# U.S. Environmental Protection Agency ’s 

# Promoting Community IPM to Prevent Tick

Borne Diseases Conference

Meeting Notes

Arlington, Virginia March 30

- 31, 2011

## Promoting Community Integrated Pest Management (IPM) for Reducing **Tick**

**- Borne Dise**  **ases**

**Conference Goals**
1. Identify successful strategies for community IPM programs 2. Identify research priorities and knowledge gaps 3. Strengthen partnerships amongst participants 

### Day 1 **Introduction**

**Keith Matthews (EPA)**  Thank you for joining us today for our c ommunity IPM tick conference. Very pleased to see such a large crowd. I am the director of O PP BPPD. BPPD registers reduced

- risk biopesticides and pesticides. It is o ne of the registering programs in OPP. They also have a mandate for pollution prevention. In the pollution prevention aspect of the role is where IPM falls. IPM has a long history in the E nvironmental S tewardship B ranch (ESB) and is something that we have been involved with for many years. Initially we planned this conference for 80 to 100 part icipants. The level of interest has continued to grow. We now have over 150 attendees and 100 people who have registere d for the webinar portion.

Tick

- borne diseases are a very important and significant public health issue. Ticks are vectors for anaplasmo sis
, babesiosis
, e h rlichiosis, R ocky M ountain spotted fever and Lyme disease as well as other pathogens . This conference will focus on IPM as a prevention strategy. Prevention is smart and cost effective, we want to stop problems before they happen and gro w out of control. Session 1 will focus on community IPM. Session 2 will focus on protecting childr en and outdoor environments . Lisa Jackson ’ s priority

- protecting children

- this is a huge problem for children an d they will be impacted by tick

- borne disease s. We will address this in session 2. In s ession 4
, we will look at school age children and older America ns as highest risk groups. This session will recommend and suggest ways to best communicate to at risk populations. We will also talk about protecting outdoor workers, measuring the impact, research strategies, and the cost effectiveness of prevention. We will do a case study for public health protection and a summary of resea rch needs and knowledge gaps. It is a very full and useful agenda. I look forwa rd to the next few days.

**Charles “**  **Ben ”**  **Beard (CDC)** I want to begin by applauding EPA for the effort in pulling together such a distinguished group for this meeting. When Candy had mentioned this meeting, I felt like she had stolen our thunder

- CDC was dis cussing having a meeting with stakeholders for prevention. We are eager to collaborate with all stakeholders for Lyme disease prevention. We see this as a huge mission for us at CDC. Lyme disease is 7 th on the list of 70

- 80 diseases reported to CDC each ye ar. Our number 1 priority is to secure the necessary information, methods, and collaborative relationships required to launch a national Lyme disease prevention program. We have a goal to reduce the prevalence of Lyme disease in the US.
**Christopher Zarba (EPA)**  Associate Director for the O ffice of R esearch and D evelopment

- I was looking at the attendance list and was impressed by the number and diversity of people attending. There are over 5 , 000 years of advanced education in this room right now. Thank you for coming, particularly those who have traveled significant lengths to get here. EPA ’s O ffice of R esearch and D evelopment has 1
, 800 employees. We are a missionPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 2 agency that does research to meet our customer’s needs. We do a lot of this work in house. Ho wever , there are instances when we do not have enough resources and need to go outside to obtain the expertise and equipment we need. We frequently see the newest issues facing the a gency such as hydro fracking, biofuels, and nano

- technology. We determined that having a consistent strategy with all the right people that is broadly accepted as a path forward was very important. Marketing this strategy is also very important . Given the difficult budgets we need to be aggressive, and target our approaches

as we ll as to embrace collaboration. We are here to identify success areas, identify research priorities, and strengthen our partnerships. With the ultimate goal of developing a plan

- we hope to take forward (this will be available for comment) . W e can look at this plan and determine what is relevant to our organization, develop the plan, and move forward. Hopefully we will have a follow on meeting in a few years after this to discuss the progress of our pla n.
A few years ago, the a gency was faced with recreati onal water use as an issue. There were 4,000 or 5,000 beach closings each year and each state has different rules and regulations for closing beaches. We came up with an action plan for beach and recreational waters, based on science, for people. About
a y ear after sending this document up to the hill and making it available

- Congress passed the Beach Act. Congress took our action plan, products, deliverables, timelines etc. and put them into the Beach Act. I am looking forward to getting the funding and mo mentum needed for this issue to move forward so we can get resources where they are so desperately needed.
**Michael McDavitt ( EPA**  **)** I would like to officially thank the organizers for this meeting. Everyone contributed to the development of this meeting so w e will have a very organic meeting. A couple details

- at break there is lunch

- fill out the provided paper if you plan to eat here . We are convening this meeting under the auspices of the Pesticide Program Dialogue Committee (PPDC) this gives us our ground ing. Be mindful of this. We are creating advice to the agency that will be considered. The speaker’s bios are in the packet in the back

. This session is interactive, if you would like to formally provide public comment, please sign up. The focus of this me eting is PREVENTION, not on DIAGNOSIS OR TREATMENT. Everyone has been touched by these diseases, my mother

- in

- law has a disease from a tick. My father developed a disease from a tick bite that has been treated as well. They cannot be avoided, and they touc h our lives everyday very personally. Each session will be in this room. There will be a panel, each will have a moderator or two. They will be chairing and organizing each session. It may be a little awkward at time, but we were looking for a maximum part icipation. Close with a quote: “Far and away the best prize that life offers is the chance to work hard at work worth doing” Teddy Roosevelt. Hopefully we will have great progress for two days.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 3 

### Session I **: Creating Institutional Structures for Community L evel IPM** 

Moderators Karl Malamud

- Roam, IR

- 4, Rutgers University Joh n Carroll, USDA Panelists Sean Healy, Monmouth County (NJ) Mosquito Extermination Commission Thomas Mather, University of Rhode Island Peter Jesson, Chadds Ford Township, PA Brooke Bissin ger, TyraTech, Inc.

**Karl Malamud Roam (IR**

**- 4**  **, Rutgers University )**  Thank you for being here. I could use your help. The IR 4 program is a partnership between USDA and land

- grant schools. The e conomics of public health pesticides are very similar to those f or m i nor crops , there is not enough incentive to develop without funding. The IR

- 4 program a lso work s with the communities that have need

— families, and organized local gov’t programs. Moving into ticks is relatively new, as is thinking about what communit ies can do together to control tick disease. Minor crops have been our bread and butter for the IR

- 4 program . There is not enough profit for companies to innovate and develop and register the best pest control technologies without some investment. I am
t rying to identify tools for public health and work with people who have need for vector control materials. I have been working closely with families and also organized vector control programs. Who will do IPM for tick

- borne diseases? This session will disc uss this. What is the paradigm for vector control ? W hat are tools that have been suggested for community based mosquito and tick control over the years?
Integrated pest management is a huge buzz word, there is a sub set called integrated vector management ( IVM) . Vectors are a type of pest, but are different than agricultural pests. We are trying to protect human health

. IVM is based on the principles that reducing contact with vectors reduces human disease and that v ector control can work to reduce vector bo rne disease . I ndividual actions are also effective. However, these can be inadequate. Community coordinated response is necessary. Eradication of a vector is rarely possible but control can reduce the disease. Eradication is not the goal usually. Reducing contact with the vector, reduces diseases. Surveillance

- you have an active program. Biological control can help, pesticides are useful tools as long as they are public health pesticides. 100 years of publically funded mosquito control

– interested in mala ria, arboviruses, and West Nile virus

. The question that is key to me is can we learn from mosquito control programs to help us develop programs for tick control and IPM ? Public education can be broad

- it usually means that someone is doing the educating, but who should educate and to whom? Land

- use planning

- make provisions to reduce contact between people and disease. Deer population management? This is contentious

- we will not see it solely to protect human health. However, we will consider it. These ma y have ancillary benefits for human health protection. Biological control

- there are a lot of exciting ideas abou t using fungi for reducing tick

- borne diseases. We need to know what good ideas are out there. There is a suite of chemical prevention strategi es. Using barriers is important, tick control on deer (4

- poster idea), tick control on rodents (ti ck control on nesting materials and baited food with acaricides so rodents receive a systemic load of the chemical to reduce the tick load on the rodents).

A rea wide control of ticks with pesticides is the least likely to be promoted here today. This is a big difference for mosquitos where area wide control is supported . We need to know what your ideas are. We have been asked to develop discussion pieces

- I su ggest: Do we know enough to recommend thatPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 4 local governments spend money on vector control of tick

- borne diseases? What do we need to do to develop recommendations? Who will make recommendations? What research needs to be done and by whom to determine what works where ? Should we measure effectiveness?
**John Carroll (USDA)**  Where do we go from here? Where implies a plan, we need to know where we are going and how to get there. Who will initiate dialogue with existing institutions or creat e new institutions? We

- the people in this room

- should start this off and other people can get involved. There have been meetings and great ideas have come out but these have died out. We need a plan. This session is about institutions. There are institutions at various levels . Large long established institutions are the hardest to change. In smaller institutions it is easier to promote change. Large institutions however have the infrastructure and resources for change. We need to make difficult choices. It is difficult to star t new programs, whether it is with in an existing program or starting a new one. We have eco nomic constraints. Desired and realizable g oals: s urveillance, t ic k population management, and r eduction of Lyme disease cases. We need to make decisions on prioriti es. We want to see reduction but how will we do it? Areas with emerging problems and areas with an entrenched problem both need attention. Existing problem

- this will receive attention. However, this is a spreading problem. The range of the tick is expandi ng into new areas. We have seen it move westward in Maryland for instance. The local population may not be aware of it yet. These people need to be involved. Not just the ones where there have been problems with Lyme disease for the past 20 years. In summa ry, vectors cross property lines and create a community level problem . At some levels we will need to deal with institutions. We need to define our goals, make plans, and initiate actions.
**Sean Healy (Monmouth County (NJ) Mosquito Extermination Commission**  **)** Genesis of the mosquito control in Monmouth County. Mosquito control district was founded in 1914. It began looking at the salt marsh mosquito. In 1990

- started looking at some tick related initiatives . In 1992 the commission looked into a larger initiat ive for ticks

- large scale field trials to control Ixo des scapularis . We used aerial applications of granules . This was the first area wide project for tick control in New Jersey. What drove the commission to actively implement a tick control program into the mosquito control problem? The director at the time , Martin Chomskey, felt that the best way to control ticks in these area s was through mosquito control districts that were already established. Lyme disease was the number 1 reported arthropod borne dis ease in NJ and the c urrent level of funding was insufficient. Mosquito control is mandated by law in New J ersey at the county level. It is very specific and narrowly defined

- it did not include a provision for these institutions to undertake tick related a ctivities.

In 1994

- Monmouth C ounty spearheaded changes to this provision to enable mosquito control agencies to undertake tick control. In 1997

- the governor signed this into law Public Law. The commission followed this by adopting a resolution to desig nate the mosquito commission as the commission to undertake tick related activities. From the onset of the program

- commissioners said that tick control needed to be budgeted separately from funding to control mosquitos. At that time they instituted the ti ck program at Monmouth County with a separate budget than the mosquito control districts. Funds for the tick program do not impact the mosquito control program. We have continued to collaborate and look at projects that can be implemented at the county le vel. The only ongoing tick control projec t is county wide and uses the 4

- poster program. We also have a tick identification program and testing
program . We research ticks in the county.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 5 Q&A Question Karl Malamud

- Roam: Do we have the knowledge needed for tick control? Where does the county go next? Response Sean Healy

- I think that is the real question we are trying to address, do we have the tools we need to move forward in this type of program. This has been an overwhelming and daunting task

- how do y ou get to all the people at risk. Can you do this fairly and adequately? There are ways of approaching this and it is possible. We look at peridomestic mosquito problems that are backyard containing breeding mosquitos. We had to convert our strategies to g et the most bang for our buck. We have to do control in peoples yards to try to address the problem and in communities.
**Thomas Mather ( University of Rhode Island)**  We have a peridomestic problem. We have potential for help at higher levels of government. W e need people to make individual homeowner level decisions to make a large difference. Homeowners can make control inconsistent because people can opt out. How do we facilitate translation of training and information about control ? Who are the people devel oping programs? What is their background and credibility? This should be a bottom up approach. We need to think about getting people (homeowners) to ask for assistance. We need to develop decision support tools to help people make decisions. One way is to incentivize them. If I offer you 100 dollars, you would be more likely to do what I ask. At the U niversity of R hode I sland , we have a small EPA grant to develop a decision support tool for the peridomestic environment. We need trained tick controllers to h elp meet the demand for control tools adequately

- for instance, five sprays may not be necessary bu t rather a single timed spray.

In Rhode Island, we held the first deer tick management certification program for P est C ontrol O perators (PCO s ) . This will be the first group of people to be certified for deer tick management in people’s backyards

- we had the first 15 graduates last week. They do not get their certification unless they provide for us their new tick bite protection/tick bite prevention plan so w e can assess whether or not they have used science to address the issue. It is not good enough to say that I will do 4 sprays because the label on the control agent says so. Tick risk calculator

- the early phases focus on surveillance, without surveillance you do not know the level of risk. This calculator provides r isk appropriate recommendations necessary to make good decisions. Even in a highly deer tick endemic community, there will be landscapes in peoples backyard that do not have ticks. As a result, understanding the level of control needed varies by location, risk, etc. By understanding risk, it is easier to make decisions and tools to make these decisions are necessary. We need to motivate people in PCO industries to have tools to access town level, and individual risk parameters in yards to create action plans.
**Peter Jesson (Chad d**  **s F**  **ord Township, Pennsylvania)** The level of Lyme disease is currently unacceptable. We need to document the need for initiative s

. We have worked towards e stablishing a tic k reduction program in a 4
, 000 resident rural township. We surveyed the township by letter

- it told us we had an unacceptable problem and we should go forward with tick control initiatives . More recently
, I uploaded an online survey which we are trying to get every resident in the township to fill out. It is quick and easy for people who have not had Lyme disease . It also has branching to allow for people affected by Lyme disease to put in as much information as they wo uld like . The data is instantly put in to a spreadsheet so it can be manipulated. I have added local wildlife management unit columns so I can identify which unit residents are in. The survey shows that so far 150 households have responded with about 400 individuals . About 130 people have had L yme disease and there were 225 Lyme disease i ncidents. The systematic approach

- we chose the northern section of the township and we will institute a systematic drive with volunteers to contact the residents in this block ofPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 6 the town and get them to fill o ut the survey. We will then move onto other sections. Involving appropriate organizations

- we have the township administration, the civic association, Pennsylvania Game Commission, USDA , LDASEPA ( L yme D isease A ssociation of Southeastern P ennsylvania) , and

u niversities in the area committed to the issue. We are doing bow hunting for the deer part of our program. We put in place a research effort

- I have scoured the literature to determine the elements we need to put into place for our program. The research e ffort determined the following efforts for tick control:

**•** Searching the literature for approaches

**•** Reduction of deer population through bow

- hunting

**•** Damminix Tick T ubes ® (rodent nesting material)

**•** Personal p rotection

**•** Spraying properties with pesticides

**•** 4

- post er d eer f eeders (expensive)

**•** Bait Boxes (unavailable)

**•** Vaccination

– contraception (n ot in PA)

**•** Fungus (still in research)

**•** Domesticated f owl (probably not effective)
We are attempting to reduce the deer population through bow hunting. We have a huge deer
popu lation 140 deer per square mile. This is a huge effort to get it down to any level where it will have an impact on the tick levels. We will be stocking Damminix T ick T ubes ® and will let people purchase them if they would like them for their properties. It would be too expensive to do this on our own throughout the count y. We are considering spraying. The township wants us to do this program for free. We have several task f orces to address these issues

- Public Information and Survey Task Force, D e er C ontrol Task Force, D eer Population Measurement Task Force with USDA, Tick Measurement Task F orce.

Resident Awareness P rogram

- long term , surveys, information distribution, website etc. Tick Reduction Milestones Program

- scoured the literature and published a re port.
We have a plan developed and are in the process of implementing the plan. We divided the township into 12 management sections. We have all of the things that will allow us to look at one house from satellite and look at vegetation and determine how t o handle it for deer hunting.
Long term we will do annual surveys to reduce the deer population to 10 per square mile if possible. We need surrounding townships to get on board to maintain this. We would like to fully educate our residents with regards to personal protection and spraying property with pesticides. Over all, the long term plan is to:

**•** Annual Lyme surveys

**•** Keep reducing deer population (10 sq mi les )

**•** Annual tick survey

**•** Fully educate and inform residents

**•** Keep track of new approaches

**•** Encourage sur rounding townships to implement similar approachesPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 7 **Brooke Bissinger (Tyra Tech)**  She has studied a plant

- based repellent for her PhD. Many people are afraid of synthetic pesticides but people are afraid to use these chemicals. We need better education progr ams so people are not afraid of these materials or we need truly efficacious plant based repellent s.
Q&A Question Karl Malamud

- Roam, IR

- 4, Rutgers University

- Deer control is much more acceptable than it was 20 years ago

- likely because people are sick o f hitting deer with their cars, having them eat their gardens etc. I would like to ask, should we be making recommendations regarding deer population management? Response Peter Jesson

- There has been interest in townships and surrounding townships for dee r population management. It will likely spread easily through our area because we have not received a lot of negative response to deer population management. Attitudes have changed regarding this issue, people are much more on board with this issue. I beli eve that the interest that people are showing in our township will spread. Chadsford Township is on the state of Delaware border and is 40 miles west of Philadelphia.

Question Pat Smith, Lyme disease Association

- Many of the cases came from the Naval Wea pons Station. Why do we not have more of a collaborative effort? They have been mapping ticks in these bases. How are they controlling the ticks in these controlled setting? Why don’t we approach the military because they are an established entity that has had dealing with this and try to get help from them on what we should do? Response Karl Malamud

- Roam

- the Armed Forces Pest Management Board

- is meeting next week. They discuss research priorities. This is a topic on their agenda. I will try to get this on their agenda.

