Knowledge, Prevention Practices,
and Risk of Tick-Borne Illnesses in
Hispanic and Non-Hispanic Persons
Shu Yang Hu (JHSPH MMI)
Primary Preceptor: Dr. Katherine Feldman (DHMH)
Secondary Preceptor: Dr. Christina Nelson (CDC)
Photo by DAVID ILIFF.
License: CC-BY-SA 3.0
Project Purpose
To examine differences in knowledge, attitudes, and practices
surrounding tick borne illness (TBI) in
Hispanic and non-Hispanic populations.
This map released by the Yale School of Public Health on Friday, Feb. 3, 2012 shows a map which indicates areas of the eastern United States where people
have the highest risk of contracting Lyme disease based on data from 2004-2007. (AP Graphic/Yale School of Public Health, Maria Diuk-Wasser)
Preceptor Organization
Organizations involved:
•
DHMH
•
University of Virginia
•
CDC (Fort Collins, CO)
Photo from Maps.com
Tick Borne Illnesses
Some ticks carry pathogens that can cause
human disease, including:
• Babesiosis
• Ehrlichiosis
• Rocky Mountain spotted fever
• Anaplasmosis
• Tularemia
• Lyme Disease (LD)
Bottom Photo (left to right): The blacklegged tick larva, nymph,
adult male and adult female. Photo from Dr Daniel Cameron.
LD Symptoms
Local Infection: erythema migrans (EM), may
be accompanied by headache, arthralgias,
myalgias, and fever
Late Infection: facial palsy, meningitis,
radiculoneuropathy, carditis, or
arthritis
Public Health Significance
•
LD: most common nationally notifiable vector-borne
illness in the United States
– 36,307 confirmed and probable cases in 2013
•
Common Risk factor: Outdoors
– Outdoor workers in Lyme-endemic areas have 5.1
greater odds of occupational tick exposure
•
Hispanics at risk?
– Represent 44.8% of grounds maintenance workers
and 42.8% of workers in the farming, fishing, and
forestry industries in US
– 7 million in Northeast/Midatlantic Region
– 30.7% of the population had no health insurance in
2010
Photo from O’Malley, M, Brown,
A, Sharfstein, J. (2013).
Objectives
What is the level of knowledge and awareness about TBI, particularly LD, in
Hispanic populations relative to non-Hispanic populations?
What preventive practices are followed regarding LD by these populations?
How might the attitudes of these populations relate to their current
practices?
If adequate public health knowledge, awareness, and/or practices regarding
TBI are lacking, identify priority areas for improvement.
Methodology
January 2015
Revise survey materials.
Goal: Complete 110
surveys from each ethnic
groups
Consult with
subject matter
experts
Site Selection and
Obtaining Permission
Input data into Excel.
Data analysis using
Excel and Stata 13.
On-site Survey
Administration
DHMH IRB Approval
May 2015
Definition of Hispanic: a person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin regardless of race. (U.S. Census Bureau, 2010)
Data Variables
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Zip Code
County of Residence
Age
Number of household members
Primary language spoken at home
Race/Ethnicity
Education level
Employment status
Previous LD diagnosis
Property characteristics (lawn, type of
residence)
Protective behaviors (time spent outdoors)
Tick attachment in the past year (crawling,
bites)
Knowledge of TBI
Born in the USA
English and Spanish
Versions
Results
•
•
•
•
N=168 participants, 83 Hispanic and 85 Non-Hispanic
Median age: 40 years old
– significantly younger population of Hispanics were surveyed than Non-Hispanics
(Pearson chi-square test, p-value<0.001)
Gender: Male (42.2%) in Hispanics, Male (23.5%) in Non-Hispanics
Primary Language: Spanish (80.5%) in Hispanics, English (100%) in Non-Hispanics
Hispanics
Time Spent
Outdoors
Non-Hispanics
Number
Percent
Number
Percent
3 hours or
less
39
52.0%
23
29.9%
4-10 hours
25
33.3%
37
48.1%
11-20 hours
6
8.0%
8
10.4%
21-30 hours
1
1.3%
1
1.3%
>31 hours
4
5.3%
8
10.4%
P-value
0.090
Knowledge of TBI and LD between Hispanics and Non-Hispanics
Non-Hispanic
79%
Correctly
Correctly identifiedticks
at least LDas
as a TBI
answered
vectors
Hispanic
37%
Non-Hispanic
68%
Correctly
Correctly identifed ticks as vector for LD
answered LD as
TBI
Hispanic
23%
0%
10%
20%
30%
40%
Both: Pearson chi-square test, p-value<0.001.
