1016/j.ttbdis.2013.12.001

Koetsveld, J., Kolyasnikova, N. M., Wagemakers, A., Stukolova, O. A., Hoornstra, D., Sarksyan, D. S., ... Hovius, J. W. (2018). Serodiagnosis of Borrelia miyamotoi disease by measuring antibodies against GlpQ and variable major proteins. *Clinical Microbiology and Infection*, *0*(0). https://doi.org/10.1016/j.cmi.2018.03.009.

Krause, P. J., & Barbour, A. G. (2015). Borrelia miyamotoi: The newest infection brought to us by deer ticks. *Annals of Internal Medicine*, *163*(2), 141–142. https://doi.org/10.7326/M15-1219

Krause, P. J., Carroll, M., Fedorova, N., Brancato, J., Dumouchel, C., Akosa, F., ... Lane, R. S. (2018). Human Borrelia miyamotoi infection in California: Serodiagnosis is complicated by multiple endemic Borrelia species. *PLOS ONE*, *13*(2), e0191725. https://doi.org/10.1371/journal.pone.0191725

Lee, S. H., Vigliotti, J. S., Vigliotti, V. S., Jones, W., & Shearer, D. M. (2014). Detection of borreliae in archived sera from patients with clinically suspect Lyme disease. *International Journal of Molecular Sciences*, *15*(3), 4284–4298. https://doi.org/10.3390/ijms15034284

Margos, Gabriele, Natalia Fedorova, Joyce E. Kleinjan, Christine Hartberger, Tom G. Schwan, Andreas Sing, and Volker Fingerle. “Borrelia Lanei Sp. Nov. Extends the Diversity of Borrelia Species in California.” *International Journal of Systematic and Evolutionary Microbiology* 67, no. 10 (October 2017): 3872–76. https://doi.org/10.1099/ijsem.0.002214.

Molloy, P. J., Telford, S. R., Chowdri, H. R., Lepore, T. J., Gugliotta, J. L., Weeks, K. E., ... Berardi, V. P. (2015). Borrelia miyamotoi disease in the Northeastern United States: A case series. *Annals of Internal Medicine*, *163*(2), 91–98. https://doi.org/10.7326/M15-0333

Perronne, C. (2014). Lyme and associated tick-borne diseases: global challenges in the context of a public health threat. *Frontiers in Cellular and Infection Microbiology*, *4*. https://doi.org/10.3389/fcimb.2014.00074

Rollend, L., Fish, D., & Childs, J. E. (2013). Transovarial transmission of Borrelia spirochetes by Ixodes scapularis: a summary of the literature and recent observations. *Ticks and Tick-Borne Diseases*, *4*(1–2), 46–51. https://doi.org/10.1016/j.ttbdis.2012.06.008

Rudenko, N., Golovchenko, M., Vancova, M., Clark, K., Grubhoffer, L., & Oliver, J. H. (2016). Isolation of live Borrelia burgdorferi sensu lato spirochaetes from patients with undefined disorders and symptoms not typical for Lyme borreliosis. *Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases*, *22*(3), 267.e9-15. https://doi.org/10.1016/j.cmi.2015.11.009

Rudenko, N., Golovchenko, M., Grubhoffer, L., & Oliver, J. H. (2011). Updates on Borrelia burgdorferi sensu lato complex with respect to public health. *Ticks and Tick-Borne Diseases*, *2*(3), 123–128. https://doi.org/10.1016/j.ttbdis.2011.04.002

Salkeld, D. J., Cinkovich, S., & Nieto, N. C. (2014). Tick-borne pathogens in Northwestern California, USA [Letter to the editor]. *Emerging Infectious Diseases*, *20*(3), 493–494. https://doi.org/10.3201/eid2003.130668

Stanek, G., & Reiter, M. (2011). The expanding Lyme Borrelia complex—clinical significance of genomic species? *Clinical Microbiology and Infection*, *17*(4), 487–493. https://doi.org/10.1111/j.1469-0691.2011.03492.x

Telford, Sam R., Heidi K. Goethert, Philip J. Molloy, Victor P. Berardi, Hanumara Ram Chowdri, Joseph L. Gugliotta, and Timothy J. Lepore. “Borrelia Miyamotoi Disease: Neither Lyme Disease Nor Relapsing Fever.” *Clinics in Laboratory Medicine* 35, no. 4 (December 2015): 867–82. https://doi.org/10.1016/j.cll.2015.08.002.

Wroblewski, D., Gebhardt, L., Prusinski, M.A., Meehan, L.J., Halse, T.A., Musser, K.A. (2017). Detection of Borrelia miyamotoi and other tick-borne pathogens in human clinical specimens and Ixodes scapularis ticks in New York State, 2012–2015. *Ticks and Tick-Borne Diseases*, *8*(3), 407–411. https://doi.org/10.1016/j.ttbdis.2017.01.004

Yale Researchers Identify Extent of New Tick-Borne Infection. (2014, May 8). *Electronic Component News*. Retrieved from https://www.ecnmag.com/news/2014/05/yale-researchers-identify-extent-new-tick-borne-infection

**Pathology/Pathophysiology**

Graves, Christopher J., Vera I. D. Ros, Brian Stevenson, Paul D. Sniegowski, and Dustin Brisson. “Natural Selection Promotes Antigenic Evolvability.” *PLOS Pathogens* 9, no. 11 (November 14, 2013): e1003766. https://doi.org/10.1371/journal.ppat.1003766.

Rogovskyy, A. S., & Bankhead, T. (2013). Variable VlsE is critical for host reinfection by the Lyme disease spirochete. *PLOS ONE*, *8*(4), e61226. https://doi.org/10.1371/journal.pone.0061226

Thorp, A. M., & Tonnetti, L. (2016). Distribution and survival of Borrelia miyamotoi in human blood components. *Transfusion*, *56*(3), 705–711. https://doi.org/10.1111/trf.13398

**Gaps in Knowledge/data**

Gugliotta, J. L., Goethert, H. K., Berardi, V. P., & Telford, S. R. (2013). Meningoencephalitis from *Borrelia miyamotoi* in an Immunocompromised Patient. *New England Journal of Medicine*, *368*(3), 240–245. https://doi.org/10.1056/NEJMoa1209039

Krause, P. J., Narasimhan, S., Wormser, G. P., Rollend, L., Fikrig, E., Lepore, T., ... Fish, D. (2013, January 16). Human Borrelia miyamotoi Infection in the United States [Letter to the editor]. *New England Journal of Medicine, 368*, 291–293** https://doi.org/10.1056/NEJMc1215469

**Evidence of acute infection and support for treatment of acute infection**

Clark, K. L., Leydet, B., & Hartman, S. (2013). Lyme borreliosis in human patients in Florida and Georgia, USA. *International Journal of Medical Sciences*, *10*(7), 915–931. https://doi.org/10.7150/ijms.6273

Cutler, S. (2015). Relapsing Fever Borreliosis. In Schlossberg, D. (Ed.), *Clinical Infectious Disease*, Second Edition. Cambridge: Cambridge University Press. https://doi:10.1017/CBO9781139855952

Rudenko, N., Golovchenko, M., Grubhoffer, L., & Oliver, J. H. (2011). Updates on Borrelia burgdorferi sensu lato complex with respect to public health. *Ticks and Tick-Borne Diseases*, *2*(3), 123–128. https://doi.org/10.1016/j.ttbdis.2011.04.002

Rudenko, N., Golovchenko, M., Vancova, M., Clark, K., Grubhoffer, L., & Oliver, J. H. (2016). Isolation of live Borrelia burgdorferi sensu lato spirochaetes from patients with undefined disorders and symptoms not typical for Lyme borreliosis. *Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases*, *22*(3), 267.e9-15. https://doi.org/10.1016/j.cmi.2015.11.009

**Evidence for persistent infection/chronic symptomatology/chronic co-infection**

Lee, S. H., Vigliotti, J. S., Vigliotti, V. S., Jones, W., & Shearer, D. M. (2014). Detection of borreliae in archived sera from patients with clinically suspect Lyme disease. *International Journal of Molecular Sciences*, *15*(3), 4284–4298. https://doi.org/10.3390/ijms15034284

Lee, S. H., Vigliotti, J. S., Vigliotti, V. S., Jones, W., Moorcroft, T. A., & Lantsman, K. (2014). DNA sequencing diagnosis of off-season spirochetemia with low bacterial density in Borrelia burgdorferi and Borrelia miyamotoi infections. *International Journal of Molecular Sciences*, *15*(7), 11364–11386. https://doi.org/10.3390/ijms150711364

Lee, S. H., Vigliotti, V. S., Vigliotti, J. S., Jones, W., & Pappu, S. (2010). Increased Sensitivity and Specificity of Borrelia burgdorferi 16S Ribosomal DNA Detection. *American Journal of Clinical Pathology*, *133*(4), 569–576. https://doi.org/10.1309/AJCPI72YAXRHYHEE

Lee, S. H., Vigliotti, V. S., Vigliotti, J. S., Jones, W., Williams, J., & Walshon, J. (2010). Early Lyme disease with spirochetemia - diagnosed by DNA sequencing. *BMC Research Notes*, *3*, 273. https://doi.org/10.1186/1756-0500-3-273

Rudenko, N., Golovchenko, M., Vancova, M., Clark, K., Grubhoffer, L., & Oliver, J. H. (2016). Isolation of live Borrelia burgdorferi sensu lato spirochaetes from patients with undefined disorders and symptoms not typical for Lyme borreliosis. *Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases*, *22*(3), 267.e9-15. https://doi.org/10.1016/j.cmi.2015.11.009

**Evidence of Transmission by blood transfusion**:

Thorp, A. M., & Tonnetti, L. (2016). Distribution and survival of Borrelia miyamotoi in human blood components. *Transfusion*, *56*(3), 705–711. https://doi.org/10.1111/trf.13398

**Clinical Case(s) illustrating how co-infection affects diagnosis and treatment**

**Patients study group**

Rudenko, N., Golovchenko, M., Vancova, M., Clark, K., Grubhoffer, L., & Oliver, J. H. (2016). Isolation of live Borrelia burgdorferi sensu lato spirochaetes from patients with undefined disorders and symptoms not typical for Lyme borreliosis. *Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases*, *22*(3), 267.e9-15. https://doi.org/10.1016/j.cmi.2015.11.009

**Deer Tick Virus (DTV) / Powassan virus (POWV)**

**Clinical Picture/Syndromic Surveillance**

Centers for Disease Control and Prevention. (2015a). *Arboviral Diseases, Neuroinvasive and Non-neuroinvasive 2015 Case Definition*. Retrieved from https://wwwn.cdc.gov/nndss/conditions/arboviral-diseases-neuroinvasive-and-non-neuroinvasive/case-definition/2015/

Dehio, C. (2004). Molecular and cellular basis of bartonella pathogenesis. *Annual Review of Microbiology*, *58*(1), 365–390. https://doi.org/10.1146/annurev.micro.58.030603.123700

Ebel, G. D., & Kramer, L. D. (2004). Short report: duration of tick attachment required for transmission of powassan virus by deer ticks. *The American Journal of Tropical Medicine and Hygiene*, *71*(3), 268–271.

Lessell, S., & Collins, T. E. (2003). Ophthalmoplegia in Powassan encephalitis. *Neurology*, *60*(10), 1726–1727.

