PENNSYLVANIA LYME DISEASE PREVENTION PROGRAM
by
Kirsten Lunn
B.S. in Biology, Grove City College, 2009
Submitted to the Graduate Faculty of
Health Policy and Management
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2014
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Kirsten Lunn
on
December 12, 2014
and approved by
Essay Advisor:
Gerald Barron, MPH
______________________________________
Associate Professor and Director MPH Program
Health Policy and Management
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Ronald E. Voorhees, MD, MPH
______________________________________
Professor of Public Health Practice, Epidemiology
Associate Dean for Public Health Practice, Office of the Dean
Director, Center for Public Health Practice
Senior Program Advisor, Allegheny County Health Department
Department of Epidemiology
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Keri-Ann Faley
Cardiovascular Health Section Manager
Pennsylvania Department of Health
Harrisburg, PA
______________________________________
ii
Copyright © by Kirsten Lunn
2014
iii
Gerald Barron, MPH
PENNSYLVANIA LYME DISEASE PREVENTION PROGRAM
Kirsten Lunn, MPH
University of Pittsburgh, 2014
ABSTRACT
As of 2013, Pennsylvania (PA) has the highest Lyme disease case count (number of cases) in the
United States (US). Lyme disease has become a disease of significant public health concern.
There were 4,981 confirmed cases in PA in 2013, yet this number may be ten times higher due to
underreporting. Lyme disease impacts all ages, genders, races, and ethnicities. However, the
highest rates in PA are among whites, males, and those between the ages of 5 to 14 and above
55. Risk for Lyme disease is dependent upon the number of ticks infected with B. burgdorferi,
the density of ticks in the environment, and the extent of contact between a person and ticks.
In order to reduce the Lyme disease incidence rate in PA, it is recommended that the
Pennsylvania Department of Health (PA DOH) implement a Lyme Disease Prevention Program
(Program). An effective Program will have two components: a pilot program delivered through
the Chester County Health Department in Chester County, PA, and a statewide program. The
pilot will utilize advisory committees on county-, district-, and state-levels to involve
stakeholders and to inform future Program activities and will implement prevention education for
the general public and health care professionals. The statewide program will implement
education for the public and health care professionals. This paper outlines the goals, objectives,
activities, and budget for the Program.
iv
TABLE OF CONTENTS
1.0
INTRODUCTION ........................................................................................................ 1
1.1
PROBLEM STATEMENT ................................................................................. 1
1.2
LYME DISEASE BURDEN ............................................................................... 1
2.0
1.2.1
U.S. Lyme Disease Burden .............................................................................. 1
1.2.2
PA Lyme Disease Burden................................................................................ 2
BACKGROUND .......................................................................................................... 3
2.1
LYME DISEASE ................................................................................................. 3
2.1.1
Signs and Symptoms ........................................................................................ 4
2.1.2
Treatment ......................................................................................................... 5
2.1.3
Risk Factors...................................................................................................... 5
2.1.3.1 Location.................................................................................................. 6
2.1.3.2 Hosts ....................................................................................................... 9
2.1.3.3 Season ................................................................................................... 10
2.1.3.4 Activities ............................................................................................... 13
2.1.3.5 Age, Gender, Race, and Ethnicity ..................................................... 14
3.0
PROGRAM DESCRIPTION .................................................................................... 18
3.1
LOGIC MODEL ................................................................................................ 21
3.2
ANNUAL BUDGET .......................................................................................... 22
v
3.3
BUDGET JUSTIFICATION ............................................................................ 26
4.0
PA’S PUBLIC HEALTH NETWORK AND LYME ACTIVITIES ..................... 30
5.0
OBJECTIVES – ANNUAL ACTIVITIES ............................................................... 32
5.1
OBJECTIVE 1 ................................................................................................... 32
5.1.1
Objective 1 Title: Increase Collaboration with Stakeholders. .................. 32
5.1.2
Objective 1: Annual Activities ...................................................................... 35
5.1.2.1 Form a State-Level Advisory Committee ......................................... 35
5.1.2.2 Form a County-Level Advisory Committee ..................................... 36
5.1.2.3 Form a District-Level Advisory Committee ..................................... 36
5.1.2.4 Develop a Report Format ................................................................... 37
5.1.2.5 Hold Meetings for the State-Level Advisory Committee ................ 37
5.1.2.6 Hold Meetings for the County-Level Advisory Committees ........... 37
5.1.2.7 Hold Meetings for the District-Level Advisory Committees ........... 37
5.1.2.8 Collect Reports from both District-Level and County-Level
Meetings .............................................................................................................. 38
5.2
OBJECTIVE 2 ................................................................................................... 38
5.2.1
Objective 2 Title: Increase Awareness through Lyme Disease Prevention
Education for the General Public ............................................................................. 38
5.2.2
Objective 2: Annual Activities ...................................................................... 39
5.2.2.1 Create Educational Materials for the General Public ..................... 39
5.2.2.2 Send a Notification to all Relevant Stakeholders ............................. 40
5.2.2.3 Implement Prevention Education for the Public ............................. 41
5.2.2.4 Create, Release, and Disperse a Press Release Template ................ 44
vi
5.2.2.5 Determine Relevant Areas for Signs ................................................. 44
5.2.2.6 Encourage Sign Posting ...................................................................... 45
5.3
OBJECTIVE 3: .................................................................................................. 45
5.3.1
Objective 3 Title: Increase Awareness through Lyme Disease Prevention
Education for Health Care Professionals ................................................................. 45
5.3.2
Objective 3: Annual Activities ...................................................................... 46
5.3.2.1 Release a Health Alert ........................................................................ 46
5.3.2.2 Email all Healthcare Professionals .................................................... 47
5.3.2.3 Make Patient Education Materials Available for Health Care
Professionals ....................................................................................................... 47
5.3.2.4 Create Education Materials for Health Care Professionals............ 48
5.3.2.5 Implement Prevention Education for Health Care Professionals .. 48
APPENDIX A : POTENTIAL STAKEHOLDERS ................................................................. 51
APPENDIX B : EDUCATIONAL MATERIALS RESOURCES .......................................... 53
BIBLIOGRAPHY ....................................................................................................................... 56
vii
LIST OF TABLES
Table 1: PA counties with the highest Lyme disease case counts in 2013. ............................... 8
viii
LIST OF FIGURES
Figure 1: Sizes of blacklegged ticks at different lifecycle stages, as compared to a U.S. dime.
......................................................................................................................................................... 4
Figure 2: 5-year average incidence rate (new cases per 100,000) for Lyme disease in
Pennsylvania by county, 2009-2013. ............................................................................................ 7
Figure 3: Lifecycle of the blacklegged ticks. ............................................................................. 12
Figure 4: Mean annual Lyme disease case count (confirmed cases only) by age and sex in
the United States, 2001-2010. ..................................................................................................... 15
Figure 5: Lyme disease incidence rate (number of cases per 100,000) by age in
Pennsylvania, 2000-2011............................................................................................................. 16
ix
ACRONYMS
The following is a list of several acronyms used throughout this document.
BCHS
CT DPH
DHSS
Bureau of Community Health Systems
Connecticut Department of Public Health
Delaware Department of Health and Social
Services
Pennsylvania Department of Conservation and
Natural Resources
Pennsylvania Department of Health
Health Alert Network
Integrate Tick Management
Massachusetts Department of Public Health
Maine Department of Health and Human
Services
Minnesota Department of Health
New Hampshire Department of Health and
Human Services
New York State Department of Health
Pennsylvania Health Alert Network
United States Bureau of the Census
Virginia Department of Health
Vermont Department of Health
Wisconsin Department of Health Services
DCNR
DOH
HAN
ITM
MA DPH
ME DHHS
MDH
NH DHHS
NY DOH
PA HAN
US BOC
VDH
VT DOH
WI DHS
x
1.0
1.1
INTRODUCTION
PROBLEM STATEMENT
As of 2013, Pennsylvania has the highest Lyme disease case count in the United States.
