disclosures ticked off: what every np needs to know · –approximately 3–30 days after initial...

Ticked off: What every NP needs to know about tick-borne infections

Vanessa Pomarico-Denino, EdD, FNP-BC, FAANP

FacultyFitzgerald Health Education Associates,

North Andover, MANortheast Medical Group (NEMG) APRN

Adjunct faculty for Southern CT State University and Quinnipiac University

Disclosures

• No real or potential conflict of interest to disclose.

• No off-label, experimental or investigational use of drugs or devices will be presented.

Fitzgerald Health Education Associates 2

Objectives

• At the end of the presentation, the participant will be able to:– Differentiate between types of

tick-borne diseases. – Recognize clinical presentation of

specific infections.


Objectives(continued)

• At the end of the presentation, the participant will be able to: (cont.)– Understand current therapies to

treat specific tick-borne and vectorborne diseases.

– Interpret findings of laboratory testing.


ReferencesAll references are listed in your

program, as well as at the end of this presentation.


Tick-borne Pathogens

•Transmitted through bite of infected ticks–Bacteria, virus, protozoal– High risk

• Those who work outdoors, high grass, forestry, construction, landscaping, RR, wildlife or park management

– Peak season• April to October; highest in June to August



Fitzgerald Health Education Associates. All rights reserved. Reproduction is prohibited. Prior permission required for use of questions or course content.

1

Tick-borne Pathogens(continued)

•Transmitted through bite ofinfected ticks (cont.)– Are considered reportable diseases

to DPH– Consider widespread testing due to

concomitant infection risk


Types of Tick-borne Diseases

• Lyme• Babesia• Anaplasmosis (also

known as Ehrlichia)• Rocky Mountain

Spotted fever• Powassan


Lifecycle of a Tick

• Lifecycle approximately 2 years• 4 life-stages

– Egg– Six-legged larva– Eight-legged nymph– Adult


Lifecycle of a Tick (continued)

• When eggs hatch, ticks must feedon a blood meal at every stage inorder to survive.– Feedings are approximately 10 minutes

to 2 hours.– A cement-like substance is secreted to

insure attachment to host.


How Transmitted

• “Questing”• Ticks wait on hind legs

on ends of blades of grass and leaves.

• They attach to suitable host aftermaking contact.


Source: www.CDC.gov/ Public Health Image Library ID #10871 Photo by James Gathany

How Transmitted(continued)

• Front legs attach onto host to begin feed– Infection is

transmitted through tick saliva that has an anesthetic property.

• Tick will feed thenfall off host untiltime to feed againin next lifecycle.


Source: www.CDC.gov/ Public Health Image Library ID #8680. Photo by James Gathany



2

How to Remove a Tick

• There are several commercially made tick removal kits.

• Fine-tipped tweezers as close to the skin where tick is embedded work just fine.– Pull upward with steady, even pressure.– Clean area with soap, water, or

rubbing alcohol.– Pincers (mouth parts) can remain in

the skin despite removal and allowed to heal over.


How to Remove a Tick (continued)


Image source: https://www.cdc.gov/lyme/removal/

How NOT to Remove a Tick

• Lit cigarette or match• Nail polish• Petroleum jelly


Lyme Disease (Borrelia Burgdorferi)

• Spirochete– Transmitted by infected

ticks, usually deer ticks

• Originated in Lyme, CT– Most common

tick-borne diseasein the country

– Also found in Australia, Asia, Europe


Lyme Disease True or false?

Tick must generally be in place>24 hours in order to transmit

infection to host.


True

Lyme Disease (Borrelia Burgdorferi) (continued)

• Different ticks– Not all carry Lyme

• Tick bite frequently unnoticed– Tick may be in area that

is not noticeable.– Can engorge itself and

fall off without ever being detected




3

Tick vector

Geographic location

% of infection (dependent upon region)

Carrier

Ixodes scapularis

Northeastern, north central and mid-Atlantic regions of U.S.

