3. “something hungry is about to hatch”
the emerging threat of tick-borne disease in the UK
Richard Birtles
Infection Biology Group, University of Liverpool
National Centre for Zoonosis Research
4.
5. ticks in the UK, Europe and around the world
o ticks are second only to mosquitoes as vectors of pathogens of
medical and veterinary importance.
o in UK, Europe and across the temperate northern hemisphere,
ticks of the genus Ixodes are widespread and are vectors of
numerous pathogens.
6. ticks in the UK
o Ixodes ricinus, the sheep or deer tick,
feeds on most mammals/birds, is
widespread in the UK and is the most
frequent biter of humans
o other Ixodes species also present in UK;
these species have a far more limited
host range, but some will also bite
humans.
7.
8. tick abundance in the UK is on the rise
o the distribution of Ixodes ricinus has
expanded by 17% in comparison with
the previously known distribution.
o people perceive there to be more ticks
today than in the past at 73% of
locations studied.
o reported increases in tick numbers
coincided spatially with perceived
increases in deer numbers.
Scharlemann JP et al. Trends in ixodid tick abundance and
distribution in Great Britain. Med Vet Entomol 2008;22:238-47.
9. deer (tick host) abundance in the UK is on the rise
Roe deer bag density (number shot per 100 hectares) synoptically by county and
by decade from 1960 to 1999. Source: Game & Wildlife Conservation Trust
10. incidence of tick-borne diseases in the UK is also on
the rise
England & Wales (HPA)
year
number of LB cases
Scotland (HPS)
11. tick-borne pathogens in the UK
agent disease medical/veterinary relevance in UK
Borrelia burgdorferi lyme borreliosis 2,000+ human cases p.a. Disease also reported
in companion animals & horses.
Anaplasma granulocytic anaplasmosis, Major pathogen of young sheep, also reported
phagocytophilum pasture fever, tick pyaemia in companion animals & horses. No human cases
(yet). c1,000 human cases p.a. in New England.
Babesia spp. Babesiosis B. divergens causes redwater fever in cattle. No
known medical relevance.
louping ill virus louping ill Major pathogen of young sheep, also reported
in horses. No human cases. Close relative of tick-
borne encephalitis virus.
12. clinical manifestations of lyme borreliosis
syndrome manifestation
erythema migrans expanding red/blue-red patch, with /without
(v common) central clearing - advancing edge typically
distinct.
lyme lymphocytoma painless blue-red nodule
(rare)
acrodermatitis chronica long-standing red/blue-red lesions,
atrophicans eventually becoming atrophic
lyme neuroborreliosis meningo-radiculitis, meningitis, facial palsy
lyme arthritis recurrent attacks or persisting joint swelling
in one/few large joints
lyme carditis (rare) acute onset AV conduction disturbances,
myocarditis
ocular disease conjunctivitis, uvelitis, …
Stanek et al. Lyme borreliosis: clinical case definitions for diagnosis & management in Europe. Clin Microbiol Infect 2010
13. lyme borreliosis – long-term sequelae controversy
Objective long-term sequelae
o uncommon in properly treated patients
o patients with neuroborreliosis may take weeks to months to fully recover – recovering
patients may complain of neurasthenic symptoms
o in some (<10%) patients with lyme arthritis, recovery may take several months
o no evidence of better response to further antibiotic treatment
Subjective long-term sequelae
o some patients report ongoing, recurrent or persistent symptoms after appropriate
treatment of proven LB = post-lyme syndrome.
o symptoms include reduced performance, fatigue, irritability, distubances in sleep,
concentration and memory
o various control studies have failed to support the idea that persistence of borrelial
infection is the cause of such symptoms
o no evidence that further antibiotic treatment helps resolution
Stanek et al. Lyme borreliosis: clinical case definitions for diagnosis & management in Europe. Clin Microbiol Infect 2010
14. diagnosis & treatment of lyme borreliosis
o clinical diagnosis of erythema migrans, esp. with
appropriate patient history.
o serology is mainstay of lab diagnosis in UK –
currently a 2 step approach, involving ELISA then
Western blot.
o PCR-based methods available, but not widely
adopted. Not standardised, but good potential.
o oral doxycycline recommended as first-line
treatment for all non-neurological, & some
neurological, presentations
o intravenous ceftriaxone recommended for patients
with some forms of neuroborrelosis
16. when & where can you catch LB in the UK?