Although Lyme disease impacts all ages, genders, races, and ethnicities, the highest rates are
among whites, males, and those between the ages of 5 to 14 and above 55. Risk for Lyme is
dependent upon the number of ticks infected with B. burgdorferi, the density of ticks in the
environment, and the extent of contact between a person and ticks.
1.2
LYME DISEASE BURDEN
1.2.1 U.S. Lyme Disease Burden
In the US in 2013, there were 27,203 confirmed and 9,104 probable cases of Lyme disease,
which is a total of 36, 307 confirmed and probable cases. The incidence rate during that same
year was 8.6 cases per 100,000 population (Centers for Disease Control and Prevention, 2014a).
These statistics reveal an increase from 2012, with 30,831 confirmed and probable cases and an
incidence rate of 7.0 cases per 100,000 population (Centers for Disease Control and Prevention,
2013a). Because of underreporting, the CDC estimates that the true number of Lyme disease
1
cases diagnosed per year is 300,000, which is around ten times higher than the actual case count
reported each year. The chief of epidemiology and surveillance for the CDC’s Lyme disease
program commented on this underreporting: “This new preliminary estimate confirms that Lyme
disease is a tremendous public health problem in the US, and clearly highlights the urgent need
for prevention” (Centers for Disease Control and Prevention, 2013b).
1.2.2 PA Lyme Disease Burden
In 2013, Pennsylvania had the highest number of confirmed Lyme disease cases and the highest
sum of confirmed and probable Lyme disease cases in the US. There were specifically 4,981
confirmed and 777 probable cases in PA, a sum of 5,758 cases. PA also had the eighth highest
incidence rate, with a rate of 39 cases per 100,000 population (Centers for Disease Control and
Prevention, 2014a). These statistics highlight a need for greater disease prevention measures in
PA. This need is even more augmented when underreporting is taken into consideration, as the
number of Lyme disease cases could be up to ten times greater.
2
2.0
BACKGROUND
2.1
LYME DISEASE
Lyme disease is caused by Borrelia burgdorferi (B. burgdorferi), a corkscrew-shaped bacterium,
also known as a spirochete (Centers for Disease Control and Prevention, 2013c; Stafford, 2007).
This bacterium is spread through the bite of infected ticks. Infected ticks are limited to
blacklegged ticks (Ixodes scapularis), commonly known as the deer tick, which spread Lyme in
the northeastern, mid-Atlantic, and north-central US, and the western blacklegged tick (Ixodes
pacificus), which spreads Lyme on the Pacific Coast (Centers for Disease Control and
Prevention, 2013c).
Ticks have four lifecycle stages, but only the last three must have a blood-meal to
survive: egg, six-legged larva, eight-legged nymph, and adult. Thus, humans are bitten by larva,
nymph, and adult ticks (Centers for Disease Control and Prevention, 2014b). Because both the
larvae and nymphs feed on hosts that can act as reservoirs for B. burgdorferi, more adult ticks
than nymphs are infected (Stafford, 2007). Humans can be infected by the bite of adult ticks, but
they are large and more likely to be removed before bacterial transmission. Instead, humans are
most often infected by the bite of nymphs, which are difficult to see at a size of less than 2mm,
similar to the size of a poppy seed (Figure 1). A tick must normally be attached for 36-48 hours
to transmit the bacterium (Centers for Disease Control and Prevention, 2013c).
3
(Centers for Disease Control and Prevention, 2013c)
Figure 1: Sizes of blacklegged ticks at different lifecycle stages, as compared to a U.S. dime.
2.1.1 Signs and Symptoms
The signs and symptoms of Lyme disease present themselves in three stages. Without treatment,
Lyme disease could progress from the early localized stage, to the early disseminated stage, to
the late disseminated stage. The early localized stage is characterized by erythema migrans
(EM), which is a red, expanding rash commonly known as the “bull’s-eye” rash. It is also
characterized by “fatigue, chills, fever, headache, muscle and joint aches, and swollen lymph
nodes” (Centers for Disease Control and Prevention, 2013d). The early disseminated stage is
characterized by EM lesions in other areas of the body, Bell’s palsy, meningitis, pain and
swelling in large joints, shooting pains, heart palpitations, and dizziness. Without treatment
symptoms may resolve within a few weeks to months or may create further difficulties. The late
disseminated stage is characterized by arthritis, joint pain, swelling, and, in rare cases, chronic
neurological problems. Even with treatment, Lyme patients may experience symptoms.
4
Even with the recommended 2-4 weeks of treatment, 10-20% of patients have symptoms
lasting months to years, especially for those diagnosed later (Centers for Disease Control and
Prevention, 2011; Centers for Disease Control and Prevention, 2013d; Centers for Disease
Control and Prevention, 2014c). This is called post-treatment Lyme disease syndrome. Its
symptoms include “muscle and joint pains, cognitive defects, sleep disturbance, or fatigue”
(Centers for Disease Control and Prevention, 2013d). According to the CDC, patients "almost
always get better with time," even if it takes months (Centers for Disease Control and
Prevention, 2011).
In about 1% of Lyme disease cases, patients may also experience Lyme carditis, which is
mild, moderate, or severe "heart block." In these cases, Lyme bacteria enter the heart tissue
(Centers for Disease Control and Prevention, 2014d).
2.1.2 Treatment
Treatment for early localized stage of Lyme disease consists of antibiotic treatment for
approximately 14 days. The range is 14 to 21 days. Both adults and children are treated with
amoxicillin, doxycycline, or cefuroxime axetil, and dosage amounts vary both by antibiotic type
and by whether a person is an adult or child (United States Department of Health and Human
Services, 2014).
2.1.3 Risk Factors
Risk for contracting Lyme disease depends largely on the prevalence of B. burgdorferi infection
in ticks, the density of ticks in the environment, and the extent of contact between a person and
5
ticks. The density of ticks in the environment “varies by place and season,” and the extent of
contact depends on the “type, frequency, and duration of a person’s activities in a tick infested
environment” (Pennsylvania Department of Health, 2013c). Ultimately, a greater amount of
exposure to an area with a high number of infected ticks increases risk.
2.1.3.1 Location
Lyme disease risk varies by region, state, and county. In the US, risk is highest in the
northeastern, mid-Atlantic, and north-central states (Centers for Disease Control and Prevention,
2013c). In Pennsylvania specifically, Lyme disease risk varies by county. Figure 2 shows the 5year average incidence rates in PA counties from 2009 to 2013. The counties with the highest
incidence rates have white stars overlaid on top, with over 100 new cases per 100,000 population
each year. These counties were Butler, Clarion, Armstrong, Jefferson, Elk, Cameron, Clearfield,
Fulton, Montour, Wyoming, Wayne, and Chester, in no particular order. Table 1 reveals the
case counts for ten counties with the highest Lyme disease case counts in PA in 2013. Chester
County, which also appears in Figure 2 with a star, had the highest case count of all other PA
counties.
Within counties, the greatest risk for tick bites and Lyme disease occurs in suburban
residential areas and rural homes when both are adjacent to wooded areas. Tick hosts thrive in
these areas (Connecticut Department of Public Health, 2008). The Virginia Department of
Health similarly notes that areas with expanding suburban development have a higher prevalence
of Lyme disease (Virginia Department of Health).
6
(Pennsylvania Department of Health, 2013b)
Figure 2: 5-year average incidence rate (new cases per 100,000) for Lyme disease in
Pennsylvania by county, 2009-2013.1
1
Disclaimer: "These data were provided by the Bureau of Health Statistics and Research, Pennsylvania
Department of Health. The Department specifically disclaims responsibility for any analyses, interpretations or
conclusions."
7
Table 1: PA counties with the highest Lyme disease case counts in 2013.
Jurisdiction
2013 Case Count
1. Chester
489
2. Bucks
337
3. Butler
332
4. Clearfield
308
5. Montgomery
301
6. Jefferson
236
7. Armstrong
232
8. York
219
9. Indiana
208
10. Westmoreland
159
(Pennsylvania Department of Health, 2013a)
8
Data on the incidence rates per county is available on the PA DOH website by clicking
on Diseases and Conditions on the tabs along the left hand of the webpage and scrolling down
until Lyme disease is reached. This opens up a page on the Lyme Disease Task Force. The
bottom of the page contains a link to information on Lyme disease, which opens up a Lyme
Disease Fact Sheet. At the very bottom of the Fact Sheet, the last link will take the reader to
county- and region-level Lyme disease data. The second-to-last link will take the reader to
helpful maps and graphs, which illustrate the data from the last link.