Question Robert Coney, EPA Region 1

- This is in regards to the training program for PCOs

- what type of training did they receive? Was it public health? What kind of material was taught? Changing plantings? Changing composition in your ya rd? Response John Carroll

- people were getting certification credits in category III

- horticulture and landscape. They also could have had it in public health. There are several strategies to understand. Different strategies can be implemented to control ticks and reduce exposure. We talked a little about surveillance, evaluating yards, etc. We want them to be armed with what is tick habitat, why it is tick habitat, and move from there. It is important to engage people and let them be part of the surveilla nce in a passive way. If you find a tick, put it in a bottle, we can take a look at it. A lot of people do not know a lot of about ticks. We need to educate people so they know different types of ticks are out there. All ticks come in different sizes

- if i t is large it still could be an adult deer tick.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 8 Question David Gaines

- There are a fair number of repellent s on the market. There are many people who do not like DEET. I t seems to be the only repellent researched for efficacy for ticks. Most of the pr oducts on the market have been studies for repellency for mosquitos but not ticks. Does the EPA plan to look at these products regarding their repellency for ticks? Response Karl Malamud

- Roam

- The military is funding significant research and development o n repellent s to protect them from tick

- borne diseases. There is federally funded research on repellent s

- whether it is sufficient that is another question. For many years EPAs focus has been on making sure products were safe. Efficacy was the focus for pub lic health. There is a good efficacy website. Response Brooke Bissinger

- There has been a lot less research on efficacy for ticks. There are a number of studies that are looking at different active ingredients. It concerns me that this information is not being provided to the public. People with access to journals can see this information. There seems to be a knowledge gap between the research being conducted and the public. David Gaines

- we have seen very little on repellency to ticks. I wrote a review ar ticle on tick control strategies, if anyone would like to see it, I would be happy to share it. Response Candy Brassard

- We are in the middle of rulemaking for product performance data rule. There have been many questions about ticks including the test o rganism and what should be on the label. There are biochemical and conventional products being included in this rule. Response Keith Matthews

- we are working a rule that will require efficacy data for public health control agents. Response John Carroll

- there is an information disconnect. We have worked with the Army, we have done two tests using human volunteers. These have shown these formulations are effective for 12 hrs. in these tests on specific repellent s. There is information in the literature. R esponse Joe Piesman

- Community Prevention and Training

- We at CDC

- funded four states to work on community prevention of Lyme disease

- Massachusetts, New York, Connecticut, and New Jersey. The vaccine came out around this time and was quickly taken off the market. Outreach was a focus of this. Connecticut was the most effective at moving training forward

- area wide acaricides are widely effective and can be used against Lyme disease

. The problem is they are overused on occasion. Pest control operators do no t need to spray weekly

- we need one adequate timed spray before the season starts. By participating in the program the PCOs were registered as having taken the course and this information was translated throughout the township. Coming out of these programs

- there are two manuals that are useful

- Kirby Stafford’s IPM for the Home owner and also another manual.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 9 Question Question for Peter Jesson from Webinar participant

- CDC has funded these unity education and management projects in four states. What you are doing in your community is interesting. You mentioned you will be following up so you know who does what

- will you be researching the combinations and factors that are effective for control? Secondly, you mentioned that there are fewer deer

- sustainab ility of control methods

- what about anticipating any decrease in hunter participation or not having enough deer? What might you be anticipating to encourage participation in the future? Response Peter Jesson

- As the population decreases the hunters may l ose interest. If they want to hunt in Chadsford, they may have to make a low count. We have access to the landowners that they do not. We also have one of the most attractive deer hunting areas in the state. We are expecting those who are dedicated to help solve the Lyme program will continue participation. We are hoping by tracking the deer population, tick population, and disease incidence that we will have a record year after year to determine if what we are doing is effective or not.

Question Lisa Pr esident of National Tick

- borne Disease Advocates

- With the budget challenges at state, local, and federal level

- what about the dialogue with the USDA? In Texas we had a study come out that Cattle ticks are carrying different pathogens. Response Mat Pound

- Cattle fever ticks carry babesis specific to cattle.

Question Sherry Glick

- How is the data from the tick calculator used? I am interested in how this can be used for IPM and kids. Response Thomas Mather

- The calculator is specific for homeowners. It walks through 45 questions about what your yard looks like, how it is use, current practices for tick bite protection. It then calculates a number between 1 and 100. It then lets you try implementing a control strategy through the tool and see how the risk number can drop. Web address: it is not quite available yet, I have been stalling launching it, I like to get things right. It should be available for a few states hopefully sometime this season.

Question Do we know enough to make tentative recommendati ons? Response Karl Malamud

- Roam : We know enough to make tentative recommendations. There are recommendations that can be made to individuals, homeowners, communities, states etc. There are actions that are appropriate for individuals and a role for the fe deral government in research and data, reviewing case loads, and looking at long term trends. John Carroll: It is interesting to see how this problem has evolved and mechanisms to control have evolved. Monmouth County and Chadford Township have both evolv ed completely d ifferently.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 10 

### Session II **: Protecting Children in Schools and Outdoor Environments**

Moderators Kathy Murray, Maine Department of Agriculture, Food, and Rural Resources Thomas Green, IPM Institute of North America Panelists Christine Dunat han, Friends Community School, College Park, MD Benedict Pagac, U.S. Army Public Health Command

- Region North Shirley Schantz , National Association of School Nurses Herbert Bolton, U.S. Department of Agriculture Audrey Moore, U.S. EPA Region 2 Clara Fuente s, U.S. EPA
**Kathy Murray (Maine Department of Agriculture)**  Why focus on children

- they are our future. Schools are at risk. We talked about peridomestic issues. Many schools are in suburban and rural areas and are close to tick habitat. I receive calls ev ery year from schools seeking help. The goals of this session are to:

• Discuss IPM practices used effectively at schools and other outdoor environments to reduce children’s risks of exposure to tick

- borne diseases

.

• Identify priority needs and knowledge gap s in research, education, regulation and implementation to protect children at schools and other outdoor environments.

• Develop coordinated strategies for community IPM programs and strengthen partnerships among organizations, agencies, schools and other pu blic facilities. We SHOULD focus on children’s health and ensure they are protected from exposure to tick

- borne diseases. Children rely on adults to help check their bodies for ticks after outdoor play, direct activities away from tick infested areas, ass ist with application of repellents, and get necessary medical care when needed. Children may be more vulnerable to exposures because of their behaviors (climbing trees for instance or building forts in the woods), and perhaps because their immune systems are not fully developed.

Tick IPM in schools is a combination of managing people and managing pests. There are a number of jobs and different job descriptions of people involved in managing school properties and facilities. People who play a role include: coaches, parents, office staff, teachers, maintenance staff, students,
nurses, and contractors (pest control and landscaping). It takes a lot of effort to facilitate coordination between these groups. School nurses and the school board play a huge role.

S chool nurses can help prevent and identify tick

- borne diseases and provide guidance to parents.

Role of the School Nurse:

 Prevent and identify tick

- borne illnesses in schools

 Early detection and referral

• Monitor student’s symptoms to improve outcomes

• Adv ocate for post

- diagnosis accommodations for students with ongoing symptoms

 Provide guidance to parents and guardians

• Prevention, detection and treatment

 Assist with school district policy development

The Friends Community School is located in a very tick infested area. There are many encounters with ticks. The school shares land with deer, foxes and other wildlife. There is also a stream along the eastern edge of the property which is part of the Chesapeake Bay watershed. The forest starts outside of thePromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 11 d oor. Once they moved into the building they realized they had a tick problem. One of the parents had a contact at USDA and they enrolled in a study run by John Carroll. They create d a multiple point IPM program which included:

• Field policy and dress code

• T eacher education

• Parent education

• Biannual testing

• Duct tape for each teacher

• Repellent

• Pyrethrins on socks

• Garlic barrier spraying program

• Deer feeder

• Tick tubes spring and fall

• Chickens

The U.S. Army has worked to protect Boy Scouts from ticks during th e J amboree. “Large, outdoor nature events held in known tick habitat can be a major public health challenge. ” A multitude of protective measures ranging from the simple (raising awareness via signs) to the sophisticated (producing GIS threat maps and estab lishing an on

- site field lab to identify attached ticks and test them for pathogens via PCR) can successfully mitigate disease risk. Successful tick and tick

- borne disease management in large outdoor public events relies on: advanced planning, early stak eholder communication & coordination, systematic sampling, wise IPM decision making, delineation of risk, re

- evaluation and modification, quick diagnostic turnaround, and on

- site/on

- call expertise. Events such as scouting jamborees are noteworthy in that, in some cases, hundreds of thousands of national and international participants interface closely with nature for a two

- week period and then return home. Preventive measures are the first priority but they should dovetail with on

- going diagnostic monitorin g and documentation so that follow

- up actions can take place, if needed, with patients having suspected
exposures. US Army has worked closely with the Boy Scout Jamboree with almost 100,000 participants each year. This area is complex. They created tick ri sk zone maps, a mobi le laboratory to test them for B orellia , etc.

With an increased emphasis on getting kids outdoors ( No Child Left Inside initiatives, s chool gardening, experiential lea rning) e nvironmental education information is needed to protect chi ldren from tick

borne diseases.
Charge questions for the panel are:
1) What is your organization doing to protect children from tick

- borne diseases at schools and other public spaces, what challenges do you face, and what should EPA do to help you to

overco me those challenges and support your programs. 2) What guidance can you offer to school administration and staff, or to managers of parks, children’s camps and other outdoor spaces frequented by children, in terms of facilities management, education, and stab le funding sources if needed, to reduce risk of tick

- borne diseases. 3) What are the top priority needs for research to reduce children’s risk of exposure to tick

- borne diseases at schools and other outdoor environments?Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 12 **Thomas Green (IPM Institute of Nort**  **h America)** The IPM Institute of North American was started in 1998. The industry was opening up to our needs to protect the environment. One of our first jobs was working with the Food Alliance which certifies production and IPM is one of their requirement s as opposed to organic. Their producers have to use IPM to participate in the program. Food Alliance then provides marketing support and an e co

- l abel. Eco

Apple is another marketing strategy where we embrace IPM. The IPM I nstitute has been around for 12
y ears working in agriculture and communities. The IPM Star program was started using the organic model where we go onsite to the school programs and if we approve of what they are doing we certify them with the IPM Star. We also work closely with military s chools. We have had an impact on cleaning up improper use of pesticides.

This is not rocket science; it is simple things like putting door sweeps in schools and other mechanical control mechanisms. We can reduce pest complaints by 60% just by putting doo r sweeps in schools. We want high level IPM in schools by 2015. We are coordinating our efforts

- it is the first time we have done this. We are infiltrating people already working in schools and getting leaders from these organizations on board with the pr ogram. This has been going on since 2006. IPM has been recognized as a continuum of practices. We are striving to implement IPM in these schools, empower people to create sustainable programs and then let them take it from there. We have people using produ cts improperly because of resistance and overuse. There are a lot of unknowns with regards to products that we are using now not just pesticides but pharmaceuticals etc. We want to minimize our reliance on pesticides. These are valuable tools that can be u sed especially targeted specific chemicals instead of broad spectrum pesticides.

Accomplishments to date: Demonstration projects. Pilot schools use proven approaches, such as assessments, workshops, targeted newsletters
, and pest monitoring to successfull y demonstrate IPM in their region and state. Each year, our goal is to initiate demonstrations in at least five new states that have not previously completed a demonstration project. Established 12 school IPM pilot projects throughout four regions:

• Ascen sion Parish, Louisiana

• Brookings, South Dakota

• Flandreau, South Dakota

• Westville, Illinois

• Lincoln, Nebraska

• Omaha, Nebraska • Chariho, Rhode Island

• Exeter, New Hampshire

• White River Junction, Vermont

• Salem Keizer, Oregon

• Sterling, Colorado

• Russe llville, Arkansas

New demonstrations have been starting across the country, adding to our success in prior years. Over 300,000 students and 20,000 teachers have been impacted by school IPM demonstrations in recent
years. New demonstration projects:

• Cat lin, Illinois

• Champaign, Illinois

• Vermillion County, Illinois

• Bozeman, Montana

• Dothan Brook, Vermont • Hartford School District, Vermont

• Indianapolis, Indiana

• Caliche Schools, Colorado

• Albuquerque, New Mexico

• Rio Rancho, New MexicoPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 2 Self

- expanding c oalitions use professionals already trained and working in demonstration schools to recruit and mentor professionals from other school systems in their states. Have established school IPM coalitions in 15 different states including:

• Alabama

• Arizona

• Co lorado

• Illinois

• Indiana

• Missouri

• Montana

• Nebraska • New Hampshire

• New Mexico

• Ohio

• Pennsylvania

• Utah

• Vermont

• Washington

Lessons learned include the need to identify the key decision makers and champions in the districts. Asthma affects 6% of our kids. Compelling messages can activate decision makers so they work on things we want them to work on. There are m any opportunities with new partners. Green schools may put planning in place that may increase tick habitats. We need to work together to mini mize tick habitats and schools. This has been a broad effort with support from a variety of agencies and organizations. Would like to leverage the support we are receiving. We would like to learn more on how we can get involved. Regions are really doing a lot of work and have working groups. Schools can be used as tools to get information out to the community. If we educate students now, they will become better consumers in the future and hopefully will support IPM initiatives.

**Christine Duna than (Friend**  **s Community School, College Park, MD)** I became involved in this group because of John Carroll . I represent the microcosm of implementation. The Friends Community School has young children. We are a green school located on a forested 17 acre site and are ad jacent to Greenbelt National Park. We have wetlands and various animals. Our program is hands on and we try to integrate experience with classroom learning. We envisioned we would have a very active use of our property and we would get the kids outside a l ot to do science, math etc. We had a rude awakening when we moved in. We did not know we had ticks. We had a camp before we officially started school. A lot of the campers were getting ticks so we had to move the camp to an emergency location. We are a Qua ker school serving 200 kids K

- 8. The type of site we have is protected, we want to be green and be good stewards of the earth and all that goes into this. We immediately began researching IPM strategies to look into this problem.

In addition to deer, fox, and many small mammals we have a creek with frogs, fish etc. We did not want to just spray anything that could endanger these species. Didn’t want to just spray randomly

. Immediately brought in pest

- management companies and they suggested spraying lots of strong stuff, and didn’t appreciate the environmental concerns. We had a problem. We brought in for profit pest management companies that suggested spraying pesticides inside and outside the school. I started doing research and did not want to spray indoo rs and outdoors. One key thing they did was study the problem, look for experts. We signed up with John Carroll to join his study. We needed to know the kind of ticks, the location, etc. We were very grateful to have the information and advice John deliver ed to document our baseline situation and figure out next steps.
I developed a tick management plant with short medium and long term goals. Immediately when we showed it to the faculty people were concerned with what their kids would be exposed to. We had other parents saying the kids could not go outside at all. Some parents said we should do everything to get ridPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 2 of ticks possible. We had three major attitude approaches to deal with. Timing was an issue of course, in the fall the second wave of ticks was coming out. We needed to limit exposure to the children. Because we are an independent school we adopted the policy and did not have to worry about the school board etc. We had children play on the blacktop, insisted children wear shoes, long socks, etc. We had a lot o f behaviors we had to change. We developed criteria and steps to take to be minimally invasive. We wanted to be as effective as possible at the least cost. We did not want to spray anything that would impact fish and wildlife. We developed a multiple point plan with a field policy and dress code. We started a teacher education program. We had the campus tested twice a year to determine the effectiveness of the steps we were taking. We issued rolls of tape to teachers so the students woul d put it around the socks. W e trimmed around the trails. We abandoned paths and started taking kids to parks with asphalt paths until we could spray. We sprayed with a garlic barrier spray. W e had every kid bring in socks and we treated the socks with pyrethrin

. T he kids would wear thes e socks if they went outside. We spra yed nematodes

- I cannot say whether this was effective or not. We established a deer feeder and put out tick tubes. We took a flock of chickens and had chickens onsite that we would move around every few weeks. It was quite a decision piece.

**Herbert Bolton (USDA** 

**- National Institute of Food and Agriculture**  **)** W e are the branch of the USDA that has extramural programs. We are a grant agency for research, education, and extension. We depend on our l and

- grant partners to do our research through grants, education, and outreach . To support IPM

- our organization is focusing on research, education, and extension. At NIFA we do not have a grant portfolio directed towards ticks or towards IPM. The Farm Bill was focusing on issues facing agriculture. We do have some special grants however that focus on ticks

. Check out tick encounter.org w hich is a very interesting site that we were able to help support through our grant

. In extension efforts we support the f unding of the regional IPM centers. Some of this funding has gone towards IPM in schools. Our land

- grant partners go into the community a lot. The se land

- grant university specialists are a first line of resource. The grants that they receive from us suppor t these efforts. New effort by land

- grant universities is e X tension

- they all cannot be doing the same thing over and over in the same states. This is web

- based. There are leaders in communities of interest. Go to eextension.org they will pop up. These are practices across the land

- grant universities. I suggest that this is a way to track research and to suppo rt these systems independently. Recommendations

- encourage people to check out what state extension programs have to offer. Tom Mather is right on. Wh at people are willing to do is based on their understanding of risk. If risk is low or non

- existent

- you will burn them out. People are already trying to focus on keeping their families healthy. It is important to consider risk.
Top priorities for researc h and outreach

- we need surveillance at a greater level for ticks. We need an inventory of federal outreach materials. We need to see what state agencies have already developed collect resources
, and do an inventory of what is out there. We can overwhelm p eople with material, we need to see what is out there, what is the best of the best, what is science based etc. There is a great need for social scientists to be involved

- so we can consider what people are going to do with the information received . They c an help determine how people set up programs and why. Outreach and Materials

- let’s look at what we have. You have to ask yourself who is the target audience, how do you want people to respond, we need focus groups, surveys, etc. and re

- adjust our focus on the user (the school , people in the school, parents). W hat is the information that they want, not the informat ion that we think they should ge t. AMCA is doing this in some parts for communities. We should bring in social media. There is a user based websi te called useability.gov which talks about making websites accessible to the user.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 3 **Benedict Pagac (US Army Public Health Command**

**- Region North)**  It was mentioned the Army had an involvement with the Scouting Jamboree

- it was a special event that has applica bility to larger scale events. The National Scout Jamboree happens every 4 or 5 years. The military has large tracks of land so they were a natural fit to hold events like this. Planning is imperative for outdoor events. You need to know the site well. Pla nning should occur a year in advance. The event occurs in the Virginia Piedmont which is tick country. In the early planning process ticks may not be on the table. There should be consideration of vectors when planning these events. This is a multidiscipli nary effort

- getting public health officials and pest experts together along with safety people to make it a successful event. It is established that you need a lot of good planning. Part of the tick approach is delineating the site into different sections . Dragging is effective in finding ticks. People should expose themselves to ticks using this method to learn something! 25 years these things still amaze me. They are amazing animals that we deal with. You learn something new every day.

It is important t o know your subject. Planning

- during an event is not inconceivable to have an onsite tick testing lab. You can fit everything you need to have an onsite lab in a standard panel van. You need electricity, water, and somewhere to put it. This allows us to p rovide people with exposure information in real time especially given the international nature of the event. There are many materials provided by local health departments. Among children there is a desensitization to paper. We explored in discussions

- soci al media to get the message out about awareness. We need to exploit social media to get information out about protecting yourself. One other lesson learned

- jiffy

- johns. In an outdoor event a major issue is the number and location of your portable toilets . If you do not have them and they are not in the right place, there are natural places to do things that will expose you to ticks. Special behaviors

- you have to go through behaviors of participants to determine exposure

- e .g.: hiking, trading patches.

