Lyme Disease Prevention and Protection Act Status Reports

PUBLIC HEALTH
(410 ILCS 450/) Lyme Disease Prevention and Protection Act.

The Lyme Disease Prevention and Protection Act, also known as the Lauryn Russell Lyme Disease Prevention and Protection Law, went into effect January 1, 2019. The act provided a background on Lyme disease and called for the creation of the Lyme Disease Prevention, Detection, and Outreach Program, and the Lyme Disease Task Force.

(410 ILCS 450/10) Sec. 10. Lyme Disease Prevention, Detection, and Outreach Program.

The act states that:

• The Department of Public Health shall establish a Lyme Disease Prevention, Detection, and Outreach Program. The Department shall continue to study the population of ticks carrying Lyme disease and the number of people infected in Illinois to provide data to the public on the incidence of acute Lyme disease and locations of exposure in Illinois by county. The Department shall partner with the University of Illinois to publish tick identification and testing data on the Department's website and work to expand testing to areas where new human cases are identified. The Department of Public Health shall establish a Lyme Disease Prevention, Detection, and Outreach Program. The Department shall require health care professionals and laboratories to report acute Lyme disease cases within the time frame required under the Control of Communicable Diseases Code to the local health department. To coordinate this program, the Department shall continue to support a vector-borne disease epidemiologist coordinator who is responsible for overseeing the program. The Department shall train local health departments to respond to inquiries from the public.

The Illinois Department of Public Health’s Division of Environmental Health (IDPH EH) Vector Surveillance and Control Program (Vector Program) and the Communicable Disease Control Section (CDCS) Vector-Borne Diseases (VBDs) Program have addressed this directive by conducting the following programmatic activities.

Prior to 2018, the Vector Program primarily conducted tick surveillance through a passive program (i.e., local health departments, clinicians, and citizens could submit ticks to the Vector Program for identification). Although this information is beneficial, it does not provide the geographic specificity or granularity of active tick surveillance data needed to direct public health action. In 2019, the Vector Program developed an active tick surveillance program, which aims to monitor tick presence, abundance, and infection prevalence in medically important ticks to direct public health action and to educate citizens and clinicians of local risks.

The active tick surveillance program began with an intergovernmental agreement (IGA) between the Vector Program and the University of Illinois (U of I) Natural History Survey Medical Entomology Laboratory (INHS MEL). The purpose of the IGA is to conduct targeted tick surveillance in areas of disease foci or outbreak locations, establish sentinel sites for recurring tick surveillance over time, and collect, identify, and test ticks for pathogens of public health concern.

The Vector Program developed a system for selecting counties for active tick surveillance based on the Centers for Disease Control and Prevention (CDC) Tick Surveillance Objectives outlined in its 2019 Surveillance for Ixodes scapularis and pathogens in this tick species in the United States publication. The first two objectives are outlined below and must be met before moving onto other objectives:

• Classify county status for I. scapularis: established, reported, or no data available
• Classify county status for presence of specific pathogens in I. scapularis ticks: present or no data available

In addition to these county statuses for Ixodes scapularis and Borrelia burgdorferi (the causative agent of Lyme disease), the Vector Program also incorporated the five-year human Lyme disease incidence for each county and prioritizes counties that have high numbers of Lyme disease incidence.

The Vector Program coordinates with the INHS MEL each season to reexamine priority counties for surveillance to ensure the most up to date data is utilized for county selection. The INHS MEL then conducts active tick surveillance in the IDPH recommended counties and identifies and tests those ticks for pathogens of public health importance.

The first goal of the active tick surveillance program is to determine what counties have Ixodes scapularis present. For a county to be established, six or more ticks of the same life stage must be found in a 12-month period, or two or more life stages must be found in a 12-month period. For a county to be reported, less than six ticks of the same life stage must be found within a 12-month period. In 2018, Illinois had 37 established counties, six reported counties and 59 counties with no data available. After the 2021 active tick surveillance season, Illinois had 56 established counties, 18 reported counties, and 28 counties with no data available. Figure 1 illustrates the progress of the active tick surveillance program in county status over the past three years. A current distribution map is also included in Attachment 1.