15–65% Mammals, birds, reptiles, amphibians (snakes, frogs)

Ixodes pacificus

West coast 2% adult ticks2–15% nymph ticks

Lizards, birds, mammals

Ixodes ricinus

Europe 4–16% Wood mice, cattle, deer, small rodents

Ixodes persulcatus

Asia 27% Sheep, cattle, horse, dog

Transmission

• Spread through the bite of an infected tick

• Most common areas– Groin– Axillae– Scalp

• Most common timeof year– Spring and summer


Source: www.CDC.gov/ Public Health Image Library ID #2417

Transmission(continued)

• Ticks not known to transmit Lyme disease include– Lone star ticks (Amblyomma americanum)– American dog tick (Dermacentor variabilis)– Rocky Mountain wood tick

(Dermacentor andersoni)– Brown dog tick

Fitzgerald Health Education Associates 21 Fitzgerald Health Education Associates 22

Source image: https://www.cdc.gov/lyme/datasurveillance/maps-recent.html

Incidence of RecentlyConfirmed Lyme Cases (2017)

• CT: 1381*• CA: 84• MA: 321*• NJ: 3629*• NY: 3502*


• PA: 9250* • TN: 15• IN: 92• HI,OK: 0

– Source: https://www.cdc.gov/lyme/datasurveillance/maps-recent.html

* Denotes high incidence of infection

Clinical Presentation

• Flu-like symptoms (“summer flu”) and possibly a rash

• Stage 1: Early localized infection– Approximately 3–30 days after initial tick bite– Erythema migrans

• Localized erythema at site of insertion– Target lesion with central area of clearing

• 10–20% of patients do not develop rash or lesion.




4




Clinical Presentation(continued)

• Stage 2: Early disseminated infection– Weeks to months after initial infection– 50–60% of patients with EM

become bacteremia– Malaise, fatigue*, fever, HA (sometimes

severe), neck pain, generalized myalgia/arthralgia

– *Fatigue can persist for months.



• Stage 2: Early disseminated infection (cont.)– Cranial nerve VII

palsy or meningitis(10–15%)• Rare complication –

AV block (~4–10%) or myopericarditis, panophthalmitis


Source image: author-James Heilman, MD https://commons.wikimedia.org/wiki/File:Bellspalsy.JPG


• Stage 3: Late, persistent infection– Can occur months to years after

initial infection– Moderate to severe generalized

arthralgias (60%)– Monarticular or oligoarticular arthritis

involving the knee or hip usually self-limiting• Joint aspiration yields a mean WBC 25,000/mcL

with predominance of neutrophils



• Rare neurologic manifestations– Subacute encephalopathy, sleep

disturbance, memory loss, mood changes, intermittent paresthesias, ataxia, spastic paraparesis, bladder dysfunction



• If patient presents with symptoms of Bell’s palsy, heart block or myopericarditis, test for Lyme disease!



Source: ECG courtesy of Nick Tullo, MD



5

Diagnosis and Treatment

• National surveillance case definition– 30-day window of exposure prior to onset

of symptoms– Erythema migrans as diagnosed by HCP– At least one late manifestation of disease– Confirmatory lab testing


• True incidence unknown due toseveral factors.– Serologic testing is not standardized.– Clinical manifestations are not specific

and can mimic other illness or infection.– Serology is not sensitive enough in early

stage of disease leading to false negative readings.

– Source: Papadakis, M., and McPhee, S. (2017). Current Medical Diagnosis And Treatment. (56th ed). New York, NY: McGraw-Hill


Incidence of Lyme Disease

Lab Testing

• ELISA two step testing (EIA)– If ELISA is +, Western blot assay to

detect both IgM and IgG antibodies– IgM + within 2–4 weeks (~70%)

• Can seroconvert to IgG after 6 weeks

– IgM Western blot (IFA) must have two of the following three bands present – 23, 39, and 41kDa for diagnosis


Lab Testing (continued)

• ELISA two step testing (EIA) (cont.)– IgG must have 5/10 bands + for diagnosis– ESR may be elevated.– LFT abnormalities, shift in WBC


Criteria for Prevention Treatment for Known Tick Bite ≤72 Hours

• Tick is identified as an adult or nymph Ixodes scapularis tick.