New York State Department of Health. (2017, October 20). *New York State Department of Health reminds New Yorkers to Take Precautions Against Ticks During Fall Outdoor Activities* [Press release]. Retrieved from https://www.health.ny.gov/press/releases/2017/2017-10-20_powassan_virus_dutchess_county.htm

Piantadosi, A., Rubin, D. B., McQuillen, D. P., Hsu, L., Lederer, P. A., Ashbaugh, C. D., ... Lyons, J. L. (2016). Emerging cases of Powassan virus encephalitis in New England: Clinical presentation, imaging, and review of the literature. *Clinical Infectious Diseases*, *62*(6), 707–713. https://doi.org/10.1093/cid/civ1005

Smith, R., Woodall, J. P., Whitney, E., Deibel, R., Gross, M. A., Smith, V., & Bast, T. F. (1974). Powassan virus infection: A report of three human cases of encephalitis. *American Journal of Diseases of Children*, *127*(5), 691–693. https://doi.org/10.1001/archpedi.1974.02110240077010

Thomm, A. M., Schotthoefer, A. M., Dupuis, A. P., Kramer, L. D., Frost, H. M., Fritsche, T. R., ... Kehl, S. C. (2018). Development and validation of a serologic test panel for detection of Powassan virus infection in U.S. patients residing in regions where Lyme disease is endemic. *MSphere*, *3*(1), e00467-17. https://doi.org/10.1128/mSphere.00467-17

**Sequelae**

Centers for Disease Control and Prevention. (2015b). *Powassan Virus: Symptoms and Treatment.* Retrieved from https://www.cdc.gov/powassan/symptoms.html

Ebel, G. D. (2010). Update on Powassan virus: emergence of a North American tick-borne flavivirus. *Annual Review of Entomology*, *55*, 95–110. https://doi.org/10.1146/annurev-ento-112408-085446

**Pathology/Pathophysiology**

Frolova, M. P., Isachkova, L. M., Shestopalova, N. M., & Pogodina, V. V. (1985). Experimental encephalitis in monkeys caused by the Powassan virus. *Neuroscience and Behavioral Physiology*, *15*(1), 62–69.

Lindquist, L., & Vapalahti, O. (2008). Tick-borne encephalitis. *The Lancet*, *371*(9627), 1861–1871. https://doi.org/10.1016/S0140-6736(08)60800-4

McLean, D. M., & Donohue, W. L. (1959). Powassan virus: Isolation of virus from a fatal case of encephalitis. *Canadian Medical Association Journal*, *80*(9), 708–711.

Piantadosi, A., Rubin, D. B., McQuillen, D. P., Hsu, L., Lederer, P. A., Ashbaugh, C. D., ... Lyons, J. L. (2016). Emerging cases of Powassan virus encephalitis in New England: Clinical presentation, imaging, and review of the literature. *Clinical Infectious Diseases*, *62*(6), 707–713. https://doi.org/10.1093/cid/civ1005

Tavakoli, N. P., Wang, H., Dupuis, M., Hull, R., Ebel, G. D., Gilmore, E. J., & Faust, P. L. (2009). Fatal case of deer tick virus encephalitis. *The New England Journal of Medicine*, *360*(20), 2099–2107. https://doi.org/10.1056/NEJMoa0806326

**Evidence for Treatment**

El Khoury, M. Y., Camargo, J. F., White, J. L., Backenson, B. P., Dupuis, A. P., Escuyer, K. L., ... Wong, S. J. (2013). Potential role of deer tick virus in Powassan encephalitis cases in Lyme disease-endemic areas of New York, USA. *Emerging Infectious Diseases*, *19*(12), 1926–1933. https://doi.org/10.3201/eid1912.130903

Gritsun, T. S., Lashkevich, V. A., & Gould, E. A. (2003). Tick-borne encephalitis. *Antiviral Research,* *57*(1–2), 129–146. https://doi.org/10.1016/S0166-3542(02)00206-1

Hicar, M. D., Edwards, K., & Bloch, K. (2011). Powassan virus infection presenting as acute disseminated encephalomyelitis in Tennessee. *The Pediatric Infectious Disease Journal*, *30*(1), 86–88. https://doi.org/10.1097/INF.0b013e3181f2f492

Piantadosi, A., Rubin, D. B., McQuillen, D. P., Hsu, L., Lederer, P. A., Ashbaugh, C. D., ... Lyons, J. L. (2016). Emerging cases of Powassan virus encephalitis in New England: Clinical presentation, imaging, and review of the literature. *Clinical Infectious Diseases*, *62*(6), 707–713. https://doi.org/10.1093/cid/civ1005

Sung, S., Wurcel, A. G., Whittier, S., Kulas, K., Kramer, L. D., Flam, R., ... Tsiouris, S. (2013). Powassan meningoencephalitis, New York, New York, USA. *Emerging Infectious Diseases*, *19*(9), 1549–1551. https://doi.org/10.3201/eid1909.121846

**Evidence of acute infection and support for treatment of acute infection**

Hermance, M. E., & Thangamani, S. (2017). Powassan virus: An emerging arbovirus of public health concern in North America. *Vector Borne and Zoonotic Diseases (Larchmont, N.Y.)*, *17*(7), 453–462. https://doi.org/10.1089/vbz.2017.2110

**Evidence for persistent infection/chronic symptomatology/chronic co-infection**

**Co-infection**

In one study “4 out of 8 POWV single ticks from the Midwest were co-infected with B. burgdorferi (50%), demonstrating the potential for concurrent transmission of Lyme disease and POWV to humans.” Among 106 patients with suspected, acute tick-borne disease, 10.4% tested positive for POWV, and of the 11 positive POWV samples, 81.8% were also positive for Lyme. In a second study, among 94 patients with suspected acute tick-borne disease, 14.9% tested positive by POWV IFA, and of those samples, 64% were also Lyme positive. High rates of co-infection have therefore been demonstrated for patients living in the Midwest (Wisconsin), and may in part explain chronic resistant neurological symptoms in those suffering with PTLDS.

Knox, K. K., Thomm, A. M., Harrington, Y. A., Ketter, E., Patitucci, J. M., & Carrigan, D. R. (2017). Powassan/deer tick virus and Borrelia burgdorferi infection in Wisconsin tick populations. *Vector Borne and Zoonotic Diseases (Larchmont, N.Y.)*, *17*(7), 463–466. https://doi.org/10.1089/vbz.2016.2082

Thomm, A., Schotthoefer A., Kehr, S., Kramer, L., Frost, H., Fritsche T., Knox, K. (2016, May 19–22). Development of a serologic test panel for detection of Powassan virus infection [Abstract]. *Clinical Virology Symposium*, 249.

**Maternal-fetal transmission**

Arthropod borne flaviviruses (Powassan virus, tick-borne encephalitis virus [TBEV], West Nile virus [WNV], and Zika virus) can cause fetal malformations. Apart from known fetal malformations from Zika fetal syndrome (microcephaly, facial disproportionality, cutis gyrata, hypertonia and/or spasticity, hyperreflexia, and irritability), the genitourinary, cardiac and digestive systems may also be affected. For WNV, among 72 infants born to women in the US who acquired WNV during pregnancy (as reported to the CDC), 10.6% had major birth defects, including aortic co-arctation, cleft palate, Down syndrome, Lissencephaly, Microcephaly, and Polydactyly.

O’Leary, D. R., Kuhn, S., Kniss, K. L., Hinckley, A. F., Rasmussen, S. A., Pape, W. J., ... Hayes, E. B. (2006). Birth outcomes following West Nile Virus infection of pregnant women in the United States: 2003–2004. *Pediatrics*, *117*(3), e537–545. https://doi.org/10.1542/peds.2005-2024

**Persistence**

In primates infected with TBEV, symptomatic animals had detectable virus up to 738 days post recovery. ZIKV is also known to have established persistence in primate models and BALB-C and B6 mice, and WNV establishes persistence in mice, golden Syrian hamsters, and Rhesus Macacques. In humans, WNV RNA was demonstrated in 20% of urine samples collected from convalescent patients 1.6-6.7 years after WNV infection, and Zika virus has been shown to have late sexual transmission secondary to persistence in the semen. IgM antibodies to WNV and TBEV are also known to persist for greater than 12 months in serum and CSF. POWV persistence is unknown, however, “increasing and substantial evidence of viral persistence in humans, which includes the isolation of RNA by RT-PCR and infectious virus by culture, continues to be reported. Viral persistence can also be established in vitro in various human, animal, arachnid and insect cell lines in culture. Although some research has focused on the potential roles of defective virus particles, evasion of the immune response through the manipulation of autophagy and/or apoptosis, the precise mechanism of flavivirus persistence is still not well understood” (Murray et al., 2017).

Hudopisk, N., Korva, M., Janet, E., Simetinger, M., Grgič-Vitek, M., Gubenšek, J., ... Avšič-Županc, T. (2013). Tick-borne encephalitis associated with consumption of raw goat milk, Slovenia, 2012. *Emerging Infectious Diseases*, *19*(5), 806–808. https://doi.org/10.3201/eid1905.121442

Mlera, L., Melik, W., & Bloom, M. E. (2014). The role of viral persistence in flavivirus biology. *Pathogens and Disease*, *71*(2), 137–163. https://doi.org/10.1111/2049-632X.12178

Murray, K. O., Gorchakov, R., Carlson, A. R., Berry, R., Lai, L., Natrajan, M., ... Mulligan, M. J. (2017). Prolonged detection of Zika virus in vaginal secretions and whole blood. *Emerging Infectious Diseases*, *23*(1), 99–101. https://doi.org/10.3201/eid2301.161394

Murray, K., Walker, C., Herrington, E., Lewis, J. A., McCormick, J., Beasley, D. W. C., ... Fisher-Hoch, S. (2010). Persistent infection with West Nile virus years after initial infection. *The Journal of Infectious Diseases*, *201*(1), 2–4. https://doi.org/10.1086/648731

Prisant, N., Bujan, L., Benichou, H., Hayot, P.-H., Pavili, L., Lurel, S., ... Joguet, G. (2016). Zika virus in the female genital tract. *The Lancet Infectious Diseases*, *16*(9), 1000–1001. https://doi.org/10.1016/S1473-3099(16)30193-1

Stiasny, K., Aberle, J. H., Chmelik, V., Karrer, U., Holzmann, H., & Heinz, F. X. (2012). Quantitative determination of IgM antibodies reduces the pitfalls in the serodiagnosis of tick-borne encephalitis. *Journal of Clinical Virology*, *54*(2), 115–120. https://doi.org/10.1016/j.jcv.2012.02.016

Turmel, J. M., Abgueguen, P., Hubert, B., Vandamme, Y. M., Maquart, M., Guillou-Guillemette, H. L., & Leparc-Goffart, I. (2016). Late sexual transmission of Zika virus related to persistence in the semen. *The Lancet*, *387*(10037), 2501. https://doi.org/10.1016/S0140-6736(16)30775-9

**Clinical Case(s) illustrating how co-infection affects diagnosis and treatment**

Concurrent infection with POWV and Lyme disease is not rare. Without neuroinvasive disease, the long-term effects of co-infection is unknown.