2.1.3.2 Hosts
Within locations, the risk of contracting Lyme disease may be impacted by the presence of tick
hosts. Deer are key hosts for blacklegged ticks. The size of the deer population often determines
the number and distribution of the blacklegged tick population. Thus, where deer populations
are overabundant, tick populations are often overabundant. Areas with adequate food and shelter
for the deer, such as a “mosaic of light fragmented woodland and woodland edges, clearings and
abundant shrubs, berries, grass, and forbs, and a lack of predators” attract deer (Stafford, 2007).
The residential landscape often encourages their presence (Stafford, 2007). Thus, these locations
may have a greater number of deer and ticks and greater rates of Lyme disease.
Both rodents and birds can also act as hosts for ticks. Thus, they are important in
transmitting B. burgdorferi to ticks and bringing ticks onto a person’s property. The level of
their importance depends on the number of these hosts in the environment, whether they are
infected with B. burgdorferi, and the number of ticks that feed on them. Of all animals, Stafford
labeled white-footed mice as the “most abundant and efficient animal reservoir” for Lyme
disease. More than 90% of white-footed mice are infected with B. burgdorferi, and more than
half are infected with B. burgdorferi and the bacteria causing anaplasmosis (Anaplasma
9
phagocytophilum) and babesiosis (Babesia microti). They infect 12 times the number of ticks as
chipmunks and 221 times the number of ticks as meadow voles. Next to white-footed mice,
eastern chipmunks are the second-most important rodent for maintaining Lyme disease. Shorttailed shrews act as reservoirs for both B. burgdorferi and B. microti and may help maintain
levels of these bacteria (Stafford, 2007). Where these rodents thrive, there may be a greater
number of ticks that are also infected.
Habitats where rodents reside include dense vegetation and ground cover plants. Whitefooted mice in particular live in woodland and brush habitats. The eastern chipmunk requires
vegetative cover, as exists in such places as woodland with undergrowth and brushlands.
In addition to the white-footed mouse, eastern chipmunk, and other rodents, birds can be
hosts for ticks. Specifically, they act as hosts for blacklegged tick larvae and nymphs. Certain
species actually carry B. burgdorferi, such as the American robin, veery, grackle, common
yellowthroat, Carolina wren, and house wren. Other species do not carry the bacteria and merely
act as hosts, including the gray catbird and woodthrush. It is difficult to determine the impact
birds have on the number of ticks in residential areas, and one study indicated that they may
actually dilute the number of ticks in comparison to mice. One study did note, however, that the
American robin increased the presence of nymphs in certain residential landscapes. Although,
the American robin can carry B. burgdorferi, but after two months, their ability to act as a
reservoir is reduced. Berry plants attract these birds (Stafford, 2007).
2.1.3.3 Season
Adult ticks are most active during cool months, and nymphs are most active during the spring
and summer, specifically between April and July, although ticks can be active when
temperatures are above 32 degrees Fahrenheit (Centers for Disease Control and Prevention,
10
2013c; Pennsylvania Department of Health, 2013c; New York State Department of Health,
2011). Because the statistics show that 98% of Lyme disease cases are associated with the bite
of nymphs, the seasonality of nymphs is most relevant when characterizing risk (Stafford, 2007).
The shaded area in Figure 2 shows similar data: humans are at greatest risk for infection during
the late spring and summer (Centers for Disease Control and Prevention, 2014b).
11
(Centers for Disease Control and Prevention, 2014b)
Figure 3: Lifecycle of the blacklegged ticks.
12
2.1.3.4 Activities
A person’s risk for developing Lyme disease depends largely on that person’s activities, such as
living, playing, or working. Doing these activities at a high frequency or for a prolonged period
of time near tick habitat and during a time of year that ticks are most active increases risk. Tick
habitat includes "Wooded, brushy, or overgrown grassy areas that are favorable for deer and the
tick’s rodent hosts" (Pennsylvania Department of Health, 2013c).
Individual Activities
Kirby C. Stafford III, Ph.D., Vice Director and Chief Entomologist of the Connecticut
Agricultural Experiment Station found that around 75% of Lyme disease cases are associated
with activities done around the home, such as playing or doing garden or yard work. For
example, playing puts children at a high risk of being exposed to ticks (Stafford, 2007).
Activities done away from the home that put people at risk include recreational activities like
hiking, camping, fishing, and hunting.
Occupations
Worksites near "high, wild grass, mixed hardwood forests, bushes, and leaf litter" put workers at
risk of being exposed to ticks. Occupations that put a person at greater risk include the
following:






Brush clearing workers
Construction workers
Landscapers
Farmers
Forestry workers
Irrigation worker
13




Land surveyors
Park or wildlife management workers
Utility line worker
Trail construction/management workers
The above list of occupations was taken from a New Hampshire publication (New
Hampshire Department of Health and Human Services, 2014).
2.1.3.5 Age, Gender, Race, and Ethnicity
To understand the risk of Lyme disease, it is important to understand how varied its impact is by
age, gender, race, and ethnicity. Based on the average annual Lyme disease case count between
the years of 2001 and 2010, Lyme disease was most common among boys aged 5-9 in the US
(Figure 4). Although it impacted all ages, the age groups in which it predominated were children
aged 5-9 and 10-14 and in adults aged 45-49 and 50-54. In these age groups, Lyme disease was
more common among males than females (Centers for Disease Control and Prevention, 2013e).
14
(Centers for Disease Control and Prevention, 2013e)
Figure 4: Mean annual Lyme disease case count (confirmed cases only) by age and sex in
the United States, 2001-2010.
15
(Epidemiologic Query and Mapping System)
Figure 5: Lyme disease incidence rate (number of cases per 100,000) by age in
Pennsylvania, 2000-2011.2
2
Disclaimer: "These data were provided by the Bureau of Health Statistics and Research, Pennsylvania Department
of Health. The Department specifically disclaims responsibility for any analyses, interpretations or conclusions."
16
Lyme disease’s impact on ages, genders, races, and ethnicities is similar in PA. As of
2011, the rate of Lyme was highest among children aged 5-14 years. This was true for all years
between 2000 and 2011. In 2011, the second highest rate of Lyme disease was in adults aged 55
years or older. This was also true in 2010, but between the years of 2000 and 2009, the rate was
consistently the second highest among adults aged 45-54 years. In 2011, Lyme disease was
higher among males than females, and was higher among whites than blacks and Hispanics.
This was true for all years between 2000 and 2011 (Epidemiologic Query and Mapping System).
Lyme disease’s impact on children is particularly important. Children have a higher risk
for contracting Lyme disease, which may be due to more time outside and a reduced likelihood
of noticing and removing ticks (Stafford, 2007; New Jersey Department of Health and Senior
Services, 2008).
17
3.0
PROGRAM DESCRIPTION
There is no doubt that the need for a Lyme Disease Prevention Program (Program) is immediate.
The ultimate goal of the potential Program is to reduce the Lyme disease incidence rate in PA.
In order to meet this goal, the Program has three objectives: increase stakeholder involvement,
increase awareness and implementation of prevention measures through Lyme disease
prevention education for the general public, and increase awareness through Lyme disease
prevention education for health care professionals. All Program activities aim to meet these
objectives. If these objectives are met, it is assumed that the goal of reducing the incidence rate
will also be achieved. To view a step by step explanation of how the achievement of these
objectives will lead to achievement of the Program goal, please see the Program logic model
(Chapter 3.1).
In order to effectively implement these activities, the Program will be divided into two
components: a pilot program and a statewide program. The pilot would consist of activities
meant to achieve all three objectives, and the statewide program would consist of activities
meant to achieve the last two objectives, which involve general public education and health care
professional education. If successful, activities carried out in the pilot would eventually be
administered statewide.
