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The Pennsylvanian’s Ultimate Guide to Ticks

Pennsylvania has the most cases of Lyme disease, an illness transmitted by blacklegged ticks, in the country. Here's what you need to know to prevent and address the infection.


ticks

Tick-borne diseases, particularly Lyme disease, are a major problem in Pennsylvania. Here’s what you need to know. / Photograph courtesy of Getty Images

May is generally a lovely month in the Philly region. It’s not hot or humid enough for us humans to be walking pools of sweat yet (looking forward to you, July). But temps have risen and skies have cleared enough for us to spend our Saturdays enjoying our natural surroundings — sipping Sly Fox lagers at Parks on Tap, taking our pups on hikes through the Wissahickon, or exploring one of the many waterfall-laden trails just a few hours from the city.

Yet May is also when nymphal, or immature, blacklegged ticks start to prowl those same green and wooded spaces. These minuscule buggers are the most likely ticks in Pennsylvania to cause Lyme disease, an often misdiagnosed and controversial illness that has been on the rise over the past 25 years. To wit: From 1991 to 2017, the number of reported cases of Lyme disease in the United States more than quadrupled.

Pennsylvania’s at the epicenter of that increase. In 2017, the year for which the most recent data is available, our state had the most cases in the country — 10,0001, according to Quest Diagnostics. The Philadelphia Department of Public Health (PDPH) is notified of 200 to 300 cases in Philly specifically each year, and underreporting means that number is probably higher. “We know we have had Lyme here for at least the past few decades,” says Dana Perella, acute communicable disease program manager at PDPH, “and we have a lot of it.” So much, in fact, that Lyme may become a significant financial burden for the state. A 2017 study estimated that, “in Pennsylvania, if only confirmed cases are included, [it] could result in an additional healthcare cost of approximately 22 million dollars.”

The state’s taking the issue seriously. In 2014, the Pennsylvania General Assembly passed an act to establish a Lyme and Related Tick-Borne Diseases Task Force that would provide “recommendations related to education and awareness…to improve Pennsylvania’s response to the tick-borne disease burden.” As a result, the Pennsylvania Department of Environmental Protection is conducting a five-year survey of ticks in every county, with a focus this spring and summer on the adult American dog tick, the adult lone star tick, and those pesky blacklegged tick nymphs.

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Ticks are really, really small. / Photograph courtesy of Elizabeth Rementer

Although Pennsylvania has been wrestling with the problem of Lyme disease for decades, the state wasn’t always a hotspot for the infection. In a study published this month, Pennsylvania State University researchers found that the blacklegged tick became more prominent in the state in the ’90s. They linked the growth to the reforestation efforts and climate change dynamics transforming the landscape at the time, and other experts agree. “We have changed the ecology,” says Garth Ehrlich, a Drexel University professor of microbiology and immunology who serves as the executive director of three Research Centers of Excellence in the Institute for Molecular Medicine & Infectious Disease. “We have almost no predators left — no wolves, no coyotes, no bobcats, no pumas. So the white-footed mouse, which is the primary reservoir of [the bacterium that causes Lyme disease], has exploded. There are literally billions of them. And the tick population has exploded to feed on the white-footed mouse. This is coupled with the enormous warming of our region; usually a lot of ticks would die during the winter, but now most of them survive, so they’ve been able to move into places they’ve never lived before and expand their territory. It’s a double whammy.”

As terrifying as all that sounds, we know resilient Pennsylvanians aren’t the type to let a tiny arachnid (ticks have eight legs, like spiders, so they’re not technically insects) scare you away from the outdoors. That’s why we talked to Lyme disease specialists, researchers, and physicians to answer your questions about how to check for ticks, what to do if you get a tick bite, and how you’ll likely be treated if a doc thinks you have the infection.

Prevention

What do blacklegged ticks look like?

The culprits are about the size and shape of a poppy seed. (Last year, the CDC tweeted a photo of a poppy seed muffin with a few ticks on it to illustrate how difficult it can be to tell the difference.) In the Philly area, these nymphal versions of the blacklegged tick, also known as the deer tick, are the most likely to carry Lyme disease, although adult ticks, which are about the size of an apple seed, can be infected with it as well. However, not all ticks spread Lyme disease, so don’t assume you have it just because you’ve been bitten. About 40 to 50 percent of the ticks the PDPH has collected have tested positive for Lyme disease.

Who’s most likely to be bitten? 

Those who are hiking, camping, or doing anything else in forested areas. However, even if you never leave the city limits, you’re at risk, especially if you spend time in parks or in the northwestern or northeastern parts of the city, where there’s more green space. For instance, Dana Perella of PDPH says the agency has seen high rates of Lyme disease for folks who live in Center City. Staffers are conducting extensive interviews to determine why, but the current theory is that these residents are more likely to engage in activities, like outdoor recreation, where they’re coming into contact with ticks.

Perhaps they also tend to be pet owners; a 2017 study from the Maryland Department of Health and Mental Hygiene found those who owned a dog or a cat were twice as likely to find a tick on themselves. (This study surveyed residents of Connecticut, Maryland, and New York, not Pennsylvania.)

How do I prevent tick bites and Lyme disease?