50%
60%
70%
80%
90%
100%
Prevention Measures against Ticks between Hispanics (N=56) and Non-Hispanics
(N=64).
41
45
38
40
35
30
25
20
19
25
19
17
19
8
15
1
10
6
1
5
0
5
Wear repellent
Shower after
coming indoors
Insecticide
treated clothing
Check body for
ticks
Other steps
No Steps
Hispanics
Non-Hispanics
• More Non-Hispanics (29.7%) would perform body checks than Hispanics (8.9%)
(Pearson chi-square test, p-value= 0.018).
• No steps to protect against ticks  largest number of people
Discussion
• Hispanics were significantly less knowledgeable about TBI
compared to Non-Hispanics
• Substantial number of people in both groups would take no
prevention measures
– Showering and body checks were more preferred
• Areas for improvement
 Reach out to young Hispanic adult
populations
 Have bilingual informational
materials ready
 Need for more visible public
health information
Photo from Health Impact News (2015)
Limitations
Small sample size
Self-reported data
Photo from Pet Life (2015)
IRB process
Photo from Hydro-Clean (2015)
Lessons Learned
• Site-specific: Expect and respect barriers to obtaining
permission
• Crucial to be familiar with target population’s language
• IRB application process
Acknowledgements
DHMH
JHSPH PHASE
Dr. Katherine Feldman
Shaylee Mehta
Mary Armolt
SB Wee
Heather Rutz
Kimberly Mitchell
Jennifer Le
Beth Resnick
CDC
Dr. Christina Nelson
University of Virginia
Andy Starr
References
Schwartz, BS, Goldstein, MD. Lyme disease in outdoor workers: risk factors, preventive measures, and tick removal methods. Am J Epidemiol.
1990 May;131(5):877-85.
Smith PF, et al. Occupational risk of Lyme disease in endemic areas of New York State. Ann N Y Acad Sci. 1988;539:289–301.
Nelson, C, Starr, JA, Kugeler, K, and Mead, P. (2015). Lyme Disease in the U.S. Hispanic Population: A Summary of 2000-2013 U.S. Surveillance
Data. Unpublished manuscript.
US Department of Labor, Bureau of Labor Statistics (February 2014). Labor Force Statistics from the Current Population Study. Retrieved
March 2015, from www.bls.gov/cps/cpsaat11.htm.
Ennis, SR, Ríos-Vargas, M, & Albert, NG (2011). The Hispanic Population: 2010. US Department of Commerce, Economics and Statistics
Administration, US Census Bureau.
CDC. Notice to readers: Final 2013 reports of nationally notifiable infectious diseases. MMWR Morb Mortal Wkly Rep 2014;63(32):702-715.
Wormser, GP. Early Lyme disease. N Engl J Med. 2006 Jun 29;354(26):2794-801
Stanek G, Wormser GP, Gray J, Strle F. Lyme borreliosis. Lancet 2012;379:461-73.
DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith, U.S. Census Bureau, Current Population Reports, P60-239, Income,
Poverty, and Health Insurance Coverage in the United States: 2010, U.S. Government Printing Office, Washington, DC, 2011.
O’Malley, M, Brown, A, Sharfstein, J. (2013). Hispanics in Maryland: Health Data and Resources. Maryland State Department of Health and
Mental Hygiene, Office of Minority Health and Health Disparities.
Department of Labor, Licensing and Regulation. (2014). Retrieved May 2, 2015, from
http://www.dllr.state.md.us/lmi/laus/baltimorecity.shtml