The pilot program would be carried out in Chester County and would consist of advisory
committees, educational presentations for the general public, and educational presentations for
18
health care professionals. Chester County was chosen because, in 2013, it had the greatest Lyme
disease case count in the state (Pennsylvania Department of Health, 2013a). Thus, the Program
would go where the need is greatest. Within Chester County, the Program PHPA at the state
level would collaborate with the Chester County Health Department to hold advisory meetings
and to administer educational presentations to the general public and health care professionals.
All other components aside from the advisory committees and prevention education for
the general public and health care professionals would be administered statewide. Thus,
activities such as notifying stakeholders of the availability of materials and releasing a health
alert, as listed in the Logic Model Activities column, would be administered statewide.
An essential component of all education activities is the inclusion of integrated tick
management (ITM) strategies. ITM involves using a number of evidence-based prevention
measures for reducing ticks. These strategies are included in the Tick Management Handbook,
written by K.C. Stafford III, Ph.D., of the Connecticut Agricultural Experiment Station in
Connecticut (Stafford, 2007). This handbook acts as a general tick-management guide for the
public, public health officials, and pest control operators, and it is highly advisable that the
public is made aware of the strategies.
Initially, the Program will focus on building awareness of ITM by including it in
education for the general public and health care professionals. It will leave implementation of
ITM prevention strategies to the public. These strategies include personal protection measures,
such as tick checks and tick removal; landscape management, such as changing landscape
vegetation to make it less likely to sustain tick and host populations; management of host
abundance, such as keeping hosts out of the yard with fences, reducing host abundance, and
managing host habitat to reduce host numbers; host-targeted acaricides, such as using devices
19
that apply pesticides to mice, chipmunks, or deer; area application acaricides, such as spraying
insecticides to reduce tick abundance; and biological and natural control, such as using fungal
pathogens and plant extracts to control tick abundance (Stafford, 2007).
ITM strategies have been determined to be effective. For example, regarding landscape
management measures, lawns that are well maintained have fewer ticks, expect in areas near tick
habitat, such as woodlands, stonewalls, or heavy groundcover and ornamental vegetation
(Stafford, 2007). Thus, it is possible to reduce the risk of being bitten by a tick through the
utilization of these strategies. It is highly recommended that the PA DOH educate the general
public and health care professionals on these strategies.
When educating on ITM, it may be important to highlight several warnings and caveats.
First, there will naturally be “ecological, economic, and sociological costs and benefits” to any
ITM measures chosen (Stafford, 2007). Second, ITM does not involve eliminating ticks but
involves reducing their numbers and preventing tick bites. Third, it also encourages using
pesticides responsibly, such as by limiting use and exposure (Stafford, 2007). There may be
other important warnings and caveats to share with the public, but these three may give the
public a clearer understanding of ITM’s potential impact and its purpose and goals
.
20
3.1
LOGIC MODEL
21
3.2
ANNUAL BUDGET
Categories
Personnel Services
Staff Personnel
Public Health Program Administrator
District-Level Committee Meeting Facilitator
Fringe Benefits
Life and Health Insurance ($20,712/position/year)
Other Fringe Items (30.4%)
Total
Total Costs
Total
$
Time Requested
53,927
100%
$ 8,296
15%
$
$
$
23,898
18,916
105,038
Consultant Services
State-Level Committee Meeting Facilitator
Total
$
$
13,445
13,445
Equipment
Computer
Chair
Panels
Total
$
$
$
$
2,100
700
2,900
5,700
Supplies
Office Supplies ($75.00/month/employee)
Educational Materials: Tick Identification Cards
Brochures
Pre and Post Surveys
Total
$
$
$
$
$
840
420
1,200
384
2,844
Travel
$
3,080
Contractual Costs
Chester County Health Department
Community Health Nurse
County-Level Committee Meeting Facilitator
$
$
13,293
13,445
22
23%
20%
23%
Total
$
Categories
Personnel Services
Consultant Services
Equipment
Supplies
Travel
Contractual Costs
Commonwealth Services Cost
Indirect Costs
Total
26,738
Total Cost
$ 105,038
$
13,445
$
5,700
$
2,844
$
3,080
$
26,738
$
$
17,825
$ 174,669
______________________________________________________________________________
Budget Appendix A
Total: $13,445
1. Name of Consultant: Unknown, State-Level Committee Meeting Facilitator
2. Organizational Affiliation: Unknown
3. Nature of Services to be rendered: For the Program’s first year, a State-Level Committee
Meeting Facilitator (Facilitator) will be responsible for facilitating meetings with the
State-Level Advisory Committee. This will include taking all necessary steps to ensure
that meetings runs successfully and that Program goals, objectives, and activities are
discussed at the meeting. Thus, the Facilitator will perform such activities as
communicating with all potential meeting attendees, finding a venue, ordering
refreshments, creating a meeting agenda, taking meeting notes, and writing meeting
reports.
4. Relevance of Service to the Project: The Facilitator’s position is essential to increase
collaboration with stakeholders.
5. Number of Days of Consultation: Four days for the meetings and 28 days total to prepare
for the meetings.
23
6. Expected Rate of Compensation: $13,445 given for all expenses incurred by the
Facilitator. The time expected of the Facilitator would be around 3 weeks to prepare for,
attend, and report on each meeting, which would be approximately 12 weeks out of the
year. Thus, we would request around 23% of this person’s time. 23% of a PHPA’s
salary is approximately $12,445. Extra funds amounting to $1,000 would be added for
travel and unexpected expenses, making total compensation $13,445.
Total Compensation
((3 weeks*4 meetings)/52 weeks/yr)*$53,927 = $12,445
$12,445 + $1,000 = $13,445
7. Method of Accountability: The PHPA will monitor the Facilitator’s consultant
agreement and ensure that the Facilitator completes his or her duties in a satisfactory
manner.
Budget Appendix B
Total: $27,293.00
1. Name of Contractor: Chester County Health Department, a department within the
County of Chester.
2. Method of Selection: The contractor was selected as sole source. Chester County was
chosen to carry out a pilot for the Program because it has the highest case count of Lyme
disease in Pennsylvania.
3. Period of Performance: The contract period is for one year.
4. Scope of Work: The contractor will be responsible for administering the pilot program
section of the Program. They will oversee the County-Level Advisory Committee, give
presentations to both the general public and health care professionals, and be responsible
24
for the completion of all deliverables that go along with these activities. Such
deliverables include the production of meeting notes, meeting reports, and pre- and postsurveys.
5. Method of Accountability: The PHPA will monitor the contractual agreement and
activities of Chester County Health Department. All deliverables from activities must be
given to the PHPA, who will determine if they were completed in a satisfactory manner.
6. Itemized Budget and Justification:
See Program Budget for specific amounts.
The Community Health Nurse would be responsible for conducting educational sessions.
He or she would be compensated for 20% of a Community Health Nurse’s salary, which
provides money to prepare for and give presentations once a week throughout the year.
The County-Level Committee Meeting Facilitator would responsible for facilitating
meetings with the County-Level Advisory Committee. This will include taking all
necessary steps to ensure that the meeting runs successfully and that Program goals,
objectives, and activities are discussed at the meeting. Thus, he or she will perform such
activities as communicating with all meeting attendees, finding a venue, ordering
refreshments, creating a meeting agenda, taking meeting notes, and writing meeting
reports.
25
3.3
BUDGET JUSTIFICATION
A. Salaries and Wages Total: $62,223.00
Public Health Program Administrator (PHPA)
The PA DOH has a job description for a Public Health Program Administrator. This job
description has been adapted for this Program, with nearly exact wording, to capture the
nature of a PHPA position within the PA DOH.
The PHPA will devote 100% of his/her time to assessing, developing, and
revising the Program. He or she will collect and analyze information pertaining to the
Program and disseminate it to technical and administrative staff and others; conduct
outreach and promotional activities regarding the Program; evaluate, develop and
monitor contracts and grants; and provide technical assistance and consultation to health
care providers, contractors and others. He or she will develop budgetary requests and
gather budget related data.