• Estimated to have been attached and engorged for ≥36 h

• Must be in a highly endemic area where prevalence of B. burgoderferi infections are ≥20%

– Source: NEJM Journal Watch


Outpatient Treatment of Lyme Disease One of the following regimens…

• Doxycycline 100 mg PO BID × 10–21 d– Do not use in pregnancy, ? Lactation

OR• Amoxicillin 500 mg PO TID × 14–21 d

– Safe for pregnancy/lactating womenOR

• Cefuroxime axetil 500 mg PO BID ×14–21 d




6

Inpatient Treatment of Lyme Disease with Cardiac Complications

• Ceftriaxone (drug of choice) 10–28 days of therapy– Pedi: 50–100 mg/kg/day IV once daily– Adults: 2 g IV once daily

• PCN G potassium: 10–28 days of therapy– Pedi: 200,000–400,000 million units/kg/day

in divided doses every 4 hours– Adult: 18–24 million units/kg/day IV every

4 hoursFitzgerald Health Education Associates 37

Outpatient Treatment – PediOne of these regimes…

• Amoxicillin 50 mg/kg PO daily in 3 divided doses– Maximum of 500 mg

per dose– 14–21 days


• Doxycycline– Age ≥8 years– PO 4 mg/kg per day

in 2 divided doses– 100 mg per dose– 10–21 days

Outpatient Treatment – PediOne of these regimes…(cont.)

• Pedi (cont.)– Cefuroxime axetil 30 mg/kg PO daily in

2 divided doses• Age >8 years• Maximum of 500 mg per dose • 14–21 days


Treatment Alternatives – Adult

• To be used if PCN allergic or intolerant of other recommended medications– Lower efficacy profile

• Azithromycin– 500 mg PO daily ×

7–10 days


• Clarithromycin– 500 mg PO BID ×

14–21 days

• Erythromycin– 500 mg PO QID ×

14–21 days

Treatment Alternatives – Pedi

• Azithromycin– 10 mg/kg/day PO daily × 7–10 days

• Erythromycin– 30–50 mg/kg/day PO in 4 divided doses

× 14 days

• Clarithromycin– 15 mg/kg/day in 2 divided doses ×

14–21 days


PosttreatmentLyme Disease Syndrome (PTLDS)

• Formerly referred to as chronic Lyme– Controversial– No documentation or studies to

prove/disprove its existence• Persistent joint pain, fatigue, or

difficulty thinking for >6 months after treatment for Lyme

• Refer to infectious disease specialist if symptoms persist beyond treatment.




7


Source: The Hartford Courant 9/14/2017

University of Massachusetts Medical School trialing a single injection as prevention from acquiring Lyme disease before someone is even exposed.


Source: www.CDC.gov/ Public Health Image Library

Babesiosis

• Protozoan parasitic infection transmitted by ticks, usually on cattle, wild animals

• Generally found in the coastal northeastern U.S.– 95% of the cases were reported by

7 states – CT (205), MA (537), NJ (159), NY(471), RI (172).• Total for U.S. in 2014=1744• Became nationally reportable disease in 2011


Babesiosis (continued)

• Causes B. microti or B. divergens• Infected by same ticks carrying

B. burgdoferi– Nymph ticks the size of a poppy seed– People rarely know they were bitten by

a tick.– + vertical transmission from mother

to fetusFitzgerald Health Education Associates 46

Clinical Presentation of Babesia

• Flu-type symptoms gradually worsening– Fever, HSM

• Arthralgias, myalgias– May not have any rash

• Hemolytic anemia, thrombocytopenia


Clinical Presentation of Babesia(continued)

• Symptomatic within a week but may be asymptomatic for many months– Incubation can be 1–9 weeks

• Can be fatal in elderly or peoplewithout spleen




8

Diagnosing Babesia

• Detailed history of high risk exposure and high index of suspicion

• Labs– CBC with anemia due to RBC destruction

and low platelets– Proteinuria– Hemoglobinuria– Elevated LFTs, BUN/creatinine


Diagnosing Babesia(continued)

• Manual peripheral blood smear– Can need more than one sample to

detect parasites– Must request manual reading!


