13 24 Hours Of Attachment Is An Estimate - Not a Safety Blanket

By now you may have heard the news that the CDC announced that there are over 300,000 estimated cases of Lyme disease in the United States each year.

For many people, this estimate came as a shock, but it really shouldn't be - the CDC itself has stated in the past that reported cases are a fraction of actual case numbers - especially in highly endemic areas - and researchers have also stated a case count of 30,000 was an underestimate.

Many Lyme disease patients and advocacy groups felt vindicated by the announcement, as it confirmed their position that the number of people contracting Lyme disease was always much larger than official numbers which were originally reported. The below chart, for example, was created by Open Eye Pictures, which produced the controversial film on Lyme disease, Under Our Skin:

Click to zoom in for a closer look.

Open Eye Pictures created this chart back in 2011, based on data directly from the CDC but without direct access to the insurance study, patient survey, and other information the CDC used recently to adjust their new estimate to 300,000 annual cases of Lyme disease. As one can see, their estimate managed to come pretty close to the CDC's - if not potentially higher.

With this announcement, news outlets, park rangers, and medical experts began warning the public once again to take proper precautions to prevent tick bites and to do body checks for ticks after being outdoors.

Some are also informing people that if they don't spot a tick right away, not to worry - if a tick is removed properly within 24 hours, it is highly unlikely to transmit any tickborne disease.

While there is truth in that statement, unfortunately it isn't exactly accurate and doesn't cover all kinds of ticks and any tickborne infections they might be carrying.

This chart shows only a small fraction of tickborne infections currently known to be pathogenic to people along with their transmission times (and in some cases, typical attachment times):

Sample of Well-known and Newly Emerging Tickborne Diseases in North America and Europe and Their Estimated Transmission Times

Tickborne Infection	Pathogen	Tick Species	Location	Estimated Transmission Time Upon Attachment
Lyme disease Borreliosis	Borrelia burgdorferi sensu strictu	Ixodes scapularis, Ixodes pacificus	North America	36-48 hrs; 24 hours or more; potentially less
	Borrelia burgdorferi	Ixodes ricinus	Europe	Less than 24 hours
	Borrelia afzelii	Ixodes ricinus	Europe	Less than 24 hours
	Borrelia garinii	Ixodes ricinus	Europe	Less than 24 hours
Tickborne Relapsing Fever	Borrelia miyamotoi	Ixodes scapularis, Ixodes pacificus	North America	unknown
		Ixodes ricinus	Europe	unknown
	Borrelia turicatae	Ornithodoros turciata	North America	30 seconds with a total tick attachment time 15-90 minutes
	Borrelia hermsii	Ornithodoros hermsii	North America	30 seconds with a total tick attachment time 15-90 minutes
Human Monocytic Ehrlichiosis	Ehrlichia chaffeensis	Amblyomma americanum, Ixodes pacificus, possibly Dermacentor variabilis	North America	12 to 24 hours
Human Ewingii Ehrlichiosis	Ehrlichia ewingii	Amblyomma americanum	North America	suspected 12 to 24 hours
Anaplasmosis (formerly HGE)	Anaplasma phagocytophilum (formerly Ehrlichia phagocytophilum)	Ixodes scapularis, Ixodes pacificus, Dermacentor variabilis	North America	12 to 24 hours
Babesiosis	Babesia duncani	Ixodes pacificus	North America	24 to 36 hours
	Babesia divergens	Ixodes ricinus	Europe	24 to 36 hours
	Babesia microti	Ixodes scapularis	North America	24 to 36 hours
Rocky Mountain Spotted Fever	Rickettsia rickettsii	Dermacentor andersoni, Dermacentor variabilis	North America	4 to 6 hours
Q Fever	Coxiella burnetii	Dermacentor andersoni (rare*)	North America	unknown - suspected fast as highly infectious
		Ixodes ricinus, others  (rare*)	Europe	unknown - suspected fast as highly infectious
Powassan Virus or Powassan Encephalitis	Lineage 1 or 2 Flavivirus	Ixodes cookei, Ixodes scapularis	North America	~15 minutes
Heartland Virus	Group V Phlebovirus	Amblyomma americanum	North America	unknown
Tickborne Encephalitis (TBE)	Flaviviridae Flavivirus	Ixodes ricinus	Europe	Within minutes

* Q fever is usually transmitted to people by exposure to contaminated raw dairy products, inhalation of aerosol fluids from pregnant animals, blood transfusions, and in utero. Tickborne infection with Q fever can happen - either through a tick bite or exposure to tick fecal matter - but along with cases of sexual transmission,  this is rare compared to other methods.