Use insect repellent with a deet concentration of at least 20 percent. (Although deet has gotten a bad rap when it comes to public perception over the years, it’s generally safe and effective as long as you follow the instructions. Hot tip: Don’t ingest it.) For clothing and gear, Perella recommends Permethrin, an EPA-approved spray that repels and sometimes even kills ticks, mosquitoes, and many other insects that come in contact with it for six weeks or six washings after it’s applied.

After you’ve been hiking or park chilling or really doing anything outdoors, take off the clothes you were wearing and throw them in the dryer for 10 minutes. The heat and speed is likely to kill any hangers-on.

Ticks like warm, moist areas with thin skin where they can easily attach, so check your armpits, your groin area, the backs of your knees, in your belly button, behind your ears, and under your hairline for any ticks once you come inside. Even if they’ve attached themselves, it takes at least two days for ticks to transmit Lyme disease, so if you’re able to remove them early (fine-tipped tweezers are the best method), you’re less likely to be infected.

Examine your pets if they’ve been out scampering on the trail with you. The Centers for Disease Control and Prevention recommends checking for ticks in and around their ears, around their tails and eyelids, under their collars and front legs, and between their back legs and toes. And, finally, talk to your veterinarian about tick protection methods.

How do I get rid of a tick?

The Pennsylvania Department of Health and the CDC advise dousing it in alcohol, wrapping it in tape, or flushing it down the toilet.

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Ticks on ticks on ticks. / Photograph courtesy of Elizabeth Rementer

Symptoms

What symptoms will I develop if I’m bitten by a tick with Lyme disease?

In the early stages, Lyme typically shows up as flu-like symptoms — fever, headache, aches and pains — as well as a rash. Some people display the classic bullseye, with dark and light areas, but Abington Hospital infectious disease specialist Joseph Hassey says this trademark pattern doesn’t actually show up all that often. The rash tends to look more like a large red circle and is the size of an orange on average, he says. However, about 20 percent of people with Lyme disease don’t develop any sort of rash.

If you don’t head to a doctor and/or get diagnosed at that time, the disease can progress in a variety of ways. Within two to four weeks, you can get Bell’s palsy, during which a nerve weakens and causes one side of your face to droop. Or you can get heart block, where your heart beats too slowly, producing shortness of breath, weakness, and/or skipped beats and palpitations. Or you can get meningitis (symptoms include headache, fever, and a stiff neck). Or pain that originates in your spinal cord and shoots down an arm or a leg. Or many of those circular rashes. “Usually at that point, somebody’s going to see their doctor because something’s clearly going on,” Hassey says. “When you’re having terrible pain or breathing problems or cardiac issues, it would be very unusual to not see a medical provider at that stage.”

But, if you don’t have the typical symptoms or if your illness gets misdiagnosed, Lyme could then show up weeks to even a year later as arthritis (typically in a knee), memory lapses, or, again, that shooting pain or meningitis. This illustrates the major problem with diagnosing the disease: You can get so many different symptoms, at different times, that simply figuring out you have Lyme can be an uphill battle.

Can’t I just take some kind of blood test to figure it out? 

Yes, but there are caveats. The common Lyme disease tests measure your body’s immune system response to the bacterium that causes Lyme, instead of whether the bacterium is in your blood or not. For people who come in with that early rash, this response may not have even started yet, so the blood tests are typically negative. Ehrlich, the Drexel researcher, also notes that the tests were developed using the strain of the bacterium that was common in the 1970s, and folks can be infected with a variety of different strains now. Plus, he says, blood isn’t the best place to look for the bacterium because it can move into the skin, joints, and nerves. Whole-body imaging tests for Lyme are in development, but they’re not widely available yet.

Treatment

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A paperclip next to adult and nymphal ticks showcases how small ticks actually are. / Photograph courtesy of Elizabeth Rementer

So, if I’m diagnosed with Lyme disease, how do I get better?

If you’re in the early stages of the disease — with the rash, fever, aches, and pains — you’ll likely receive 10 to 14 days of antibiotics. Hassey says the chance of curing the condition if you’re treated appropriately then is 95 percent. If Lyme is further along, doctors might turn to several weeks worth of antibiotics or IV versions.

What if I’ve been told I don’t have Lyme disease but continue to have what I think are Lyme-related symptoms?

Don’t assume it’s Lyme. “I always tell patients that if you put everything into the Lyme basket, you’re going to miss other things,” says Marina Makous, a doctor who runs a private practice in Exton and treats a significant portion of patients with suspected or diagnosed Lyme disease. “If you only have a hammer, everything looks like a nail. While we have to be vigilant and think about it, we also have to be mindful that even people with Lyme can get other illnesses.” For instance, ticks can also pass along babesiosis, a malaria-like disease, or anaplasmosis, which can present with similar symptoms to Lyme disease, like fever and chills.

What if I have been treated for Lyme but continue to have what I think are Lyme-related symptoms? 

Some people do deal with joint pain, sleep disruptions, or other residual effects of the Lyme infection. “I have to explain to people that Lyme infection could be compared to a hurricane,” Makous says. “Even after the hurricane passes, you still have to rebuild all the infrastructure and fix the bridges and the roads and the roofs.” Antibiotics aren’t necessarily the right approach to these issues. (Cue the controversy around Lyme disease; there’s a good summary here.) As always, you should consult your doctor and come up with a treatment plan that works for you.

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