Diagnosing Babesia(continued)

• Indirect immunofluorescent antibody– Anti-Babesia IgG titers >1:64– Antibodies detected 2–4 weeks

after infection– Titers generally rise to ≥1:1024 during

the first weeks of illness and decline gradually over 6 months

– Can remain detectable at low levels fora year or more


BabesiaOutpatient Treatment

•First-line–Atovaquone 750 mg PO BID plus

azithromycin 500–1000 mg PO on day 1 then 250–1000 mg PO for 7–10 days

•Alternative–Clindamycin 600 mg PO TID + quinine

650 mg PO TID for 7–10 days• Higher adverse effect profile


Blood Donation

• Patients diagnosed with Babesia are indefinitely deferred from donating blood.– Currently, no routine screening for Babesia

with blood donation exists.

• Patients should be advised to refrain from blood donations unless their specimen is screened for Babesia.


BabesiaMedication Risks

• Antimalarials• Pregnancy category C• Use with caution if breast feeding• Pedi patients must weigh >11 lbs (5 kg)

– Azithromycin• Safe for pregnancy, lactation and pedi patients




9

BabesiaMedication Risks

(continued)

• Antimalarials (cont.)– Clindamycin

• Pregnancy category B• Is excreted in breast milk but is compatible

with breast feeding• Contains benzyl alcohol, which has been

associated with a fatal "gasping syndrome" in premature infants


Babesia Case Study

• Isabelle, 85-year-old female patient• Presents with one week history of

fatigue, fever (unmeasured) and “feeling washed out”

• PMH- Type 2 DM, HTN, hyperlipidemia, hypothyroid

• PSH- Noncontributory


Babesia Case Study(continued)

• Medications– Metformin 500 mg PO daily– Amlodipine/valsartan/HCTZ (Exforge

HCT®) 160/5/25 mg– Levothyroxine (Synthroid®) 175 mcg– ASA 81 mg– MVI



• SH- Married to husband 61 years• Lives in own home• Still drives• Active at home

– Reports having been working in her garden two weeks prior to onset of symptoms



• VS– BP 100/62 mm Hg– HR 44 bpm– RR 14– Temp 102˚F (38.9˚C)

• Pt was transferred to ED for admission and sepsis workup.


Babesia Case Study Labs

• WBC 7.4 × 1000 units/L (4–10 ×1000 units/L)– Platelets 105 × 1000 units/L (140–440)– Neutrophils 50% (37–84%)

• 0.5 proportion (0.37–0.84 proportion)




10

Babesia Case Study Labs (continued)

• WBC 7.4 × 1000 units/L (4–10 ×1000 units/L) (cont.)– Lymphocytes 25% (8–49%)

• 0.25 proportion (0.08–0.49 proportion)• Atypical lymphocytes 9% (0.9 proportion)

– Monocytes 14% (4–15%)• 0.14 proportion (0.04–0.15% proportion)


Babesia Case Study Labs(continued)

• RBC– 3.4 (3.8–5.9 M/uL)

• Hgb– 9.7 g/dL (12.0–18.0)

(97 g/L [120–180])• Hct

– 29.1 g/dL (37–52%) (0.29 proportion[0.37–0.52])


• BUN– 30 mg/dL (10.7 mmol/L)

• Creatinine– 1.0 mg/dL (88.4

µmol/L)• ALT

– 49 unit/L (0–34 unit/L)• AST

– 53 unit/L (0–34 unit/L)