Knox, K. K., Thomm, A. M., Harrington, Y. A., Ketter, E., Patitucci, J. M., & Carrigan, D. R. (2017). Powassan/deer tick virus and Borrelia burgdorferi infection in Wisconsin tick populations. *Vector Borne and Zoonotic Diseases (Larchmont, N.Y.)*, *17*(7), 463–466. https://doi.org/10.1089/vbz.2016.2082

**Rickettsia (Rocky Mountain Spotted Fever - RMSF)**

**Epidemiology**

Álvarez-Hernández, G., Roldán, J. F. G., Milan, N. S. H., Lash, R. R., Behravesh, C. B., & Paddock, C. D. (2017). Rocky Mountain spotted fever in Mexico: past, present, and future. *The Lancet Infectious Diseases*, *17*(6), e189–e196. https://doi.org/10.1016/S1473-3099(17)30173-1

Demma, L. J., Traeger, M. S., Nicholson, W. L., Paddock, C. D., Blau, D. M., Eremeeva, M. E., ... McQuiston, J. H. (2005). Rocky Mountain spotted fever from an unexpected tick vector in Arizona. *New England Journal of Medicine*, *353*(6), 587–594. https://doi.org/10.1056/NEJMoa050043

Drexler, N. A., Dahlgren, F. S., Heitman, K. N., Massung, R. F., Paddock, C. D., & Behravesh, C. B. (2016). National surveillance of spotted fever group rickettsioses in the United States, 2008–2012. *The American Journal of Tropical Medicine and Hygiene*, *94*(1), 26–34. https://doi.org/10.4269/ajtmh.15-0472

Drexler, N. A., Yaglom, H., Casal, M., Fierro, M., Kriner, P., Murphy, B., ... Paddock, C. D. (2017). Fatal Rocky Mountain spotted fever along the United States-Mexico border, 2013–2016. *Emerging Infectious Diseases*, *23*(10), 1621–1626. https://doi.org/10.3201/eid2310.170309

Wells, G. M., Woodward, T. E., Fiset, P., & Hornick, R. B. (1978). Rocky mountain spotted fever caused by blood transfusion. *The Journal of the American Medical Association,* *239*(26), 2763–2765.

**Clinical Picture/Syndromic Surveillance**

Archibald, L. K., & Sexton, D. J. (1995). Long-term sequelae of Rocky Mountain spotted fever. *Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America*, *20*(5), 1122–1125.

Bergeron, J. W., Braddom, R. L., & Kaelin, D. L. (1997). Persisting impairment following Rocky Mountain Spotted Fever: a case report. *Archives of Physical Medicine and Rehabilitation*, *78*(11), 1277–1280.

Buckingham, S. C., Marshall, G. S., Schutze, G. E., Woods, C. R., Jackson, M. A., Patterson, L. E. R., ... Tick-borne Infections in Children Study Group. (2007). Clinical and laboratory features, hospital course, and outcome of Rocky Mountain spotted fever in children. *The Journal of Pediatrics*, *150*(2), 180–184, 184.e1. https://doi.org/10.1016/j.jpeds.2006.11.023

Drexler, N. A., Traeger, M. S., McQuiston, J. H., Williams, V., Hamilton, C., & Regan, J. J. (2015). Medical and indirect costs associated with a Rocky Mountain spotted fever epidemic in Arizona, 2002–2011. *The American Journal of Tropical Medicine and Hygiene*, *93*(3), 549–551. https://doi.org/10.4269/ajtmh.15-0104

Gorman, R. J., Saxon, S., & Snead, O. C. (1981). Neurologic sequelae of Rocky Mountain spotted fever. *Pediatrics*, *67*(3), 354–357.

Kirkland, K. B., Marcom, P. K., Sexton, D. J., Dumler, J. S., & Walker, D. H. (1993). Rocky Mountain spotted fever complicated by gangrene: report of six cases and review. *Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America*, *16*(5), 629–634.

Masters, E. J., Olson, G. S., Weiner, S. J., & Paddock, C. D. (2003). Rocky Mountain spotted fever: a clinician’s dilemma. *Archives of Internal Medicine*, *163*(7), 769–774. https://doi.org/10.1001/archinte.163.7.769

Woods, C. R. (2013). Rocky Mountain spotted fever in children. *Pediatric Clinics of North America*, *60*(2), 455–470. https://doi.org/10.1016/j.pcl.2012.12.001

**Pathology/Pathophysiology**

Saraiva, D. G., Soares, H. S., Soares, J. F., & Labruna, M. B. (2014). Feeding period required by Amblyomma aureolatum ticks for transmission of Rickettsia rickettsii to vertebrate hosts. *Emerging Infectious Diseases*, *20*(9), 1504–1510. https://doi.org/10.3201/eid2009.140189

**Evidence for Treatment**

Botelho-Nevers, E., Socolovschi, C., Raoult, D., & Parola, P. (2012). Treatment of Rickettsia spp. infections: a review. *Expert Review of Anti-Infective Therapy*, *10*(12), 1425–1437. https://doi.org/10.1586/eri.12.139

Biggs, H. M. (2016). Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever and other spotted fever group rickettsioses, ehrlichioses, and anaplasmosis—United States. *MMWR. Recommendations and Reports*, *65*. https://doi.org/10.15585/mmwr.rr6502a1

“Consequences of Delayed Diagnosis of Rocky Mountain Spotted Fever in Children --- West Virginia, Michigan, Tennessee, and Oklahoma, May--July 2000.” Accessed May 3, 2018. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4939a2.htm.

Cross, R., Ling, C., Day, N. P. J., McGready, R., & Paris, D. H. (2016). Revisiting doxycycline in pregnancy and early childhood—time to rebuild its reputation? *Expert Opinion on Drug Safety*, *15*(3), 367–382. https://doi.org/10.1517/14740338.2016.1133584

Paddock C. D., & Alvarez-Hernandez G. (2018) *Rickettsia rickettsii* (Rocky Mountain spotted fever). In: Long, S. S., Prober, CG, and Pickering, L. K. (Eds.),. *Principles and Practice of Pediatric Infectious Diseases*, 5th Edition (pp. 952–957). London: Elsevier, London.

Pöyhönen, H., Nurmi, M., Peltola, V., Alaluusua, S., Ruuskanen, O., & Lähdesmäki, T. (2017). Dental staining after doxycycline use in children. *Journal of Antimicrobial Chemotherapy*, *72*(10), 2887–2890. https://doi.org/10.1093/jac/dkx245

Todd, S. R., Dahlgren, F. S., Traeger, M. S., Beltrán-Aguilar, E. D., Marianos, D. W., Hamilton, C., ... Regan, J. J. (2015). No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. *The Journal of Pediatrics*, *166*(5), 1246–1251. https://doi.org/10.1016/j.jpeds.2015.02.015

Volovitz, B., Shkap, R., Amir, J., Calderon, S., Varsano, I., & Nussinovitch, M. (2007). Absence of tooth staining with doxycycline treatment in young children. *Clinical Pediatrics*, *46*(2), 121–126. https://doi.org/10.1177/0009922806290026

**Gaps in Knowledge/Data**

Mosites, E., Carpenter, L. R., McElroy, K., Lancaster, M. J., Ngo, T. H., McQuiston, J., ... Dunn, J. R. (2013). Knowledge, attitudes, and practices regarding Rocky Mountain spotted fever among healthcare providers, Tennessee, 2009. *The American Journal of Tropical Medicine and Hygiene*, *88*(1), 162–166. https://doi.org/10.4269/ajtmh.2012.12-0126

O’Reilly, M., Paddock, C., Elchos, B., Goddard, J., Childs, J., & Currie, M. (2003). Physician knowledge of the diagnosis and management of Rocky Mountain spotted fever: Mississippi, 2002. *Annals of the New York Academy of Sciences*, *990*, 295–301.

Zientek, J., Dahlgren, F. S., McQuiston, J. H., & Regan, J. (2014). Self-reported treatment practices by healthcare providers could lead to death from Rocky Mountain spotted fever. *The Journal of Pediatrics*, *164*(2), 416–418. https://doi.org/10.1016/j.jpeds.2013.10.008

**Evidence of acute infection and support for treatment of acute infection**

Botelho-Nevers, E., Socolovschi, C., Raoult, D., & Parola, P. (2012). Treatment of Rickettsia spp. infections: a review. *Expert Review of Anti-Infective Therapy*, *10*(12), 1425–1437. https://doi.org/10.1586/eri.12.139

Masters, Edwin J., Gary S. Olson, Scott J. Weiner, and Christopher D. Paddock. (2003, April 14). Rocky Mountain spotted fever: A clinician’s dilemma. *Archives of Internal Medicine* *163*(7). 769–74. https://doi.org/10.1001/archinte.163.7.769.

Todd, S. R., Dahlgren, F. S., Traeger, M. S., Beltrán-Aguilar, E. D., Marianos, D. W., Hamilton, C., ... Regan, J. J. (2015). No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. *The Journal of Pediatrics*, *166*(5), 1246–1251. https://doi.org/10.1016/j.jpeds.2015.02.015

Woods, C. R. (2013). Rocky Mountain spotted fever in children. *Pediatric Clinics of North America*, *60*(2), 455–470. https://doi.org/10.1016/j.pcl.2012.12.001

**Maternal-fetal transmission and Transfusion Risk**

Pitassi, Luiza Helena Urso, Pedro Paulo Vissotto de Paiva Diniz, Diana Gerardi Scorpio, Marina Rovani Drummond, Bruno Grosselli Lania, Maria Lourdes Barjas-Castro, Rovilson Gilioli, et al. “Bartonella Spp. Bacteremia in Blood Donors from Campinas, Brazil.” *PLoS Neglected Tropical Diseases* 9, no. 1 (January 2015): e0003467. https://doi.org/10.1371/journal.pntd.0003467.

Vieira-Damiani, Gislaine, Pedro Paulo Vissotto de Paiva Diniz, Luiza Helena Urso Pitassi, Stanley Sowy, Diana Gerardi Scorpio, Bruno Grosselli Lania, Marina Rovani Drummond, et al. “Bartonella Clarridgeiae Bacteremia Detected in an Asymptomatic Blood Donor.” *Journal of Clinical Microbiology* 53, no. 1 (January 1, 2015): 352–56. https://doi.org/10.1128/JCM.00934-14.

**Evidence of blood transfusion/transmission**

Wells, G. M., Woodward, T. E., Fiset, P., & Hornick, R. B. (1978). Rocky mountain spotted fever caused by blood transfusion. *The Journal of the American Medical Association,* *239*(26), 2763–2765.

**Clinical Case(s) illustrating how co-infection affects diagnosis and treatment**

**Chronic symptoms**

Bergeron, J. W., Braddom, R. L., & Kaelin, D. L. (1997). Persisting impairment following Rocky Mountain Spotted Fever: a case report. *Archives of Physical Medicine and Rehabilitation*, *78*(11), 1277–1280.

Kushawaha, A., Brown, M., Martin, I., & Evenhuis, W. (2013). Hitch-hiker taken for a ride: an unusual cause of myocarditis, septic shock and adult respiratory distress syndrome. *BMJ Case Reports*, *2013*. https://doi.org/10.1136/bcr-2012-007155

Sexton, DJ et al. Dual infection with Ehrlichia chafeensis and a spotted fever group rickettsia: A case Report. Emerging Infectious Diseases. Apr-June 8, Vol. 4 Issue 2, p311. 6p. 2

**Bartonella spp.**

**Clinical Picture/Syndromic Surveillance**

Boulouis, H.-J., Chang, C.-C., Henn, J. B., Kasten, R. W., & Chomel, B. B. (2005). Factors associated with the rapid emergence of zoonotic Bartonella infections. *Veterinary Research*, *36*(3), 383–410. https://doi.org/10.1051/vetres:2005009

Breitschwerdt, E., et al. Emerg Infect Dis. 2012

Breitschwerdt EB, R. G. Maggi, W. L. Nicholson,2 N. A. Cherry, and C. W. Woods. Journal Of Clinical Microbiology, Sept. 2008, p. 2856–2861 Vol. 46, No. 9 0095-1137/08/$08.000 doi:10.1128/JCM.00832-08

Breitschwerdt EB. Bartonelllosis m One Health and all creatures great and small

Vet Dermatol. 2017 Feb;28(1):96-e21. doi: 10.1111/vde.12413. Review.