The second goal of the Vector Program’s active tick surveillance is to determine what counties have pathogens of public health concern, specifically Borrelia burgdorferi for the purpose of the act. Prior to 2018, limited research had been done in Illinois to define counties with B. burgdorferi presence. As of 2021, the active tick surveillance program has identified B. burgdorferi from I. scapularis ticks collected from 36 counties (Attachment 2).

Additionally, the Vector Program is not limited to Ixodes scapularis surveillance alone. Tables 1 outlines the ticks that have been collected by the INHS MEL through this active tick surveillance program IGA with the Vector Program.

In March 2020, the Vector Program arranged through its IGA with the INHS MEL for two INHS MEL staff members to travel to CDC Fort Collins, Colorado for tick molecular testing training. The INHS MEL is the only lab in Illinois to have been trained in tick molecular testing by the CDC. The INHS MEL’s testing criteria align with the testing requirements of CDC. Table 2 outlines pathogen testing conducted by INHS MEL as part of the IGA with the Vector Program.

The IDPH EH active tick surveillance program initiative is primarily funded through the Used Tire Fund (Illinois State Special Fund 294). The Vector Program entered into a three-year IGA (IDPH contract #15300002I) with INHS MEL July 1, 2020, with an end date of June 30, 2023. The INHS MEL receives $200,000 each state fiscal year for a total of $600,000 to conduct active tick surveillance activities in Illinois.

Additionally, in FY22, the Vector Program was awarded $65,000 through the CDC Epidemiology and Laboratory Capacity (ELC) Budget Period 3 funding to enhance the active tick surveillance program. The ELC funding was provided through an intergovernmental agreement to the INHS MEL in November 2022. This increased the three-year IGA amount to $665,000 as of June 2022.

In May 2022, the Vector Program applied for CDC ELC Budget Period 4 funding for active tick surveillance and will be notified of a potential award in August 2022.

The Vector Program distributes Vector Surveillance and Control Grants to 97 local health departments through the Comprehensive Health Protection Grant bundle. The vector grants are funded through the Emergency Public Health Fund (Illinois State Special Fund 240). Below are the past five-year funding awards:

• Fiscal Year 2019: $2.8 million
• Fiscal Year 2020: $2.8 million
  
• Fiscal Year 2021: $2.8 million
  
• Fiscal Year 2022: $2.2 million
  
• Fiscal Year 2023: $2.5 million
  

The Vector Surveillance and Control Grants are used primarily to fund West Nile virus surveillance and prevention as specified in the statute (415 ILCS 5/55.6a). However, certified local health departments may utilize up to 20% of their grant award for non-mosquito vectors.

Average 10-year tickborne disease human incidence was calculated by county for the years 2010-2019. Cases were counted based on county of residence at the time of symptom onset. All probable and confirmed cases for each disease were included. Case definitions were based on the recommended CDC and Council of State and Territorial Epidemiologists (CSTE) case definition for the year of symptom onset. The 10-year tickborne disease incidence maps were created by the Vector Program using ESRI ArcGIS software.

Ten-year Tickborne Disease Incidence maps were added Oct. 29, 2021 to the IDPH website. These maps are also included in this document (Attachment 3).

The Vector Program created an interactive tick mapping application to report the surveillance findings from the active tick surveillance program. The mapping application was created and is maintained by the Vector Program through ESRI ArcGIS software.

The Illinois Tick Surveillance Mapping Application is divided into tabs for each of the four ticks of public health importance: blacklegged tick, Lone Star tick, Gulf Coast tick, and American dog tick. In each individual tick species’ tab are additional tabs showing the current tick’s distribution map in Illinois, along with any pathogens that have been tested for in that tick. Counties on the map may be selected to see a detailed description of ticks collected and tested in that county.

The Illinois Tick Surveillance Mapping Application is updated at a minimum of twice a year when the INHS MEL sends the Vector Program its IGA reporting deliverable of a six-month report. It is also updated more frequently if data is available.

Tick collection, identification, and pathogen testing data are displayed on the interactive Illinois Active Tick Surveillance Mapping application. Additionally, data are reported to the CDC through the ArboNET data reporting platform.