District-Level Committee Meeting Facilitator
The District-Level Committee Meeting Facilitator will be responsible for facilitating
meetings with the District-Level Advisory Committee. This will include taking all
necessary steps to ensure that the meeting runs successfully and that Program goals,
objectives, and activities are discussed at the meeting. Thus, he or she will perform such
activities as communicating with all meeting attendees, finding a venue, ordering
refreshments, creating a meeting agenda, taking meeting notes, and developing a
committee meeting report.
26
This District-Level Committee Meeting Facilitator will be compensated for 15%
of his or her time, since approximately 2 weeks would be required to prepare for, attend,
and report on each meeting. 15% of a PHPA’s salary is approximately $8,296. Because
he or she would be a district-level employee, the facilitator works for the state and would
be given fringe benefits, as well. See Fringe Benefit Total for calculations of fringe for
this employee and the PHPA.
Compensation
((2 weeks*4 meetings)/52 weeks/yr)*$53,927 = $8,296
B. Fringe Benefit Total: $42,814.00
Within the PA DOH, fringe benefits include life and health insurance and other fringe
items. Life and health insurance are $20,712 per position per year, and other fringe items
are 30.4% of total salary. Because the District-Level Committee Meeting Facilitator will
only work 15% of the time, he or she will only be compensated for 15% of $20,712, and
30.4% will be taken from $8,296 for other fringe items.
Personnel Fringe Benefits Budget
Life and Health Insurance
Total: $23,898.00
Other Fringe Items (30.4% of total salaries) Total: $18,916.00
Fringe Benefits = Life and Health Insurance (for PHPA and District-Level Committee
Meeting Facilitator) + Other Fringe Items (for PHPA and District-Level Committee
Meeting Facilitator)
= ($20,712.00 + 0.15*20,712.00) + 30.4%*($53,927.00 + $8,296)
27
= $23,898.00 + $18,916.00 = $42,814.00
C. Consultant Costs – See Program Budget Appendix A Total: $13,445.00
D. Equipment Total: $5,700.00
The computer, chair, and panels will be placed within the PA DOH and will
enable the PHPA to carry out his or her duties for the Program. Prices of the panels were
based upon the OFM® RiZe™ 47x72 Single Workstation, Gray/Cherry, Item:333753,
Model:811588018673, from Staples® with sales tax (Staples, 2014a).
E. Supplies Total: $2,844.00
Office supplies would be used by the PHPA to carry out his or her daily duties.
The PA DOH may need to reimburse the Chester County Health Department for
educational materials given during presentations for the pilot program. Educational
materials that may be needed are tick identification cards, brochures, and pre- and postsurveys. These materials would be given to every presentation attendee. If it is estimated
that an average of 100 people attend each educational presentation and that
approximately twelve presentations are given each year, the presentations would reach
around 1,200 people.
Tick identification cards could be printed like postcards and handed out to
attendees at each presentation to aid in the identification of Lyme-carrying ticks. Staples
offers postcards at a prices of $34.99 per 100 (Staples, 2014b). If 1,200 postcards were
needed, the cost would come to $419.88, which is approximately $420.00.
28
Office Depot would charge $1,200.00 to print and fold 1,200 brochures (Office
Depot, Inc., 2014a). These brochures would be given to attendees for educational
purposes.
Attendees would also be given pre- and post-surveys to test their knowledge of
Lyme disease before and after presentations. If the survey were 4 sheets long and each
person needed two surveys, 9,600 sheets of paper would be needed to provide for 1,200
people. Office Depot would charge around $384.00 for black and white copies (Office
Depot, Inc, 2014b).
F. Travel Total: $3,080.00
In-State Travel
Most of the PHPA’s travel would be in-state. He or she might travel from the PA DOH
to locations in Chester County for presentations when needed, which is an estimate of
160 miles round trip. Using an estimated six trips to account for six presentations,
lodging, mileage, parking, tolls, and subsistence for one year end up being approximately
$3,080.
G. Contractual Costs – See Program Budget Appendix B Total: $27,293.00
29
4.0
PA’S PUBLIC HEALTH NETWORK AND LYME ACTIVITIES
The Program will rely heavily on PA’s current public health network and take advantage of this
network’s current Lyme disease activities. Major parts of the Program will initially be
administered through the pilot in Chester County. However, PA’s network divides its services
across the state and is able to reach more state residents because of this, making it an ideal
network to transition from pilot activities to statewide activities.
PA’s public health network divides its services amongst district offices (districts), state
health centers (centers) and local health departments. All districts have a district executive
director, a district nurse administrator, community health nursing staff, and clerical staff, and
nearly all have epidemiology research associates. Many of the nursing staff and all of the
epidemiology research associates work on Lyme disease activities. The nursing staff includes
eight communicable disease nurse consultants, and all districts have at least one communicable
disease nurse consultant, with two districts having two. These communicable disease nurses do
education annually at hospitals and urgent care centers, ensuring that these health care
organizations know how to report all reportable diseases, including Lyme disease. Aside from
nurses, there are a total of six epidemiology research associates who work in the district offices,
with one in each district, except for the southwest and northeast districts. The southwest does
not have an epidemiology research associate but is covered by the northwest. The northeast
district has two.
30
The centers have nursing staff, clerical staff, and nursing supervisors who travel
throughout their assigned counties. Many nurses who work in the centers do Lyme disease
investigations with the diagnosing physician. And many of the nurses will do Lyme disease
presentations when requested (S. Podolak & J. Shirk, personal communication, August 8, 2014).
Local health departments include both county and municipal health departments, such as
the Chester County Health Department, and operate differently from the centers. They act
independently of the PA DOH, which means that the PA DOH is not present where the local
health departments are located. They provide public health services for their jurisdiction (S.
Podolak & J. Shirk, personal communication, August 8, 2014).
31
5.0
OBJECTIVES – ANNUAL ACTIVITIES
5.1
OBJECTIVE 1
5.1.1 Objective 1 Title: Increase Collaboration with Stakeholders.
Advisory committees shall be formed for the pilot program on the state, district, and county
levels to increase stakeholder involvement. Each advisory committee shall meet at least
quarterly, and each advisory committee shall develop a report after each meeting that will be
submitted to the other two advisory committees within 30 days of the meeting.
Justification:
The importance of stakeholder participation in the development of a Lyme Disease Prevention
Program cannot be overstated. According to the National Association of County and City Health
Officials (NACCHO), community participation in such processes as program development may
lead to more effective, sustainable solutions to problems (National Association of County and
City Health Officials, 2014). Stakeholder involvement is recommended by and has been tested
by the Connecticut Department of Public Health (CT DPH), as well. Consequently, advisory
committees were included in the Program.
Activities under this objective are based upon recommendations from a guide created by
32
the CT DPH and tailored for the pilot of this Program. The CT DPH’s guide, called “How to
Establish a Local Health Tick-borne Diseases Community Intervention Program,” was created
for Connecticut’s local health departments after both conducting Lyme prevention research in
three CT health districts and surveying local health officials on establishing local Lyme disease
intervention programs (Connecticut Department of Public Health, 2008). The recommendations
in this guide were used for the pilot of PA’s Program because of CT DPH’s experience in
carrying out Lyme and tick-borne interventions, especially since much of this experience is at the
local-level.
The CT DPH’s experience in Lyme prevention, particularly at the local-level, makes it a
trustworthy source of guidance for PA’s Program. The CT DPH conducted Lyme disease
prevention research through cooperative agreements with the Centers for Disease Control and
collaborated with the following stakeholders during that process: the Connecticut Agricultural
Experiment Station (CAES), the Connecticut Emerging Infections Program at the Yale
University School of Medicine, the University of Connecticut’s Geography Department and
Center for Survey Research and Analysis, the Westport Weston Health District (WWHD), the
Ledge Light Health District (LLHD), and the Torrington Area Health District (TAHD). It
implemented interventions in twenty-one towns within the WWHD, LLHD, and TAHD, which
are health districts in Connecticut, to improve prevention efforts for Lyme and other tick-borne
diseases. These community-level interventions resulted in a number of lessons learned, from
which the PA DOH can also learn (Connecticut Department of Public Health, 2008). The PA
DOH can apply these lessons by carrying out similar Lyme and tick-borne disease interventions
within each PA county, starting with a pilot in Chester County.