T he military is involved in making sure military families have as healthful a living environment as possible. Military members are in harm’s way and so are their families. There has been a big push in providing better child development centers and youth act ivity centers. These are often placed in the more bucolic areas to provide a good setting. A lot of thought needs to be put into play areas, manicured areas, fences, buffer zones, etc. Ticks will be found in unconventional habitat

- this needs to be conside red. Balls go over fences and someone has to go out of these areas. EPA can help by doing what they are doing

- looking at new repellent s, doing good registration, providing good guidance material that people can do. They are doing a good job but areas can be offered to target for the future.
**Shirley Schantz**  **( National**  **Association of School Nurses (NASN)**  **)** W e are located in Silver Spring
, Maryland. Before that we were in Colorado. The NASN is a national organization and we have chapters in 49 states, D.C., an d an overseas chapter. We have over 15,000 members. There are about 75,000 school nurses in the U.S. There are school nurses in 75% of our schools every day . The NASN has been involved with the EPA tools for schools program for the past 8 years. One thing that we do is IPM. We have a program and bring our nurses to the conference and at any rate we have trained school nurses about indoor air quality. We have educated about 5000 school nurses about IPM. These nurses then educate parents, staff, children etc. We provide a weekly digest and can promote some policies. W e also produce articles in our evidence based journal. We have a good network of communication to school nurses. We can publish information that you wan t disseminated throughout to nurses. A s choo l nurse is the health authority in the school. If there are children that go to the office or the parents see changes in behavior

- nurses can identify children having symptoms

- we can do a health assessment and determine if they need to go to a primary care provided which is outside the

area of expertise to the teachers. A s chool nurse can identify illnesses even if it is vague and determine the child needs to seek further medical attention. We have great communication with teachers, families,Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 4 students in th e schools. We focus on prevention. If we can identify areas of prevention to recommend to schools or school boards , and to the community and we can help promote these. We would be happy to promote programs. We want to focus on children’s health, preventing the issues and keeping children health y , in class and ready to learn. The number of children with asthma is increasing

- about 10% of all children have asthma. The school community and building has to be a safe, clean area that provides a healthy environme nt for everyone who comes into the schools. The EPA

- I would like to encourage the EPA to provide evidence based information that we can communicate to families and to promote evidence based policie s. Top research priority

- I would like to know the real in cidence of tick

- borne diseases in schools. Evidence that IPM actually affects the incidence of tick

- borne diseases. We want to show that a healthy environment promotes decreased absenteeism and an increase in academic success. We want happy and healthy chi ldren.
**Audrey Moore (EPA, Region 2)** I have been with EPA for about 20 years now. For the past 10 years I’ve been working for agricultural initiatives , school and community IPM. Our region has a well

- established outreach program that we have been targeting schools and trying to promote IPM. I also am involved in the PESP grant program. We funded a grant to the University of Medicine and Dentistry in New Jersey to put together an interactive training program for children regarding tick awareness and preventi on for 4 th and 5 th graders. The actual program consists of a prevention video and an interactive game. The children can then identify what a tick is, how to identify a bite, what to do when bitten. We are hoping to get this material out there once it is co mplete. We need to collaborate on future projects. Starting to lose some of their state level partners. Happy to have this opportunity to find other potential collaborators, stakeholders etc. to work together.

Q&A Question Pat Smith

- Question to Tom

- Sch ool districts have a fear of being sued. Districts tend to be afraid of having problems and admitting it. Have you run across that and how do you deal with it? Response Tom Green

- Y es , I have run across that

- most recently there was a bedbug meeting

- I ma de some remarks for a colleague about the bedbug problem in their district and the phone was ringing off the hook. Larger districts may have a professional manager on staff to deal with these issues. In other small districts they may not have these resourc es. Working with people and determining success is a good way to determine how schools can deal with this liability. It is easier to find experts and provide support to school districts.

Question Conservation Org

- The real need to continue to encourage o ur children to be exposed to outdoor environments

- how can we do this given the tick problem? This is a real research need. Response Shirley Schantz

- The more we allow children to go outside the more we expose them to risk. We need to consider this in cos t and benefit analyses. The only way to do this is prevention strategies. Prevention needs to be addressed along with encouraging our children to go outside.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 5 Question Karl Malamud Roam

- If we do monitoring and decide we did 12 interventions and the ra te went down

- how can we decide what is being effective? Response Christine Dunathan

- W e struggled with this. We implemented all of these things over time. We started a few, dropped them. Started others, then tested again. We did several at a time. The fi rst thing we had to do was promote a change in behavior. We have eliminated areas where there were a lot of ticks. I suggest that the federal government reach out with groups that deal with kids to not brush this off and take tick

- borne disease more seriou sly.

Question Question: The tick seasons etc. are very different in different parts of the season. How can we move towards regionalizing advice. My concern is use of social media. My point is we need to regionalize our efforts. Response Herb Bolton: T here are people planning social media etc. who are mapping by zip code and you can receive information by county. Thomas Mather: We need to partner with regions to make regionally appropriate information available. We do not receive much feedback. We need to incentivize informational sharing. There are mechanisms that are simple.

Question Sherry Glick

- Are there developed and proved school curriculum regarding tick prevention? Response Kathy Murray

- I have a grant to teach kids about IPM in the classroo m. We have tick lessons that Audrey’s grantee that has developed. There are pest control companies that do this as well. Response Bob Maurais, Mainely Ticks

- W e have taken an approach to deal with this in Maine. We try to model Tom’s website. We create po sters, community based form. Everything is community based. This is a paradigm shift. Things are not the same as they were before.

In Summary: Need for better surveillance methods and data

- we need to make this information available to those who need i t. We need to inventory the materials available, find the best of the best, and make them readily available. We need to involve social scientists. Planning is needed. We need to invite partners to reach out and invite others for collaboration such as with the NASN

.



### Session III: **Landscape Planning and Tick Management**

Moderators and Speakers Montira Pongsiri, U.S. EPA Howard Ginsberg, U.S. Geological Survey Kirby Stafford, Connecticut Agricultural Experiment Station Panelists Wink Hastings, National Par k Service Laura Jackson, U.S. EPA Terra Rentz, the Wildlife Society Robert Snieckus, U.S. Department of Agriculture Kevin Sweeney, U.S. EPA Kendra Briechle, The Conservation FundPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 6 **Montira Pongsiri (EPA)**  We are talking about landscape planning and tick ma nagement. The questions for the panel include:

1. How can we engage the landscape design professions in the prevention of tick

- borne diseases? 2. What is the best way to provide information on tick

- borne disease prevention to professional planners and landscape architects?
These strategies have been untapped. We want to look at these and take steps towards incorporating them into landscape design.
**Howard Ginsberg (USGS)** The genesis of this session is from something a lot of tick biologists have experienced. L ooking at layout and landscape design

- people may be artificially creating habitats for ticks. Minor changes in planning for landscape design could change this

- this could reduce the number of people getting bit and suffering from tick

- borne diseases. This strategy does not require people to do a lot on their part. Rather, the design is implemented and it is done. Lyme disease is the most important vector disease in temperate

areas. One tick species is the vector for Lyme disease , one pathogen but various reservoirs. There are two populations of ticks living in one place at the say time due to the lifecycle. The nymphal stage is what causes a majority of the Lyme disease cases. This stage of tick is usually making people sick and is the stage we want to con centrate on.
Approaches to managing ticks and Lyme disease include:

**•** Self

- protection precautions

**•** Habitat manipulation

**•** Manipulation of host populations

**•** Biological control

**•** Pesticide applications

o broadcast

o host

- targeted

The goal for IPM for tick

- borne diseases is to i ntegrate techniques so as to efficiently lower probability of exposure to pathogen . Research suggests that .25 percent of nymphs are infected. On average mice are bitten by 30 to 2000 ticks each summer. This suggests that it is very difficult to control natural reservoirs. Studies demonstrate that prevention is the most cost effective and BEST way to reduce people being exposed to the pathogen. Ticks have habitat requirements. Good tick habitat is found in thickets, and woody cover.
You will not find ticks in poor habitat like open fields

. Nymphal abundance is related to relative humidity in leaf litter. Canopy cover is also related to nymphal abundance. It is not quite that simple however. Things are happening on a yearly bas is that affects the habitats that ticks are living in. Factors change from year to year that affect tick abundance. You can have a very good tick habitat with a lot of ticks however if you manage the environment so that people are not encountering the tick s you will reduce number of people being bitten. Ixodes scapularis nymphs require:

• moist leaf litter

• typically with forest canopy cover

• appropriate hosts presentPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 7 Landscape features that lower tick abundance and number of tick bites include:

• dry at ground level

• open forest canopy

• appropriate hosts excluded (local? area

- wide?)

• people discouraged or excluded from tick habitat

Crushed rock or woodchip barriers can be very uncomfortable environments for ticks. This can make a huge amount of difference. Fenci ng keeps people out of tick environments rather than discouraging ticks from the area. Paths to separate people from tick habitat

- stone, crushed rock, etc. There will be very few on the path because it is poor habitat. They will avoid it. Paths through th e woods provide little protection from ticks

- clearing off the leaf litter can help. Boardwalks

- these keep people out of tick habitat and ticks will for the most part not go up onto the boardwalk. These are simple ideas that if incorporated properly can m ake a large difference.
**Kirby Stafford, Connecticut Agricultural Experiment Station** There have been a number of approaches to try to manage people’s exposure to ticks and contro l ling the vector to begin with. Tick management includes:

• Personal Protection Measures

• Habitat or landscape modifications

• Biological and natural control

• Area

- wide chemical control

• Host reduction or exclusion

• Host

- targeted acaricides

• Host

- targeted vaccines

Emergence of Lyme disease has been linked to reforestation and suburbanizati on that expose humans to habitat and hosts that favor Ixodes scapularis

. Many studies have linked forest edge (reviewed Killilea et al. 2008) and lower host diversity (LoGiudice et al. 2003, etc.) (favoring deer and white

- footed mice) with the risk of Lyme disease

. Authors examined LD incidence and land

- cover metrics for 12 counties in Maryland. LD (Lyme disease) incidence rate most explained by edge

- contrast index, a measure of forest

- herbaceous edge plus larger percent forest cover. Edge contract index ma y explain Lyme disease Incidence.

Lyme disease risk is linked to peridomestic exposure. Distribution of Ixodes scapularis in the home environment:

• 67.3% woods, 21.6% ecotone, 2% on the lawn

• 82% nymphs are within 3

- m of the lawn edge with woods, stone wall s, ecotone, etc.

Risk linked to peridomestic activity:

• Estimated 75% ticks are picked up outdoors at home

• Indicated activity: Play 47%; Yard work 18%; Gardening 12%; Elsewhere neighborhood 4%

CDC funded a number of studies to declare a war on ticks look ing at pesticides and landscape decisions

. Residential landscape management includes:

**•** Mowing, pruning

**•** Clearing brushPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 8 **•** Restrict groundcover

**•** Leaf litter removal

**•** Landscape barriers

**•** Deer fencing

**•** Deer resistant plantings

Studies indicate that:

**•** Insecticidal soap and silical gel with pyrethrin & PBO provided 78

- 100% control nymphal ticks Pachysandra , sod, stones or woodchips.

**•** Alaska yellow cedar sawdust or woodchips and cellulose acted as barriers to nymphal tick movement, but only the sawdust impeded crossing up to 1 month.
When you incorporate changes like leaf litter removal and landscape barriers you see big results. Essentially, there needs to be a tick zone and a tick safe zone. The tick zone should be cut off using a barrier.

From 1999

- 2002, three CT health districts initiated intensive community

- based intervention programs increase awareness Lyme disease and encourage use prevention measures. Brochure came out

- get your backyard in the zone. A Spanish version was also created. This brochure was targeted tow ards landscape designers. This includes suggestions, methods, etc. Materials are available and n eed wider circulation.
A study was conducted on k nowledge, attitudes, and behaviors regarding Lyme disease p revention in Connecticut r esidents (Gould et al., 20 08). This study considered residents in three CT health districts who were surveyed in 1999, 2002, and 2004. The survey found that:

**•** In WWHD ( Westport Weston Health District ) , use of all environmenta l measures increased from 1999 to 2002 and were sustained as of 2004.

**•** Most respondents willing remove brush or leaf litter (91%) or place wood chip or gravel barriers (82%).

**•** Fewer willing to use deer fences (52%) or spray pesticide (47%).

**•** 44% willing to spend up to $100, 37% spend more than $100.

Another study w as conducted that considered Peridomestic Lyme disease Prevention based on population

- based case

- control (Connally et al., 2009). This study: Examined personal protection, landscape modification, and chemical control in a prospective case

- control study in CT.

• Checking for ticks within 36 hours of time in the yard was protective against LD.

• Bathing within 2 hours of time in the yard was protective.

• Fencing of any type was protective, but mechanism unclear.

• No other landscape modifications (mowing, leaf litte r clearing, presence of playscapes, mulch or gravel barrier) were protective.

• Having stone wall, birdfeeders, vegetable garden, woods adjacent to property made no difference between cases and control (sample size also small in some cases).

NOFA Standards for Organic Land Care create standards to follow. This is the heart of the Organic Land Care Program which:

• Provides a definition of “organic” in land care

• This definition is used for educational purposes (course, public outreach)Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 9 • Also specifies materials and practices that professionals pledge to use in providing organic land care to their clients

The specific tick (pest) management NOFA standards for Organic Land Care include:

• Preferred Tick bite prevention (avoid tick areas, pants in socks, repellents? ) Tick checks to detect and remove before pathogen transmission Environmental modifications (landscape practices) Host management (deer fencing & herbal, soap, human hair as repellents)

• Allowed Biological agents (parasites & pathogens) Diatomaceous earth & insecticidal soaps Botanical insecticides, including plant extracts, such as pyrethrum and minimum

- risk or 25b insecticides ( FIFRA Section 25b), which are exempt federal registration and do not have to demonstrate efficacy

• Prohibited All synthetic insect icides and piperonyl butoxide as an insecticide synergist Any pesticide formulated with any inert ingredient not allowed by the National Organic Program.
This suggests the need for MORE TOOLs.

Invasive plants is a huge issue in and of itself. Lyme disease is very prevalent in areas where barberry is invasive. Charles Lubelczyk and colleagues found a close association of Ixodes scapularis with the type of habitat and plant species. Ticks are associated with exotic vegetation. This research raised a questio n: can you control ticks by removing barberry? The results of the study conducted by Scott Williams and colleagues (2009) demonstrated that:

• Barberry infested 40

- 70% sites and was reduced from 62% of cover to 3% cover by mechanical cutting and burning wit h propane in controlled areas in 3 sites in CT

• Questing adult blacklegged tick abundance greatest in areas Japanese barberry

• Greater abundance larval ticks on mice in barberry

• Larval ticks sig. fewer in 2008 in controlled areas

• Significance difference in t he mean number of larval ticks and the amount of barberry.

• Barberry provides habitat for the host

• Barberry Management

. Questing adult blacklegged tick abundance was greatest in areas with Japanese barberry. This invasive plant provides suitable habitat fo r the tick and rodent hosts. Managing Japanese barberry significantly reduced the density of spirochete infected ticks to nearly 60% of that of unmanaged infestations.

Measures to reduce tick

- borne diseases that fit within an organic or least

- toxic tick m anagement framework include:

• Personal prevention measures and tick checks

• Landscape management practices

• Deer fencing, resistant plantings, and accepted repellentsPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 10 • Pyrethrin insecticides (limited effectiveness w/o PBO) with desiccants and insecticidal so ap

• Biological ( Metarhizium should be an option by 2012)

• Botanical compounds, plant essential oils

• Host

- targeted insecticides much better environmentally, but chemicals used are not organic (permethrin, fipronil). Limited use to date.

**Wink Hastings (Nation al Park Service)**  Projects

- rivers and trails program of the NPS (National Park Service) . We work directly with community groups and non

- profit groups not directly in the parks. I also work for the Chesapeake Bay Program

- we are trying to protect and restor e the quality of the water resource. The main projects I work on are land conservation, watershed management, comprehensive land use plans, and large landscape conservation. With land trusts we are helping them prioritize lands within their service area to best meet the needs and mission of the organization. There is o pportunity to manage pests through land conservation. Cacapon and Lost Rivers Land Trust in West Virginia is an example

- they are trying to use strategic conservation planning. Watershed manag ement is pretty much the same. It is with local governments usually. I have been working on projects in New York State and Maryland. There is opportunity to add additional objectives, purposes etc. to the work being done to address other pest management ne eds.
Invasive species are very problematic particularly in the north east. There are a lot of land managers focused on eliminating invasive . This is an area of opportunity. With comprehensive planning there is a decision making process. Green infrastructu re plans are useful in landscape planning. We try to target areas where the natural resources are important and vulnerable to future growth. The Idea is to protect these areas in the path of growth. Cheverly is developing a green infrastructure plan for th e community. One of their focuses is invasive species management and the reintroduction of natural species. Storm water is a big thing too but we can manage it with vegetation. If we focus on putting in natural cover and remove invasives we can make a diff erence. The BW parkway is another area we are looking at. The most beneficial thing in this conference is that organizers pulled in planners and landscape architects

there is plenty of opportunity to influence the work of landscape designers and landscape planners. I am reminded of what Shunryu Suzuki said, “I in the beginner’s mind
, there are many possibilities, in the expert’s mind there are few. ” I identified a few things I thought would be helpful. Local planning at the county level often does not inclu de environmental or public health factors in making land use decisions.
Very few consider anything beyond the socioeconomic factors with a little bit of the environment when planning land use . There is an opportunity to increase awareness of things like t ick management into the scheme of things. Research is important. It needs to be understandable to practitioners . Messaging is absolutely critical. There are 18 million people living in the Chesapeake Bay watershed

- a majority of these people ( 98% ) do not k now that the quality is affected by what they do. Demonstration projects are a useful tool to use. Green infrastructure is trying to address a whole slew of things

- protecting working lands, agriculture, conservation areas, etc. Ecosystem maintenance

- NPS does not like to talk about controlled burning, but fire management is critical to a lot of invasive species. There is a program called crime prevention through landscape design. This may be a good model to use to create trainings for land use planners an d architects to create landscapes to address ticks. Think outside the box. The Farm Bill provides a lot of funding. Partnerships

- recreational equipment

- have them put a logo on their clothing and products to remind people ticks are out there. ESRI

- has be en designing applications to be used by local planners and non

- profits. National Geographic

- have an article on ticks

- free advertising.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 11 **Panel Discussion** Questions for Consideration:

1. How can we engage the landscape design professions in the prevention of tick

- borne diseases? 2. What is the best way to provide information tick

- borne disease prevention to professional planners and landscape architects? 3. How can landscape design foster both conservation and prevention of tick

- borne diseases?

Laura Jackson

- We nee d to consider large areas as well as small areas like lawns. We need to promote healthier wildli fe to reduce the prevalence of B orellia . Large scale planning is difficult in our culture. However this is imperative.

Terra Rentz

- I want to encourage the invo lvement of state wildlife and fish ery agencies. Urban and suburban hunting programs for deer have been increasing throughout the country. There have been numerous studies that have shown huge impacts to deer and tick populations. Bow hunting takes a lot lo nger to take down target populations. Firearm hunting is more effective in taking down deer. Prescribed burns are a tool to use

- annual burns in habitats where regular fire is appropriate have been shown to reduce tick numbers. Without an annual firing
, h owever , tick populations may increase. Reducing groundcover and leaf litter through firing. When it comes to exclusion devices for wildlife in our environments

- they are great for small scale environments. In large scale environments some of these tools ar e not practicable. We need to encourage people to go outside and we do not want people to fear going into the woods. The more we can become more tech savvy in how we reach out to people the better we can get our message out.

Robert Snieckus

- My eyes have been opened today. We focus on private lands and work on a voluntary basis. With the impact we have on private lands

- we can put this information into technical standards. Professional journals need to start publishing information on landscape planning for ticks. EPA should put links up regarding what partners are doing. Public outreach on the M all. Green roofs on historic buildings. Additional construction phases. Disconnecting our downspouts and putting them into rain gardens. Public awareness and visibil ity is important. EPA needs to do this.

Kendra Briechle

- There are a variety of partnerships we could use

- developers, urban land institute, parks and recreation, trail designers, the Appalachian Trail C onservancy, federal and state agencies. The ways to do this vary

- we can use online outreach and in person outreach. We need to identify the right people and vehicles within organizations to communicate our strategies. It is imperative that we have the right message as well. Design guidelines need to be dis seminated to profess ionals as well. Linking to exis ting efforts

- we talked about invasives, state wildlife action plans

- green infrastructure design

- we need to look at strategic planning and management of open space, working farms and forest, and

conserva tion lands

- there are a variety of scale efforts and there would be great cross over if we link to these efforts

- ex) minimizing edge effect. There might even be an opportunity to protect species. This may help to prevent other species. Training forum or m ore specialized look at this issue would be beneficial

- bring various professions together.