Breitschwerdt, E. B. (2014). Bartonellosis: One health perspectives for an emerging infectious disease. *ILAR Journal*, *55*(1), 46–58. https://doi.org/10.1093/ilar/ilu015

Chomel BB1, Kasten RW. Bartonellosis, an increasingly recognized zoonosis.J Appl Microbiol. 2010 Sep;109(3):743-50. doi: 10.1111/j.1365-2672.2010.04679.x.

DeCiccoMD Anthony, B. Niluk Peiris, MD, Cecilia Kelly, MD, Michael Latreille, MD

Donald Jungkind, PhD. Two Cases of Co-Infection with Babesiosis and Lyme Disease. 2012. Jefferson, The Medicine Forum, Vol. 13 [2012], Art. 15 http://jdc.jefferson.edu/tmf/vol13/iss1/15?utm_source=jdc.jefferson.edu%2Ftmf%2Fvol13%2Fiss1%2F15&utm_medium=PDF&utm_campaign=PDFCoverPages

Joussen, A. M., & Wong, D. (Eds.) (2013). *Graefes Archive for Clinical and Experimental Opthalmology*. *251*(3):1001-1002.

Kosoy M, Hayman DT, Chan KS. 2012. *Bartonella* bacteria in nature: where does population variability end and a species start? Infect. Genet. Evol. 12:894-904.

MacDonald K.A., Chomel B.B., Kittleson M.D., Kasten R.W., Thomas W.P., Pesavento P., A prospective study of canine infective endocarditis in northern California (1999– 2001): emergence of Bartonella as a prevalent etiologic agent, J. Vet. Intern. Med. 18 (2004) 56–64.

Mozayeni MD Bobak Robert, Ricardo Guillermo Maggi, PhD, Julie Meredith Bradley, BS, Edward Bealmear Breitschwerdt, DVM. Rheumatological presentation of Bartonella koehlerae and Bartonella henselae bacteremias A case report. Medicine (2018) 97:17

Pachner 1988 –Borrelia burgdorferi in the nervous system: the new "great imitator".

Pachner AR1. Ann N Y Acad Sci. 1988;539:56-64.

Rolain, JM, P Brouqui, ME Koehler, C Maguina, MJ Dolan, and D raout. Minireview, Recommendations for the Treatment of Human infections caused by Bartonella species. Antimicrobial agents and chemotherapy . June 2004:: 1921-1933

Swanson Stephen J. David Neitzel,2 Kurt D. Reed,3 and Edward A. Belongia. Coinfections Acquired from Ixodes Ticks. Clinical Microbiology Reviews, Oct. 2006, p. 708–727 Vol. 19, No. 40893-8512/06/$08.000 doi:10.1128/CMR.00011-06

Sytykiewicz H1, Karbowiak G, Werszko J, Czerniewicz P, Sprawka I, Mitrus J. Molecular screening for Bartonella henselae and Borrelia burgdorferi sensu lato co-existence within Ixodes ricinus populations in central and eastern parts of Poland. Ann Agric Environ Med. 2012;19(3):451-6.

Tuya Ximena L, Raffo Escalante-Kanashiro, Carmen Tinco, Maria J. Pons, Verónica Petrozzi, Joaquim Ruiz, and Juana del Valle. Case Report: Possible Vertical Transmission of Bartonella bacilliformis in Peru. Am J Trop Med Hyg. 2015 Jan 7; 92(1): 126–128.doi: 10.4269/ajtmh.14-0098PMCID: PMC4347366 PMID: 25371184

**Bartonella Case Report**

Breitschwerdt, E. B., Mascarelli, P. E., Schweickert, L. A., Maggi, R. G., Hegarty, B. C., Bradley, J. M., & Woods, C. W. (2011). Hallucinations, sensory neuropathy, and peripheral visual feficits in a young woman infected with Bartonella koehlerae. *Journal of Clinical Microbiology*, *49*(9), 3415–3417. https://doi.org/10.1128/JCM.00833-11

**Microbiology**

Breitschwerdt, E. B., & Kordick, D. L. (2000). Bartonella infection in animals: Carriership, reservoir potential, pathogenicity, and zoonotic potential for human infection. *Clinical Microbiology Reviews*, *13*(3), 428–438.

Maggi, R. G., Mozayeni, B., Pultorak, E. L., Hegarty, B. C., Bradley, J. M., Correa, M....Breitschwerdt, E. B. (2012). Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease-endemic region. *Emerging Infectious Diseases*, *18*(5), 783-791. https://dx.doi.org/10.3201/eid1805.111366.

**Epidemiology**

Boulouis, H.-J., Chang, C.-C., Henn, J. B., Kasten, R. W., & Chomel, B. B. (2005). Factors associated with the rapid emergence of zoonotic Bartonella infections. *Veterinary Research*, *36*(3), 383–410. https://doi.org/10.1051/vetres:2005009

Breitschwerdt, E. B., & Kordick, D. L. (2000). Bartonella infection in animals: Carriership, reservoir potential, pathogenicity, and zoonotic potential for human infection. *Clinical Microbiology Reviews*, *13*(3), 428–438.

Regier, Y., O’Rourke, F., & Kempf, V. A. J. (2016). Bartonella spp.―a chance to establish One Health concepts in veterinary and human medicine. *Parasites & Vectors*, *9*, 261. https://doi.org/10.1186/s13071-016-1546-x

**Maternal-Fetal Transmission and Transfusion Risk**

Breitschwerdt, E. B., Maggi, R. G., Farmer, P., & Mascarelli, P. E. (2010). Molecular evidence of perinatal transmission of Bartonella vinsonii subsp. berkhoffii and Bartonella henselae to a child. *Journal of Clinical Microbiology*, *48*(6), 2289–2293. https://doi.org/10.1128/JCM.00326-10

Pitassi, L. H. U., Diniz, P. P. V. de P., Scorpio, D. G., Drummond, M. R., Lania, B. G., Barjas-Castro, M. L., ... Velho, P. E. N. F. (2015). Bartonella spp. bacteremia in blood donors from Campinas, Brazil. *PLOS Neglected Tropical Diseases*, *9*(1), e0003467. https://doi.org/10.1371/journal.pntd.0003467

Regier, Y., O’Rourke, F., & Kempf, V. A. J. (2016). Bartonella spp.―a chance to establish One Health concepts in veterinary and human medicine. *Parasites & Vectors*, *9*, 261. https://doi.org/10.1186/s13071-016-1546-x

Vieira-Damiani, G., Diniz, P. P. V. de P., Pitassi, L. H. U., Sowy, S., Scorpio, D. G., Lania, B. G., ... Velho, P. E. N. F. (2015). Bartonella clarridgeiae Bacteremia Detected in an Asymptomatic Blood Donor. *Journal of Clinical Microbiology*, *53*(1), 352–356. https://doi.org/10.1128/JCM.00934-14

**Pathophysiology**

Dehio, C. (2004). Molecular and cellular basis of Bartonella pathogenesis. *Annual Review of Microbiology*, *58*(1), 365–390. https://doi.org/10.1146/annurev.micro.58.030603.123700

**Symptoms, Signs and Testing**

Balakrishnan N., et al. “Vasculitis, Cerebral Infarction and Persistent Bartonella Henselae Infection in a Child. - PubMed - NCBI.” Accessed May 4, 2018. https://www.ncbi.nlm.nih.gov/pubmed/27161220.

Maggi, Ricardo G., Marna Ericson, Patricia E. Mascarelli, Julie M. Bradley, and Edward B. Breitschwerdt. “Bartonella Henselae Bacteremia in a Mother and Son Potentially Associated with Tick Exposure.” *Parasites & Vectors* 6 (April 15, 2013): 101. https://doi.org/10.1186/1756-3305-6-101.

**Bacteremia and Disease Persistence**

Dehio, C. (2004). Molecular and cellular basis of Bartonella pathogenesis. *Annual Review of Microbiology*, *58*(1), 365–390. https://doi.org/10.1146/annurev.micro.58.030603.123700

Ericson, M., Balakrishnan, N., Mozayeni, B. R., Woods, C. W., Dencklau, J., Kelly, S., & Breitschwerdt, E. B. (2017). Culture, PCR, DNA sequencing, and second harmonic generation (SHG) visualization of Bartonella henselae from a surgically excised human femoral head. *Clinical Rheumatology*, *36*(7), 1669–1675. https://doi.org/10.1007/s10067-016-3524-2

Harms, A., & Dehio, C. (2012). Intruders below the radar: Molecular pathogenesis of Bartonella spp. *Clinical Microbiology Reviews*, *25*(1), 42–78. https://doi.org/10.1128/CMR.05009-11

Maggi, R. G., Mozayeni, B., Pultorak, E. L., Hegarty, B. C., Bradley, J. M., Correa, M. ... Breitschwerdt, E. B. (2012). Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease-endemic region. *Emerging Infectious Diseases*, *18*(5), 783–791. https://dx.doi.org/10.3201/eid1805.111366.

**Coinfection Persistence**

Angelakis E, Raoult D. Pathogenicity and treatment of Bartonella infections. Int J Antimicrob Agents. 2014 Jul;44(1):16-25. doi: 10.1016/j.ijantimicag.2014.04.006.

Breitschwerdt, E. B., Hegarty, B. C., Qurollo, B. A., Saito, T. B., Maggi, R. G., Blanton, L. S., & Bouyer, D. H. (2014). Intravascular persistence of Anaplasma platys, Ehrlichia chaffeensis, and Ehrlichia ewingii DNA in the blood of a dog and two family members. *Parasites & Vectors*, *7*, 298. https://doi.org/10.1186/1756-3305-7-298

Eskow, E., Rao, R. V., & Mordechai, E. (2001). Concurrent infection of the central nervous system by Borrelia burgdorferi and Bartonella henselae: evidence for a novel tick-borne disease complex. *Archives of Neurology*, *58*(9), 1357–1363.

Finlay, B. B., & McFadden, G. (2006). Anti-immunology: evasion of the host immune system by bacterial and viral pathogens. *Cell*, *124*(4), 767–782. https://doi.org/10.1016/j.cell.2006.01.034

Kordick, S. K., Breitschwerdt, E. B., Hegarty, B. C., Southwick, K. L., Colitz, C. M., Hancock, S. I., ... MacCormack, J. N. (1999). Coinfection with multiple tick-borne pathogens in a Walker Hound kennel in North Carolina. *Journal of Clinical Microbiology*, *37*(8), 2631–2638.

MacDonald, K. A., Chomel, B. B., Kittleson, M. D., Kasten, R. W., Thomas, W. P., & Pesavento, P. (2004). A prospective study of canine infective endocarditis in northern California (1999-2001): emergence of Bartonella as a prevalent etiologic agent. *Journal of Veterinary Internal Medicine*, *18*(1), 56–64.