33
Implementation:
The purpose of forming advisory committees is to involve stakeholders and gain their support.
(Connecticut Department of Public Health, 2008). When the advisory committees meet, they
will carry out a number of responsibilities essential for creating a successful and sustainable
Program. Their responsibilities will be to brainstorm and develop additional or improved
Program strategies and activities, as was similarly suggested by the CT DPH, and to do so
specifically for the area which they oversee (Connecticut Department of Public Health, 2008).
For example, an advisory committee in Chester County would develop program strategies and
activities for Chester County. The Program strategies and activities should achieve the short,
medium, and long-term outcomes listed in the Program logic model and any additional goals
they deem essential (Chapter 3.1). Other major responsibilities will be determining baseline data
for all relevant Program objectives and outcomes; setting specific targets for all relevant Program
objectives and outcomes to make them measureable, including establishing a desired decrease in
Lyme disease incidence rate if possible; creating a timeline for achieving Program objectives and
outcomes; and discussing individual responsibilities for meeting the Program objectives and
outcomes. All of these responsibilities should be accomplished at the advisory committee
meetings.
Advisory meetings for each advisory committee will be held quarterly. Thus, there will
be one meeting per month, beginning with the State-Level Advisory Committee (explained
later). The meeting schedule was established to coincide with Lyme Disease Task Force
meetings, which also must be held quarterly (Lyme and Related Tick-Borne Disease
Surveillance, Education, Prevention and Treatment Act, 2014). The following is an example of
the annual meeting schedule:
34












Month 1: State-level Meeting
Month 2: County-level Meeting
Month 3: District-level Meeting
Month 4: State-level Meeting
Month 5: County-level Meeting
Month 6: District-level Meeting
Month 7: State-level Meeting
Month 8: County-level Meeting
Month 9: District-level Meeting
Month 10: State-level Meeting
Month 11: County-level Meeting
Month 12: District-level Meeting
For further details on the process of establishing advisory committees, holding committee
meetings, and general information on how to develop a Lyme disease intervention at the countylevel, please read How to Establish a Local Health Tick-borne Diseases Community Intervention
Program (Connecticut Department of Public Health, 2008).
5.1.2 Objective 1: Annual Activities
5.1.2.1 Form a State-Level Advisory Committee
An advisory committee shall be established at the state level. It shall include all employees
involved with the Program at the Pennsylvania Department of Health, including the Program’s
Public Health Program Administrator (PHPA) (please see the Program Budget Justification for a
job description), a State-Level Committee Meeting Facilitator (please see Budget Appendix A of
the Program Budget to read a description of duties), and at least one employee from the Bureau
of Community Health Systems. It shall also include a representative from the PA DOH
southeast district who is a part of the District-Level Advisory Committee and a representative of
the Chester County Health Department who is a part of the County-Level Advisory Committee.
35
All committee members must be educated on tickborne diseases using a PowerPoint
presentation, the Tick Management Handbook, and/or other relevant materials prior to the first
meeting.
This committee shall meet in conjunction with the Lyme Disease Task Force. According
to Senate Bill 177 of the Pennsylvania General Assembly, which is now Act 83, the Lyme
Disease Task Force was set up to investigate and advise the PA DOH on ways to improve efforts
surrounding Lyme and other tick-borne diseases, including surveillance, prevention, education,
and treatment (Lyme and Related Tick-Borne Disease Surveillance, Education, Prevention and
Treatment Act, 2014; Pennsylvania Medical Society, 2014). Accordingly, the Task Force will
make recommendations, and the PA DOH State-Level Advisory Committee will use their
recommendations to update, improve, and carry out their Program goals, objectives, and
activities.
5.1.2.2 Form a County-Level Advisory Committee
One advisory committee will be established in Chester County and will be led by the Chester
County Health Department. The committee shall include a minimum of one employee from the
Chester County Health Department and members from the community with diverse backgrounds
and experience. All members will be educated on tickborne disease, using such materials as a
presentation and the Tick Management Handbook, prior to the first meeting.
5.1.2.3 Form a District-Level Advisory Committee
An advisory committee will be established in the PA DOH Southeast District and overseen by
the Bureau of Community Health Services within the PA DOH. The committee shall include at
least one employee of the district office to lead and organize the committee and one member
36
from the Chester County Health Department. All members will be educated on tickborne
disease, using such materials as the Tick Management Handbook, prior to the first meeting.
5.1.2.4 Develop a Report Format
The PHPA shall develop a report format that must be used when creating and submitting reports
after committee meetings. This report shall include such items as the number and names of
attendees and any changes to Program goals, objectives, and activities that are discussed during
the meeting.
5.1.2.5 Hold Meetings for the State-Level Advisory Committee
Hold at minimum quarterly meetings with the committee. At these meetings, discuss such topics
as program goals, objectives, and activities. Ask committee members how they will help meet
these goals.
5.1.2.6 Hold Meetings for the County-Level Advisory Committees
Hold at minimum quarterly meetings with the County-Level Advisory Committee. This
committee will be run by one employee from the Chester County Health Department. At these
meetings, the organizers shall hand out tick-borne disease educational materials to inform
community members and surveys to determine local concerns about tick-borne diseases.
5.1.2.7 Hold Meetings for the District-Level Advisory Committees
Hold at minimum quarterly meetings with the district-level committee. During these meetings,
topics such as program objectives, goals, and strategies will be discussed. Meeting attendees
should be asked how they are willing to help meet these goals.
37
5.1.2.8 Collect Reports from both District-Level and County-Level Meetings
Reports shall be collected from the district-level and county-level meetings by the State-Level
Advisory Committee. Reports shall include all updated goals, objectives, and activities
discussed during the meeting.
Evaluation:
Objective 1 will be evaluated by tracking whether reports are produced after each committee
meeting. The number of reports should be equal to the number of meetings held annually, which
should be a minimum of four per committee and a minimum total of 12 meetings. All reports
will be evaluated, as well, to determine whether all required components are included.
It will also be documented whether each report is discussed during meetings for the next
highest committee, which would be during the following month. For example, it will be
documented whether reports from the local level are read during meetings at the district level.
This documentation will be sent to the Program PHPA for review.
5.2
OBJECTIVE 2
5.2.1 Objective 2 Title: Increase Awareness through Lyme Disease Prevention Education
for the General Public
The PA DOH shall increase the amount of prevention education within PA, both in Chester
County and statewide. All activities under this objective will be administered statewide, except
38
for Activity 3, which will be administered through the pilot. ITM strategies should be include in
education wherever the PHPA deems relevant.
Implementation:
The PA DOH will increase the amount of prevention education for the pilot by encouraging the
Chester County Health Department to conduct a minimum number of presentations each year. If
presentations are not requested, The Chester County Health Department will be responsible for
reaching out to organizations, such as camps, schools, and hospitals.
It is possible that the Program will increase the number of presentations statewide, in
addition to increasing them in the Pilot. Employees working in the Program will implement
activities under Objective 2, such as posting educational information on their Lyme website, and
will encourage district offices, state health centers, local health departments, and relevant
stakeholders to take advantage of these activities, such as by utilizing the educational
information in their own presentations. Initially, however, the Program will not aim to increase
presentations statewide. If the pilot is successful, the PA DOH may be able to administer the
pilot statewide and, thus, increase the number of presentations statewide.
5.2.2 Objective 2: Annual Activities
5.2.2.1 Create Educational Materials for the General Public
Educational materials shall be created on the dangers of ticks and tickborne diseases and
available prevention, diagnosis, and treatment options. A critical part of these educational
materials will be the inclusion of ITM strategies where appropriate.
39
Evaluation:
Evaluation will occur by tracking whether new educational materials, including a presentation,
such as a PowerPoint presentation, are produced or whether old educational materials are
gathered for use.
Implementation:
It is preferable for the PA DOH to create standardized and updated educational and promotional
materials to post online and print for dissemination. However, doing so may be an impractical
use of time and money resources. There are a number of existing resources that the PA DOH
can use to save time and money. Please see Appendix B to see more information on resources
and to view a list of available resources. Before using any of the materials, it would be advisable
for a public health professional, such as an epidemiologist, to review the information to ensure
that it is credible.