Kevin Sweeney

- We need to decrease exposure. We need to bring this work into government contracting. If we force contractors to address this issue when there is mo ney involved this will provide incentive. There needs to be something done with regards to communication about use of pesticides.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 12 Q&A
Comment Ben Beard ( CDC )

- I wanted to make a point

- the single highest risk group is children from 5

- 8 years of age. W e think a majority of these cases are occurring in back yards. This suggests why mosquito control districts have been less able to tackle this issue. The way habitat is fragmented in suburban areas we cannot just target yards

- we need to get communities to gether. We need to get the message out and provide recommendations for limiting exposure of people to ticks by managing the various reservoirs and behavior.

Question Tom Mather ( URI )

- I keep hearing it would be good to have standards

- who will be charg ed with actually doing this? I was talking with a major developer in several states and they want standards before we reach out to them. We should push towards practical things that should be done and developing standards rather than focusing on rhetoric. Planning needs to consider moving people away from forests. Look at Europe

- their Lyme disease encounters are primarily recreational not peridomestic. Response Howard Ginsberg

- I s there a venue for formal dialogue to happen for planning? This would make a huge difference. Response Wink Hastings

- W e could develop permitted guidelines for developers

- If they have information and guidelines immediately they are very willing to do things. Response Kendra Briechle

- There have been some guidelines regarding landscape planning today

- we should get this information out. We need to connect with the Smart Growth network on this issue. There is an EPA office to help manage this and there are a slew of organizations involved. Response Ellen Stromdahl (U.S. Army )

- Developer

- if I want to develop my undeveloped land, I have to have the landscape engineer and planner to create the plan. I then need to have a developer give me a permit. There is a political process that needs to be considered. There was a landscape plan developed at a conference with EPA and landscape planners etc.

Question Ellen Stromdahl

- Isn’t there a small community in Maine that drew up landscape plans...in the mee ting last year...East Falmouth
, ME? Response Montira Pongsiri

- W as a planner givin g us a primer on land use planning and processes

- we talked about the politics. He based it all on well

- developed science informing where species are in corridors. Just to include this science took a huge effort. This gave us information on what we need to do and what needs to be communicated to the public in order to include this kind of information in the planning process? We have the essential science we need to inform the planning process. With regards to scaling things up this will require more informa tion. We have a community practice on landscaping and community health. We want to make this useful for people to use. We have identified other partners we need to include as part of this discussion.

Question Questioner: Landscape recommendations did not seem to have an impact on the people to receive ticks given the CDC study. How much more do we need to know with regards to the efficacy of these recommendations? Response Kirby Stafford

- O t is very difficult to take studies one step forward and prove im pact on human disease. Lyme disease surveillance increased as a result of community basedPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 13 projects. Lyme disease incidence went up due to this

- in reality however our surveillance became more effective. Trying to demonstrate an impact on Lyme disease itsel f is VERY difficult. Response Ben Beard

- as you increase awareness for tick

- borne diseases

- case numbers increase because people are more involved.

Question a Mindy Block

- C an someone speak more about the fungi used to reduce ticks? Response a Kirby Stafford

- O ne potential approach as an alternative to synthetic pesticides is the use of biopesticides. There are entomopathogenic fungi being looked at. Novozymes is proceeding on developing and marketing a fungi for tick control. They have built a formu lation plant up in Canada. They are still working out some details. They want to have it available this year. It should be available by 2012. Question b David Brassard

- does it work? Response b Kirby Stafford

- it does work. It may not be as effective as a synthetic chemical but it does work.

Question How effective are guinea hens at controlling ticks and have you seen homeowners use them? Response Howard Ginsberg

- They do eat a lot of ticks, only one study has looked at it. Two study sites. In one ther e was no significant difference, in another site, it did lower somewhat the level of ticks. There was no follow

- on so hard to know what happened following year.



### Session IV: **Public Outreach Strategies to Reach Targeted Populations**

Moderators Emily Ziel inski

- Guiterrez, Centers for Disease Control and Prevention Patricia Smith, Lyme Disease Association Panelists Diane Blanchard, Time for Lyme, Inc. Douglas Fearn, Lyme Disease Association of Southern Pennsylvania, Inc. Jennifer Reid, Ridgefield (CT) Healt h Department Kathy White, Lyme Association of Greater Kansas City Katie Kuffner, Chester County (PA) Health Department Anne Kjemtrup, California Department of Public Health

**Pat ricia**  **Smith (**  **Lyme Disease Association)**  Session questions:

1. What are obstacles y ou encounter to getting the public to adopt tick prevention measures (especially IPM) and how do you overcome them? 2. In this era of fiscal constraints, what gives your program “bang for the buck”? 3. What does your program offer that advances the national fi ght against tick

- borne diseases?Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 14 **Diane Blanchard (Time for Lyme, Inc.)** I want to give you a synopsis of what we have done. We created an in school curriculum

- we began in 1998

- there was not a lot of information targeted towards kids. We were being call ed into schools to explain to kids what ticks look like, where you can get them, and what to do if you receive them. We went to the school board and asked to develop an in school curriculum for a more global approach. We spent 2 years developing the curric ulum for the schools to include in their health classes. We are proud of the outcome. We have four individual curriculum books for each grade we targeted (K, 3, 6, 9) we want to promote student knowledge and skills regarding tick bite prevention and what t o do when a tick is found. These kids go home and bring the information back that they learn at school. They ask their parents to do nightly tick checks etc. In 6 th and 9 th grade we step up the learning. We address the symptoms, treatment, disease progress ion etc. We have videos for these programs. We use a CDC video that we cut down to a 20 minute segment. In 9 th grade we have another video called living the Lyme life

we watch students go through the disease, talk to doctors etc. We have been successful i n getting the program out. We have about 450 packets that have been distributed. With each curriculum comes four binders. They include instructional material, assessments, take home materials. We also provide a nurses packet. If they feel a child is at ris k for Lyme
, they call the parent and discuss the issue with the parents. We are partnering with the Red Cross. This has allowed us to target the message to kids. The challenges of the program are getting it out there. It is a competitive field to create cu rriculum for the health and safety field. It is important to discuss with children risks of contracting tick

- borne pathogens.
**Douglas Fearn ( Lyme Disease**  **Association of South ern Pennsylvania**  **, Inc.)** W e developed our organization with people who have had Ly me disease or people who had family members impacted. We had a very good core group of people with different experience s . We decided to focus on public education. I wrote a booklet preceding this group because I became tired telling people the same thing o ver and over. I believe in doing something once and having it continue to work so this is why we developed the pamphlet. We partnered wi th the Chester County H ealth D ept. and Pennsylvania Farm B ureau to form an organization with goals similar to ours. We p ooled resources and did a survey among Pennsylvania Farm Bureau members (3200 people with a 10% response rate) and we got a lot of valuable information. 20 to 30 percent of people had personal experience with Lyme disease . We also learned that although peo ple were knowledgeable about how they get Lyme disease they did NOT engage in prevention measures. Only about 10% were engaging in prevention. We need to motivate people to take prevention m easures

- how do you do this? In 2010
, we did over 200 presentation s to:

**•** Local townships and public meetings,

**•** Public and private schools

**•** Service organizations

**•** Farming organizations

**•** Environmental groups

**•** Parks nature centers,

**•** Conservations groups

**•** Libraries, churches health fairs, boy scouts, community events,

Almost ever y event we do, leads to additional invitations. We do not have to ask to speak anymore we are invited. We tell people what Lyme disease is, how you get it, prevalence in their area, symptoms, diagnosis and treatment, and try to promote prevention. It is im portant to scare people a little bit to get them to listen to your prevention programs.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 15 **Jennifer Reid (Ridgefield (CT) Health Department)**  Community Coordinator for BLAST Tick

- B orne Diseases program for the Ridgefield (CT) Health Department. This was creat ed in 2008 with the help of a startup grant. The grant allows BLAST to develop materials that can be used for outreach anywhere. Collaboration is the hallmark of our program. Collaboration needs to occur between research ers and the community. We need to kn ow how to avoid tick encounters, remove ticks, and detect ticks quickly. We try to listen carefully to people. Our message is short and easy to understand to reach a wide audience. We try to make things fun to attract people to our booth at events we go to . Program attendees regularly say that they thought they knew about ticks but after the program realize there was a lot that they had not known. We need to encourage people that these are diseases that they are worth preventing. BLAST program materials are available free on the website. The town of Richfield has an active tick task force. We use free marketing opportunities. Our community Prevention and Early S ymptom Identification Program is:

**•** Based on science

**•** Health Belief Model

**•** Affordable

**•** Reproducible

**•** Eas y to understand and remember

**•** Maximize marketing opportunities

**•** Make it fun

BLAST is an easy to remember acronym:

**•** B athe or shower soon after coming indoors

**•** L ook for ticks and remove with tweezers

**•** A pply repellents for skin and/or clothing

**•** S pray the peri meter of your yard for ticks

**•** T reat your pets
Our display is consistent with bright lime green coloring allowing us to stand out. The acronym is easy to remember. Some people are willing to listen because of their pets. We hold training sessions regularly

. Volunteers include teachers, nurses, business people, etc.
**Kathy White (Lyme Association of Greater Kansas City)** Lyme disease has been reported in all 50 states. Lyme disease is underreported in southern and central
states. Many people are dying from th is. Children and adults are bed

- ridden for years and months before dying from the disease. Most people are getting tick

- borne diseases in the Central and Southern United States from lone star tick s. American Dog ticks also carry some . I work for the Lyme A ssociation of Greater Kansas City. There is not a single symptom of Lyme disease you cannot get from lone star tick bites. We provide education packets to public schools in the Kansas City area. We have done this through grants and donations. Our goal now is to give an education packet to every public school in the state of Kansas and Missouri. We have quite a few schools to reach with this organization. Our packets have a handbook that has information for teachers and nurses. It also contains brochures. It includes the LDA ABCs of Lyme Disease . We have the LDAs Lymer Primer . We also include information for doctors, nurses etc. We have a tick remover in the packet

- it has a narrow v

- shaped slot. We include information on how to remove the tick, what to do wi th the tick, personal prevention, how to make your property safe from ticks. There is a dvd with four programs for different age levels made by the Lyme Disease Association with funding and help from CDC.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 16 **Katie Kuffner ( Chester County**  **(PA) Health Departme**  **nt )**  Chronic Disease and Injury Prevention Division

- We started surveillance of Lyme disease in 1998. Many cases are underreported or misdiagnosed. Some of the programs we have a parallel to what Doug Fearn mentioned. We have been able to partner together a nd provide resources. In 2000, we received funding from CDC to create signs at our county parks. T hese are large signs that we put out in parks . We also provide presentations, attend fairs, community events for outreach strategies. We are working closely

w ith the migrant mushroom farmer’s information on providing education to workers. We have worked with the boy scouts for a public health badge. We work with other local organizations and have tried to train the trainer. We are working with park staff to dis seminate information. We work with camp counselors. The PLAC advisory committee

- we work with them to address the issue. We did a study in 2001 to access people’s attitudes and information regarding Lyme disease . We had the same reaction as Doug’s survey. People know they are at risk but are not engaging in prevention strategies.
**Anne Kjemptrup (**  **California Department of Public Health )**  California represents the west coast tick issues. We do not typically have a lot of peridomestic exposure. We have wide bas ed IPM control for mosquitoes. Local control agencies have been able to add tick control to our mosquito control districts. Our website has a lot of information available and I was asked to showcase this along with our materials available. The principles b ehind our tick

- borne disease
program

- surveillance and science based. We have partnerships with local agencies and legislatively mandated advisory committee providing us valuable input on our education component. We try to identify target populations

- such as physicians, school children, and occupational health program and identify the needs for these programs then develop materials. We try to emphasize the importance of the evaluation of the materials. We then promote the material and share it with people. The tick database is a collection of data on ticks being tested for the Lyme disease pathogen. We tried to add
context

- we have a pdf document with explanation and a map

- with counties so you can see county specific tick data. We are adding GPS data of wh ere the ticks were found. Risk varies by yardage and throughout time. Has this proved useful? It has

- we have promoted it through physician newsletters and helps to improve decisions

- decision support tool.
Q&A
Comment Katie Kuffner

- T he park signs have become very weathered. To deal with this we created low cost signs for the parks who were concerned people would be too fearful and stop visiting.

Comment Judy Anderson ( DEET organization )

- W e had a webinar that was for medical professionals with physi cians

- we had 500 people login to the webinar. It is online and we have had many people to obtain information. So many primary care and emergency room physicians do not know the symptoms as they present. I encourage you to use webinars as an approach.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 17 Comment Karen Daughty ( Richfield
, Connecticut )

- I t is difficult to recognize the true nature of this disease. A lot of people have personal experience with this through a family member and these people are willing to do anything to prevent it. On the other hand, we have groups of people who have not had contact with this and they are not willing to try to prevent this. We need to target physicians. Response Anne Kjemptrup

- W e do try to target physicians. We need to recognize that this is an ongoing proces s. There are competing diseases. There is no such thing as a program that will answer everything people may need information on. Response Kathy White ( Lyme Association of Kansas City )

- W e have an information booth at a conference of young resident doctors and give them information on Lyme disease . We are trying hard to educate doctors. Response Pat Smith

- We have always thought that one thing Health Departments could do is put out material to physicians registered in their states and let them know that n ot everyone gets an EM rash. There are physicians that do not know that many people do not get EM rashes. Response Anne Kjemptrup

- In

- the California health department , the focus is on awareness and prevention. What we have on diagnosis and treatment is very minimal. We do not want to get in between the patient and physician.

Question Tom Brennan ( EPA )

- I am curious to know your perspective on the science and outreach

are we getting materials back and forth etc.? Response Emily, Zielinski

- Guiterre z ( CDC )

- We do not always put new findings into practice and outreach nearly as quickly as we could or we should. Many times we wait for new evidence and sometimes we wait too long. There is a need for a variety of methods. In the public health sciences w e need to balance between things that are new and offer opportunities and finding our coalitions to get the information across. Response Jennifer Reid ( BLAST )

- W e find that the most simple prevention strategy is bathing or showering after outdoor activi ties. It is easy for people to do and we need to include it in our speeches.

Comment Ben Beard

- T here is a lot of work that needs to be done to educate physicians. On our website, you can link to a physician education CME course that can be taken in Lyme disease . I hear a lot about this physician education issue a lot. Early action is necessary. Recognizing Lyme disease and treating it early is the best way to reduce long last impacts and reduce impact.

Question Jay, EPA

- Is there information about exp eriences or advice given regarding which tick repellent s people have experience with and recommend? Response Pat Smith

- In my talks
, one of the biggest bits of feedback from people is that they want a natural product that they can use. I used a microen capsulated formula on my lawn and it has been effective. Response Thomas Mather

- I think you were talking about repellent s

- Brooke said she had a review she would be happy to share with people. One problem is a lot of this data has not been collected for deer ticks.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 18 Comment Misdirected efforts in resources

- we should spend more time and money on risk reduction rather than diagnosis and treatment because this is a personal issue.

Pat Smith

- organizations like LDA can be the eyes and ears for the gove rnment. We hear things, see things
, etc

. and are in contact with people on the ground. We need to bind together to do something.
Emily Zielinski

- Guiterrez

- W e have a number of differences in what we look at

- but we need to continue to engage with each oth er and find common ground to work together. Barriers to IPM

- crowded environment

- lots calling people’s attention . W e need to engage people in risk perception, counter misperceptions. Low funding is a huge problem. We need to balance the fearfulness that people have. We need to help people prioritize the actions they can do. We need to engage in partnerships and find funding. We need to find efficiencies. We need to find ways to make things happen. We need to use new technological tools. People offer marke ting skills

- we need to make things attractive to consumers, we need to focus on at risk populations, and we need to assess populations through focus groups, needs assessments. We need evaluation due to limited resources and time so let’s make sure what we are doing has an effect. Need to take new research and turn it into programing. Bringing people together on risk reduction and prevention. 

### Day 1 Conclusion
**Brooke Bissinger (Tyra Tech)** Summation of the D ay. What I found as an overarching theme with five components: prevention, education (particularly science based), using new technologies for education, surveillance for tick hosts and ticks, compliance by the public, and communication between groups.
Session I: creating institutional structures

- people d escribed experience

- question do we have enough information to make recommendations to individual control units to make recommendations? The answer is yes. Do we have data to make recommendations? There is a lot of data available, but more data is always u seful. There is a need for communication between different partners and we need to disseminate information more broadly. What research and by whom? What research is necessary? What about the cost? Surveillance is needed. Given the economic climate, funding is an issue. There are some funding opportunities available.
Session II: Children between ages 5 and 9 are at highest risk from tick

- borne diseases. We need to focus on managing people. Social sciences are very important. IPM in schools

- need to work to educate students and lead to better educated adult tax payers. We learned about methods employed in schools. We heard about direct and indirect funding opportunities. There is a need for an inventory of outreach materials that exist. Nurses are a key in de tecting infecting children in schools and disseminating information in schools. There is a disconnect in older students

- we need to remind them these risks are out there and vector borne disease is a serious problem.
Session III: Landscape plays a big role in tick control. Fire regimes can reduce tick pops if done annually. Creating tick zones, and barriers can be effective. 75% of ticks people pick up are likely from their yard. We need to design guidelines for professionals. We need communication between researchers and lawn

care professionals. Conservation biology is used to protect species, can it be used to prevent species?
Session IV: Many different forums can be used to reach people

- health fairs, booths, seminars, conferences, community meetings etc. Public needs to recognize the seriousness of the problem. Lyme disease curriculum available to schools. Blast program gives us an excellent acronym. Multi

- lingualPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 19 programs are important. We need to look at the risk and benefit to humans. Social science to ols are important. How do you motivate people even if they are aware that using risk reduction methods are imperative ? 

### Introduction Day 2
**Chris Zarba (EPA**

**- Office of Research and Development**  **)** T he goals of the meeting are to develop a broad strategy, identif y research priorities, and develop partnerships. We are identifying who may be good candidates for filling out our outline. We are exploring options for putting the docume nt from the conference up so it is accessible to conference participants. We are look ing at Google docs. Hopefully people will take lead and help in the development of the report. We will draft a first draft; distribute it to individuals registered for the conference and work to finalize the document. It is more powerful to have a broad co nsensus to move this forward. We can have people working on different aspects of the strategy. There will be different projects and proposals that different organizations can do. It is time for EPA to step up and do its part. If we work together our chance for success is much more likely. Within 9 months to a year we will have a proposal that is fund ready.



