Increasing Threat Seen in Tick-borne Diseases

There is a 10-15% fatality rate in reported cases of Powassan encephalitis, with many survivors suffering long-term neurological damage. Symptoms usually begin suddenly 7-14 days following infection, and include headache, fever, nausea and vomiting, stiff neck, and sleepiness. Later, breathing distress, tremors, confusion, seizures, coma, paralysis, and death can occur.

The illness was discovered in 1958 after a five year old boy from Powassan, Ontario died of severe encephalitis. Between 1958 and 2010 fewer than 60 cases of Powassan encephalitis were reported in North America. In 2011, there were 16 confirmed cases in the United States. Recently, the number of cases reported in upstate New York has increased dramatically.

Rick Ostfeld, a disease ecologist at the Cary Institute of Ecosystem Studies said, “We’ve seen a rise in this rare but serious illness in parts of New York State that are hotspots for Lyme disease. And we suspected it was tied to an increase in black-legged ticks carrying deer tick virus, particularly on the east side of the Hudson River.”

Over the course of a five-year study, researchers assessed more than 13,500 ticks of seven species of ticks in seven counties and proved Mr. Ostfeld’s theory – there was an increase in the number of black-legged ticks carrying deer tick virus in counties east of the Hudson river.

Laura Kramer, a research scientist at the Wadsworth Center, said, “Our findings are consistent with deer tick virus infection rates in people revealed in clinical tests by the New York State Department of Health. Of fourteen individuals testing seropositive for deer tick virus, ten were residents of Westchester, Putnam, or Dutchess counties. Another two were from Albany and Suffolk counties, areas with burgeoning black-legged tick populations.”

Unlike Lyme disease, anaplasmosis, and babesiosis, which take feeding black-legged ticks hours to transmit, deer tick virus transmission can occur in just 15 minutes. This leaves very little “grace period” for removing ticks, and underscores the importance of vigilance in tick hotspots.

Ostfeld concludes, “When patients present with encephalitis symptoms in areas with high levels of Lyme disease, especially during the summer, physicians need to consider Powassan encephalitis. While rare, it’s associated with significant complications. There is no vaccine or specific antiviral therapy, the best strategy remains prevention.”

Knowledge of Powassan encephalitis has grown largely as a result of West Nile virus surveillance. Both are part of the flavivirus group of arboviruses. More extensive arbovirus testing may reveal that deer tick virus is more widespread than previously thought.

Not a Healthy Outlook for HIEs

Some $548 million in the HITECH Act was devoted to offering startup funding to HIEs, which have helped to fill gaps in EHR interoperability. But that money is set to run out by the end of the year. “The health care providers are not willing to pay for the service at the level needed,” said Adler-Milstein. “They don’t see enough value, and that’s because much of it doesn’t accrue to them. It goes to patients and to health insurance companies. The central challenge is that the incentives and the business model are not aligned yet for this to really work.”

In an additional update to the challenges being faced by HIEs, the latest report from the Robert Wood Johnson Foundation (RWJF)  indicates that participation in Operational HIE efforts is low among public health departments, and that public health reports were the least common type of data exchanged:

Test results were the most common type of data exchanged (82% of efforts). The next most  common type was patient summary care records (exchanged in 79% of efforts). Discharge summaries were the most common type of data exchanged from inpatient  settings (66% of efforts) and clinical summaries were the most common type of data  exchanged from ambulatory settings (61% of efforts). Public health reports were the least common type of data exchanged (occurring in only 30% of efforts).

The RWJF report also noted that “The two public health-related stage 1 meaningful use criteria (syndromic surveillance and reportable lab results) were least likely to be supported by the HIE efforts. A small subset of HIE efforts supported all six HIE-related meaningful use functionalities.”

So what will happen in January when the funding runs out? Ideally leaner, more efficient alternatives to HIEs will find an approach that ensures that all stakeholders who benefit from health information exchange pay to support it. “In particular,” said Adler-Millstein and her colleagues, “efforts to exchange health information need to better engage private payers.”

Image Source: Health Information Technology in the United States: Better Information Systems for Better Care, 2013

MERS-CoV Found to be Less Transmissible Than SARS

The study indicated each patient would, on average, infect 0.69 others–so three infected patients would pass the virus on to just two people–as compared with an infection rate of 9.8 per patient for the SARS virus.

From September 2012 to date, the World Health Organization has been informed of a total of 79 laboratory-confirmed cases of infection with MERS-CoV, including 42 deaths. It was reported yesterday that a man in the UK has died from a case of MERS-CoV.

“Given the overall pattern where we’re seeing steady cases, and where we don’t know what the future brings, what we just want to make sure is that we can move as quickly as possible if we need to,” said Keiji Fukuda, the WHO’s assistant director-general for health security and environment, at a briefing in Geneva today. “We’re not in the midst of any acute event right now.”

The WHO plans to convene a committee of experts on July 9th (and again on July 11th if necessary) to decide whether MERS-CoV poses a public health emergency of international concern. The experts gathered for the committee will assess information on the outbreak and advise the WHO on whether it needs to make any further recommendations about the risk posed by the virus.