If the PA DOH were to create new educational materials, this could be done by
collaborating with the state-, district-, and county-level advisory committees, the Bureau of
Epidemiology, the district offices, the state health centers, and the local health departments. ITM
strategies should be incorporated.
5.2.2.2 Send a Notification to all Relevant Stakeholders
The PA DOH shall create a list of all relevant stakeholders, especially district offices, state
health centers, local health departments, camps, and schools, and inform them through email of
the availability of educational materials online, including presentations. This email shall also
encourage these stakeholders to forward the email to relevant stakeholders. Please see Appendix
A for information on potential stakeholders.
40
Evaluation:
Evaluation will occur by tracking the development of a list of stakeholders and by tracking
whether an email is created and disseminated to these stakeholders.
5.2.2.3 Implement Prevention Education for the Public
This activity specifically falls under the pilot portion of the Program. The PA DOH shall
encourage the Chester County Health Department to increase the number of Lyme disease
educational presentations to a minimum of 6 per year. The PA DOH shall also develop pre- and
post-surveys to give before and after the presentations to test knowledge gained and shall
develop three- and six-month follow-up surveys to test knowledge retained. These surveys shall
be disseminated to the Chester County Health Department who can then give them to
presentation attendees.
Justification:
It is beneficial to compare the PA DOH with other state health departments to determine how to
administer the Program most effectively. One comparison is between the PA DOH and the
Maine Department of Health and Human Services (ME DHHS). Sara Robinson, the State Level
Surveillance Epidemiologist at the ME DHHS, estimated that the ME DHHS gives a total of
around 40 to 50 presentations per year (personal communication, August 4, 2014). Staff
members at the state level and at the local level are responsible for giving these presentations (S.
Robinson, personal communication, August 4, 2014). At the local level, two city health
departments and six districts each give presentations to their area. The PA DOH would give
41
presentations with a similar structure but would delegate most presentations to the local health
departments and state health centers.
As a way to estimate the number of presentations PA DOH could be giving, the
populations of Maine and Pennsylvania were compared (1,328,302 and 12,773,801, respectively,
as of 2013) (United States [U.S.] Census Bureau, 2014a; U.S. Census Bureau, 2014b).
Proportionally, PA DOH would be required to do over 480 presentations in order to reach the
same number of people as the ME DHHS. Thus, if presentations were given statewide, each of
the 60 state health centers and 10 local health departments would give seven presentations. For
now, the objective will be to administer at least six educational presentations within the pilot of
Chester County.
Implementation:
Educational presentations will be administered initially by the employees at the Chester County
Health Department. When this component of the Program is administered statewide, it will
utilize PA’s public health network. If educational presentations were expanded statewide,
educational presentations would be administered through state health center nurses.
Many community health nurses at the state health centers have expressed interest in
doing more Lyme disease presentations and have requested up-to-date materials, such as tick
identification cards and pamphlets. Currently, if they give any materials away, they download
and print CDC materials. They are also interested in having an updated, standardized, and
approved PowerPoint presentation. They currently use an approved PowerPoint, but it is a year
or two old (S. Podolak & J. Shirk, personal communication, August 8, 2014). There is need for
updated materials and the interest to do more exists.
42
Evaluation:
Evaluation would occur by tracking the number of presentations given within Chester County.
The Chester County Health Department would be responsible for annually reporting to the PA
DOH the number of presentations given, the names of stakeholders represented at the
presentation if the presentation were given to a particular group or organization, and the number
of people in attendance.
To evaluate the presentation, pre- and post-surveys would be given out before and after
the presentations. They would test knowledge gained. The Program PHPA would be
responsible for analyzing this data.
Before giving the presentations, all participants would have the opportunity to sign up to
take a three- and six-month follow-up survey to test knowledge retained, to determine the
number of homes with ITM strategies implemented, besides personal protection measures, and to
determine if there was an increase in implementation of personal protection measures. Three and
six months after the presentation, the Chester County Health Department shall send an email to
all members who offered their contact information. To remove the burden of analysis from the
Chester County Health Department, the Program PHPA would analyze this data.
Evaluation would also occur by collaborating with relevant stakeholders at the county
level to determine if there is an increase in purchase of equipment for ITM strategies (other than
personal protection measures), such as host fencing, topical application devices, and acaricides,
and an increase in the purchase of repellants. The PHPA would be responsible for collaborating
with these stakeholders and analyzing the data collected from them.
43
5.2.2.4 Create, Release, and Disperse a Press Release Template
The PA DOH shall create a sample press release on the dangers of Lyme disease and other tick
borne diseases in PA, post it on their website, disperse it to all local health departments, district
offices, and state health centers, and encourage these stakeholders to create press releases for
their jurisdictions or local newspapers.
Implementation:
These press releases might be used by the PA DOH or by local health departments, district
offices, and state health centers whenever they deem necessary.
Evaluation:
The PA DOH will evaluate this activity by tracking whether a template is created and dispersed.
5.2.2.5 Determine Relevant Areas for Signs
The PA DOH shall cooperate with relevant stakeholders, including but not limited to other state
departments, such as the Department of Conservation and Natural Resources, district offices,
state health centers, and local health departments, to determine which areas should include signs
warning of the dangers of ticks, including but not limited to State parks and lands.
Evaluation:
Evaluation for this activity will consist of tracking whether a list of stakeholders is created.
44
5.2.2.6 Encourage Sign Posting
The PA DOH shall communicate with relevant stakeholders, including but not limited to other
State departments, such as the Department of Conservation and Natural Resources,
county/municipal health departments, camps, and schools, to raise awareness of tick-borne
diseases and promote the ordering and posting of signs that warn of the danger of ticks. The PA
DOH shall encourage these stakeholders to order signs from the CDC and post them. The PHPA
shall also create a survey for evaluation of this activity.
Evaluation:
To evaluate sign posting, the PA DOH shall send a survey to all relevant stakeholders to
determine the number of signs ordered and posted.
5.3
OBJECTIVE 3:
5.3.1 Objective 3 Title: Increase Awareness through Lyme Disease Prevention Education
for Health Care Professionals
Increase health care provider awareness of the dangers of Lyme disease for 100% of relevant
health care providers. All activities under this objective will be administered statewide, except
for Activity 5, which will be administered through the pilot. Where relevant, activities will also
include education on ITM strategies. Building awareness among health care professionals will
empower them to build awareness among patients.
45
5.3.2 Objective 3: Annual Activities
5.3.2.1 Release a Health Alert
The PA DOH shall send an alert through the Pennsylvania Health Alert Network (PA HAN)
reminding health care professionals of Lyme disease and other tick-borne diseases. The alert
shall include surveillance updates.
Justification:
Several of state health departments send out health alerts to health care professionals throughout
tick season on tick borne diseases. For example, the New Hampshire Department of Health and
Human Services (NH DHHS) sends out alerts through their HAN each May to hospitals and
providers. NH DHHS reminds professionals that it is tick season and updates them on relevant
information, such as reporting (W. Howe, personal communication, July 17, 2014). As another
example, the Delaware Department of Health and Social Services (DHSS) sends out an alert
through their HAN each spring with both tick-borne and mosquito-borne disease education,
including information on treatment and prevention (P. Eggers, personal communication, July 30,
2014). The PA DOH could reach health care professionals in a similar manner.
Implementation:
The PA DOH also has a HAN to communicate with “state and local public health agencies,
healthcare providers, hospitals, and emergency management officials” (Pennsylvania Department
of Health, 2014). In an interview, the BCHS suggested utilizing the HAN. For example, they
46
suggested that the PA DOH put together an instructional guide and send it to providers through
the PA HAN (S. Podolak & J. Shirk, personal communication, August 8, 2014). Using the PA
HAN, the PA DOH could replicate other state health departments who send alerts, and they
could send alerts each year by May 1.