In state fiscal year 2019, the Vector Program entered into an IGA with the University of Illinois to “provide educational opportunities for certified local health departments in Illinois. Trainings shall include in-person and web-based events and the educational subject matter shall cover tick dragging and flagging, tick identification, and active tick surveillance safety guidelines….at least one in-person training shall occur for local health department staff in each of the six IDPH regions.” Training dates and locations are listed here:

• April 4, 2019—Tazewell County Health Department
• April 5, 2019—Jackson County Health Department
  
• April 12, 2019—Madison County Health Department
  
• April 19, 2019—Winnebago County Health Department
  
• April 26, 2019—Champaign-Urbana Public Health District
  
• May 3, 2019—Kendall County Health Department
  

A total of 44 counties participated (Figure 2) in these trainings with 81 participants in total.

On June 25, 2019, the Vector Program and IDPH Communicable Disease Vector Program gave a joint presentation at the 2019 Public Health and Health Care Coalition Preparedness Summit. Below is the abstract of the presentation.

On March 25, 2021, the Vector Program and the INHS MEL provided a joint presentation to the Illinois Department of Natural Resources (IDNR). This presentation provided IDNR staff with an update on ticks and pathogens located in Illinois and explained efforts in active tick surveillance that were happening in and around state parks.

The Vector Program was present at both the 2019 and 2021 Illinois State Fairs in Conservation World. A booth was set up to provide educational materials to the public on both ticks and mosquitoes (Figure 3). Fair goers had the opportunity to ask questions of Vector Program staff and learn about efforts in Illinois to discover what tick species are present and what pathogens they are carrying. Educational materials and mosquito / tick repellent wipes were available for guests. The Vector Program intends to continue educational efforts at the 2022 Illinois State Fair.

The Illinois Mosquito and Vector Control Association (IMVCA) is a non-profit organization consisting of individuals interested in promoting the economic, environmental, and ecologically sound management of mosquitoes and other arthropod vectors and pests, in order to enhance human and animal health and well-being. The mission is to provide leadership, information, and education concerning the suppression of mosquito and other vector transmitted diseases and the reduction of pest annoyance levels caused by mosquitoes and other arthropods of public health importance in Illinois. The annual meeting is primarily attended by local health department personnel, mosquito abatements districts, universities, and other members interested in vectors in Illinois.

The Vector Program provides a presentation at the IMVCA conference, which is held annually in November. Additionally, the Vector Program staff are active members in IMVCA, preside on the IMVCA Executive Board, and serve as the current association vice-president.

The Vector Program attends the annual CDC Vector Week grantee meeting in Fort Collins, Colorado, which shares vector-borne disease information to Epidemiology and Laboratory Capacity funding recipients, vector control organizations, and state and local health departments.

The Vector Program has created, ordered, and/or printed several educational materials for use by local health departments, clinicians, and citizens of Illinois. These materials have been provided directly to local health departments, shared on social media accounts, and distributed at the Illinois State Fair and DuQuoin State Fair.

The Vector Program has created the following items in-house and printed them for public use.

• After You Pick, Check for Ticks (Attachment 4)
  • Mushroom hunting flyer to educate the public on how to protect against ticks while foraging for morels and other edible mushrooms.
• Got Lyme? Illinois Does (Attachment 4)
  • Poster created for Lyme Disease Awareness Month to inform clinicians and the public that Lyme Disease is present in Illinois and should be considered in tickborne disease diagnoses.
• Tick Identification Wallet Card (Attachment 4)
  • A 3.5 inch by 2 inch card illustrates common ticks encountered in Illinois and how to remove them. The Vector Program had 100,000 copies of this card printed and distributed them to local health departments and the public at the state fairs.

The Vector Program also ordered and/or had printed several CDC materials for distribution to local health departments, clinicians, and the public.