### Session V: **Protecting Outdoor Workers Exposed to Ticks**

Moderator Tom Delaney, the Professional Landcare Network (PLANET) Panelists Brenda Jackslitsch , National Institute for Occupational Safety and Health (NIOSH) Rob Harrison, Orkin, Inc. David Brassard, U.S. EPA Sarah Fletcher, Sterling Family Practice Jim Fredericks, National Pest Management Association (NPMA)

**Tom Delaney (Professional Landcare Ne twork (PLANET))**  Topic is protecting outdoor workers from exposure to ticks. Our workers are outside and exposed to ticks frequently. PLANET has a diverse membership. Our members design, build, and maintain landscapes. They also do chemical care for lawns and interior scapes. We create and maintain the quality of life in our communities across America. The Tick and Lyme Disease S urvey was done between March and May 2010 as a Zoomerang survey with 102 companies participating. Most answering were companies in our OSHA PLANET

- STARS program which are concerned about safety in the work place. Licensing

- there are different types of licenses

- structural pest control and ornamental and turf work. If you look at the labeling you can determine if something is an orna mental and turf label or structural label. We had a good percentage of people say that their workers encountered ticks. 78% of the companies study said that their workers came in contact with ticks while working in the landscape. The companies saying that their workers came into contact with ticks were then asked if they know about Lyme disease

. While there is a fair number who know about Lyme disease , 32% were not aware and this is concerning. 89% of the companies said they would like to have information t o make their employees aware of the problems associated with ticks and Lyme disease

. There was not a large percentage of companies that treat for ticks and fleas (only 24%) . When this does occur, it is a perimeter pest control service in states that allow for this. Members give monthly publications to their customers. We cannot do a good job if customers do not do their part. We should partner with homeowners. 71% of companies said that they would like to have information to pass on to their customers about Lyme disease

. Members who were more aware of tick issues, were located in states with higher incidences ofPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 20 Lyme disease . Our members want more information and are willing to disseminate information to their customers. We have taken information that NIOSH put together and put it out for members. These were questions we wanted the panel to talk about. Learning from examples is a valuable tool. When we hear about various ways that people are exposed, we can try to pin point behavioral things that should be

av oided in the future. This is similar to pesticide poisoning

- when you learn how someone was exposed, you can determine ways to avoid this exposure.
**Brenda Jacklitsch (N ational Institute for Occupational Safety and Health**  **(NIOSH) )**  Yesterday there was a lot of talk about different groups that are affected by ticks such as children. Today we are talking about outdoor workers. Outdoor workers spend their entire day outside and are in contact with environments with ticks frequently. NIOSH

- part of the Department of Health and Human Services under the CDC. NIOSH is a research agency that provides recommendations. O ccupational S afety and Health Administration is under the D epartment of Labor

- r egulatory.
NIOSH provides various services including:

**•** NIOSH Topic Page s: Occupational safety & health info arranged by subject

**•** Health Hazard Evaluation Program: Investigates potentially hazardous working conditions when requested by employers or employees at no cost

**•** NIOSH Publications: FREE documents & brochures available online or mailed

**•** Databases: Ex. Pocket Guide to Chemical Hazards, etc.

**•** CDC Info: Ask questions and get answers

Tick

- borne diseases at NIOSH are not necessarily a high priority item right now however they do have several people working on this. They have be en working on building up materials for dissemination to workers. We ask that employers provide workers with training on Tick

- borne diseases, transmission, symptoms and prevention before employees go out into the field. We also recommend that employers

enc ourage symptoms and illness reporting by employees. We ask employers to tell workers about the various diseases that ticks transmit, that the ticks that transmit these diseases look like, and the pathogens that cause the illness. We ask that employers focu s on diseases specific to their area. Ticks may have multiple hosts throughout their life cycle. Ticks can regularly be found on deer, small mammals, and birds. People come in contact with ticks when they spend time in wooded or grassy areas where these ot her host animals can be found. We want some simple life cycle information to be communicated to workers. We ask that employers remind workers about when tick season begins. We want them to be careful during these months and ensure that they ar e taking prev entative measures. We ask employers to go through a list of possible symptoms. We ask they tell the workers they may not have all the symptoms but rather only a few. Common symptoms include:

**•** Fever

**•** Fatigue

**•** Headache

**•** Joint pain

**•** Body/muscle aches

**•** RashPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 21 We ask that employers show workers national and state data on Lyme disease

. We ask that workers take charge of protecting their employees by looking into the areas that the workers are in. For example

- eliminating the leaf litter, setting rodent traps, putting up barriers, keep the grass mowed short. We also ask that employers discuss or provide employees with proper clothing and repellent s. This includes:

**•** Long sleeves and long pants

**•** Tucking pants into socks or boots

**•** Light colored clothing for easy tick spotting

**•** Repellent s with >20% DEET for skin

**•** Permethrin for clothing
Employers should provide instructions for appropriate ways to check for and remove ticks. This may include checking skin and clothes daily for ticks, when washing and drying clothes use the hot se tting in the dryer, if a tick is attached use only appropriate removal techniques. The proper removal technique is
to:

**•** Remove the tick as soon as you notice it.

 Use fine

- tipped tweezers to firmly grasp the tick very close to your skin.

 Avoid crushing th e tick’s body.

 With a steady motion, pull the tick’s body away from your skin.

 Do not be alarmed if the tick’s mouthparts remain in the skin, the tick can no longer transmit bacteria.

 Clean your skin with soap & warm H 2 O or alcohol.

NIOSH also has r esources for outdoor workers including laminated cards and various other resources available on the website.
Q&A: Question Jorge Arias

- Do you have these materials only in English or in other languages? Response Brenda

- Right now our materials are in E nglish and in Spanish.

Question Candy Brassard (EPA)

- Is there one particular occupation that you feel has a higher incident rate of tick

- borne diseases? Where should we target as federal partners? Response Brenda

- NIOSH does not have any studies on thi s. I would say anyone out in the woods.

Question Emily CDC

- Are there regular studies NIOSH does regularly? Maybe we could incorporate some questions in surveys to determine where people are exposed, if they have been sick, and if they use repellent

. Re sponse Brenda

- I am not aware of surveillance that we have regarding tick

- borne or vector borne diseases. If we get enough response, we will be able to put this on our agenda.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 22 Question Judy Anderson ( DEET education program )

- I want to suggest to you th at people do not know how to properly apply repellent s. It may be useful for people to be told about this information. A lot of people do not understand how to use repellent s properly. People for whom English is a second language, do not understand that a repellent is different than an insecticide. There are nuances that people in this room need to be mindful of. This is critical. Another point that you mentioned was that for ticks you need about a 20% concentration of DEET. Response Brenda

- T hose are some very good points, and I believe we have some information on repellent application.

Comment Joe Piesman

- There are a lot of studies that have been conducted on occupational exposure. The literature is sprinkled with some of this information how ever ther e is a need for more.

Comment Anne Kjemptrup

- W e have done some studies on U.S. Forest Service and National Park Service workers and some have been put into our report systems. One thing we found was that people who took clothing precautions were more l ikely to receive a tick bite. We think that this is because they are m ore aware of the tick problem.
**Ron Harrison (Orkin , Inc.)**  The way we confront ticks in Orkin is that someone’s child has a tick, a pet has a tick, or people find ticks in their house, people find ticks outside their house. We are faced with risk. What is the risk involved with putting products in a house, outside, and on the pets. Typically if you find ticks inside
, we do some service inside if customers want it. People see the risk of the pesticide application as being greater than the risk of ticks. We have a better time offering a service for ticks in the Northeast however this is not the case in other areas. The frequency of the service is another issue. The once a year service, whic h works, does not fit most PCO’s models. To come in once a year is not lucrative or favorable. To make money, businesses are saying that they want reoccurring service for tick control but it is not needed so we are not doing it.
**Jim Fredericks (National P est Management Association (NPMA))**  This is an exciting time for me. I have spent all of my waking hours thinking about bedbugs so it is nice to talk about something different. Take a look at our website: pestworld.org for the best management practices for bedbugs so please take a look at it.
We conducted an online survey through our members. We represent the professional pest management industry. We use online surveys to take the temperature of our membership and learn more about our members. We had a lot more responses to our bedbug survey than our tick survey. Although there is awareness, it is not a priority and they are not taking precautions.
Nearly all of the workers were coming into contact with ticks. These P est M anagement P rofessionals (PMPs) are outside the homes surveying the property to make recommendations and for treatment purposes. One thing our technicians often encounter is that termites will swarm in the spring so a lot of treatments occur before the swarm. We consider wildlife control tec hnicians. These people are out in the surrounding area and in the transition area. We see that there is a lot of exposure out there.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 23 There are a number of tick

- borne diseases out there but we focused on Lyme disease . We found that most people would like i nformation to provide to their employees. The NPMA prides themselves on educating PMPs so we wanted to determine how best to present educational material to our membership. We have a webinar series we do almost weekly. A great topic would be on protecting yourself from tick

- borne diseases. We usually reach 200 people and up to 500 people. We sell educational materials through our bug store. Things like educational material may be good to put on our bug store. One service we provide to our member companies i s a pre

- printed newsletter that they can customize and send to their customers. A great article for the newsletter would be about preparing yourself for ticks, how to be aware etc. We are well positioned to educate our employees and our
customers.

These e ducational opportunities can go into awareness. We can give recommendations about landscape design, personal protection, and IPM. PMPs are prepared to get the word out about this. A good example is when WNV was all the rage. A number of PCOs did backyard b arrier treatments in yard to reduce the number of mosquitoes biting in the yard. In addition to providing treatments, many PMPs went out and gave IPM recommendations on how people can reduce the problem in their yard and community such as getting rid of st anding water. We try to educate our customers on the service that they need not necessarily the service that they want.
Almost everyone who participated do treat for fleas and ticks (93.33%) . This is indicative of respondents but not necessarily indicativ e of the industry. Many PCOs are not providing this service. We are trying to figure out how this fits into the p rofessional p est m anagement business model. The industry is built on recurring services. We hear that one single well timed application can pro vide treatment for an entire year. This provides a challenge to the PPM business. While this is a challenge, it can be overcome and integrated closely with existing IPM programs and strategies.
Members wanted different educational materials including news letters, website references, and brochures to download and print.
Example: Bed Bug Survey (March 2010) 550 responses. Our response level was very low for this survey. This is indicative of the level awareness and top of mind. If this was a survey about be dbugs we would have gotten a great response. We want to educate workers but we also want to have our clients engaged as well and interested in IPM. We communicate with workers and recommend that technicians change and launder clothes daily. This thinking c omes from pesticide exposure. Showering every day is important to reduce exposure. These recommendations are in place but can be applied to ticks. One area we can do a better job is performing a diligent tick check. We need to teach people how to properly remove ticks. There are many ways to do this and very few are the right way. We need to help people become more aware of the symptoms of tick

- borne illness. We need systems and programs within our member companies to report this to management. All in all w e are in a position to impact community wide IPM. As part of bringing this service, we have a lot of work to do to educate our customers and workers about tick

- borne illness.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 24 Q&A:
Comment Pat Smith

- Assume that when you mention laundering clothes that y ou include putting them in the dryer because this is what kills the ticks. Also, people need to know that when showering, it is typically easier to detect ticks. The ticks do not simply detach. A number of firms have laundry services so that workers can co me back take off their uniforms and have them washed. More and more firms are buying a washer and dryer for the office.

Question Karl Malamud Roam (IR

- 4)

- For protecting your workers, do you have a sense of how many are wearing uniforms with permet h rin in them? Is this something you could recommend? In regard to protecting communities, what do you see the role of government verses the role of individuals in terms of vector protection services? Response Jim

- There are very few if any companies that are u sing permethrin impregnated uniforms right now. There is an opportunity for real collaboration and cooperation. The education piece has a role both from governmental agencies and the private industry. As part of the services that PCOs provide, education is necessary. We need to educate our clients to truly help the situation. We give recommendations on how to help technicians do their job properly, how to detect problems early etc. We could integrate tick prevention in this as well. A piece meal approach to tick management is something that needs to be addressed.

Question Kevin Moran ( Northeast Rep. for Turfgrass Association )

- One of the issues the industry is seeing
, especially in the n ortheast
, is a disconnect between state regulators and the industry. Some states discourage the professional industry from becoming involved. Small cottages surrounded by woodland

- recreational area

- is where they are picking up ticks. It is the structural industry in ant control and termite control that will be in these h omes. We need to work with states to encourage the structural industry to become involved with tick control. It is a peridomestic problem. We hope we get states to encourage industry to train their personnel. Response Jim

- T here has been some confusion wi th our member firms with what types of licensing that they need to do for tick control. There are differences state to state on how this is defined. This is an area we are trying to navigate. This is a new type of service and we need to iron out wrinkles l ike this.

Question Robert Koethe ( EPA Region 1 )

- Customers

- part of what you all do is to inform the customer of what they need rather than what they want. Is there monitoring? Does anyone do any tick drags befor e they determine what is needed? Respon se Jim

- I do not know the answer to your question, I see that as being an effective way to begin this conversation in neighborhoods. We saw this with mosquito control. Companies would go into neighborhoods and lay oviposition traps with their names on it a nd then go through and collect them and talk to the customers about the issue. Tick drags would be an effective way to start getting the conversation going.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 25 Question Robert Koethe ( EPA Region 1 )

- This survey was on ticks and fleas. Was this about pets as well? Response Jim

- Y es. Most questions focused on ticks however. Robert

- An excellent education tool may be the four poster feeding stations. Regardless of how effective they are, they are visible and may be an education tool so people are thinking a bout ticks.

Comment Tom Mathers (URI)

- Pat Smith brought up a nice point and it is not trivial. Back in the day, we check for ticks by checking our head. I was being interviewed a year ago, he said I suppose you recommend everything that people say to d o to prevent ticks. I said I do not. I could recommend it but no one does it. It just adds to the blah blah blah of the message. It is time to shake things up a little bit. Putting DEET on exposed skin

- this message may not be that effective. I am wonderin g why this is effective. I would say 1 out of 100 people may tuck their socks in. This has us thinking more and more about tick repellent clothing aspect. This is something that your industry should endorse. This is a tremendously effective practice. A lit tle known service

- I nsect S hield

- actually has a service for $ 7.95 per item they will take your clothes and treat them. They will go through 70 washes before they need to be treated. This is a cost effective truly protective method that should be used to p rotect PCOs. For almost $ 120 a year, this can be done. One thing I would like to mention is my thoughts on getting people out flagging. It would be a good idea, but it could backfire because they may not be able to find a tick. My tick crew every year is c ollege students. It takes them about a week to really learn to flag for ticks. I wonder if this is the right thing to do. If you have a truly motivated person, this will work. If they go out and do not find anything it may have a deleterious impact. This i s a low yield proposition. If we flag in yards, and we find ticks, people are fighting over each other to see the ticks.

Comment Kent McClure ( Veterinar ian )

- W s you talk about educating people about lawn treatments and protecting themselves. Vets are ta lking to people on a regular basis about fleas and ticks. We provide educational materials to people. As you talk about putting information out, I encourage you to reach out to Vets. Downloadable information would be very valuable. This would be a useful t hing driving people to obtain information. Response Jim

- we try to make a conscience effort to reach out to people who benefit from our educational materials.

Comment Todd Peterson ( EPA )

- You mentioned the thing about customers, they want something,
you r PCOs go out and have to tell them what they really need. We have had a lot of comments about misuse of pesticides and misunderstanding. The industry is out there as a face of this issue. Wouldn’t it be nice we could tell people to watch a video on the is sue before the PCO is going into their yard? It may be helpful for people to be educated before the service is provided. WE see a lot of misuse of products and encourage people to read the label. People do not read the label. Maybe we should be asking peop le to do something different. Response Jim

- We do have a role here and could put out informational videos.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 26 Comment Susan Little

- DEE T education program

- One of the really important things in this whole process is consistent messaging. I would like to place a bit of caution

- we may not want PCOs to directly talk with customers about this rather we should provide them with materials to distribute instead. I would like to follow up with what Tom Mathers said

- it is very difficult to tuck socks in when it is hot outside but it is effective. W e need a toolbox initiative of data that can be used.

Question Craigs Hollinsworth University of Massachusetts

- Comment about tucking your pants into your socks

- Gators are an option.

Question Candy Brassard ( EPA )

- M y question is, do you find the practices for your PCO in tick

- borne endemic areas may be different than the rest of the company. Response Jim

- I do not know for sure. I am willing to speculate and say that yes in New England, Mid

Atlantic

- there is be tter awareness. In areas of the country where awareness about tick

borne illness is greater there will be different practices.

Question Dave Brassard ( EPA )

- I have a question, a couple years ago a product came out called max

force tick bait station. It was like a four poster device for mice. It was a little trap the mice walked in, it fed, and as it walked in their coat is treated with an acaricide. I expected to see this on the shelves of Home Depot. They decided to market it through the PCO community i nstead. My question to NPMA is what went wrong? This product is no longer being marketed because it was a disaster in how it was rolled out. How could this have been rolled out better? Response Jim

- I t is a neat product and was exciting. I am not a market ing person. I do not have expertise on how it could have been done better.

**David Brassard (EPA)** Sarah Fletcher (Family doctor in Sterling, VA)

- There is a disconnect between education and changing behavior.
Q&A Question I heard a discussion about tic ks being inside the home. I understand that ticks do not infest homes with exception of the brown dog tick. I do not understand treating inside the home. Response Ron Harrison

- We see ticks wandering around, migrating towards a house, animals bring them i n. We had three customers saying that they have ticks all over their house and they would like something to happen. Customers do not care about why but they do not want to ticks inside. We know that the ticks are not going to survive but that they are ther e.

Comment One of the best products that people are embracing is permethrin clothing sprays. When I go to the stores, I have been seeing these products less and less. There is something seriously wrong with the marketing of the best products available fo r tick prevention. I do not know how we get the word out there. If a consumer cannot buy a product on the market, how are they going to obtain the product?Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 27 Question Company that makes clothing repellent s

- name and phone number? Response Insect S hield in Greensboro North Carolina.

Question Ed Brandt ( EPA )

- Sarah, we had a conversation beforehand and I would like to elaborate on it. We were talking about tick checks and bathing. Response Sarah

- T hese are typically along clothing lines such as the bra line, panty line. This is where we pull off most of them. Response Tom Mathers

- W e have a product called T ick E ncounter. You can put in the tick you might find and it may suggest areas where you may look. I see dilemmas. Checking for ticks is very importa nt but people do not check themselves in the mirror. They are usually in places where people do not want to look. Messages are lost. We have to really bring it out to people. My former graduate student made this observation because they say it is great for kids but people take showers with their glasses off. We need to qualify information! I keep talking about treated clothing; this is as easy as getting dressed in the morning. We can start a revolution trying to bring about tick control. We need stakeholde r groups that can start to do this sort of thing. PCOs understand these products but do they use them on themselves? We need them to carry these things on in their home lives and to spill over to their neighbors. Groups need to step up and do it to start t he initiative.

Comment Tom Delaney

- 40 to 50 percent of landscapers are Hispanic. In people of color
, it may be more difficult to find ticks and to see rashes. Response Sarah Fletcher

- I work in a free clinic and see a lot of Hispanic workers coming i n very sick. These people do not seek medical care until they are very sick and have to go in.

Question a Carrie Gaudien from Richfield Connecticut

- Who is participating in the survey when you send it out? Is it reaching a secretary and not necessarily going to the right person? People think they know about Lyme disease , even as far as tick removal people say they know how to remove ticks. We need to reeach people on how to properly remove ticks. Response a Tom Delaney, PLANET

- the individuals participa ting were the safety officers. It is tough regarding who the contact person is with a company. Question b Carrie

- would it help to do this at their trade shows or training events? Response b Tom Delaney

- yes

Question Karl Malamud Roam

- T his has to do w ith uniforms and the Armed services. Lesson learned

when you have uniforms, compliance is very high. Phase I

- having people spray clothing; Phase II

- professional spraying services. Professional spraying is more effective. Are we receiving any compensatio n claims for tick related illness? Response Ron Harrison

- W e have not had any. I think people will only change behaviors when they understand the risk. In certain areas of the country, people are not concerned at all. We are working with CDC with these 16 00 properties; our technicians will be protected with treated clothing for this study.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 28 Comment David Gaines

- Permethrin treated clothing is the best way of preventing ticks that I have found in the field. The sprays available to the home consumer can be applied unevenly. They can also be applied unevenly. I wish we could buy products used by the military. These products are more effective and can be applied evenly.