Babesia Case Study Labs(continued)

• Rapid Lyme– Negative

• TSH– 23 milli-international

units of per liter (0.4–4.0 mIU/L)

• CXR– Negative for PNA


• UA– Negative

• EKG– Sinus bradycardia

• Day 3– Babesia peripheral

smear + for parasites

Babesia Case Study Medications

• Doxycycline 100 mg IV BID empirically• Azithromycin 1000 mg IV on day 1

then 500 mg IV days 2–9• Atovaquone 750 mg PO every 12 hours• Clindamycin 600 mg IV every 6 hours• Probiotic


Complications during Hospitalization

• Afib– Fever induced – Temps 103˚F (39.4˚C)

• Aspirational PNA• Sick sinus syndrome

– ITP post pacemaker insertion• CHF – Acute diastolic HF• Hearing loss secondary to antibiotics• Colitis


Babesia Case Study (continued)

• Multiple PRBC and platelet transfusions• Pt discharged to home on day 28

with VNA• Weekly CBC until normal range • Weekly Babesia smears until negative

parasite count (4 weeks)• PATIENT EDUCATION!




11


Source: Used with permission from Graham Hickling, PhD, University of Tennessee.

Ehrlichiosis or Anaplasmosis

• Human monocytic ehrlichiosis (HGE) caused by Ehrlichia chaffeensis from the Lone Star tick from white-tailed deer

• Became reportable in 1999– <1000 cases reported in 2008

• Now known as human granulocytic anaplasmosis (HGA)


Ehrlichiosis or Anaplasmosis(continued)

• More prevalent Northeastern and Midwestern U.S.

• Peaks June-December– May-August

• Highest transmission time• Short incubation

– 9 days–2 weeks• Can be fatal in <1% of those who

are untreatedFitzgerald Health Education Associates 69


• Other modes of transmission– Has been found in refrigerated blood– Blood transfusions– Organ transplant



• Prodrome– Malaise, rigors, fever, HA, myalgia, N/V/D– Rash is rare.– Coinfection with Lyme disease, Babesia

not uncommon


Diagnosis and TreatmentEhrlichiosis or Anaplasmosis

• Indirect immunofluorescence assay (IFA) – Gold standard

• PCR assay– Most sensitive during first week of illness

• Enzyme immunoassay (EIA)– Serologic only gives + or (-) result

High false positive• Peripheral blood smear




12


(continued)• CBC/diff

– Thrombocytopenia and leukopenia are common.• Platelets <150,000/mL• WBCs <4000/mL

– Lymphopenia• <1500 lymphocytes/mL



(continued)

• LFTs– Transaminitis is common in ~83%

of patients.– Elevated ALT/AST and indicator of

liver damage– Generally is reversible.


Diagnosis and TreatmentEhrlichiosis and Anaplasmosis

(continued)• Presence of morulae

– Large, mulberry-shaped aggregates or microcolonies of Ehrlichia inside the monocyte in approximately 20% of infected patients


Diagnosis and TreatmentEhrlichiosis and Anaplasmosis

(continued)• Treatment

– Doxycycline 100 mg PO BID × 10–14 days• Pedi <45 kg (100 lbs.)• 2.2 mg/kg body weight given twice a day

× 10–14 days– Rifampin PO if pregnant/lactating or

pediatric patient– Use of antibiotics other than doxycycline

increases the risk of patient death– Source: American Academy of Pediatrics Committee on Infectious Diseases


Rocky Mountain Spotted Fever (RMSF)

• Causative organism– Rickettsia rickettsii

• Can be potentially fatal if not treated within the first few days

• Spread by dog tick or wood tick, fleas, lice and mice

• 5–14 day incubation period


Rocky Mountain Spotted Fever (RMSF) (continued)

• Has been detected in almost every state in the US– >60% of cases have been found in