There Are Unknowns In Tickborne Disease Transmission Times

Note that in the above chart, some items are marked unknown. This is because - as far as could be determined, no lab animal model transmission studies for that specific organism have been completed.

Incubation research may have been conducted - and this can inform us how long it takes before animals show signs and symptoms of being infected - but it does not inform us how long a tick must be attached before an infection can occur.

For example, the chart above contains information on Borrelia miyamotoi as one causative agent of relapsing fever, but transmission time from a hard-bodied Ixodid tick is currently unknown.

Until recently, it was thought relapsing fever spirochetes only colonize soft-bodied ticks and persist in their salivary glands, where they can transmit infection to blood quickly. But does the same situation apply to all hard-bodied ticks Borrelia miyamotoi colonizes? Is it the organism, or the tick's physiology, or both which determines how quickly Borrelia miyamotoi can be transmitted on average?

Heartland Virus is another example where transmission time is unknown. Heartland Virus is so new, very little is known about it.

Transmission Time Varies Based On Pathogen And Tick Species

Some pathogens are transmitted from a tick to its host in a few minutes - not hours - and so the 24 hour guideline does not apply to them. Relapsing fever organisms and tickborne viruses often fall into this category.

Some pathogens are transmitted more rapidly from one tick than they are from another. In Europe, there is evidence Lyme disease spirochetes are transmitted to their host more rapidly due to Ixodes ricinus' physiology. So if you live in Europe or visit there and get bitten by Ixodes ricinus, if the tick was attached for under 24 hours you are more likely to contract Lyme disease than if you were bitten by an Ixodes tick in North America.

Note, too, that transmission times can be periodically revised based on new data - and if anything, the trend has been demonstrating infection transmission could take place in less time than originally determined.

Overview Of Risk Factors In Tickborne Disease Transmission

What your risk is for contracting particular tickborne infections can vary, depending on:

• The geographic location you were in when you were bitten; 
• The type of tick which has bitten you;
• How recently the tick may have fed on another host;
• How many infectious organisms it has in its salivary glands;
• Whether or not the tick is carrying other pathogens;
• How long the tick has been attached; 
• How the tick has been removed.

Those are risk factors involving the tick. But there are also host factors as well. Different hosts - including humans - have different immune systems and responses to specific tickborne strains of pathogens, and this, too, can determine the outcome of how or even if an infection will occur.

The Bottom Line

So what does the 24 hour guideline mean? It means many tickborne infections are less likely to infect you if a tick has been removed within 24 hours, but it isn't an ironclad guarantee that you won't contract an infection.

The best thing to do, of course, is to prevent ticks from getting on you in the first place. Prevention is key. No ticks means no tick bites, and not having to worry about what kind of tick has bitten you and what disease it might be carrying.

Wear permethrin coated clothes and use DEET spray on exposed skin. Wear pants tucked into socks and long-sleeved shirts and stick to the middle of the trail when hiking.

The second best thing to do is to do a regular tick check outdoors with a friend and not wait until you come home. Brush off any loose ticks, and carefully remove ticks with tweezers or narrow forceps as soon as you find them. Clean the tick bite area and place antibiotic lotion on it, then save the tick(s) you find in a well-sealed container for identification and testing at a tick testing lab.

There is no 100% guarantee that even with early tick removal, you will avoid contracting a tickborne infection. But your odds of getting infected are greatly reduced the sooner you properly remove a tick.