Maggi, R. G., Mascarelli, P. E., Havenga, L. N., Naidoo, V., & Breitschwerdt, E. B. (2013). Co-infection with Anaplasma platys, Bartonella henselae and Candidatus Mycoplasma haematoparvum in a veterinarian. *Parasites & Vectors*, *6*, 103. https://doi.org/10.1186/1756-3305-6-103

Maurin M., Gasquet S., Ducco C., & Raoult D. (1995). MICs of 28 Antibiotic Compounds for 14 Bartonella (Formerly Rochalimaea) Isolates. *Antimicrobial Agents and Chemotherapy, 39*(11), 2387–2391 0066-4804/95/$04.0010

Moutailler, S., Moro, C. V., Vaumourin, E., Michelet, L., Tran, F. H., Devillers, E., ... Vayssier-Taussat, M. (2016). Co-infection of ticks: The rule rather than the exception. *PLOS Neglected Tropical Diseases*, *10*(3), e0004539. https://doi.org/10.1371/journal.pntd.0004539

Tuya, X. L., Escalante-Kanashiro, R., Tinco, C., Pons, M. J., Petrozzi, V., Ruiz, J., & del Valle, J. (2015). Possible vertical transmission of Bartonella bacilliformis in Peru. *The American Journal of Tropical Medicine and Hygiene*, *92*(1), 126–128. https://doi.org/10.4269/ajtmh.14-0098

**Evidence for Treatment**

Horowitz, R. I., & Freeman, P. R. (2016). Are Mycobacterium drugs effective for treatment resistant Lym disease, tick-borne co-infections, and autoimmune disease? *JSM Arthritis, 1*(2), 1008.

Mozayeni ILADS International Conference Washington DC Oct 10 2014 Neuroloigcal Spectrum in the diagnosis and treatment of Lyme disease

Rolain, J. M., Brouqui, P., Koehler, J. E., Maguina, C., Dolan, M. J., & Raoult, D. (2004). Recommendations for treatment of human infections caused by Bartonella species. *Antimicrobial Agents and Chemotherapy*, *48*(6), 1921–1933. https://doi.org/10.1128/AAC.48.6.1921-1933.2004

**Gaps in Knowledge/data**

Billeter, S. A., Levy, M. G., Chomel, B. B., & Breitschwerdt, E. B. (2008). Vector transmission of Bartonella species with emphasis on the potential for tick transmission. *Medical and Veterinary Entomology*, *22*(1), 1–15. https://doi.org/10.1111/j.1365-2915.2008.00713.x

Dietrich, F., Schmidgen, T., Maggi, R. G., Richter, D., Matuschka, F.-R., Vonthein, R., ... Kempf, V. A. J. (2010). Prevalence of Bartonella henselae and Borrelia burgdorferi sensu lato DNA in ixodes ricinus ticks in Europe. *Applied and Environmental Microbiology*, *76*(5), 1395–1398. https://doi.org/10.1128/AEM.02788-09

Reis, C., Cote, M., Rhun, D. L., Lecuelle, B., Levin, M. L., Vayssier-Taussat, M., & Bonnet, S. I. (2011). Vector competence of the tick Ixodes ricinus for transmission of Bartonella birtlesii. *PLOS Neglected Tropical Diseases*, *5*(5), e1186. https://doi.org/10.1371/journal.pntd.0001186

Vayssier-Taussat, M., Moutailler, S., Michelet, L., Devillers, E., Bonnet, S., Cheval, J., ... Eloit, M. (2013). Next generation sequencing uncovers unexpected bacterial pathogens in ticks in Western Europe. *PLOS ONE*, *8*(11), e81439. https://doi.org/10.1371/journal.pone.0081439

**Opportunities/Path Going Forward**

Borgermans, L., Goderis, G., Vandevoorde, J., & Devroey, D. (2014). Relevance of chronic lyme disease to family medicine as a complex multidimensional chronic disease construct: a systematic review. *International Journal of Family Medicine*, *2014*, 138016. https://doi.org/10.1155/2014/138016

Cameron, D. J., Johnson, L. B., & Maloney, E. L. (2014). Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. *Expert Review of Anti-Infective Therapy*, *12*(9), 1103–1135. https://doi.org/10.1586/14787210.2014.940900

Horowitz, R.I. (2012, August 1). Clinical Roundup: Selected Treatment Options for Lyme Disease: Multiple Causative Factors in Chronic Disease. *Alternative and Complementary Therapies,* *18*(4), 220–225. https://doi.org/10.1089/act.2012.18407.

Horowitz, R.I. (2013). *Why Can’t I Get Better? Solving the Mystery of Lyme and Chronic Disease*. NYC: St Martin’s Press.

**Evidence of acute infection and support for treatment of acute infection**

Raybould, J. E., Raybould, A. L., Morales, M. K., Zaheer, M., Lipkowitz, M. S., Timpone, J. G., & Kumar, P. N. (2016). Bartonella endocarditis and pauci-immune glomerulonephritis: A case report and review of the literature. *Infectious Diseases in Clinical Practice (Baltimore, Md.)*, *24*(5), 254–260. https://doi.org/10.1097/IPC.0000000000000384

**Evidence for persistent infection/chronic symptomatology/chronic co-infection**

Harms, A., & Dehio, C. (2012). Intruders below the radar: molecular pathogenesis of Bartonella spp. *Clinical Microbiology Reviews*, *25*(1), 42–78. https://doi.org/10.1128/CMR.05009-11

Minnick, M. F., & Battisti, J. M. (2009). Pestilence, persistence and pathogenicity: infection strategies of Bartonella. *Future Microbiology*, *4*(6), 743–758. https://doi.org/10.2217/fmb.09.41

Okaro, U., Addisu, A., Casanas, B., & Anderson, B. (2017). Bartonella species, an emerging cause of blood-culture-negative Endocarditis. *Clinical Microbiology Reviews*, *30*(3), 709–746. https://doi.org/10.1128/CMR.00013-17

Pulliainen, A. T., & Dehio, C. (2012). Persistence of Bartonella spp. stealth pathogens: from subclinical infections to vasoproliferative tumor formation. *FEMS Microbiology Reviews*, *36*(3), 563–599. https://doi.org/10.1111/j.1574-6976.2012.00324.x

**Clinical Case(s) illustrating how co-infection affects diagnosis and treatment**

Horowitz, R.I., M.D. et.al. (2003). Bartonella Henselae: Limitations of Serological Testing: Evaluation of Elisa and Polymerase Chain Reaction Testing In a Cohort of Lyme Disease Patients and Implications for Treatment [Abstract]. 16th International Scientific Conference on Lyme Disease & Other Tick-Borne Disorders, Hartford, Connecticut, June.

Horowitz, R. I., & Freeman, P. R. (2016). Are Mycobacterium drugs effective for treatment resistant Lyme disease, tick-borne co-infections, and autoimmune disease? *JSM Arthritis,, 1*(2), 1008.

**Evidence of Chronic coinfection states/Other Pathogens**

**Clinical Picture/Syndromic Surveillance**

Eskow, E., Adelson, M. E., Rao, R.-V. S., & Mordechai, E. (2003). Evidence for disseminated Mycoplasma fermentans in New Jersey residents with antecedent tick attachment and subsequent musculoskeletal symptoms. *Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Diseases*, *9*(2), 77–87. https://doi.org/10.1097/01.RHU.0000062510.04724.07

Horowitz R.I., M.D. et.al. (2003). Mycoplasma Infections in Chronic Lyme Disease: A Retrospective Analysis of Co-Infection and Persistence Demonstrated by PCR Analysis Despite Long Term Antibiotic Treatment [Abstract]. 16th International Scientific Conference on Lyme Disease & Other Tick-Borne Disorders. Hartford, Connecticut, June

Nasralla, M., Haier, J., & Nicolson, G. L. (1999). Multiple mycoplasmal infections detected in blood of patients with chronic fatigue syndrome and/or fibromyalgia syndrome. *European Journal of Clinical Microbiology & Infectious Diseases: Official Publication of the European Society of Clinical Microbiology*, *18*(12), 859–865.

Nicolson, G. L. (2008, May 1). Chronic Bacterial and Viral Infections in Neurodegenerative and Neurobehavioral Diseases. *Laboratory Medicine* *39*(5) 291–99. https://doi.org/10.1309/96M3BWYP42L11BFU.

Nicolson G. L., Haier J., Nasralla M., Nicolson N. L., Ngwenya R., De Meirleir K. (2000). Mycoplasmal infections in Chronic Fatigue Syndrome, Fibromyalgia Syndrome and Gulf War Illness. *Journal of Chronic Fatigue Syndrome*, *6*(3/4): 23–39. http://doi:org/10.1300/J092v6n03_03

Nicolson G. L., Nicolson N. L., Haier J. (2011). Chronic Fatigue Syndrome patients subsequently diagnosed with Lyme Disease *Borrelia burgdorferi*: evidence for *Mycoplasma* species co-infections. *Journal of Chronic Fatigue Syndrome, 14*(4): 5–17. http://doi:org/10.3109/10573320802091809

Nicolson, G. L., Gan, R., & Haier, J. (2003). Multiple co-infections (Mycoplasma, Chlamydia, human herpes virus-6) in blood of chronic fatigue syndrome patients: association with signs and symptoms. *APMIS: Acta Pathologica, Microbiologica, et Immunologica Scandinavica*, *111*(5), 557–566.

Nicolson G. L., Nasralla M., Franco A. R., Nicolson N. L., Erwin R., Ngwenya R., Berns P. A. (2000). Diagnosis and integrative treatment of intracellular bacterial infections in Chronic Fatigue and Fibromyalgia Syndromes, Gulf War Illness, Rheumatoid Arthritis and other chronic illnesses. *Clinical Practice of Alternative Medicine, 1*(2): 92–102. http://www.immed.org/infectious%20disease%20reports/06.16.12%20pdf%20updates/CPAM-GLNetal.-00.1.21.pdf

Sánchez-Vargas, F. M., & Gómez-Duarte, O. G. (2008). Mycoplasma pneumoniae―an emerging extra-pulmonary pathogen. *Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases*, *14*(2), 105–117. https://doi.org/10.1111/j.1469-0691.2007.01834.x

Waites, K. B., & Talkington, D. F. (2004). Mycoplasma pneumoniae and its role as a human pathogen. *Clinical Microbiology Reviews*, *17*(4), 697–728, table of contents. https://doi.org/10.1128/CMR.17.4.697-728.2004

**Gaps in knowledge/Opportunities for Expanded Treatment Options**

Horowitz, R.I. (2012, August 1). Clinical Roundup: Selected Treatment Options for Lyme Disease: Multiple Causative Factors in Chronic Disease. *Alternative and Complementary Therapies,* *18*(4), 220–225. https://doi.org/10.1089/act.2012.18407.

Horowitz, R.I. (2013). *Why Can’t I Get Better? Solving the Mystery of Lyme and Chronic Disease*. NYC: St Martin’s Press.

Horowitz, R.I. (2017). *How Can I Get Better? An Action Plan for Treating Resistant Lyme and Chronic Disease.* NYC: St Martin’s Press.

Parks, C. G., Miller, F. W., Pollard, K. M., Selmi, C., Germolec, D., Joyce, K., ... Humble, M. C. (2014). Expert panel workshop consensus statement on the role of the environment in the development of autoimmune disease. *International Journal of Molecular Sciences*, *15*(8), 14269–14297. https://doi.org/10.3390/ijms150814269

Peschken, C., & Hitchon, C. (2012). Rising prevalence of systemic autoimmune rheumatic disease: increased awareness, increased disease or increased survival? *Arthritis Research & Therapy*, *14*(Suppl 3), A20. https://doi.org/10.1186/ar3954

Pfau, J. C., Serve, K. M., & Noonan, C. W. (2014). Autoimmunity and asbestos exposure. *Autoimmune Diseases*, *2014*, 782045. https://doi.org/10.1155/2014/782045

**Probiotics and Prebiotics**

Castagliuolo, I., Riegler, M. F., Valenick, L., LaMont, J. T., & Pothoulakis, C. (1999). Saccharomyces boulardii protease inhibits the effects of Clostridium difficile toxins A and B in human colonic mucosa. *Infection and Immunity*, *67*(1), 302–307.