• 1,000 copies of Fast Facts: Protecting Yourself from Ticks and Mosquitoes (11 inch by 4 inch fact card)
• 20,000 copies of Tickborne Diseases of the US: A Reference Manual for Health Care Providers
  
• 1,000 copies Prevent Tickborne Diseases (Bookmark)
  
• 1,000 copies of Prevent tickborne disease in people and pets (2.5 inches by 8.5 inches)
  
• 1,000 copies of Prevent Bug Bites - What to Know Before You Go (11 inches by 17 inches poster)
  
• 1,000 copies of Lyme Disease: What you need to know (eight-page brochure)
  

• The VBD Program is managed by a VBD epidemiologist program manager who conducts human surveillance on 22 mosquito- and tick-borne diseases. Surveillance is the ongoing, systematic collection, analysis, and interpretation of health-related data essential to planning, implementation, and evaluation of public health practice. IDPH conducts human VBD surveillance through electronic reporting via the Illinois National Electronic Disease Surveillance System (I-NEDSS). I-NEDSS is an electronic platform by which suspect human VBD cases with positive laboratory reports are electronically imported from commercial and private laboratories for patients who reside in Illinois. Some cases may be manually entered into I-NEDSS by IDPH or the local health department (LHD) if the laboratory is not enrolled in electronic reporting via I-NEDSS. The program epidemiologist utilizes I-NEDSS 1 to monitor the imported VBD data to ensure the LHD is investigating in a timely manner for each suspect case in their respective jurisdiction and to create daily, weekly, and quarterly reports by querying data to identify areas that require additional follow up as follows:
  • Daily review of new laboratory and provider reports in the Illinois National Electronic Disease Surveillance System (I-NEDSS) for 22 VBDs that involves monitoring for cases that are new or unusual to Illinois.
  • Weekly review of six reports for22 tick- and mosquito-borne illnesses to identify gaps in data. Variables queried include clinical symptoms, laboratory reports, serotype, treatment, exposure history, where disease was acquired, death information, case classification, and cases that have been opened greater than 30 days.
  • Review of death certificates in the Illinois Vital Records Reporting System (IVRS) to determine if the cause of death was attributed to the illness or complications from the illness.
  • Cases found to have gaps in data are sent back to the LHD conducting the investigation and followed up with an email to the LHD requesting further study and completion of the report before it can be closed.
  • For cases opened greater than 30 days, an email is sent to LHDs notifying them their case investigations need to be completed so the case can be closed.
  • Respond to questions from the CDC regarding case investigation data that has been submitted to them.
  • Monitor cases who have tested positive for a VBD and have received or donated blood and received or donated organs/tissue for transplant into another person. When a case such as this has been identified, further follow up and collaboration with the CDC, the local health department, the blood and/or organ/tissue donor facility, and potentially another state public health department must be done for testing of the donor and/or recipient for the pathogen in question.
• Laboratory reports are the primary means by which IDPH receives suspected reports of Lyme disease and other VBDs. In accordance with Illinois Administrative Code Section 690.698 Tickborne Diseases, laboratories report suspected cases of Lyme diseases (and other tick-borne diseases) to IDPH via electronic laboratory reporting (ELR) into the Illinois National Electronic Disease Surveillance System (I-NEDSS) within seven days. Each lab report is electronically sent to the LHD in the jurisdiction where the case resides via I-NEDSS so the LHD can begin their investigation.
  
