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right-hand column like this one does at the top

EMERGING TICKBORNE ILLNESSES

infection is more common in the immunocompromised population and secondary opportunistic infections were common in patients who died.4

References 1. Lyme Disease. Data and surveillance. Centers for Disease Control and Prevention. https://www.cdc.gov/lyme/stats/index.html. Published November 13, 2017. Accessed April 9, 2019.

Conclusion

2. Parasites: babesiosis. Centers for Disease Control and Prevention.

Tickborne diseases in the United States will continue to be a significant public health problem, and ongoing expansion of these vectors emphasizes the need for effective prevention methods. Surveillance of expansion of vectors over the past 20 years has shown an overall 277% increase from 69 to 260 counties in highincidence areas for Lyme disease.1 This is likely a surrogate marker for the expansion of other tick populations. Avoidance of tick bites remains the mainstay of prevention, and patients should be educated to use insect repellents as directed. Products with higher percentages of DEET [N,N-diethyl-meta-toluamide] are preferred and are directly applied to exposed skin and clothing. The product label includes details about how and where to apply the repellent, how often to reapply, and how to use it safely on children. For those patients wary of DEET, a newer odorless, nongreasy repellant known as picaridin has been available in the United States since 2005. Created by Bayer from plant extract, picaridin is the best-selling insect repellant in Europe and Australia, is equal in efficacy to DEET, and does not dissolve plastics or other synthetics.The United States Environmental Protection Agency has a website tool14 that provides guidance on which insect repellant is most appropriate based on duration of exposure and which insects it repels, season, and region. Additionally, permethrin products can be applied to clothing and shoes, but not to skin, to kill ticks on contact. It is usually effective through several washings. Patients should be educated to avoid high-risk areas if possible, especially wooded and brushy areas, overgrown grasses, and leaf litter. Hikers and those who enjoy recreational outdoor activities should walk in the center of cleared trails, cover exposed skin (ie, tuck pant legs into socks), and perform thorough tick checks immediately after engaging in outdoor activities to increase likelihood of prompt removal. Clinicians should be comfortable identifying specific tick vectors and be familiar with endemic geographic regions for disease exposure. Prompt recognition and treatment of isolated infection or coinfection with babesiosis, HME, and HGA improves outcomes. Information on other tick-borne infections in the United States, including spotted fever rickettsioses, southern tick-associated rash illnesses, and tickborne viruses (ie, Colorado tick fever, Powassan) is available from the CDC.15 ■

https://www.cdc.gov/parasites/babesiosis/. Published May 24, 2016. Accessed April 9, 2019. 3. Krause PJ, Vannier EG. Babesiosis: microbiology, epidemiology, and pathogenesis. UpToDate website. https://www.uptodate.com/contents/babesiosismicrobiology-epidemiology-and-pathogenesis?search=babesiosis&source= search_result&selectedTitle=3~69&usage_type=default&display_rank=3. Published May 7, 2018. Accessed April 9, 2019. 4. Sexton DJ, McClain MT. Human ehrlichiosis and anaplasmosis. UpToDate website. https://www.uptodate.com/contents/human-ehrlichiosis-andanaplasmosis?search=human ehrlichiosis&source=search_result&selectedTit le=1~150&usage_type=default&display_rank=1. Published August 15, 2016. Accessed April 9, 2019. 5. Snowden J, Simonsen KA. Ehrlichiosis. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2018. 6. Ehrlichiosis: signs and symptoms. Centers for Disease Control and Prevention. https://www.cdc.gov/ehrlichiosis/symptoms/index.html. Updated January 17, 2019. Accessed April 9, 2019. 7. Anaplasmosis: signs and symptoms. Centers for Disease Control and Prevention. https://www.cdc.gov/anaplasmosis/symptoms/index.html. Updated January 11, 2019. Accessed April 9, 2019. 8. Dunn JM, Krause PJ, Davis S, et al. Borrelia burgdorferi promotes the establishment of Babesia microti in the northeastern United States. PLoS ONE. 2014;9(12):e115494. 9. Knapp KL, Rice NA. Human coinfection with Borrelia burgdorferi and Babesia microti in the United States. J Parasitol Res. 2015;2015:587131. 10. Brennan-Krohn T. Nothing new under the sun: detecting Babesia as it reemerges. American Society for Microbiology website. https://www. asm.org/index.php/clinmicro-blog/item/6790-nothing-new-under-the-sundetecting-babesia-as-it-reemerges. Published September 5, 2017. Accessed April 9, 2019. 11. Dumler JS, Choi KS, Garcia-Garcia JC, et al. Human granulocytic anaplasmosis and Anaplasma phagocytophilum. Emerg Infect Dis. 2005; 11(12):1828-1834. 12. Tickborne diseases of the United States: tick bites/prevention. Centers for Disease Control and Prevention. https://www.cdc.gov/ticks/ tickbornediseases/tick-bites-prevention.html. Updated January 10, 2019. Accessed February 9, 2019. 13. Akel T, Mobarakai N. Hematologic manifestations of babesiosis. Ann Clin Microbiol Antimicrob. 2017;16(1):6. 14. Find the repellent that is right for you. United States Environmental

Kimberly Damato, PA-C, is a physician assistant in neurosurgery at Brookdale University Hospital and Medical Center, in Brooklyn, NewYork. Danielle Kruger, PA-C, MS Ed, is an associate professor in the physician assistant program at St. John’s University, in New York City.

Protection Agency. https://www.epa.gov/insect-repellents/find-repellent-rightyou. Updated June 14, 2017. Accessed April 9, 2019. 15. Tickborne diseases of the United States. Centers for Disease Control and Prevention. https://www.cdc.gov/ticks/diseases/index.html. Updated January 10, 2019. Accessed April 9, 2019.

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