Horowitz, R.I. (2017). *How Can I Get Better? An Action Plan for Treating Resistant Lyme and Chronic Disease.* NYC: St Martin’s Press.

Lawley, T. D., Clare, S., Walker, A. W., Stares, M. D., Connor, T. R., Raisen, C., ... Dougan, G. (2012). Targeted Restoration of the Intestinal Microbiota with a Simple, Defined Bacteriotherapy Resolves Relapsing Clostridium difficile Disease in Mice. *PLOS Pathogens*, *8*(10), e1002995. https://doi.org/10.1371/journal.ppat.1002995

McFarland, L. V. (2006). Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. *The American Journal of Gastroenterology*, *101*(4), 812–822. https://doi.org/10.1111/j.1572-0241.2006.00465.x

Na, X., & Kelly, C. (2011). Probiotics in Clostridium difficile Infection. *Journal of Clinical Gastroenterology*, *45*(Suppl), S154–S158. https://doi.org/10.1097/MCG.0b013e31822ec787

**Mitochondrial Dysfunction in Chronic and Infectious Diseases**

Nicolson, G. L. (2014). Mitochondrial Dysfunction and Chronic Disease: Treatment With Natural Supplements. *Integrative Medicine: A Clinician’s Journal*, *13*(4), 35–43.

Nicolson G. L., Settineri R., Ellithorpe E. (2012). Lipid Replacement Therapy with a glycophospholipid formulation with NADH and CoQ10 significantly reduces fatigue in intractable chronic fatiguing illnesses and chronic Lyme disease. *International Journal of Clinical Medicine, 3*(3): 163–170. doi:10.4236/ijcm.2012.33034

**Membrane Lipid Replacement for Cellular Membrane Damage due to Lyme- Associated and Other Infections**

Nicolson G. L., Ellithorpe R. (2006). Lipid replacement and antioxidant nutritional therapy for restoring mitochondrial function and reducing fatigue in chronic fatigue syndrome and other fatiguing illnesses. *Journal of Chronic Fatigue Syndrome, 13*(1): 57–68. doi:10.1300/J092v13n01_06

Nicolson, G., Rosenblatt, S., Ferreira, G., Settineri, R., C. Breeding, P., R. Ellithorpe, R., & Ash, M. (2016). Clinical uses of Membrane Lipid Replacement supplements in restoring membrane function and reducing fatigue in chronic diseases and cancer. *Discoveries*, *4*, e54. https://doi.org/10.15190/d.2016.1

Nicolson, G. L., & Ash, M. E. (2017). Membrane Lipid Replacement for chronic illnesses, aging and cancer using oral glycerolphospholipid formulations with fructooligosaccharides to restore phospholipid function in cellular membranes, organelles, cells and tissues. *Biochimica et Biophysica Acta (BBA) - Biomembranes*, *1859*(9, Part B), 1704–1724. https://doi.org/10.1016/j.bbamem.2017.04.013

Nicolson G. L., Settineri R., Ellithorpe E. (2012). Lipid Replacement Therapy with a glycophospholipid formulation with NADH and CoQ10 significantly reduces fatigue in intractable chronic fatiguing illnesses and chronic Lyme disease. *International Journal of Clinical Medicine, 3*(3): 163–170. doi:10.4236/ijcm.2012.33034. http://dx.doi.org/10.4236/ijcm.2012.33034

Nicolson, G. L., Settineri, R., & Ellithorpe, R. (2012). Glycophospholipid formulation with NADH and CoQ10 significantly reduces intractable fatigue in western blot-positive ‘chronic Lyme disease’ patients: Preliminary report. *Functional Foods in Health and Disease*, *2*(3), 35–47.

**General Treatment Recommendations**

Yusim, Y. et al, "Blue dyes, blue people: the systemic effects of blue dyes when administered via different routes". J Clin Anesth 19 (4): 315–321.

General Treatment Resources

Biggs, H. M. (2016). Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever and other spotted fever group rickettsioses, ehrlichioses, and anaplasmosis—United States. *MMWR. Recommendations and Reports*, *65*.

Bakken, J. S., Folk, S. M., Paddock, C. D., Bloch, K. C., Krusell, A., Sexton, D. J., ... & McQuiston, J. H. (2006). Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis—United States. *MMWR Recomm Rep*, *55*, 1-27.

Priority #3: Alpha-gal Meat Allergy

Chinuki Y, Ishiwata K, Yamaji K, Takahashi H, Morita E. Haemaphysalis longicornis tick bites are a possible cause of red meat allergy in Japan. Allergy 2016; 71: 421–425

Bircher AJ, Hofmeier KS, Link S, Heijnen I. Food allergy to the carbohydrate galactose-alpha-1,3-galactose (alpha-gal): four case reports and a review. Eur J Dermatol. 2017;27(1):3–9.

Apostolovic D, Tran TA, Starkhammar M, Sanchez-Vidaurre S, Hamsten C, Van Hage M. The red meat allergy syndrome in Sweden. Allergo J Int. 2016;25(2):49–54.

Thomas A.E. Platts-Mills, MD, PhD, FRS*,Alexander J. Schuyler, BS, BA, Anubha Tripathi, MD, Scott P. Commins, MD, PhD. Anaphylaxis to the Carbohydrate Side Chain Alpha-gal Immunol Allergy Clin N Am 35 (2015) 247–260 http://dx.doi.org/10.1016/j.iac.2015.01.009

Steinke JW, Platts-Mills TA, Commins SP. The alpha-gal story: lessons learned from connecting the dots. J Allergy Clin Immunol. 2015; 135:589-96.

Commins SP. Carbohydrates as allergens. Curr Allergy Asthma Rep. 2015; 15:492-6.

Mozzicato SM, Tripathi A, Posthumus JB, Platts-Mills TA, Commins SP. Porcine or bovine valve replacement in 3 patients with IgE antibodies to the mammalian oligosaccharide galactose-alpha-1,3-galactose. J Allergy Clin Immunol Pract. 2015; 2:637-8.

Tripathi A, Commins SP, Heymann PW, Platts-Mills TA. Diagnostic and experimental food challenges in patients with non-immediate reactions to food. J Allergy Clin Immunol. 2015; 135:985-7.

Commins SP, James HR, Stevens W, Pochan SL, Land MH, King C, Mozzicato S, Platts-Mills TA. Delayed clinical and ex vivo response to mammalian meat in patients with IgE to galactose-alpha-1,3-galactose. J Allergy Clin Immunol. 2014; 134:108-115.

Tripathi A, Commins SP, Heymann PW, Platts-Mills TA. Delayed anaphylaxis to red meat masquerading as idiopathic anaphylaxis. J Allergy Clin Immunol Pract. 2014; 2:259-65.

Kennedy JK, Stallings AP, Platts-Mills TAE, Oliveira W, Workman LT, James HR, Tripathi A, Lane CJ, Matos L, Heymann PW, Commins SP. Galactose-alpha-1,3-galactose and delayed anaphylaxis, angioedema, and urticaria in children. Pediatrics. 2013; 131:1545-52.

Commins SP, Platts-Mills TAE. Tick Bites and Red Meat Allergy. Curr Opinion in Allergy and Clinical Immunology.2013; 13:354-9.

Hamsten C, Tran TA, Starkhammar M, Brauner A, Commins SP, Platts-Mills TA, van Hage M. Red meat allergy in Sweden: association with tick sensitization and B-negative blood groups. J Allergy Clin Immunol. 2013; 132:1431-4.

Commins SP, Platts-Mills TA. Delayed Anaphylaxis to Red Meat in Patients with IgE Specific for Galactose alpha-1,3-Galactose (alpha-gal). Curr Allergy Asthma Rep. 2013; 13:72-7.

Rispens T, Derksen NI, Commins SP, Platts-Mills TA, Aalberse RC. IgE Production to α-Gal Is Accompanied by Elevated Levels of Specific IgG1 Antibodies and Low Amounts of IgE to Blood Group B. PLoS One. 2013; 8:e55566.

Masilamani M, Commins SP, Shreffler W. Determinants of food allergy. Immunol Allergy Clin North Am. 2012; 32:11-33.

Mullins RJ, James HR, Platts-Mills TA, Commins SP. The relationship between red meat allergy and sensitization to gelatin and galactose-alpha-1,3-galactose. J Allergy Clin Immunol. 2012; 129:1334-42.

Commins SP, James HR, Kelly LA, Pochan SL, Workman LJ, Perzanowski MS, Kocan KM, Fahy JV, Nganga LW, Ronmark E, Cooper PJ, Platts-Mills TAE. The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-α-1,3-galactose. J Allergy Clin Immunol. 2011; 127:1286-93.

van Nunen SA. Tick-induced allergies: mammalian meat allergy and tick anaphylaxis. Med J Aust. 2018 Apr 16;208(7):316-321.

Paddock, C. D., and M. J. Yabsley. “Ecological Havoc, the Rise of White-Tailed Deer, and the Emergence of Amblyomma Americanum-Associated Zoonoses in the United States.” *Current Topics in Microbiology and Immunology* 315 (2007): 289–324.

Sonenshine, Daniel E. “Range Expansion of Tick Disease Vectors in North America: Implications for Spread of Tick-Borne Disease.” *International Journal of Environmental Research and Public Health* 15, no. 3 (March 9, 2018): 478. https://doi.org/10.3390/ijerph15030478.

Springer, Yuri P., Catherine S. Jarnevich, David T. Barnett, Andrew J. Monaghan, and Rebecca J. Eisen. “Modeling the Present and Future Geographic Distribution of the Lone Star Tick, Amblyomma Americanum (Ixodida: Ixodidae), in the Continental United States.” *The American Journal of Tropical Medicine and Hygiene* 93, no. 4 (October 2015): 875–90. https://doi.org/10.4269/ajtmh.15-0330.

Cortinas, R., and S. Spomer. “Lone Star Tick (Acari: Ixodidae) Occurrence in Nebraska: Historical and Current Perspectives.” *Journal of Medical Entomology* 50, no. 2 (March 2013): 244–51.

Stromdahl, E. Y., and G. J. Hickling. “Beyond Lyme: Aetiology of Tick-Borne Human Diseases with Emphasis on the South-Eastern United States.” *Zoonoses and Public Health* 59 Suppl 2 (September 2012): 48–64. https://doi.org/10.1111/j.1863-2378.2012.01475.x.

Goddard, Jerome, and Andrea S. Varela-Stokes. “Role of the Lone Star Tick, Amblyomma Americanum (L.), in Human and Animal Diseases.” *Veterinary Parasitology* 160, no. 1–2 (March 9, 2009): 1–12. https://doi.org/10.1016/j.vetpar.2008.10.089.