Comment Lindsey McClellan

- People in the industry have discussed economic models being di fficult for one year services . I in our community
, we called a company and had a treatment done in the community. We need to leverage neighborhood groups.

Question Kevin Moran

- H ow do we educate people that they do not need treatment inside the home? Are we going to work on getting outside the home and embrace IPM? Dr. Fletcher

- Where is the medical community going by working with the industry? Response Sarah Fletcher

- D octor s are hesitant to change behavior or change their knowledge base. They do not do these things themselves and they do not tell their patients to do it. Ron Harrison

- we are trying to correlate Lyme disease with ticks. There is a lab in Dallas where if you send them a tick, they can tell you if the tick carries the pathogen. Sarah Flet cher

- Insurance companies no longer pay for the testing. In the past I told patients to save their ticks, and insurance companies stopped paying for testing them.

Comment Jennifer Reid ( BLAST Program )

- A vailability of products

- people ask me where they can find permethrin, DEET, Damminex ® tubes. It is harder and harder to find these items in the store. We need to figure out how to better market them, where to put them into the store, and discuss strategies with retailers.

Question Lisa Torrey ( National Tick

- borne Disease Advocates )

- You talked about workman’s comp

this is an extremely unreliable view. We are still being misdiagnosed. Many tick

- borne diseases are misdiagnosed. Testing is unreliable. My question to you
, Ron , is how many do you have with chronic illness. Response Ron Harrison, Orkin

- Example

- people complaining with back pain from moving mattresses there is a direct correlation here. If we do not have direct correlation, it is difficult to determine.

Comment Emily Zielinski

- CDC

- W e a re working with Ron’s group and will be doing a webinar on tick and mosquito borne disease. This will educate the workers and also help them to share resources. We can share these slides with other groups as well.

Comment Sarah Fletcher

- M en generally h ave a much less severe express than women. This may complicate understanding of how many people have Lyme disease

.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 29 Comment National Center for Lyme disease

- W e are getting workers comp cases. We are finding that workers are not being educated about th e risks. We are negotiating rates for ticks. If you do a program it needs to be affordable for the average citizen and resident. Response Ron Harrison

- E conomics is the bottom line for us. There is a large population that cannot afford our bedbug service; we have to turn a profit. Sometimes we do volunteer work.



### Session VI: **Measuring the Impact of Prevention Strategy**

Moderators Ben Beard, Centers for Disease Control and Prevention Panelists Joseph Piesman, Centers for Disease Control and Prevention Jo shua Smith, Fairfax County Health Department Ellen Stromdahl, U.S. Army Public Health Command Paul Mead, Centers for Disease Control and Prevention
**Ben Beard (CDC)** I want to thank Ed and Candy for organizing the meeting. I have found the sessions very ed ucational. We wanted to focus on data gaps in this session. A few years ago I took part in HHS’s healthy people initiative. Part of this was a 40% reduction of Lyme disease . It was based on the vaccine Lymerix. With this being taken out, a lot of the recom mendations that we have been using are lacking evidence to support their value. I think we can make recommendations on what it makes sense to use. If you can reduce tick populations it is possible to reduce infection however this is an assumption. It costs a lot to go a step further and say that these methods reduce illness. We want to look at these efforts. This session is to look at what is going on and later take a look at new interventions that may be palatable. Our first speaker is Joe Piesman.
**Joe Pi esman**  **(CDC)** A decade ago CDC was engaged in a series of cooperative agreements in Connecticut New Jersey, New York and Massachusetts . The assumption was that the vaccine would have an impact on the disease but it was removed from the market due to commerci al reasons. We are left with antibiotic prophylaxis, tick control, IPM prevention. We have a lot of area wide acaricides on the market that are highly effective including carbaryl, cyfluthrin, fulvalinate, permethrin, deltamethrin etc. can give 68

- 100% con trol of nymphal Ixodes scapularis . In surveys in highly Lyme disease endemic communities

- a majority of homeowners are not willing to use these area wide acaricides. We need to identify other options. The percentage of people using the following prevention measures include:

• Long pants 49.8%

• Cleared Brush 48.6%

• Tick checks 45.7%

• Avoid woods 35.1%

• Pesticide on ground 24.4%

• Fenced property 23.1%

• Tucked pants/sock 18.3%

• Repellents/clothes 14.2%

• Used woodchip/gravel barrier 11.4%

• Vaccine 10.1%

• Pe sticide on Rodents 9.0%Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 30 There are various alternatives to area wide acaricides. Alternatives to area wide acaricides include host removal, host targeted treatments (deer and rodents), least toxic substances (soaps, desiccants, tree extracts), fungal agen ts, and landscape management.
About 20 years ago I gave a lecture at Oregon State University. After my talk

- Everything you want to know about Lyme disease but do not want to ask

- we began a screening program on tree extracts to see what was toxic. What s tood out was the extracts from the Alaska y ellow c edar. The extract we isolated was Nootkatone which is found in Alaska c edar and g rapefruit. This is a 15 carbon ring compound. It is found in citrus rind as well. It is not a common structure in nature but it is a repellent and toxicant to arthropods. In the laboratory, tests show it is highly effective as an acaricide. With Joe Karchesy (chemist at O regon State ) we were able to make a water based formulation that we were able to spray. We loaded backpack sp rayers with nookatone. When sprayed in the field
, this formula had a good knockdown effect. We had g ood populations of ticks in non

- spray areas. We had good knockdown. When we used a high pressure sprayer, we received high amounts of control around 98% for the entire duration of the tick season. When you spray this with a backpack and coat the leaf litter

- you kill the ticks only on the surface which is only about 10%. The ones underneath then avoid the area. Using a higher pressure spray you can kill more ticks in the litter. We found that:

• Natural products such as nootkatone may have a role to play in controlling the vectors of Lyme disease spirochetes

• Backpack spray application kills and/or repels ticks that are at the surface of the leaf litter but tic ks deeper in the leaf litter column are not killed and begin questing after 1

- 2 w ee ks

• High pressure spray kills virtually all the nymphs on forest plots and provides protection for entire nymphal questing season

Nookatone itself is used in the food indust ry and has a low mammalian toxicity. To get it to the homeowners

- the idea was to spray with a backpack, get the quick knock

- down and come back with a spray two weeks later there was effective knock

- down of the tick population. With a backpack sprayer
you need more than one application, likely two.
In association with the group in New Jersey we did an Integrated Tick Management (ITM) project. We did this in Monmouth County
, New Jersey. The pieces of our ITM study in NJ included a 4

- poster project, bait box es for rodents, and a barrier spray. The 4

- poster deer project was baited with corn and the acaricide used to treat the deer was amitraz. M axforce ® bait box es were used to treat rodents . The purpose was to get f ipronil (Frontline ® ) onto rodents. It gives 7 weeks of absolute protection. The idea was to have a bait box, lure the rodents in, and then have them wicked. The bait box was tested by Mark Dolan and Gary and proved effective on Mason Island. It was marketed through the pest control operators by Behr. They discontinued the bait box for commercial reasons. There is interest by other parties to relicense the bait box. We found that control of nymphal ticks was highly successful starting at 58.5% and two years later moving up to 94.3 percent. During phase II , the research team was interested in determining if they can continue the level of control achieved with 3

- pronged approach (barrier spray, 4

- poster, bait boxes) with just one method (4

- poster). We continued with just the 4

- poster. Once we got the tick populati on down, we had huge results fro m the 4

- poster project. Area

- wide acarcides are effective when people feel comfortable using them. Natural products like garlic or nookatone . Control has to be practical and economical. People are willing to spend $ 100 on average. This is a dose of reality. The future of ITM includes area wide acaricides where permitted, host targeted acaricides, host targeted vaccines, natural products, biological control agents, and it must be practical and economical for wide

acce ptance.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 31 Question Mindy Block

- I n the field
, what else did you see with nookatone? W hat else did it kill in the area? Response Joe Piesman

- W e did not do a study on impacts on non

- targeted impacts. This compound is active for a short duration.

Question Jorge Arias

- D o you think that general use of these products by the public will allow for resistance? Response Joe Piesman

- F or I xodes scapularis
, I think this resistance is highly improbable. For cattle ticks we have seen some insecticide resistance bu t these ticks are in an ideal situation to develop resistance.

Question We are embracing biologicals, are they truly working? Response Joe Piesman

- if it was based solely on efficacy we would not be searching for natural products. Area wide acaricides are highly effective. Concern over human health and safety makes these natural products an alternative that people are willing to use. Cost is very important. Nookatone in its current formulation would be highly expensive. We are interested in driving the price down.
**Ellen Stromdahl (U.S. Army Public Health Command)** Tick

- borne disease is an occupational health risk for military personnel. The DOD operates a variety of activities on tick

- borne disease because it is an occupational health risk to soldiers t raining in the field. DOD has been concerned with ticks because it poses a health risk to soldiers in the field and on bases. Military researchers have a long history of work on arthropod vectors of human disease. The earliest work on tick surveillance and on the development of repellents was lead by DOD entomologists, and innovative research and discovery on ticks continues today. Pathogen analysis is one thing that we do. In the public health command region

- North ticks are collected by a variety of method s including tick drags, CO 2 traps, small, medium , and large mammal trapping. Army was involved in the National Scout Jamboree since it was held on their land

- 40,000 scouts plus associated visitors during a 10 day period

last week in July through the first week in August

- every 4 years

. Pre

- Jamboree surveillance to provide background information and track population trends was conducted. We know from previous surveillance and tick biology that A. americanum is the m ajor pest during the Jamboree

. Based on info rmation we can provide threat maps and educational mate rials for use during the event. Targeted control efforts based on previous sur veillance at the jamboree site. Including the 4

- poster deer feeders deployed prior to the Jamboree

.
GIS mapping: There are 70 acres of high threat tick habitat within the Jamboree "Action Areas” that require control. There are 78.5 miles of tree line to be treated in the Jamboree area. Producing a theoretical threat map showing the probability of encountering lone star ticks ( Amblyomma americanum). For example for the National Boy Scout Jamboree

- GIS efforts were used to place prevention equipment like four posters

US A rmy P ublic H ealth C ommand also provides the D o D Human Tick Test Kit Program. This provides tick id. We test several thousand ticks every year from around 100 participating military installations. Results are provided back to the victim and we also try to publish results

.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 32 The Public Health Command has developed a field

- portable device or camera that creates sequ ential images of overlapping depth of field. Then software combines this “stack” of images to produce a totally an ultra high resolution image that remains focuses even as you zoom in on key taxonomical characters

– like goblets in the spiracular plate . You do not lose focus. These images are available for public use online.

The Walter Reed Biosystematics Unit is developing TickMap for ticks internationally

. Has modeling capabilities to predict distribution of ticks. It can also overlay human distribut ion and see problem areas. This includes tick

- borne disease in armed forces members. This can be accessed and you can perform queries to determine disease rates.
The Defense Medical Epidemiology database can be accessed and queries can be conducted to det ermine disease rates.
The Naval Medical Research Center is developing molecular assays for detecting tick

- borne pathogens. They are currently looking at R ickettsia

. Designed elegant assays to sort out rickettsia. Other PCR and primers are also being used. Assays are reliable and easy to use. They have been adopted by military PCR labs and are helping to standardize procedures

. The Naval Medical Research Center conducted a pilot study on “Prevalence and Clinical Characteristics of Infection caused by the N ewly Emerging Pathogen, Rickettsia parkerii, in Adults and Children Presenting to Clinics and Emergency Departments with Acute Febrile Illness.” The main objectives of this pilot study are to survey up to 100 adults and children presenting to participating clinical sites during the usual tick

- borne illness season (March

- October) with acute febrile illness in regions where sporadic Rickettsia parkeri infections have been reported in DOD personnel to determine its rate of occurrence among individuals presen ting with fever with rash or eschar, eschar alone or other illness suspected by the non

- study associated health care provider of being a possible rickettsial infection and to describe their clinical presentations and clinical courses and outcomes. The ini tial phase of the project will take place in the Tidewater region of Virginia at Naval Medical Center Portsmouth and its associated clinics, where the first known cases of human infection with R. parkeri had occurred and the Naval Hospital Jacksonville ca tchment area where R. parkeri has been identified in ticks. The subsequent phases may branch out to other MTFs including but not limited to National Naval Medical Center, Brooke Army Medical Center, Naval Hospital Camp Lejeune, and Naval Branch Health Clin ic Kingsbay.
Many patients presenting to health care facilities with fever of undetermined etiology are misdiagnosed or remain undiagnosed, but it is now recognized that many of these cases can be attributed to a rickettsial infection. The role of R. park eri in such cases has not been defined. Therefore, the key component of the study will be identification of R. parkeri infection through culture and po l yme rase chain reaction (PCR) techniques from participant specimens including blood, swabs from eschars, and punch biopsies (adults only) of eschars and skin rashes. The secondary component will be to describe risk factors for infection and clinical presentation and course of infection. Identifying cases and describing the clinical aspects of R. parkeri infec tions among DoD beneficiaries with illness previously diagnosed as having “fevers and rashes of unknown etiology” will for the first time, better define the role of this emerging pathogen in this population and potentially identify clinical features that d istinguish it from viral and other rickettsial illnesses that may present with fever with or without rash. The epidemiological information obtained from this survey will also have application for training and operational forces with activity associated ris k in endemic areas.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 33 We would like to send human samples into the lab. We would like to produce more convenient system for military documents. It is easier to discover a new pathogen than to associate it with human disease or to establish surveillance. The Armed Forces Pest Management Board w ebsite is full of info. The literature retrieval system has papers. You can order a free DVD on tick identification.
The Army Surgeon General considers permethrin

- treated uniforms one of the most important protective

me asures for Soldiers, and fully endorses permethrin factory treatment. In the past you had to use
spray

. Now uniforms are factory treated with permethrin and eventually use will be universal. In 1980 permethrin was identified as an effective repellent fo r clothing. This is the quality insurance process to ensure the safety and efficacy of treatment. A number of vendors impregnate the clothing. At present Soldiers deploying to combat areas are issued Permethrin Factory

- Treated Flame Resistant Army Combat U niforms (FRACU

- P). This is the new MultiCam uniform and designed for Afghanistan area of operation. This uniform is also pretreated with permethrin.

Question Jerry Lawson ( EPA )

- M y family, wife and daughter, have chronic Lyme. I appreciate the work that the Army is doing. Is any of this making its way to the CDC? Response Ellen Stromdahl

- I am an entomologist, not a physician. Our information does go to CDC. Most of our papers are co

- authored with entomologists in the CDC. We deal with what is in the tic k.

Question Anne Kjemtrump

- Testing ticks when you pull them off

- getting them tested for whatever

possibly for medical decision making. In California
, we do not recommend testing ticks for making medical decisions. Our incidence is so low that this may lead to false positives. I am wondering if any analysis has been done on the utility in testing ticks found on people. We recommend identifying the ticks, which is more indicative if you will be exposed to a pathogen. I think this method creates a false s ense of security or a false sense of risk. Response Ellen Stromdahl

- we test ticks because we send soldiers in the field because they have raised their hands and promise to obey. We use this in our suite of things that physicians can use you determine pot ential Lyme disease

.

Question Pat Smith ( L yme D isease A ssociation)

- Y ou are under Surgeon General? Ellen we are under D o D and part of this is with the Surgeon General. Pat

- I have a concern that although yes there is a crossover we are not getting a lot of information happening on military bases concerning tick

- borne diseases. Who do we go to so we can obtain this information and make it public? Specifically

- what is occurring on military bases as far as prevention efforts, what they are seeing with troo ps disease wise. The public has a right to know. We need this information so in civilian land we have comparable things going on. Response Ellen Stromdhal

- Outside of HIPA information

- MSMR information is free online. Just about everything that can be made public is made public. What is wrong with what you are asking is that when you say military, you expect it to be coordinated. With my human tick test program we have 100 installations and each one works with our program differently. Some programs comply a nd others do not. Everything that is public is made public.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 34 **Joshua Smith (Fairfax County Health Department)** We have a lot of cases of Lyme disease in Fairfax County. I am here to talk about tick and pathogen surveillance that we do. Fairfax County is suburban and peri

- urban with approximately 1,000,000 residents within an area of ~400 square miles. We deal with the vector side in our office. We are trying to do our part to find out what people and know and determine knowledge gaps. Fairfax County spec ifically does tick and pathogen surveillance, community outreach and education, and tries to identify what people know. Our focus was on Lyme disease at first. Our program has expanded and we are looking at other types of ticks we find in the county as wel l as the pathogens. To sample for ticks F airfax County uses CO 2 traps, dragging, flagging, and host examination (of white tailed deer and small mammals). They also visit local vet clinics and animal shelters. Fairfax County does not offer tick testing

serv ices however they do provide a tick identification service. Summary of methods on what we are using to gain information on ticks in the county. W e find a majority of lone star t icks using the id service, trapping, and vets and shelters. We have different m onitoring styles. Timing is very important as well. We have been collecting in the winter. When the temperature is going up to 40 degrees we were still collecting ticks. We want to remind people that even though it is winter time ticks are out there and th ey are active. We do have Lyme disease in the county as well as other pathogens. We did not find any R. rickettsia for Rocky Mountain s potted f ever.
We also conduct community outreach and education efforts. It is always good to get political support behin d you. Every year we have a Lyme Disease Awareness Month. This picture is of us with the Board of Supervisors and they have helped by providing forums as well. We hand out educational materials at every opportunity that we get. We understand that people ar e not always coming to these events. We want people to get our material

- we came up with an idea to make a reference guide that we mailed out to every household in the c ounty. When we had our first draft done, and people sent it back saying it’s too techni cal. We received very good feedback from a variety of people. Even though we know we have a well educated population in Fairfax County , people do not want to come home and read a very technical document. We translated it into Korean and Spanish households as well. At o utreach e vents we occupy kids with tattoos so we can talk to parents.
When we do our surveillance with the ticks we can learn about vector and disease ecology. It is difficult to measure the impact of our outreach strategies. One way to do th is is to conduct a KAP (Knowledge, Attitudes, and Practices) Study. This can be used to find out the level of knowledge about a certain topic in the community. You can then find knowledge gaps and figure out ways to fill in these gaps. It is important to d o and an initial survey then to do a follow up survey. You can then use this to measure response to a specific intervention (e.g., outreach and education), track changes in KAP, and tailor your activities. What we found in our initial survey was that 80 pe rcent of people heard of Lyme disease of this 80 percent 70 percent knew it was tick

- borne disease. We did a subset of 100 people of Spanish ethnicity. We found there was a very significant lack of understanding in the Spanish speaking community. In 2008
, we started a series of ads to try and focus on the Spanish speaking communit y. We have a few S panish speakers on staff and we have someone who can speak Spanish at our events.
We use a combination of surveillance, communication, and creativity. We are hop ing this combination will have a positive impact. This year we put out a clip that was shown in the movie theatre.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 35 Question Lisa Torrey from National Lyme disease Advocates

- I have been receiving more calls from people who are sick with Lyme disease . Th ey go to their physician that they are concerned. The doctors are saying that they do not have to worry that it is not an issue. I think that a lot of compliance will need to be done on the state level. There seems to be a real obstacle with the CSTE

- how much power do you have as a County Health Department with the State Health Department. Response Josh Smith

- W e have a relationship with VDH but we are separate agencies.