• The VBD Program manager maintains and updates information on VBDs on the IDPH web portal, which is accessible to LHD staff. Everything the LHD needs to know about conducting its case investigation for Lyme disease and other VBDs is on the IDPH web portal CD Topics A through Z pages. Each reportable VBD has a web portal page specific to that disease.
• As the LHD begins their investigation, they review the lab to ensure it meets the criteria set forth in the national Lyme disease case definition set forth by the Council of State and Territorial Epidemiologists (CSTE). For labs meeting these criteria, the LHD then contacts the ordering health care provider’s office regarding the case to discuss the lab results and obtain additional case information outlined in the I-NEDSS case report form. The case report is divided into nine sections consisting of numerous questions related to the section title, as follows: Demographics; General Illness, Clinical Symptoms, Laboratory Testing, Tick Habitat, Tick Bite, Treatment, Epidemiologic Data, and Reporting Source information.
• The LHD utilizes the new 2022 Lyme Disease Case Definition for all cases with a symptom onset date of January 1, 2022 or later to ascertain the status of each case it investigates. Case status classification distinguishes if the case has met the qualifying criteria to be counted as a case or as not a case. This national case definition is standardized across all 50 states and U.S. territories, so the same criteria are used when determining case status.
• Local health departments have been trained to educate their health care providers on reporting requirements (690.200) for VBDs when underreporting has been identified in their jurisdiction.
• LHDs have been trained to contact the health care provider (and not the case) to obtain all case information; however, if information on tick habitat, tick bite, and travel history was not collected by the provider, the LHD may contact the patient to obtain that information.
• The LHD has 30 days to complete their investigation and submit to IDPH for review. IDPH VBD staff review each case to ensure accuracy and completeness of each report. All reports that are incomplete or have reported data that do not make sense, e.g., symptom onset date reported prior to exposure history date, are sent back to the LHD to complete the missing information or update the information in question.
• Once the case has been completed and final review by IDPH VBD Program staff has been done, the case is closed. All cases that have been closed by IDPH VBD staff are sent to the CDC National Notifiable Disease Surveillance System (NNDSS) via secure data transfer on a weekly basis.

The IDPH VDB Program epidemiologist and program specialist positions are funded by the CDC Epidemiology and Laboratory Capacity (ELC) grant. The VBD Program was awarded $16,500 for printing and supplies for FY22. Additional funding opportunities for VBD human surveillance activities have not been identified.

IDPH VBD Program follows and recommends to local health departments guidance on the surveillance of all mosquito and tick-borne VBDs provided from various branches of the CDC Division of Vector-Borne Diseases (DVBD). IDPH guidance and recommendations are acquired from the following DVBD branches:

• Arboviral Diseases Branch
• Bacterial Diseases Branch
  
• Dengue Branch
  
• Rickettsial Zoonoses Branch

The IDPH web page for Lyme disease can be found at this link: https://www.dph.illinois.gov/topicsservices/diseases-and-conditions/diseases-a-z-list/lyme-disease. Content on the Lyme disease web page, noted below, includes, but is not limited to, the prevention, detection, and treatment of Lyme disease and is intended for physicians, other health care professionals and providers, and the public subject to an increased risk of contracting Lyme disease.

A new section has been created on the IDPH Lyme disease web page that includes subject matter for clinicians, including physicians, other health care professionals and providers, as well as other persons subject to an increased risk of contracting Lyme disease. Content for clinicians on the Lyme disease web page includes information on the following:

• Lyme disease incidence
• Transmission
  
• Patient assessment considerations
  
• Symptoms of the three clinical phases of Lyme disease and incubation period for each phase
  
• Collection of a thorough exposure and travel history from the patient
  
• Diagnostic laboratory testing
  
• CDC treatment recommendations for Lyme disease based on clinical presentation
  
• Post exposure prophylaxis
  
• Prevention
  

• CDC Tickborne Diseases of the United States: A Reference Manual for Health Care Providers (with information on ordering hardcopies free of charge)
• Illinois Interactive Tick Surveillance Map
  
• Caring for your patient after a tick bite
  
• How to remove an attached tick
  
• IDPH Lyme Disease Pocket Cards (for public consumption; print your own or how to request cards from IDPH VBD Program)
  
• CDC Lyme Disease Educational Brochures and how to order free of charge
  
• Scientific peer-reviewed research articles (see below)
  

• MODULE 1: Introduction to Tickborne Diseases and Disease Prevention
• Module 2: Lyme Disease Clinical Overview
  
• Module 3: Lyme Disease Testing and Diagnosis
  
• Module 4: Lyme Disease Treatment and Management
  

The following data are reported on the IDPH Lyme disease web page under the Lyme Disease Data tab.

• Reported tickborne infections in Illinois from 2011-2021
• Map of reported incidence rate of Lyme disease by county, 2010-2019
  
• Human VBD exposure data for Lyme disease and Rocky Mountain Spotted Fever are shared with the EH Vector Control Program for the following purposes:
  
  • To inform of human cases in areas where ticks have not been collected and tested for tick-borne pathogens so tick drags in the area(s) can be done.
    