region number of
HPA: “The seasonal pattern in 2008 was cases in 2008
similar to that seen in 2007 and in earlier Wales 18
years. Approximately 60% of patients
were tested in July, August and Yorkshire & 11
September; representing a likely peak of Humberside
onset of symptoms in the early summer. East Midlands 13
This is consistent with the major tick West Midlands 34
feeding period which occurs in the late
spring and early summer months. 22% of North West 55
blood samples were received and tested North East 16
during the last quarter of the year, again London 101
consistent with exposure to ticks and
'ticky' environments in the late summer South West 310
and early autumn”. South East 218
East Anglia 35
17. “where there are ticks there is lyme borreliosis”
I. ricinus distribution
18. “where there are ticks there is lyme borreliosis”
no ticks <1% ticks infected >5% ticks infected
19. “where there are ticks there is lyme borreliosis”
Mell Fell, nr Keswick
Mabie Forest
Dumfries
Dalby Forest, Pickering
Hampsfell Wood
Grange over Sands
no ticks <1% ticks infected >5% ticks infected
21. “where there are ticks there is lyme borreliosis”?
B. garinii & B. valasiana only B. garinii, B. valasiana & B. afzelii
22. summary
o the medical importance of tick-borne disease in
the UK is becoming increasingly apparent.
o climate change is likely to favour ticks.
o TBE is progressing north and west across Europe,
but is not here yet.
o clinical case definitions have been refined and
laboratory diagnostics are improving.
o we understand little about the ecology of tick-
borne pathogens and thus have no idea how to
control them.
30. Current Situation
• 350 course places/year funded
• 16 courses / year
• Immediate care courses, Emergency Medicine
courses, Paediatric pre-hospital care.
• Major Incident training – Pre–hospital and In-
hospital
35. Funding
• Education – provided by NHS
• Equipment – Sandpiper trust
• Consumables – Depends on location
• Payment – Depends on location.
36. New GP Contract
• No longer 24 hr responsibility- ? Availability
• Funding ??
37. Historical - Pre-hospital Care
• General Practice
provided
• No Paramedics
• Change to ambulance
service responsibility
• Funding difficult
• New GP Contract
• Callout difficult
41. Patient Report Forms
BASICS Scotland Patient Report Form
Surname Date
First name SAS inc. no
Address or Age Time of call
locus Sex M F Time on scene
D of B Time clear
RTC Other trauma Medical Other
INITIAL ASSESSMENT – POTENTIAL PROBLEMS Record as ‘Y’, ‘N’ or ‘?’
1y survey problems ? A B C Initial AVPU/GCS_______ C spine Back Head Chest
Initial Sp02 _______
Pelvis # Abdo Femur R L
History/additional info/drugs given #
Interventions performed
Bas A - O2 Suction Positioning NPA x1 x2 OPA
Adv A - LMA igel ETT Needle-cric Surgical airway
B - B+M Ventilated PTx-decomp Ch Drain Chest seal
C - IV access IO-needle EZ-IO Tourniquet MAST
D - Collar Full-Immob Vacc matt Pelvic splint
Fluids given________________________________
Airway problem?
Other -
Please complete online airway
survey!
Entrapped? Y / N Extrication time
Usual Meds
Discharged at scene / Admitted – PCEC / A+E / Wd______ / Other
Allergies
Time Pulse R/R BP Sp02 C Refill GCS/AVPU Other (temp/BM)
E M V
E M V
E M V
Cardiac arrest Initial rhythm VF/pVT Asystole PEA DoA/DoS
Prior CPR No of shocks Notes_______________ Time/date certified
Drugs given Epinephrine ____ Atropine____ Amiodarone____ Police PF
Other Rx GP informed Name
Other info
Time to RoSC/D Died / survived
SAS crew details F.o.S. S.M.C.
Helimed F.R.
Working assessment
E.M.R.S No P/Med
R.A.F. H.M.C
GP Name/ID ID code
R.N.L.I. M.R.T.
47. Tranexamic Acid
• 1 over 10 mins, then 1g over 8 hrs
• 1g costs £3 ( BNF )
•Watch this space
48. National Audit Office
"Current services for people who suffer major trauma are not
good enough. There is unacceptable variation, which means
that if you are unlucky enough to have an accident at night
or at the weekend, in many areas you are likely to receive
worse quality of care and are more likely to die. The
Department of Health and the NHS must get a grip on
coordinating services through trauma networks, on costs
and on information on major trauma care, if they are to
prevent unnecessary deaths."
Amyas Morse, head of the National Audit Office,
5 February 2010
49. Emergency and Urgent Response
To Remote and Rural Communities
Strategic Options Framework
October 2009
Report By: Mrs Fiona Grant
Remote and Rural Programme Manager
REMOTE AND RURAL
IMPLEMENTATION
50. Emergency and Urgent Response To Remote and Rural Communities
Strategic Options Framework
October 2009
3 level of response
• Level 1- CPR capability within the general public
• Level 2 – Retained Ambulance service and Allied Health
professionals
• Level 3 – Community practitioners including GPS, community
nurses and Paramedics.
