The limitations of personal protection and public education

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Personal protection measures have long been recommended for the prevention of Lyme disease and other tick-borne diseases. Such measures are typically divided into three categories: behavior modification, repellent use, and prompt removal of attached ticks (White, 1993; see also Table 5.1). Lyme disease prevention and educational programs in endemic areas have stressed the use of such personal protective measures (Dennis, 1995; CDC, 2000), and advice regarding personal protection against tick bites has sometimes been the major focus of Lyme disease prevention efforts on the part of public health officials (Williams et al, 1986; Sigal and Curran, 1991). This advice serves to shift responsibility for

Table 5.1 Personal protection (from White, 1993)

1. Behavior modification

• Wear light-colored clothing

• Tuck long pants into socks

• Conduct frequent clothing checks when outside

• Conduct full-body exam before going to sleep

2. Use repellents

• DEET-based products can be used on skin and clothing to repel ticks

• Permethrin-based products can be used as clothing treatments to kill and repel ticks

3. Promptly remove all feeding ticks with forceps (tweezers) or tick-removal tools

• Apply antiseptic

• Bring tick to health-care provider within 72 hours of removal to discuss whether single-dose doxycycline is appropriate for prophylaxis (Nadelman et al., 2001; Wormser, 2006)

• Contact physician if rash, fever, 'flu-like illness, or unexplained joint pain occurs.

Lyme disease prevention from the governmental health agencies to the individual, in effect minimizing the government's role in actively reducing Lyme disease incidence.

However, reliance on personal protection as the cornerstone of prevention efforts is problematic. While it is likely that strict adherence to personal protection recommendations will reduce an individual's risk of acquiring tick bites, and therefore Lyme disease, there is also convincing evidence on a population level that this strategy does not significantly reduce the overall burden of Lyme disease. The continued rising incidence of Lyme disease in the United States, despite the importance placed on personal protection measures, suggests that either this approach is not very effective or, more likely, that too few individuals are engaging in these practices consistently enough for it to be very effective (Hayes et al., 1999). For example, studies in Westchester County, New York, where Lyme disease has been endemic since 1982 and active public education has been implemented (Williams et al., 1986), show that for the six-year period from 1991 to 1996 there was a significant correlation between Lyme disease cases (as defined by the presence of EM) and the abundance of nymphal ticks (Falco et al, 1999; see Figure 5.6). Similar results were obtained in Connecticut (Stafford et al., 1998), where Lyme disease public education efforts also have been implemented (Herrington et al., 1997). These data suggest that it is the abundance of host-seeking nymphal I. scapularis that determines annual fluctuations in Lyme disease cases, regardless of the public education effort put forth.

While the diligent use of repellents likely reduces the risk of tick bites (Schreck et al, 1986; Stafford, 1989), this measure is not being used extensively by the public (Herrington et al., 1997; Shadick et al., 1997). That conclusion seems to be particularly true of residents in suburban areas where ticks are encountered virtually daily during the spring and summer months, compared to those whose risk of exposure to ticks is occasional, such as through recreational activities. A study in Pennsylvania found that twice as many people took protective measures against tick bites before outdoor employment compared with those who ventured into a yard or other property associated with their home (Smith et al., 2001). Cartter et al. (1989) found that while 90 percent of Connecticut high-school students surveyed believed tick avoidance behavior could prevent Lyme disease, fewer than 50 percent reported practicing any preventive behaviors. Even thorough training in personal protection measures is not always sufficient to prevent Lyme disease if exposure to ticks is on a daily basis. This may be because of the failure of the prevention method, but is more likely due to reduced diligence on the part of the individual (Falco and Daniels, 1993).

Thus, altering public behavior to prevent tick bites has been largely unsuccessful and public education efforts should not be the centerpiece of future Lyme disease prevention plans. Rather, an integrated approach focusing on the source of risk, namely vector ticks, would likely have the greatest chance for success.

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