**Paul Mead (CDC)** TickNet was established in 2007 to foster coordination among publi c health officials on surveillance, research, education, and prevention of tick

- borne diseases. Collaborators include state and local health departments, CDC DVBD, DPDM & Emerging Infections Program (EIP). Current extramural program goals are to support an d enhance surveillance (ELC) and applied research (EIP). We have developed a number of fliers targeted towards landscape workers and outdoor workers. We have developed a widget on our page that can be used by employers with information on tick checks, repe llent s and other prevention. We are starting some radio spots reminding people that it is tick season. Our current extramural program is a big part of tick net. The money we give to partners and states that support and enhance surveillance we also have gra nts for applied research (EIP). EIP funds grant s for applied research works on food borne illness, meningitis other pathogens, tick

- borne disease etc. Tier 1 ELC states

- these are 14 states with high rates of Lyme disease . We try to give this funding out y early to these states. Tier 2 ELC
states

- these states border states with high rates of Lyme disease and are risk of developing high rates. Tier 3 EIP sites

- Applied research arm

. We have four research projects being done in our EIP sites. Laboratory Surve y (CT, MD, MN, NY)

- Two

- stage survey to evaluate national testing volumes, test type, and rate of positivity among commercial, clinical and state labora tories for 5 tick

- borne diseases. An underreporting study is being conducted in MD, MN, and NY to try and quantify the underreporting of physician diagnosed Lyme disease and to assess medical record coding practices. They are also using active surveillance for RMSP and Erythema m irgrans in Western Tennessee (TN). Active surveillance is to better define the ep idemiology and clinical features of spotted fever group rickettsioses and EM in four West

- Central Tennessee counties.
Another study being conducted is the Lyme and other Tick

- borne Diseases Prevention Study (LTDPS) in CT, MD, and NY. The LTDPS is n ot a pe sticide or IPM trial. It is a randomized, blinded, placebo

- controlled trial to assess the efficacy of a targeted, single, springtime application of a commercially available acaricide. The primary outcome measure is prevention of human illness due to tick

- b orne diseases.
We know that pesticides can kill ticks. A single application of granular deltamethrin reduced nymphal I. scapularis by 95% at 9 days. Even though this is the case, there is a substantial minority of households that use chemical pesticides t o control ticks. For example 29% of 2,400 CT households used chemical pesticides for ticks during the survey year. Only 7% of 900 New England/Mid

- Atlantic households currently use chemical pesticides for ticks. Residential acaricide use has not been shown to reduce tick

borne disease. The assumption is that it probably works. However, this is not necessarily true. If the major source of infection is from people visiting places outside their yard, what they do inside their yard may not actually make a differ ence. If it does not work people should not use it and save money. If it does work however we demonstrate evidence to promote greater usage. We have further impetus for finding safer acaricides or other methods of yard

- based control. If this works, we show that what you do in your yard is important. By being able to tell people what it means in regards to illness will be an important step forward.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 36 The new LTDPS study is recruiting approximately 1600 households in 3 states (NY, CT, MD) through fliers, adver tisements
, and targeted mailings to county residents. The inclusion criteria include households with > or equal to 2 residents, freestanding, private property, lot size of .5 to 5 acres, not within 100 ft of water bodies, and have not been treated in the p revious year. Houses will be randomized to receive treatment. People will not be informed about what they are getting until after the study is over. The applications will be done between May 1 st and June 15 th

. Applications will be applied to the ecotone 10 feet into lawn and 20 feet into brush or wooded areas. We may end up using truck mounted sprayers rather than backpack sprayers. Post

- treatment tick collection and pathogen testing for 10% of properties will occur. Outcome measures include monthly surveys to ascertain tick bites and ticks found on participants and pets; self

- reported tick

- borne disease during study period; and medical record review to validate reported illness.
Q&A Question Pat Smith

- I assume you are using CDC criteria to determine disea se etc.? Response Paul Mead

- No

. W e are using physician diagnosed Tick

- borne disease

. W e verify it with the doctor rather than just the report from the patient.



### Session VII: **Research Strategies**

**Mat Pound** First off

- clear up a few misconceptions. Why cont rol ticks on deer? If we do not have ticks we do not have the disease. The size of the animal has to do with its importance in the lifecycle of the tick. Mice (small mammals)

- larvae feed on small mammals, takes a blood meal, drops to the ground and molts to a nymph. The nymph goes onto a medium size mammal. Takes a blood meal, drops to the ground
, and finds another meal. Once it molts into an adult, females feed on deer. The objective of Host

- targeted control of ticks on deer is p rimarily to prevent the su ccessful feeding of adult ticks on white

- tailed deer to effectively remove them as a source of blood and interrupt the tick life cycle. In addition, control of larval and nymphal ticks increases overall efficacy. Methods of preventing ticks from feeding on deer include depopulation or density reduction of deer herds (capture and transport, dispatch and donate, or immune

- contraception) and anti

- tick vaccines for deer. For chemical control there are systemically active acaricides (which can be topically appli ed, injected, or given through oral application) and topically active acaricides (pyrethroids, formamidines, macrocyclic lactones, organophosphates, phenylpyrazoles, neonicotinoids and possibly others)
My primary job is to develop technology to help APHIS eradicate cattle fever ticks back to where they were in Mexico. They eradicated ticks by treating cattle and horses. The white tail deer population was low due to screw worm fly. They charged me with making sure cattle ticks do not move forward on the bord er. Whole kernel corn as a bait and dosing medium for white

- tailed deer can be used. Corn is a good dosing medium due to deer foraging behavior. Deer require high protein, by feeding them corn, we are not increasing their population densities. If you fed d eer only corn (other than very old deer)
, they will likely die. We used ivermectic

- medicated whole kernel corn mixed with re

- cleaned whole kernel corn. We did medicated bait field trials in the following areas:

• Kerr Wildlife Management Area, Hunt, TX

– Afte r 3 seasons of treatment achieved 92, 93, and 100% control of free

- living adult, nymphal, and larval lone star ticks.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 37 • Fairfield Glade, TN

– White

- tailed deer within a large housing development were fed ivermectin

- medicated corn, and residents were so please d with reduced tick densities that they elected to fund continued treatment of deer after research terminated.

• Apache Ranch, Webb County, TX

– In 1992, an elk herd was selectively fed ivermectin

- medicated corn on this 6,500 acre ranch, and a cattle fever tic k infestation was successfully eradicated for the first time since 1956.

• Catarina Ranch, Webb County, TX

– Beginning in 1996, white

- tailed deer on 22,000 acres of the 40,000 acre ranch were treated with over 22 tons of ivermectin

- medicated corn, and in 1997 a cattle fever tick infestation lasting over 90 years was eradicated for the first time.

Free

- living ticks these are ticks that are NOT on a host. We know that by treating deer you can affect tick populations. In these trials we were looking at cattle fev er ticks and lone star ticks.

We also looked at topical control of ticks using a 10% permethrin on 4

- poster bait stations. 4

- poster deer treatment bait stations are good because we are not applying any pesticide to the environment. Rather we are aiming at primarily adult ticks to break the cycle. The 4

- poster deer treatment bait station trials resulted in:

• Kerr Wildlife Management Area, Hunt, TX

– After 3 seasons of treatment achieved 94, 92, and 88% control of free

- living adult, nymphal, and larval lone sta r ticks using an oily 2% formulation of amitraz.

• USDA Northeast Area

- wide Tick Control Project

– MD, NJ, NY, CT, and RI

– After 5 years of treatment achieved 60 to 82% control (meta

- analysis of 71% for the entire project) of blacklegged ticks using an oily 2 % formulation of amitraz.

• Goddard Space Flight Center, Greenbelt, MD

– After 3 years of treatment, achieved 98% control of free

- living nymphal blacklegged ticks. As a result of this high degree of efficacy, Goddard Space Flight Center elected to expand the treatment area and continue treatments.

The USDA Northeast Area

- wide Tick Control Project results are available

- there are 12 publications from this project. The 2% oil formulation of amitraz was volatile; it is no longer on the market. This formulation is volatile and is no longer used. There is not enough fluid to help transfer amitraz to the deer. We decided to go to a 10% permethrin formulation without a volatile component. This formulation used MUCH better.
There are various different types of poster treatment. One includes cylindrical feed chute deer feeders with ARS 2

- poster treatment adapters. This method coats the side of the neck of the deer. They spread the chemical when they groom so it ends up everywhere. We have seen 97% control of all of the ticks on the deer using the poster methods.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 38 We also did a study on a mitraz collars applied to white

- tailed deer. It is effective in reducing free

- living populations of lone star tick s. We developed an automatic deer collaring device. A deer comes into the device. As it comes in, at initial entry, the device sense and individually identifies previously collared deer and senses the presence of uncollared deer shaped mammals. It has a sensor on it. A child cannot make it fire. It also has a thermometer and rec ords the temperature. Deer run about 104 degrees. It has a needleless agricultural injector on it

- it can detach collars, attach collars, do an immunocontraception shot if the deer walks by. T he device is fully solar driven, made out of steel, 800lbs. It c osts a lot of money! To get around the cost of it, we have made 10 sham devices that are just sheet metal. We put these out in various areas and see the amount of corn that is consumed to target areas where a lot of deer are feeding. Almost every night we can collar deer. The efficacy of host targeted technologies to reduce free living populations of lone star ticks was pretty high.

Interference from n on

- target animals was a huge problem. The most important non

- target animals that interfere with deer treat ments are raccoons, feral hogs, bear, and squirrels. Raccoons are actually an asset because they carry ticks and
, if they feed on the traps
, it ’ s good. Squirrels mess up the corn, bear and feral hogs can mess up the device. To exclude non

- target animals we tried fencing. We use a low fence around the edges of it that is topped with a garden hose and has 3 electric fence wires on it. This excludes feral hogs and raccoons. Permits access by fawns, yearlings, and adult deer. The hog and raccoon excluder fence is 30 ft in diameter. It is not very expensive to implement and places a garden hose at the top so the deer have a visual cue to jump over the fence. We have an abundance of exotic wildlife that have been let loose in Texas. These can also carry ticks.
Q& A
Comment VA D ept

. of G ame and F isheries

- I appreciate you coming up and talking about this. In FFX County we are starting a 4

- poster project. In F airfax C ounty , we have to have authorization before we can use something of this. These programs have costs a nd benefits. They work but they cost money. As wildlife professionals one concern is feeding of wildlife in general. I was reminded yesterday that here in the landscape session. Someone had mentioned not planting foods that attract wildlife in areas

- baiti ng is acutely attractive to wildlife. This is something that we should not be doing. Our wildlife society had a position statement and review done on feeding wildlife. One is on feeding wildlife using corn. I have a picture of a feed site with deer standin g in it in the winter with all these trails going into it. We change the distribution of wildlife when we feed them. There are non

- target impacts

- for instance we do not want to feed raccoons because they carry rabies. In areas with bears we will have a bi g issue. Disease transmission such as tuberculosis is problematic. Feeding stations may maintain diseases in wildlife. I mentioned the habituation of wildlife and damage. This seems like a silver bullet to people but people should be aware of other conside rations.

Question Sam Talbert

- P osters are good to reduce risk presently. Reducing deer populations may be better in long term. Response Mat

- T he studies done have been 2 or 3 year studies. The question is can you knock the populations back then skip a year and do your treatment.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 39 Question Bob Pilgram

- EPA

- we have been working with 4

- poster s for a while. With regards to host organisms

- we were hearing that a lot of the species with adult ticks are raccoons and
op o ssums

- if we are addressing deer o nly, are we truly addressing the problem? Response Mat Pound

- W hen you only treat the deer you are drastically affecting tick populations.



### Session VIII: **Cost Effectiveness of Prevention**

**Martin Meltzer** Cost effectiveness of prevention. The main question here is : W hat is the cost effectiveness of prevention ? Meltzer c ould not find readily accessible published studies on this. If it is not readily accessible it is probably hidden for some good reason. Why is there no answer? There is a lot of missing criti cal data. Standardize terms

- cost effectiveness

- it is very simple it is expressed as dollars per case prevented. I am interested in Lyme disease in HUMANS. Cost per case equals cost of intervention minus the money saved over the number of cases that have been averted through the intervention. Cost effectiveness DOES NOT meant cost savings. We want to know a reasonable cost to pay to prevent one case of Lyme disease in society. We have to determine how much money we should spend. This is subjective. There i s no automatic one standard one size fits all. There is no such thing as must do. Every community and state in the country has a budget crunch. Just because something has cost savings does NOT mean that it is a must do and we should do it. We have to balan ce priorities. We need to consider return. Economics does not automatically make the decision for people. It is part of the decision making process but not the sole criteri ion . You need epidemiology and clinical information. You need to know the cost of th e clinical illness. You need t o understand the interventions and determine effectiveness. We need to consider alternatives ; F or example
, developing packages of interventions. Someone will always ask what that means for the household or tax payer. There is a geographical risk based indicator for Lyme disease . It is difficult to find a state that has not had a case. For an economist

- targeting the approach is the most cost effective method.
We looked at epidemiological data. Risk factors in Chester County , P ennsylvania included age, living in a rural setting, single homes, homes with woods or close to woods, and gardening. We MUST place risk in
context

- if you put out interventions the returns on the investment demonstrate that some people will benefit more t han others. Once you get a clinical case what happens to you? Here are examples

standard rash, arthritis, B ell ’ s palsy, heart block, etc. Probability of outcomes is consistent over time for Lyme disease
, which is surprising. We looked at five years of dat a

- different stages of Lyme disease cost different amounts to treat. This suggests patients and doctors learned how to better manage the disease and focus on the most effective treatments. We know that doctors tended to use lab tests less and less because they became better at identifying it. Productivity loss

- i.e. time at the doctors, out of work, staying home sick etc. For each confirmed L yme disease patient there are about $2,970 in direct medical costs, $4,762 in indirect medical costs, non

- medical cos ts, and productivity lost. The economic burden of LD in the U.S. in year 2000 is $ 184 million which is conservative and an underestimate. These are median values. Not every case will cost this. There is a very wide distribution of costs. We are well

aware that there are cases that are very expensive to treat, and cases that are not very expensive to
treat.
Interventions include vaccination, control of tick hosts, personal protection, and controlling ticks. Decision tree model. Nothing ever works perfectly

- even if you are vaccinated there is a possibility of contracting Lyme disease . Probabilities change which is why you vaccinate. You vaccinate to greatly reduce probabilities. Based on the probability of Lyme disease and cost per person vaccinated the costPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 40 effectiveness results indicate that we should target the vaccine to people who are currently at risk for Lyme disease . Vaccination cost effectiveness has public health policy implications. There is value in targeting by risk of acquiring Lyme disease . The re is also value in increasing probability of correct early diagnosis and successful treatment. However
, the vaccine was pulled off the market.

Interventions to control hosts include control of white

- footed mice and white tailed deer. A 2007 study by Jord an et al, Journal of Medical Entomology suggests that the risk from Lyme disease in humans stays the same despite deer reduction s . With deer eradication
, however
, we see different results.
Protective clothing does work and allow for reduced risk based on a study in CT conducted by Vazquez et al. (2008) in Emerging Infectious Disease s . This study shows that protective clothing provides for a 40% risk reduction, repellent s 2

- % and checking for ticks or spraying the property 0%. Another study conducted by Con nally et al. (2009) in the American Journal of Preventative Medicine had completely different results. Bathing within 2 hrs resulted in 40% risk reduction, repellent s for 41%, checking for ticks 45%, fencing the yard 46%, and spraying/landscaping no effec t. What people get as economist s from this information is that we can expect some impact but cannot obtain a complete elimination of risk.

Also considered self

- medicating applicators. A study conducted by Sonenshine et al (1996) in Medical Vet erinary Ento mology found that this method does work. A different study in 2009 by Brei et al. shows 7 year treatment

- see up to 90% reduction of nymphs on deer. Alternative hosts are a potential problem. This is not necessarily true everywhere. With different ecologie s this information changes. We need tick controlling technologies on hosts and make sure there are not other reservoir hosts. You have to consider interventions for multiple species.

Trouble with all these data

- they are all done well

. W hat is missing is what is the relationship between the reduction in the number of ticks and the number of human cases of tick related disease. If I am to do measure cost effectiveness strategies
, I need more information on this curve. We do have information on vaccination c ost. We do not have cost of large scale community intervention. This tells me a lot on where we are when it comes to introducing this into communities. People’s support for these types of interventions change s over time. People have a change of heart somet imes. Support of community intervention depends on risk perception, the disease, and who you are talking to. We need a large trial in the field that measures effectiveness over time. Effectiveness of intervention is likely not consistent so this should be done over time. It turns out that CDC is about to do a study like this. This is the type of study that is needed for a cost effectiveness analysis.
Q&A Question Bill Meredith

- AMCA president

- I want to make a comment about cost effectiveness

- it

concerns the ability of organized mosquito control programs to work on tick control. We heard from two counties that are well heeled, progressive districts that they have programs. Many programs on the other hand do not have a lot of money and cannot do this. They are struggling to meet their mosquito control districts. We are resource limited. We can do a lot with surveillance and monitoring, treatment, public outreach and education. What we really need is how we can increase resources for organizations that
cannot afford it. Without the increase in resource we are going to be sidelined. I want to challenge and invite EPA and CDC to work with the AMCA to see how we can get more funding to front line control agencies. We do get some support but not enough when it

com es to being out in the field. Let’s see how we can get more funding and leverage current funding. In Delaware 4 years ago we tried to develop a program, once the economyPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 41 went south, it all tanked. Response Martin

- I agree with that. When you consider comm unity control, you need to be very honest with the community about what to expect. You need to understand that what people do and say are different, that you need to manage perceptions, and you need to consider compliance. Ben Beard

- I really liked to hear that, my background is in mosquitos. What I discovered is that mosquito borne and tick

- borne disease people do not go to the same meetings. I welcome the offer that AMCA may be interested in this. If we have community investment in this, we can empower mo squito control districts to help us work towards this. We need to have conversations an d show the data that will bring community dollars to bring tick control out. Tick

- borne disease in the country cost more than mosquito borne diseases.

Question Bart H oskins

- EPA

- filling this data bucket is going to be difficult. Diagnosis of Lyme disease is so poor. Response Martin

- I am not a clinician but I do delve into the data. If you look at WNV (West Nile virus) and d engue the probability of accurate diagnosis is actually very low. As an economist, I find a lot of similarities between tick

- borne disease and mosquito borne diseases.

Question Kevin Moran

- this cost benefit analysis

- I am very interested in knowing more about what Paul Mead is doing with Orkin. We in industry are being asked by our customers to get involved. If this study with Paul Mead and Orkin works well, we need assistance in getting the industry properly trained to do this on the home level because this is what is being asked of by the custo mer. Response Martin

- I agree. These studies are very hard to run. It is difficult to get compliance over time.



### Session IX: Case Study for Public Health Protection

**Maction Komwa** Studies the approaches in the control of mosquitoes in developing countrie s specifically Uganda and Zambia. The main objectives are: to highlight cost

- effective approaches to reduce mosquito infestations and ensure minimal exposure to humans through the analytical evaluation of mosquit o behavior and control programs; and t o appl y lessons learned from this analytical approach to the control p rogram efforts of Lyme disease s.

Similarities between Malaria & Lyme disease s :

 Both are all transmitted through arthropods (insects or arachnids)

 Ticks and mosquitoes are classified as paras ites

 Transmit diseases to people by blood

- sucking

 Both diseases are strongly influenced by environmental factors

 Both are of important public health parasites to be discussed

 Control of these can be partially attained through the spraying of insecticides or other methods of reducing the insect population such as Environmental ManagementPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 42 Malaria:

**•** Is caused by one of the four types of protozoa and is a major health problem in much of the tropics and subtropics.