Appendix 1: Subcommittee Agendas and Top-Line Summaries

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 1, February 23, 2018

Agenda

Role call
	Discussion of topic to focus on for the report to the Tick-Borne Disease Working Group**Summary of Key Points**

Area of Focus – Diagnostics: Clinical and Laboratory
Area of Focus: Education/Prevention
Area of Focus: Treatment/Treatment failures

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 2, March 2, 2018

Agenda

Discuss Issues and Priorities document and resolve questions
	Finalize main points
		Vote on Issues and Priorities document
	Decide which articles to share with the group
	Discuss potential speakers to invite**Summary of Key Points**

Area of Focus – Other Tick-Borne Disorders: Alpha Gal Allergy
Area of Focus: Single Tick-Borne Infections and Co-Infections Diagnostics
Area of Focus: Treatment Guidelines for Treating Other Tick-Borne Infections and Co-Infections Area of Focus: Prevention of Tick-Borne Infections and Co-Infections
Area of Focus: Health Care Costs Associated with Other Tick-Borne Diseases and Co-Infections

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 3, March 9, 2018

Agenda

Vote on working document (Priorities and Issues)
	Identify speakers by topic
	Continue refining priorities and issues
	Discuss method for sharing documents and collaborating**Summary of Key Points**

Area of Focus: Identifying Speakers for Upcoming Meetings
Area of Focus: Continued Refinement of Issues and Priorities

Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 3, March 9, 2018

Agenda

Vote on working document (Priorities and Issues)
	Identify speakers by topic
	Continue refining priorities and issues
	Discuss method for sharing documents and collaboratingSummary of Key Points

Area of Focus: Identifying Speakers for Upcoming Meetings
Area of Focus: Continued Refinement of Issues and Priorities

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 4, March 16, 2018

Agenda

Presentations and DiscussionPresentation 1—Babesia: Major Features; Gaps in Knowledge; the Role of Babesia in the Overall Burden of Deer Tick Infections

Sam Telford, ScD, Professor of Infectious Disease and Global Health Cummings School of Veterinary Medicine, Tufts University

Presentation 2—Ticks, Bartonella Species, and Bartonellosis

Edward B. Breitschwerdt, DVM

Presentation 3—Detection of Immunoreactive Bartonella Species in Mammalian Tissues Using Advanced Imaging Techniques

Marna Ericson, PhD

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 5, March 23, 2018

Agenda

Presentation—Mast Cell Activation and Alpha-Gal Allergy
	Vote on Issues and Priorities work plan
	Divide into subgroups to write about topicsPresentation—Mast Cell Activation and Alpha-Gal Allergy

Steven Schutzer, MD, Physician-Scientist Rutgers, New Jersey Medical School
Erin McGintee, MD Physician, ENT & Allergy Associates

Topics and Questions discussed Summary of Key Points

Area of Focus: Alpha-gal allergy
Area of Focus: Issues and Priorities Work Plan

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 6, March 30, 2018

Agenda

Review Work Plan/Report to the Tick-Borne Disease Working Group
	Presentation—Lyme Bacteria, Powassan Virus, Deer Tick Virus
	DiscussionPresentation – Lyme Bacteria and Powassan Virus: an Emerging Partnership and Public Health Concern

Konstance Knox, PhDManaging Director, Coppe Healthcare Solutions, Waukesha, WI

Summary of Key Points

Area of Focus – Report to the Tick-Borne Disease Working Group
Area of Focus – Powassan Virus and Deer Tick Virus

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 7, April 6, 2018

Agenda

Roll call
	Presentation
	Q & A with the presenter
	Discussion of the report to the Tick-Borne Disease Working GroupPresentation: Diagnosis of Tick-Borne Borrelial Spirochetemia by Partial 16S rRNA Gene Sequencing

Sin Hang Lee, MD, FRCP(C), FACP, Director, Milford Molecular Diagnostics Laboratory, Milford, CT

Summary of Key Points

Key Discussion Point—Nested PCR and rRNA gene sequencing
Key Discussion Point—Report to the Tick-Borne Disease Working Group

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 8, April 13, 2018

Agenda

Roll call
	Presentations and brief Q&A with presentersPresentation 1: Diagnosis of Tick-Borne Diseases Other Than Lyme Disease

Jyotsna Shah, PhD, IGeneX, Inc., Palo Alto, CA

Presentation 2: Update on Borrelia miyamotoi, The Agent of Hard-Tick Relapsing Fever

Linda K. Bockenstedt, MD
Harold W. Jockers Professor of Medicine Yale School of Medicine

Presentation 3: Bartonella: Bacteria, Hosts, Vectors

Michael Kosoy, PhD, CDC, Division of Vector-Borne Diseases/Bacterial Diseases Branch

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 9, April 20, 2018

Agenda

Roll call
	Presentations and brief Q&A with presentersPresentation 1: Lyme Disease Complicating Factors: What can we learn from biofilms, polymicrobial infections, and genetic heterogeneity in relation to diagnosis

Garth D. Ehrlich, PhD, Executive Director, Center for Genomic Sciences Executive Director for Chronic Infections and Biofilms Professor of Microbiology and Immunology, Drexel University College of Medicine

Presentation 2: Diagnosis and Treatment of Lyme and Other Tick-Borne Diseases and Coinfections

Richard Horowitz, MD, Medical Director, Hudson Valley Healing Arts Center

Presentation 3: Clinician’s Bird’s Eye View: Coinfection

Christine Green, MD, Physician, Green Oaks Medical Center; Director, LymeDisease.org

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 10, April 27, 2018

Agenda

Roll call
	Discussion and voting on Potential Actions for the Diagnosis portion of the Results sectionSummary of Key Points

Discussion and voting on the Diagnosis section of their report to the Tick-Borne Disease Working Group.

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 11, May 3, 2018

Agenda

Roll call
	Discussion and voting on Potential Actions for the Alpha-gal Meat Allergy and Treatment portions of the Results sectionSummary of Key Points

Brief discussion and voting on the Alpha-gal Meat Allergy and Treatment sections of their report to the Tick-Borne Disease Working Group.

Other Tick-Borne Diseases and Coinfections Subcommittee Meeting Summary 12, May 4, 2018

Agenda

Roll call
	Discussion and voting on the Treatment portion of the Results section
	Discussion of the PowerPoint presentation to be used at the May 10, 2018 meetingSummary of Key Points

Discussion and voting on the remaining Potential Actions in the Treatment section of their report to the Tick-Borne Disease Working Group.
Brief discussion about the PowerPoint presentation to be used at the May 10, 2018 meeting

Appendix 2: Complete List of Issues that Could Be Addressed in the First Report to Congress

Table 1: Improving the Education, Surveillance, Prevention, Diagnosis, Treatment and Associated Health Care Costs Due to Other Tick-borne Diseases and Co-infections:

Key Theme 1: Diagnosing Other Tick-Borne Infections and Co-infections

Issue one: Educate physicians and patients on the clinical and laboratory manifestations of other tick-borne infections and co-infections, and especially syndromic surveillance, which does not focus on specific infections but sets of signs and symptoms. Acute infection also needs to be approached differently than chronic complaints, and improved education is necessary across medical subspecialties, while establishing standardized case definitions to improve care.
	Issue two: Develop accurate diagnostic testing. Which techniques are the most reliable and economical? Accurate diagnostic testing will require a broad-based approach to accurately identify multiple tick-borne pathogens, and current research reveals that some coinfections are polyclonal in nature and that many species and subspecies may be involved. Direct testing which identifies DNA, RNA, or antigens needs to be refined to identify genus, as well as species and subspecies, and there is a need for not just antibody and DNA testing, but RNA testing, transcriptome analysis, NGS, and others such as “omics” and chemokine assays. Some researchers have also found looking at the dermal niche and combining this methodology with serology, PCR and culture may give more consistent results than testing blood especially for individuals with persistent infection. Animal models can be also used to improve diagnostics.
	Issue three: Regularly screening ticks for an increase in established tick-borne infections (increasing risk) or new and emerging infections like B. miyamotoi and the DTV/Powassan virus, as new communities are constantly being discovered, expanding our geographical boundaries. Wider field surveillance is necessary, evaluating the length of attachment of ticks and transmission rates, while checking for new pathogens. We need to emphasize that we have a problem with tick borne infections to improve the quality of care.Key Theme 2: Treatment Guidelines for Treating Other Tick-borne Infections and Co- infections

Issue four: Are different treatment necessary in an acute vs chronic infection for a single agent. We know more about acute vs chronic infection. Does the duration of illness and length of time to establish a diagnosis (for both single infections and multiple co-infections) affect treatment outcome? Host-pathogen interactions, and not just antimicrobial therapies also need to be accounted for, since intracellular infections can affect mitochondrial function, causing multisystemic effects (including affecting hormones, and the autonomic nervous system).
	Issue five: Establishing evidence-based treatment guidelines, with expert opinion and patient values, to form recommendations for treating single tick-borne infections and co-infections. Research assessing the effects of different treatment approaches are needed. How does pathogenesis and treatment of single, vs multiple co-infections differ? Do multiple co-infections change the accuracy of diagnostics? How do single vs multiple simultaneous co-infections affect morbidity and mortality? Animal models can be used to study co-infections and imparts precision, and epidemiology can also be used to study co-infections (preexisting exposure and/or sequential infections).Issue six: Insurance/Payor reform: update guidelines for the treatment of other tick-borne infections and co-infections based on recent scientific advances, so that insurers pay for appropriate diagnostic and treatment approaches.Key Theme 3: Prevention of Tick-borne Infections and Co-infections

Issue seven: Review epidemiology, transmission times, gaps in entomology (tick focused) and environmental factors conferring risk. Although Ixodes scapularis transmitted single infections and co-infections are a primary focus in this first report, some patients who may be hunting, gardening, hiking, or living with domestic animals may be exposed to more than one kind of tick, as well as mosquitos, blackflies, fleas, lice, keds, midges, and potentially mites and spiders. How does this affect symptomatology, pathogenesis and our diagnostic approach?
	Issue eight: Prevent transmission of other tick-borne infections and co-infection(s) via ticks, the blood supply, and by maternal fetal transmission. To prevent transmission via the blood supply (Babesia, Anaplasma, Bartonella, relapsing fever, and? others), improved screening techniques, such as developing and using validated screening questionnaires, while improving diagnostics for multiple pathogens can be helpful.
	Issue nine: Environmental controls to prevent other tick-borne diseases and co-infections. There is a need to evaluate different approaches and consider the role of the white-tailed deer in the spread of I. scapularis and A. americanum-associated diseases. Will the risk of emerging pathogens in ticks, like the DTV/Powassan virus, create more demand and willingness to spend money on environmental controls?Key Theme 4: Other tick-borne disorders: Alpha Gal Allergy

Issue ten: Education of the public and physicians about alpha gal allergies, and symptoms (delayed anaphylactic reactions several hours after eating meat). Education is needed regarding triggers. Alpha-gal sugar is found not only in beef, but also pork, lamb, venison, goat, and bison, and the alpha gal allergy can also can be triggered by animal-based products containing gelatin, or foods/beverages/personal care products (certain perfumes, colognes), and medical products (certain IV bags contain gelatin), nutritional supplements (i.e., magnesium stearate can be mammal/animal derived), as well as "natural flavorings" which often contain mammal/animal ingredients, and adhesives (stamps, tape, band-aides).
	Issue eleven: Prevention of lone star tick bites. These would include educational programs that instruct on the use of permethrin, DEET, IR3535, picaridin, as well as prevention through proper labeling of foods/beverages/personal care products/medical products/nutritional supplements.
	Issue twelve: Treatment/Evaluating the magnitude of the problem: gaps exist in both areas, and research is needed on both the magnitude of the problem as well as the mechanisms of action that drive pathogenesis causing anaphylaxis. Patients need to be informed on the need to carry an EPI-PEN, Medrol dose pack, and Benadryl for anaphylactic reactionsKey Theme 5: Health Care Costs Associated with Other TBD’s and Co-infections