References

Lyme disease. Centers for Disease Control. http://www.cdc.gov/lyme/transmission/index.html Downloaded September 28, 2013.
Lyme disease. Centers for Disease Control. http://www.cdc.gov/features/lymedisease/ Downloaded September 28, 2013.
Piesman J, Mather TN, Sinsky RJ, et al. Duration of tick attachment and Borrelia burgdorferi transmission. J Clin Microbiol. 1987;25:557–8.
Joseph Piesman, Andrias Hojgaard, Protective value of prophylactic antibiotic treatment of tick bite for Lyme disease prevention: An animal model, Ticks and Tick-borne Diseases, Volume 3, Issue 3, June 2012, Pages 193-196.
Kahl O, Janetzki-Mittmann C, Gray JS, Jonas R, Stein J, et al. Risk of infection with Borrelia burgdorferi sensu lato for a host in relation to the duration of nymphal Ixodes ricinus feeding and the method of tick removal. Zentralbl Bakteriol 1998; 287: 41–52.
Leuba-Garcia S, Kramer MD, Wallich R, Gern L. Characterization of Borrelia burgdorferi isolated from different organs of Ixodes ricinus ticks collected in nature. Zbl Bakt 1994; 280: 468–475.
Crippa M, Rais O, Gern L Investigations on the mode and dynamics of transmission and infectivity of Borrelia burgdorferi sensu stricto and Borrelia afzelii in Ixodes ricinus ticks. Vector Borne Zoonotic Dis 2002; 2: 3–9.
Hofhuis A, Herremans T, Notermans DW, Sprong H, Fonville M, et al.  A Prospective Study among Patients Presenting at the General Practitioner with a Tick Bite or Erythema Migrans in the Netherlands. PLoS ONE 2013; 8(5): e64361.
Franc Strle, Jeffrey A. Nelson, Eva Ruzic-Sabljic, Joze Cimperman, Vera Maraspin, Stanka Lotric-Furlan, Yu Cheng, Maria M. Picken, Gordon M. Trenholme, and Roger N. Picken. European Lyme Borreliosis: 231 Culture-Confirmed Cases Involving Patients with Erythema Migrans. Clin Infect Dis. 1996; 23 (1): 61-65.
Davis GE. The endemic relapsing fevers. In: Hull TG, editor. Diseases transmitted from animals to man. Springfield (IL): Charles C Thomas; 1955. pp. 552–565.
Dworkin MS, Schwan TG, Anderson DE, Jr, Borchardt SM. Tick-borne relapsing fever. Infect. Dis. Clin. North Am. 2008; 22:449–468, viii.
Wisconsin Ticks and Tick-borne Diseases, Department of Entomology, University of Wisconsin-Madison http://labs.russell.wisc.edu/wisconsin-ticks/anaplasmosis/ Downloaded September 28, 2013.
Kramer V L, Randolph M P, Hui L T, Irwin W E, Gutierrez A G, Vugia D J. Detection of the agents of human ehrlichioses in ixodid ticks from California. Am J Trop Med Hyg. 1999; 60:62–65.
Piesman J., Hicks T. C., Sinsky R. J., Obiri G. Simultaneous transmission of Borrelia burgdorferi and Babesia microti by individual nymphal Ixodes dammini ticks. J. Clin. Microbiol. 1987; 25:2012–2013.
Piesman J., Spielman A. Human babesiosis on Nantucket Island: prevalence of Babesia microti in ticks. Am. J. Trop. Med. Hyg. 1980; 29:742–746.
Colville, J. L., and D. L. Berryhill. Rocky Mountain Spotted Fever, Handbook of Zoonoses, Mosby, Saint Louis, 2007, Pages 150-154.
Ebel GD, Kramer LD. Short report: duration of tick attachment required for transmission of Powassan virus by deer ticks. AmJTrop Med Hyg. 2004; 6:268–271.
Tickborne Encephalitis Centers for Disease Control & Prevention, 2009.
Lindquist L, et al. Tick-borne encephalitis. Lancet. 2008; 371(9627):1861-71.

This work by Camp Other 
 is licensed under a Creative Commons Attribution- 
NonCommercial-ShareAlike 3.0 Unported License.