**•** It is spread by mosquito bites

**•** The CDC estima tes that there are 300

- 500 million cases of malaria each year and more than 1 million people die from it

**•** Problem is that there is resistance to insecticides. This has led to difficulty in controlling both the rate of infection and spread of the disease.

L yme disease :

**•** Lyme disease is the most common tick

- borne illness in the northern hemisphere

**•** It is caused by the bacterium Borrelia burgdorferi

**•** It is spread by deer tick bites that harbor the bacterium

**•** Just like malaria, if the disease is left undiagnosed th e effects can be devastating for example causing arthritis and neurological symptoms

Public Health Protection in Uganda:

• Malaria is a major public health problem in Uganda

• Accounting for 25

- 40% of all outpatient attendances,

• 9

- 14% of admissions and a cas e fatality rate of 3% in Uganda (Republic of Uganda 2008).

• Strategies recommended for vector management in Uganda are:

• indoor spraying of houses with residual insecticides and

• insecticide

- treated bed nets

• Treatment through the use of anti

- malaria drugs t hough mosquitoes are becoming drug resistant.

Lyme disease and Malaria Control:

 Deer tick often hides in shady moist places

– this is also true with mosquitoes

 Vegetation clearance around homes reduces the infestation of mosquitoes + ticks

 House or yard screening (for mosquitoes, tick identification

 Environmental management

– Target life cycle of both diseases

 Modification of river boundaries, draining swamps, oil application to open water bodies

 Both malaria and Lyme disease s can be treated if diagnosed e arly so see a physician as early as possible

Treatment of Lyme disease and Malaria:

 Treatment of Lyme disease mostly with antibiotics.

 Long term use of anti

- malaria drug or antibiotics for Lyme disease can have the following
consequences:

 Costly

 Inefficie nt and potentially harmful

 Due to drug

- resistant conditions

 What are cost

- effective preventative and control measures being used in malaria control that could be part of lessons to be applied to Lyme disease control?

Environmental management is a strateg y to control Malaria. Understanding the life cycle of the diseases can help in using this tool.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 43 The cost effectiveness of environmental management Roll back malaria in Zambia was studied by Utzinger, et al. 2001). Results indicate that:

 3

- 5 Yrs

 70±95% lo w malaria related mortality, morbidity and incidence rates

 Estimated costs per disability adjusted life year (DALY) averted

 were US$ 524±591.

 Within 20 years

 Estimated 4173 deaths and 161
, 205 malaria attacks.

 Estimated costs per death and malaria attack [US$ 858 and US$22.20 respectively] Community low cost control measures in Uganda:

 Community

- implemented malaria control program

 Tailored strategy to the prevailing ecological & epidemiological conditions

 Understanding the ecological conditions which affe ct & regulate the distribution and abundance of mosquito populations.

 Local priorities depend on local resources in order to have sustainable program (through the support of government agencies).

 Home Management of Malaria

 Providing training of the communi ty members as medicine distributors (travel cost reduction to clinics)

 Distribution of anti

- malarial medicines

 Campaign, and community sensitization to caregivers (Adherence by caregivers, home cleanliness campaign etc.)

 Accessibility of anti

- malarial medi cine in many villages

 “bring appropriate drugs closer to home”

 Availability of anti

- malarial medicine at an affordable price

 Volunteers from the community (Community Medicine Distributors (CMD) are trained

 Normally two are selected per village and trained

 They evaluate and treat febrile children and are provided with ant

- malarial drugs to household care takers

 CMDs report to the nearest Health facility for supplies etc.

 This is part of cost

- effective since household caretakers don’t travel a long distance to seek for emergency treatment

 Risks are minimized (a journey of 5 km to the nearest clinic including poor infrastructure can ultimately reduce preventable conditions and deaths)

Advantages of community low cost control measures:

 Likely to be most effect ive and cost

- effective in areas with high malaria transmission

 Limited health care infrastructure

 Poor access to ant

- malarial treatment

 Communities understand that malaria is the main killer disease therefore becomes excited to participate.

Funding of com munity based control programs:

 National Malaria Control Programme & MoH

 Private Sector in Uganda

 Non

- governmental organizations

 WHO

- Geneva through the Makerere University

 U.S. President’s Malaria InitiativePromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 44  UNICEF

- UNDP

- W orld B ank

- WHO Special Programme fo r Research and Training in Tropical Diseases

Differences between the United States and Uganda:

 The control program of these diseases are scientific, technical activity that requires skilled personnel

 The majority of Ugandans are not well educated compare d to US so this can have different settings

 Availability of local resources will dictate local priorities.

 Funding is a problem and as a result in Uganda most villages rely on community efforts to sustain their programs.

Lessons Learned:

 Considering the s imilarities of the behavior of mosquitoes and ticks behavior employing both prevention interventions combined with alternative low cost strategies can help to reduce malaria and Lyme disease

.  Community efforts in Uganda can be a foundation for further rese arch that could help to develop effective local strategies that can ensure sustainability.

 Historical studies can help to modify strategies to control mosquitoes and likely ticks infestation. Conclusions:

 Ticks, and mosquitoes will continue to be important public health parasites for discussions.

 Effective control measures will not only be measured by the effectiveness of a particular method or combination of methods, but also in the methodology that will ensure sustainability and minimal exposure to humans

.  Community involvement and institutional participation could also strengthen the control

measures.

 Environmental management has a long

- term track record of successful malaria control in a diversity of ecological, epi demiological and socio

- economic setting s.

 Specific control strategies should be developed for specific country conditions

Q&A Question Bill Meredith

- I would like to make a comparison between mosquitoes and ticks. We are in this together and are dealing with vector control issues. We have onl y been trying to address Lyme disease for the past 20 years. Mosquito control we have been at for 150 years. One thing we want to compare between mosquitoes and tick control is to look at what happened before modern mosquito control. There are programs in place to stop Dengue outbreaks or mosquito born disease. We need this for tick

- borne disease.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 45 Question Karl Malamud Roam

- W hat is your experience in areas where incidence of malaria goes up and down? Do people remain engaged? Response Maction

- P ublic support when incidence drops

- what I noticed in Uganda was that yes in the sense that it is not all the people with bed nets. Bed nets require money and for them to have nets for everyone is impossible. To have this for the whole family it difficult. A

ma jority of people do not sleep under bed nets. My research was on a different topic but people were worried about malaria.

Question Karl

- do the interventions become more acceptable over time? Response Maction

- M any people in the community encourage vill agers to participate in the program. The problem is that people want incentives to do things. For example food for work

- they do construction, they get food. People see their children are dying from Malaria

- so they need.

Question Lindsey McLellan from F airfax C ounty VA. Malaria does not have an animal reservoir. It is transmitted between humans and mosquitoes and back to humans. This is one situation where we have a fundamental difference between ticks and mosquitoes. Mosquito control in the keys helped to keep Malaria levels down. We have a tougher problem with Lyme disease . Even though we can stop the disease in people, we still have an animal reservoir. Response Maction

- it was a powerful comment. Thank you.



### Session X: **Summary of Res earch Needs an**  **d Knowledge Gaps**

Discussion Leaders Ben Beard, CDC Karl Malamud

- Roam, IR

- 4 Rutgers University Herbert Bolton, USDA We found that we have a lot of questions to discuss. We hope these will yield take home points.

Ben Beard

- The questions I have had includ e:

1. T here has been some discussion on the need for specific recommendations on preventing Lyme disease , how important is data on creating these recommendations? 2. If we know we are killing ticks and we know it is working, why do we need to go through the
pro cess of documenting cases etc? 3. C an we assume that if we are reducing tick populations, we can assume we are reducing risk to people? It is very hard to receive data on human cases and commu nity trials are very expensive. 4. Another question I have is given th e current portfolio on prevention strategies including personal protective measures, four poster etc. what is showing the largest reduction in human cases? 5. From our T ick N et study we felt the best foot forward was using acarcides. What other things can be brought into community trials? 6. Another question is which of these interventions are likely to be accepted or utilized in communities?Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 46 7. Which of these afford the best cost benefit ratio? People believe there is a risk in using synthetic pesticides but how can we weigh this against prevention? Should we lean more towards zero tolerance? 8. Moving on

- multiple federal partners have done studies on Lyme disease prevention, what activities provide synergistic partnerships? 9. What efforts are being made for c oordin ated efforts? It can be disconcerting that we are doing all these projects but are unaware of what other people are doing

. 10. What are the potential obstacles towards these federal partnerships? These obstacles are not insurmountable but do exist. 11. While age ncies such as ourselves have federal mandates to reduce the impact of Lyme disease
, what else can we do other than a vaccine? 12. Who is responsible for reducing Lyme disease ? Is it individuals, city planners, local public health officials, states?

Karl Mala mud Roam

- Chris Zarba was hoping to receive a document for EPA research. We would like the discussion to help answer the question regarding EPA’s role. We do have people recording everything so let’s have a brainstorming session. If we had someone magical ly handed everyone in this room a million dollars for research projects what would you do? A few elements include

1. W hich interventions work under which circumstances? 2. Given the difficulties in evaluating cost effectiveness formally can we give a rough
ap proximation of what people should be doing? 3. Linking entomological and epidemiological success together

- how do we do this? Inevitably a number of research programs that happen will have entomological outcomes . H ow do we use this to create a robust model f or future studies? 4. The final question I have is do we know enough to make for recommendations that local governments should undertake to control tick

- borne diseases? My answer is I do not think so. I would like to hear what you think. How do we get from p oint a to point b.

Herb ert Bolton

- W e have learned about various techniques and approaches. There is some need for discussion on doing demonstration projects for community IPM. We should evaluate community IPM efforts and see what is working. We need a mu ltidisciplinary approach. We have heard a lot about Lyme disease , however I would like to emphasize that we need to consider all types of tick

- borne diseases. We have different parts of the country represented. Models may be different based on location in the country. We should give some thought to what would go into these research gaps. We heard little fragments and pieces; we need to look at holistic community approaches. I think if we do these kinds of studies we have to look at going back to social scie ntist perspectives on how people obtain knowledge in the best way. Entomologists are not the best people to know how to communicate with the communities at hand. First people acquire knowledge, then they have to change their behavior. We need to better und erstand messages received and changes in behavior ideally leading to a condition change. There are other groups that are going though the same process whether it is with bedbugs, or asthma. Change in knowledge, behavior and then condition. Many things we d o are outputs and activities, however this is a problem for many groups. Even if you have valuable techniques that work, messaging is imperative. We need qualified competent social scientists and community leaders to get messages out. I am working on a fed eral task force. They are trying to develop an asthma disparity zone. Maybe we should have a study where we have a tick

- borne disease zone demonstration project where we get all the people together and try to see what it would take. We would like to provid e an opportunity for discussion and for people to say what they think are research gaps.Promotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 47 Discussion David Gaines, V irginia Department of Health

- I was thinking that as it is pretty evident that Lyme disease is related to landscape ecology and landscape

. I am wondering if it might be worthwhile to increase outreach to schools of landscape architecture about what type of community development would be less prone to Lyme disease . In Virginia
, a lot of the Lyme disease is occurring in new developments. If we c ould get county planners and landscapers to design communities that are less prone to producing large deer, tick and white

- footed mice populations or other reservoir hosts we may have an impact on the disease in the future. Herb
, this might be one type of demonstration project. We may need a different model in this community area. We may need to consider established areas versus

new areas.

Kevin Moran

- If EPA and CDC are looking for guidelines
, education is key. IPM requires education on identifying pests, their habitats, stakeholders, modifying landscapes, and treatment. It appeared to me that one key aspect is the education of the medical community. We need the medical community to be more proactive. There are veterinarians very interested in this subject . Brochures

- maybe we need to change social media about this. People need to know when they are in tick habitat. Maybe if people know, they will engage in personal protective measures. I am wondering if EPA and CDC can work on effective control measures. W e need research guidelines that can be given to industry to educate them on proper guidelines. If we are looking for public money, this is just not there. We heard yesterday that ticks are described as a peridomestic pest. I am not sure if we should focus area wide control measures, maybe we should be spending more on localized smaller scale control efforts. I do think that we can assume that if we reduce the population we will reduce exposure and we will reduce the potential for disease spread. I hope we c an agree on this. I know we want studies on this but we should take this to the bank anyways. It scares me to think about deer birth control. I know Massachusetts looks at archery hunting the same way as they do with rifle hunting. There are very few place s to hunt deer. We need to better educate that area of government. Herb

- one group we did not have here are people from APHIS wildlife research laboratory in Colorado. They have looked closely into birth control methods for deer. We should include them as partners. Kevin

- maybe EPA and CDC can come up with a backyard version of the 4 or 2 poster.
Howard Ginsberg , USGS

- T here has been a lot of discussion in entomological risk factors. We need to target intervention to minimize exposure to ticks. We can comp are a pesticide application with a public education intervention and we can compare but we do not know how targeted either was.
Kathy White , LDA of Greater Kansas City

- T here are a great many lone star ticks causing diseases in Kansas. Rabbits are t he pr imary host of ticks in this part of the country. We may want to have some research directed into how to kill ticks on rabbits.

Todd Peterson , EPA

- I am a plant physiologist. I was looking at the presentation on malaria where we have mosquitoes, humans, a nd disease. However in ticks we have the ticks, humans, disease organisms and the reservoirs. Has CDC been looking at the organism itself? Does anyone understand that organisms enough where they can use the deer population and mitigate the organism itself? Ben Beard

one area that has not been talked about is reservoir targeted vaccines. We are funding a project evaluating reservoir targeted vaccines. We are looking at plot studies there. This is a transmission blocking vaccine. The thought is this could be used. It is modeled after the rabies vaccine. Another thing we didn’t talk about is the use of oral antibiotics. This is parallel to things the USDA was doing with oral ivermectin. One study that we have shows that if you put oral doxycycline baits out us ing these bait box delivery systems, you can protect mice. Ticks feeding on the mice are then sterilized from the spirochete. This works so well we wondered what would happen if we put it out in the field. WePromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 48 discovered when you put this out in plots you c an trap animals, put the bait out, trap them after and you have eliminated B orrelia burgdoferi in the area. This develops concerns over antibiotic resistance. There is a large back and forth that can be waged on this. One thing we thought about was using a reservoir vaccine

- we thought about using the vaccine and antibiotic together at first. Then you can stop using the antibiotic instead of vaccine. This is an overall collaborative effort.

John Carroll , USDA

- Mat Pounds discussed ivermectin

- one concern o ver the fo ur poster is the cost. Using ivermectin would be something that would be less expensive and easier to use. However allowing it to be used

- there is a concern over deer and hunting season. This may be something used in the future. I do not know wh o would tell people to be careful when using it.

Pat Smith , LDA

- I am a firm believer in education. I have spent my life there in one way or another. I firmly believe we should be bombarding people with materials on this issue. We could go through schools and provide them with materials because they are already set up for this. If I had a million dollars to use I would hit upon education. We have a distribution system already in place. I would like to reemphasize this

- if we expect people to be responsible, people’s biggest fear is the risk benefit ratio. I would like to look at alternatives to chemicals that people can use on their properties. From some of the work I have done and we have funded, I know materials are out there. We just need efficacy informa tion on these chemicals. If people are not using highly effective chemicals what is the point. If we have more people using natural products because they are not afraid of them then we will get more use. If we expect to change people’s behaviors

- we need t o present to them that this is serious. We need to make this serious it is hitting a lot of people. The surveillance that we have is terrible. For those of you who do not know a lot about what is happening, the CDC has criteria but the states are not using it. Everyone is using something different to report the numbers. It relates to this because we are not getting an accurate picture of this issue. I hear this from people everywhere from people in official and unofficial position. CSTE (Council of State an d Territorial Epidemiologists) is charged by Congress to do surveillance

- in this time they have changed the definition of this disease twice. They put forth what they feel benefits their state. What benefits their state primarily is money. States do not h ave money. This is what is seen and what a lot of people think. We have to work to change this, surveillance needs to be brought up to speed ; this is an epidemic. Until we convey this message to everyone
, we will not get a behavior change. People do not fe el it is a serious issue.

Carol Parker , EPA

- This has been an incredible conference with a wealth of material. I hope in your targeting efforts in the future you bring forward a lot of what has been discussed. We need to bring communities together. What t hey really want are model plans. I have heard a lot of great things. We should not move away from the efficacy. People want to know what works. You have given us a wealth of resources. People do not want to use pesticides but may be more willing to do so i f they learn they only need one targeted application.
Kathy White , LDA of Greater Kansas City

- I would like to reiterate what Pat Smith said. This is a huge problem and it is very underreported. I have had all sorts of problems due to a tick bite. The repo rted criteria is much too strict and is not counting a lot of us.

Tom Brennan , EPA

- first I will let people on the webinar have final thoughts. Karl has one question and I have brief wrap up.
Webinar questions:
Are some people more susceptible to contract ing Lyme disease when bitten? In other words do preexisting conditions predispose people to contracting Lyme disease ? Ben Beard

- this is about IPM andPromotin g Community IPM to Prevent Tick

- Bo rne Diseases Conference Notes 49 it is not about diagnostics. These are issues that always come up. I think that it does a disservice to g o off the IPM direction.

In c ommunity

- based IPM programs do you provide recommendations for landscaping that will reduce ticks in certain areas? Tom Brennan

- this is part of an integrated approach. We had a session on this.
Have there been fears of proper ty values falling due to ticks in certain areas? Kirby

- I am not aware of any given the extent of the distribution of Lyme disease today, one person’s property is going to have similar risk as another property in the same area if it has similar property. T om Mather

- in Rhode Island we have a million resident s , our estimation of tick distribution about 3⁄4 of residents have a possibility of encountering a tick where they live. I could see it happening in a place initially where Lyme disease first becomes an is sue. I think it could have a short term impact. I do not see it now though because it is such a pervasive problem. Pet owners are spending money that they would not have spent if the tick problem was not there. There are estimates that Lyme disease and ass ociated costs are around 30 million dollars a year in Rhode Island. 

### Conference Wrap Up

**Tom Brennan (EPA)** Thank you to Candy, Raderrio, and Ed. Also help from our colleagues at EPA

- thank you to you as well. Two people who have to the happiest people in th e room

- Kylie and Holly. Rise who set up the webinar. The panelists who have been working for months. The audience

- your participation has been the best part. We charged you to stay on point with IPM and to not drift too far from this and go into diagnosis . I would like to give us all a round of applause. I cannot get away without saying th at today is the first day of baseball season . Today is a fresh start. I was thinking
, even though vector management has been around for as long as baseball we should think of tod ay as a fresh start. On opening day, anything is possible ; as a N ationals fan anything is possible. To move away from that, this is such an important topic.

It is eye

- opening when we consider the number of people who have been impacted. The highest risk
gro up are children of 5 to 9. These illnesses are spreading across the continent. When I get back to the office, I will look at what our group does IPM and school IPM

- we have heard a comment to wrap this into school IPM

- we are trying to be creative about re aching these audiences at the same time. I challenge you to reflect on what your role is and what you can rededicate to yourself on this day. Teamwork and collaboration are very important and huge. We see so many diverse interests, talents, and abilities
, we need to harvest our diversity and get our partners to work together. One way we do this is through our PESP members many of whom are in here and are pushing for IPM. Anyone who liked this meeting should be part of our group. Within f ederal agencies we w ill be huddling together to discuss outreach and education. Look beyond your own organizations and cross lines. Together we will get a lot farther. Thank you for a great meeting and safe travels home.