• North Carolina• Oklahoma• Arkansas• Tennessee• Missouri




13

Rocky Mountain Spotted FeverClinical Presentation

• Fever• Rash

– Appears 2–5 days after infection in 90% of pts• Nonpruritic, erythematous macular rash on

wrists, forearms, ankles, trunk• Petechial rash generally not seen until after

day 6 of illness.• Pedi pts will develop rash more quickly

than adults.Fitzgerald Health Education Associates 79

Rocky Mountain Spotted FeverClinical Presentation

(continued)

• HA– Most common presenting complaint

with Pedi

• N/V/abdominal pain• Anorexia• Conjunctival irritation


Rocky Mountain Spotted FeverDiagnosis

• Important to diagnose and treat early if high index of suspicion

• Skin biopsy of rash quickest way to diagnosis due to rapid turnaround

• + antibodies after 7–10 days– Can remain elevated for several months

after resolution of infection


Rocky Mountain Spotted FeverDiagnosis(continued)

• Gold standard– Indirect immunofluorescence assay (IFA)

with R. rickettsii antigen• First sample within first week• Second sample 2–4 weeks after• Repeat 2–4 weeks


Rocky Mountain Spotted Fever Complications

• Vasculitis due to infection of endothelial cells

• Limb amputation due to decreased circulation

• Internal organ damage


• Neurological deficits• Thrombocytopenia• Hyponatremia• Elevated LFTs

Rocky Mountain Spotted FeverTreatment

• Doxycycline 100 mg PO BID × 7–14 days is treatment of choice.– Fever generally subsides within 24–72

hours after initiation of treatment.– Children <45 kg (<100 lbs)– 2.2 mg/kg body weight given twice a day

• Chloramphenicol if pregnant or allergic to doxycycline




14

Outpatient Treatment of RSMFAdditional Information for Pedi

• Doxycycline binds less readily to calcium and has not been shown to cause the same tooth staining as TCN.

• Blinded study in 2013 revealed that no differences in tooth color, staining or weakness were found between children age <8 yo who had received doxycycline and those who had not.

– Source: https://www.cdc.gov/rmsf/doxycycline/index.html

Fitzgerald Health Education Associates 85 Fitzgerald Health Education Associates 86


PreventionPermethrin 0.5% Spray

• Synthetic molecule derived from chrysanthemum flowers– Meant for use on clothing and fabric

goods only– Avoid contact with face, eyes, skin or

breathing vapor mist• One application lasts through 6 washes

or up to 6 weeks.


Prevention

• Adequate covering of all exposed skin• DEET or permethrin products• Extensive skin checks if in exposed area• Removal of tick in its entirety


Prevention (continued)

• Use of essential oils has not been studied well but is becoming more widely used by consumers.– Are considered safe for people and pose

minimal risk per CDC– Have not been evaluated by the EPA

for effectiveness


Prevention (continued)

• Use of essential oils has not been studied…(cont.)– Not all essential oils can be applied

directly to the skin without causing severe skin irritation.




15

Examples of Essential Oils Used to Prevent Tick Bites

• 2-undecanone– Essential oil from

leaves and stems of the wild tomato plant, Lycopersiconhirsutum



(continued)


• Garlic oil– Essential oil from

garlic plants


(continued)

• Mixed essential oils– Rosemary, lemongrass, cedar,

peppermint, thyme, and geraniol


• Nootkatone– Essential oils from Alaska

yellow cedar trees, some herbs, and citrus fruits

• Fungi (Metarhizium brunneum, Metarhizium anisopliae)– Used only on lawns

and gardensFitzgerald Health Education Associates 94


(continued)

Alpha-gal Galactose-alpha-1,3-galactose

• Immune response due to tick bite from a Lone Star tick causing allergy to beef and pork

• Immunoglobulin E (IgE)– Allergen binds to IgE antibodies to promote

a histamine reaction that is mild to severe (anaphylaxis)• Epinephrine (EpiPen®)

• Diagnosed via specific allergy testing labsFitzgerald Health Education Associates 95

Testing the Tick

• Many labs only test tick specimen for Lyme.