Issue thirteen: Costs of planning and implementing programs and services which educate the public on prevention. This is especially important for those who engage in recreational activities, have companion animals (a source of introducing ticks into households) and gardening, as mundane activities around the home are often the source of infection. Prevention would include, but not be limited to, forest workers, patients, and include programs to educate physicians, along with social media campaigns. The greatest good for the greatest number will come from effective prevention programs, which teach individuals about ticks, proper tick removal in a timely fashion, and signs and symptoms indicative of tick-borne infections.
	Issue fourteen: Costs of establishing prevention programs, as well as improved diagnostic   testing and improved treatment protocols (i.e., laboratory research, multicenter clinical studies). Also evaluate the costs of epidemiological activities related to tickborne diseases, including  basic, clinical, and translational tickborne disease research related to the pathogenesis of tickborne disorders and coinfections.
	Issue fifteen: health care costs secondary to disability from other TBD’s and co-infections. What is the actual cost of “Lyme mimics”? Five percent of the US population has been diagnosed with CFS/ME and Fibromyalgia, over 50 million Americans have been diagnosed with an autoimmune disorder, and every 67 seconds someone is diagnosed with Alzheimer’s disease in the United States. Borrelia, along with other bacterial infections and viruses, have been linked to all these diseases. There is therefore an urgent imperative to determine how other tick-borne diseases and co-infections are affecting other chronic illnesses, especially since disability rates are high in our country. According to the National Census Bureau in 2010, nearly 1/5 Americans were disabled. Some of the disabilities were due to visual problems, hearing problems, arthritis and neuropsychiatric/cognitive disorders (which can all be seen with tick-borne diseases). Can we lower disability rates and improve morbidity/mortality/quality of life by improving the prevention, education, diagnosis and effective treatment of other tick-borne diseases and co- infections? If we properly address issues 13, 14 and 15, instituting cost effective educational and prevention programs, we should be able to significantly help decrease the suffering and burden of chronic illness in the United States, while simultaneously lowering health care costs.Table 2: Improving Issues Related to Pathogenesis, Transmission, and Treatment of Other Tick-borne Diseases and Co-infections:

Prioritized List of Issues that Will be Addressed in the First Report to Congress

**Key Issues 1.**

**Diagnosis:**How can we best diagnose (clinically, laboratory) high priority tick-borne infections such as other Borrelia sensu lato species (excluding Lyme disease), Babesia, Bartonella, B. miyamotoi and powassan virus when occurring either singly or in combination (co-infection)? How can we best diagnose Rickettsia rickettsia, anaplasmosis and ehrlichiosis, which are also potentially fatal? Which techniques are the most reliable and economical? Is there evidence for blood transfusion or maternal-fetal transmission of Babesia, Bartonella, B. miyamotoi and powassan virus and if there how are these best diagnosed and prevented? Diagnostic testing require a broad-based approach to accurately identify multiple tick-borne pathogens, and are some coinfections polyclonal in nature, where many species and subspecies may be involved.
	**Diagnosis gaps:**a major concern is early detection (within the first week of disease presentation) of acute infections. This is a gap for all tick-borne diseases, especially in endemic areas where the lack of a positive antibody response leads to a clinician ruling out and the presence of pre-existing antibodies rules in a tick-borne disease inappropriately. Unfortunately, molecular assays currently lack sensitivity. Additionally, diagnosis of chronic, persistent and co- infections is very difficult. Thus, an important question to answer should be: what are the next generation of diagnostic assays to appropriately detect/diagnose acute (within the first week of presentation) infection, as well as chronic, persistent infections and co-infections to fill this important gap?
	**Treatment:**What is/are the best treatment regimens for Babesia, Bartonella, B. miyamotoi and powassan virus when presenting as single infections or in combination (co-infection)? Do gaps exist regarding how co-infections interact with each other? These may potentially affect our diagnostics and efficacy of treatment. What is the evidence for persistence of Babesia, Bartonella, B. miyamotoi and powassan virus and what mechanisms allow these organisms to persist? How does Anaplasma, Babesia, Bartonella, B. miyamotoi and powassan virus when presenting as single infections or in combination affect immunity to other infectious agents, morbidity, and mortality?
	**Treatment gap:**Doxycycline is effective for many of the tick-borne bacterial infections, but we need to identify other current or new antibiotics to back up/replace doxycycline. What are the antibiotics of the future to treat acute, chronic, co-infection, and persistent treatable tick-borne diseases?**Key Issue 2.**

**Alpha gal allergy:**How can we improve the awareness, diagnosis and treatment of alpha gal allergy? What is the pathogenesis underlying delayed anaphylaxis several hours after eating meat, and/or after being exposed to certain medical products, nutritional supplements and/or animal-based products?
	**Alpha gal allergy gap:**What practical steps can we take to improve the awareness, diagnosis, cause (tick(s)-association), pathogenicity, and treatment of this newly identified tick-borne disease?**Key Issue 3.**

**Priority gap:**How do co-infections compare in priority to single non-Lyme tick-borne infections in prevalence, severity, and their role in acute, chronic and persistent infections?Appendum A:

Alphabetical Listing of High Priority Tick-borne Bacterial, Parasitic and Viral infections and Other Associated Diseases
	Alpha Gal allergy
	Anaplasma (HGA)
	Babesia spp. (B. microti, B. duncani, MO-1, B. divergens, B. major)
	Bartonella spp. (over 36 different species and subspecies)
	Borrelia miyamotoi/relapsing fever borrelia (i.e., B. hermsii, B. turicatae, B. parkeri)
	Borrelia sensu lato spp. (includes multiple species, apart from B. burgdorferi ss, such as: Borrelia afzelii [ACA], Borrelia garinii [neuroborreliosis], B. spielmani [early skin disease], B. valaisana, B. lusitanea, B. bavariensis, B. bissettii, B. lanei, B. mayonii, B. carolinensis)
	Bourbon virus
	Coxiella burnetti (Q-fever)
	DTV/Powassan virus
	Ehrlichia spp. (HME, HEE, HSE, HWME)
	Heartland virus
	Rickettsial infections (RMSF, spotted fever group, scrub typhus/typhus group, 364D rickettsiosis, Rickettsia parkerii rickettsiosis, R. helvetica)
	Tick paralysis
	Tularemia
	Other bacterial infections (not necessarily tick-borne) that may be co-infecting agents, potentially increasing pathogenesis: Mycoplasma spp., *Chlamydia pneumonia*​​Appendix 3: Gabby’s Story: The Importance of Properly Diagnosing and Treating Other Tick-borne Diseases

This abbreviated story is excerpted with permission from Mr Tony Galbo, who lost his five-year-old daughter Gabriella Giada Galbo (“Gabby”) to Rocky Mountain Spotted Fever.

My daughter Gabriella Giada Galbo was born July 28th, 2006. She was our third and youngest child. Gabby was such a beautiful soul, she knew when to be serious and could make you pop a stitch laughing. She was well beyond her age of five years old. She was the most selfless person I’ve met. At 3 years old her Uncle had put together a doll house she received on Christmas, after a few minutes of Gabby playing with the dollhouse she stops and goes to tell her Uncle Thanks for putting it together. That’s the kind of person our Gabby was. We love and miss her so much.

On Tuesday May 1st, 2012 Gabby woke up with a fever and complaints of her chest hurting. My wife took her to the pediatrician’s office. Gabby was tested for strep which was negative, and she was sent home. We controlled her persistent fever with ibuprofen. On Wednesday May 2nd;Gabby was feeling lousy when her fever would spike and playing when it was normal. Later that night at 11:00 p.m. when I got home from work we checked on her, and she was burning up with a fever of 105 and had broken out in a spotted rash all over her body. We took her to our local E.R. The Doctor said she had tonsillitis and gave her 2 shots of Rocephin and we were discharged. My wife called her pediatrician roughly 8 hours later Thursday May 3rd and took Gabby to see her. The pediatrician thought Gabby had atypical coxsackie virus, said her fever would stay high for five days and by Sat/Sun it should subside. We continued to control her fever with ibuprofen. On Saturday May 5th my wife called me at work at 9:00 p.m. and said Gabby’s fever spiked to 106.1. We raced her to the E.R. at a level one trauma hospital where she was seen by the pediatric intensivist. He checked her over and said he could give her I.V. fluids if we wanted. There was no urgency even though she hadn’t urinated in 23 hours at this point. We said yes to the I.V. and labs were ordered. At around 3:30 a.m. another E.R. doctor came in and said Gabby could go home. I asked him if her blood work was ok three times, and each time he said that it was fine. My wife and my sister continued to ask the Dr. questions about why her fever would be so high. He stated a fever is the way a body fight an infection. He said, “A fever can run as high 106,107,108 even 110.” We didn’t buy what he was saying and let that go in one ear and out the other. We were discharged and arrived home, Sunday May 6th at 5:30 a.m. Later that day Gabby’s fever was between 99 - 100, the lowest it had been in six days. We thought that the virus had finally run its course.

Monday, May 7th Gabby was still not herself, so my wife called the pediatrician and left a message, and mentioned her E.R. visit on Sat/Sun. Three hours later the nurse called back and said we could bring her in that day or the next. I asked if the pediatrician had seen the blood work results from her E.R. visit. The nurse told me the pediatrician was reading them over her shoulder. I then heard the pediatrician say, “OH MY GOD IT’S A MESS CALL 911!” Gabby’s blood work was abnormal, and she needed to go to the E.R. immediately. I was told the pediatrician was putting admitting orders in the hospital computer.

We immediately got to the hospital. I grabbed the E.R. doctor, explained that she had been sent home with horrible labs and that admitting orders were in the computer. The E.R. doctor disappeared, and we never saw him again. A child life specialist came in and asked if we needed anything and I said WE NEED A DOCTOR! She came back with a pediatric hospitalist and we were moved to the pediatric floor. At 11:00 p.m. Gabby’s blood pressure plummeted, and I noticed swelling around her eyes, hands and feet. The new pediatric intensivist in charge said Gabby was third spacing and being moved to SICU. I asked him about transferring to a different children’s hospital. He said he didn’t feel they would anything different for her at that time, but we could have a transfer anytime we wanted. He stated she may get sicker before she got better, but didn’t elaborate on specifics. She received an internal line and blood pressure medications.

Tuesday May 7th, they did a lumbar puncture on her, and I refused to leave Gabby, so they let me stay. That’s where I heard the doctor tell the nurse in a whisper “we think she’s Septic.” We confronted them, and they explained they were testing and treating Gabby. They asked questions about animals and wooded areas and mentioned Rocky Mountain Spotted Fever but didn’t ask or elaborate to my wife about tick borne diseases. Three hours later I noticed Gabby’s abdomen was swollen and her breathing was rapid. I alerted the doctor who said, “OH DEAR, her liver is palpable.” I didn’t know what that meant, and said I wanted Gabby transferred to another hospital center NOW! We were told she wasn’t stable enough now, and they had to intubate her first. We had to leave the room and Gabby was crying, saying “DAD DON’T GO, I WANT MY MOMMY!” After an hour and a half, they wheeled Gabby out to be prepped for life flight that was arriving. Gabby’s face, neck, and tongue were swollen. I asked why she looked like that. They said her appearance was normal, but something didn’t seem right. When we got her to another children’s hospital the medical team acted like the president had landed. They were all scrambling to tend to Gabby. In the first two hours we saw multiple pediatric specialists. They were treating for everything. They thought Gabby had Rocky Mountain Spotted Fever from a possible tick bite. Doxycycline was given in the first two hours of arriving. In the coming hours we would take small steps forward and then ten back. Eventually there were no more steps forward, and Gabby died Friday May 11th at 10:58 a.m. While we waited for a transfer to the autopsy I was blowing on her hands and feet trying to keep her warm. I was crying, angry and started to hit the counter in the room, yelling that there has got to be “Gabby’s Law.”

Gabby was here on earth for 5 years, 9 months, and 2 weeks. Why and how did our daughter die?

                    
  


Content created by Office of HIV/AIDS and Infectious Disease Policy Content last reviewed May 9, 2018Back to top
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