51. Summary
• On-going Education programme
• Education – evidenced based and Educational
Governance in place
• Equipment
• Evidenced based equipment improvement
• Activity monitoring
• National recognition of role in rural
Emergency care
55. The RCGP Rural Forum
Annual Report
Harrogate conference 2010
Dr Malcolm Ward
56.
57.
58. RCGP Rural Practice Standing
Group
The Rural Practice Group was founded in
1993 to raise the profile of rural medicine
in the United Kingdom through education,
research and the dissemination of good
practice in rural health care.
59. The Rural Forum is born
• February 2009 UK Council votes against
NG Faculty (33:17)
• Voted for Rural Forum: (44 for, 0 against, 5
abstentions)
• Launch Glasgow November Conference
2009
60. Overall aims of the Rural forum
• To represent rural and remote general practitioners within the RCGP with
the potential to promote rural issues within and outwith the College faculties
and be the rural face of the College
• To encourage engagement with the College of those fellows/members
working in rural practice.
• To facilitate communication between and networking of rural doctors across
the UK.
• To support the professional development of rural general practitioners, with
particular reference to the required knowledge, skills and attitudes of a
general practitioner to care for patients in a rural setting.
• To promote rural practice and support associates in training with particular
reference to the required knowledge, skills and attitudes.
• To promote rural practice as a career path for associates in training and
through the College strive to ensure availability of appropriate training.
• To promote remote and rural issues at appropriate level, engaging with the
profession, managers and informing political debate.
• Democratic infrastructure
61. Membership benefits
• Belonging to a Forum which specifically represents the interests of
rural practitioners in the care of their patients at all levels.
• Once a Forum membership/constituency is established a democratic
representative structure can be created.
• A virtual system of communication via E-communication and web
based facilities.
• Opportunity to comment on, and influence College policy.
• Opportunity to influence College interaction with other relevant
agencies where their policies and initiatives may impact upon rural
healthcare. E.g. SAS consultation, Scottish OOH consultation
• E-learning: sign posting, rural modules, ?CD-ROM option
67. Steering Group 2010-2011
Elected Co-opted
• Chris Clarke (Devon) • Aidan Egleston (DDA)
• A Edwards (Wales) • David Hogg (First 5)
• Rob Lambourne • ? (AiT)
(Cumbira) • Jayne Randall-Smith
• Krystian Mears (IRH)
• Malcolm Ward (Derbysh’) • Russell Walshaw (GPC)
• John Wynne-Jones
(Powys,Wales)
68. RFSG: How we work
• Email: weekly to daily
• Small group Skype sessions
• Teleconferencing
• Face to face: 3 per year
69. Revalidation: concerns of rural
practices:
Discussions with College and GMC
1. Multi source feedback (MSF)
2. Clinical audits
3. Significant Event Auditing (SEA)
4. Learning Credits.
70. Phased introductory requirements
Evidence Yr 1 (2010-11) Yr 2 (2011-12) Yr 3 (2012-13) Yr 4 (2013-14) Yr 5 (2014-15)
Role Yes Yes Yes Yes Yes
description
Exceptional Yes Yes Yes Yes Yes
circumstances
Evidence of one two three four five
appraisals
PDPs one two three four five
PDP reviews - one two three four
Learning 50 or CPD 50 100 150 200
credits
MSFs - 0ne MSF OR one one two
Patient - one PS one one two
surveys
Review of Yes Yes Yes Yes Yes
complaints
from 2009/10
SEAs one two three four five
Clinical audits - one one two two
Probity/Health Yes Yes Yes Yes Yes
statement
71. Responding to consultations
• Scottish Ambulance Service: “Our future
strategy”
• “Your choice of GP practice” (practice
boundaries)
• GMC Revalidation
• Control of Entry regulation Scotland
• The White Paper:
“Commissioning for patients”
•
72. Networking with other agencies
• College hierarchy
• GPC
• GMC
• IRH
• RPAS
• Euripa
• DDA
• BASICs
74. Rural blog: wwwruralgp.org.uk ruralgpgooglegroup
• Independent of RCGP but • Independent of RCGP
RF associated but RF associated
• Rural GP resource and • Popular discussion forum
central portal to other for rural GPs
resources
75.
76.
77. RuralGP.com: What’s changed?
• cleaner design
• - quicker to load
• - easier to manage
• - more info on career advice - with more to
come
• - previously was prohibited by some NHS
firewalls - this should be less of a problem
78. Membership
• England – 209 members
• Northern Ireland – 11 members
• Scotland – 125 members
• Wales – 31 members
• 7 international members
Total: 383
79. Membership
The Rural Forum is open to all RCGP
Members, Fellows, and Associates in
Training who declare an interest in
rural general practice and signal their
wish to join.
80. You need the Rural Forum
and the Rural Forum needs you!