• Tickencounter.org tests for Lyme disease, Babesia and Anaplasma.– UMass Laboratory of Medical Zoology

• Tickcheck.com tests for 9 different diseases.




16

Tick-borne Disease Follow-up

• Serial CBC/diff, CMP and Babesia peripheral smear to determine eradication of parasites– If outpatient, weekly labs until negative

then one month after therapy has been completed.

– Repeat labs if patient becomes symptomatic again.


Questions?


End of PresentationThank you for your attention

Vanessa Pomarico-Denino,EdD, APRN, FNP-BC, FAANP

www.fhea.com [email protected]


References

• Buttaro T., Trybulski J., Polgar Bailey J. (2016). Primary Care: A collaborative practice. (5th ed). St. Louis, Missouri: Elsevier

• Center for Disease Control (CDC): www.cdc.gov/

• Evans, D. and Meires, J. (2016). Chikungunya Virus: A rising health risk in the United States and how nurse practitioners can help address and reduce the risk. Journal for Nurse Practitioners. 12(5): 289–298.


References(continued)

• Mcneil C., Shreve M., Jarrett A., and Perry C. (2016). Zika: What providers need to know. The Journal for Nurse Practitioners. 12(6): 359–366.

• Moore, K. (2015). Lyme Disease: Diagnosis, treatment, guidelines, and controversy. The Journal for Nurse Practitioners. 11(1): 64–69.



• NEJM Journal Watch. https://www.jwatch.org/fw115560/2019/06/27/new-draft-lyme-disease-guidelines-issued

• Papadakis M., and McPhee S. (2017). Current Medical Diagnosis And Treatment. (56th ed). New York, NY: McGraw-Hill




17

References (continued)

• Theophilus P., Victoria M., Socarras K., Filush K., Gupta K., Luecke D. and Sapi E. (2015). Effectiveness of Stevia RebaudianaWhole Leaf Extract Against the Various Morphological Forms of Borrelia Burgdorferiin Vitro. European Journal of Microbiology & Immunology. 5(4): 268–280.



• van Nunen, S. (2015). Tick-induced allergies, mammalian meat allergy, tick prophylaxis and their significance. Asia Pacific Allergy. 5(1): 3–16.

• Wooten, A. (2015). Zika Virus: An emerging threat to travelers. The Journal for Nurse Practitioners. 12(5): e237–238.


References (continued)

• Wormser G., Dattwyler R., Shapiro E., HalperinJ., Steere A., Klempner M., Krause P., Bakken J., Strle F., Stanek G., Bockenstedt L., Fish D., Dumler JS., and Nadelman R. (2006). The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical practice guidelines by the infectious diseases society of America. Clinical Infectious Diseases. 43 (9): 1089–1134.


Photo Credits

• Graham Hickling, PhD, University of Tennessee.

• CDC public health image library. https://phil.cdc.gov

• Pixnio. www.pixnio.com


• Images/Illustrations: Unless otherwise noted, all images/ illustrations are from open sources, such as the CDC or Wikipedia or property of FHEA or author.

• All websites listed active at the time of publication.


Copyright Notice

Copyright by Fitzgerald Health Education AssociatesAll rights reserved. No part of this publication may be reproduced or transmitted

in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without permission

from Fitzgerald Health Education Associates

Requests for permission to make copies of any part of the work should be mailed to:

Fitzgerald Health Education Associates85 Flagship Drive

North Andover, MA 01845-6184




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Statement of Liability

• The information in this program has been thoroughly researched and checked for accuracy. However, clinical practice and techniques are a dynamic process and new information becomes available daily. Prudent practice dictates that the clinician consult further sources prior to applying information obtained from this program, whether in printed, visual or verbal form.

• Fitzgerald Health Education Associates disclaims any liability, loss, injury or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this presentation.


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Website: fhea.com

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disclosures ticked off: what every np needs to know · –approximately 3–30 days after initial...

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