  • Human exposure maps for Lyme disease and RMSF are created using VBD data by EH Vector Control staff proficient in the ARC GIS mapping application.
    

A new tab was added to the main IDPH Lyme disease web page June 28, 2022, linking information on task force meetings in order of occurrence with the most recent task force meeting listed first.

Articles published on the IDPH public web page include synopses with a link to each article. Articles are as follows:

• Changing Trends in Age and Sex Distributions of Lyme Disease—United States, 1992-2016
• Estimating the Frequency of Lyme Disease Diagnoses, United States, 2010–2018
  
• Tick and Tickborne Pathogen Surveillance as a Public Health Tool in the United States, May 2020
  

The IDPH VBD hosts an annual webinar to educate local health department staff prior to tick and mosquito season. The May 18, 2022, webinar, which was on Lyme disease surveillance during Lyme Disease Awareness Month, had 224 staff from LHDs in attendance. The webinar covered Lyme disease surveillance: epidemiology and statistics/incidence, reporting requirements, case investigation process; utility of the IDPH Illinois Tick Surveillance Map; etiologic pathogens for Lyme disease; transmission, transmission cycle, and tick habitat; and risk factors, symptoms, diagnosis, treatment, prevention, and utility of the 2022 national case definition for Lyme disease in a case investigation.

Information for the public on the prevention, detection, and treatment of Lyme disease

• What is Lyme disease?
• How does a person get Lyme disease?
  
• What are the symptoms of Lyme disease?
  
• When should I seek a physician’s care after a tick bite?
  
• Can Lyme disease be treated?
  
• How do I avoid getting bitten by a tick?
  
• Resources (EH Vector Control Program and CDC VBD Program)
  
  • INHS Medical Entomology Laboratory Active Tick Surveillance
    
  • IQuery
    
  • National Data and Statistics
    
  • Vector Control and Surveillance
    
  • Tickborne Diseases of the United States, Reference Manual for Health Care Providers
    
  • Information for Hunters on Ticks
    
  • Lyme Disease Data and Statistics
    
• Publications (EH Vector Control Program and CDC VBD Program)
  • Tickborne Disease Incidence Maps
    
  • Reported Tickborne Cases 2011-2021
    
  • Lyme Disease Pocket Card
    
  • Tick Prevention Poster
    
  • 2021 Human Exposures
    
  • 2020 Human Exposures
    
  • 2019 Human Exposures
    

Office of Land Management – brochures, tick signs, pocket cards distributed to state park visitor centers.

Office of Licenses and Permits – In October 2022, 40,000 Lyme disease pocket cards distributed to facilities where hunting and fishing licenses are sold – one to be presented with each license sold.

IDPH Vector-Borne Diseases Program ordered and/or printed the following pamphlets, brochures, tick signs, and pocket cards and distributed to IDNR for distribution at state park visitor center kiosks (trail signs posted at trail entrances).

Produced by IDPH VBD Program epidemiologist, approximately the size of a credit card. The pocket cards have been distributed to

• Illinois facilities where hunting and fishing licenses are sold
• IDNR for distribution at state park visitor centers
• the public at the 2021 Illinois State Fair and the DuQuoin State Fair

IDPH Lyme Disease Pocket Card – educational information on the symptoms, diagnosis, treatment, and prevention of Lyme disease. One side of the card has a ruled edge for the purpose of measuring the diameter of the erythema migrans rash, and information on how to remove an attached tick.

IDPH Spotted Fever Group Rickettsial Diseases Pocket Card – bi-fold pocket card with educational information on the symptoms, diagnosis, treatment, and prevention of RMSF and Rickettsia parkeri. Also included is a timeline of symptoms for RMSF and information on how to remove an attached tick.

A total of 260,000 Lyme Disease pocket cards and 45,000 Spotted fever Rickettsiosis pocket cards were ordered and are being distributed to Illinois State parks, the Illinois State Fair, Illinois vendors of hunting and fishing licenses, and local health departments. Below is a list of all the brochures ordered from CDC and mailed to IDNR for distribution at state parks since 2019.