Both the NH DHHS and the MDH have examples of health alerts on their webpages. The
following links give access to these examples:
NH DHHS
http://www.dhhs.nh.gov/dphs/cdcs/alerts/han.htm
MDH:
http://www.health.state.mn.us/divs/idepc/dtopics/tickborne/hcp.html
http://www.health.state.mn.us/han/2014/may20tickborne.pdf
5.3.2.2 Email all Healthcare Professionals
The PA DOH shall collaborate with the Bureau of Epidemiology, district offices, state health
centers, and local health departments to disperse an email to local hospitals, who will then
disperse it to relevant health care professionals. This email will include information on the
dangers of Lyme disease and available prevention, diagnosis, and treatment options, surveillance
updates, and a guide on how to order free CDC materials that are relevant for both physicians
and patients.
5.3.2.3 Make Patient Education Materials Available for Health Care Professionals
The PA DOH and all county/municipal health departments will ensure that 95% of relevant
health care professionals in Pennsylvania have access to and are aware of their access to
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resources that educate on the dangers of Lyme disease and available prevention, diagnosis, and
treatment options to share with patients. This can be included in the health alerts and physician
emails.
Evaluation:
A survey can be sent to all physicians who receive the health alerts and emails to determine if the
information was helpful.
5.3.2.4 Create Education Materials for Health Care Professionals
The PA DOH shall create an educational presentation on tick-borne diseases that can be given to
health care professionals during lunch hours, grand rounds, monthly hospital community
presentation days, or other convenient periods of time. This presentation shall be posted on the
PA DOH webpage to make it accessible for all relevant stakeholders.
5.3.2.5 Implement Prevention Education for Health Care Professionals
The Chester County Health Department will give presentations to educate local relevant health
care professionals on such matters as the dangers of Lyme disease and of available prevention,
diagnosis, and treatment options, reporting requirements, and integrating patient education into
the work setting. Education would include identifying and reviewing all relevant resources
available for physicians to print. It would also stress the importance of educating patients on
ITM strategies, specifically personal protection. The purpose of these presentations, ultimately,
is to raise awareness among healthcare professionals and encourage them to pass knowledge on
to their patients.
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Justification:
Other state health departments make it a priority to educate their health care professionals on
Lyme disease and other tick-borne or vector-borne diseases. The Vermont Department of Health
(VT DOH) does presentations at hospitals, as hospitals have monthly community presentations.
It also does presentations with other health care professionals, including with nurses and
physicians (E. Berl, personal communication, July 17, 2014). The MDH also honors requests for
presentations from places such as clinics and health systems (E. Schiffman, personal
communication, July 21, 2014). Furthermore, the Massachusetts Department of Public Health
(MA DPH) desires to give presentations to their health care providers because they rely on them
to educate patients (C. Brown, personal communication, July 18, 2014). These are only a few
examples of state health departments that dedicate time to educating their health care
professionals.
Virginia in particular has noticed a change in their state because of presentations. Over
time, the VDH has found that Lyme presentations have been useful. Giving presentations has
noticeably raised physician awareness of Lyme disease in the state (D. Gaines, personal
communication, July 11, 2014).
Evaluation:
The evaluation of presentations given to health care professionals mimic evaluation for
presentations given to the general public. The Chester County Health Department would be
responsible for tracking and reporting to the PA DOH the number of presentations given, the
organizations or practices represented, and the number of physicians in attendance.
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Pre- and post-surveys would be given out before and after the presentations and would
test knowledge gained.
All health care professionals would have the opportunity to sign up to take a three- and
six-month follow-up survey to test knowledge retained and determine the number of healthcare
professionals who educated their patients on ITM strategies, specifically personal protection
measures. Three and six months after the presentation, the Chester County Health Department
shall send an email to all professionals who offered their contact information, to determine
whether individuals have retained their knowledge of Lyme disease.
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APPENDIX A: POTENTIAL STAKEHOLDERS











Patients
Governor
PA Government Agencies
o Department of Health
 State Health Centers
 District Offices
 Municipal/County Health Departments
o Department of Conservation and Natural Resources
o Department of Education
o Department of Environmental Protection
o Fish and Boat Commission
o Game Commission
Lyme disease task force
Pennsylvania Health Care Professionals
o Licensed Physicians
o Physician’s assistant
o Certified registered nurse practitioner
o Other licensed health care professionals
o American Academy of Pediatrics
o American Academy of Family Physicians
Veterinarians
Epidemiologists
Entomologists
Insurers
Universities
Schools
o school administrators
o faculty
o staff
o nurse
o parents
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




o guardians
o students
Camps
Boy and Girl Scouts
Science Museums
Naturalists Groups
Pest Management Facilities
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APPENDIX B: EDUCATIONAL MATERIALS RESOURCES
Overview:
There are free Lyme disease educational materials that can be ordered from the CDC website.
There are also educational materials for other tick-borne diseases on the CDC website, other
state and local department websites, and other websites. If materials are downloaded from other
websites, it is preferable to download and print materials from a reputable government website,
as suggested by CT DPH (Connecticut Department of Public Health, 2008).
CDC Resources:
The CDC has free educational materials online for Lyme disease. The PA DOH can order these
free materials from the CDC’s Lyme disease website; however, there is a limit to the number that
can be ordered at a time. The PA DOH should order as many materials as necessary and also
encourage all relevant stakeholders to order enough free CDC materials to carry out Program
objectives and activities.

Lyme disease: http://www.cdc.gov/lyme/toolkit/index.html
o All Available Resources
 Brochure
 Fact Sheets
 Outdoor Workers
 Hikers
 Golfers
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 Pregnant Women
 Parents
 Lyme disease prevention for kids
 “Don’t let a tick make you sick” comic strip
 “Don’t let a tick make you sick” crossword puzzle and information
sheet
 Prevention bookmarks
 Trail Sign
 Web Widget
 Lyme Disease Quiz
 Radio PSAs
o Resources that can be Ordered for Free
 Brochure
 Prevention Bookmark
 Trail Sign
 “Tickborne Diseases of the U.S.: A Reference Manual for Health Care
Providers”
Other Resources:
In addition to ordering free information from the CDC, it is advisable to download and print
other available resources. Materials from the CDC do not include tick identification materials.
As stated by the Connecticut Department of Public Health, it is important to include tick
identification, including identifying species and tick life stages, in educational materials to make
it easier for the public to check themselves for ticks (2008). At the VDH, Dr. Gaines specifically
noted that tick identification charts are popular among VA residents (personal communication,
July 11, 2014).
If materials will be downloaded and print costs are a concern, a recommendation is to
determine if stakeholders are willing to offer discounts for printing or for advertising at their
business (Connecticut Department of Public Health, 2008).
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CT DPH Resources


Tick Management Handbook:
o http://www.ct.gov/caes/lib/caes/documents/publications/bulletins/b1010.pdf
o If the above link does not work, use the following procedure:
 Click on http://www.ct.gov/dph/cwp/view.asp?a=3136&q=528416 and
click on the link to the Tick Management Handbook within the second
paragraph
How to Establish a Local Health Tick-borne Diseases Community Intervention Program:
o http://www.ct.gov/dph/lib/dph/infectious_diseases/lyme/howtoguide.pdf
o If the above link does not work, use the following procedure:
 Click on http://www.ct.gov/dph/cwp/view.asp?a=3136&q=395590 and
click on the link to How to Establish a Local Health Tick-borne Diseases
Community Intervention Program – (2008) under “OTHER
INFORMATION”
Other State Health Department Resources








Delaware Department of Health and Social Services:
http://www.dhss.delaware.gov/dph/epi/lyme.html
Maine Department of Health and Human Services:
http://www.maine.gov/dhhs/mecdc/infectious-disease/epi/vector-borne/lyme/
Massachusetts Department of Public Health:
http://www.mass.gov/eohhs/gov/departments/dph/programs/id/epidemiology/ticks/
Minnesota Department of Health: http://www.health.state.mn.us/lyme
New Hampshire Department of Health and Human Services:
http://www.dhhs.state.nh.us/dphs/cdcs/lyme/
Vermont Department of Health:
http://healthvermont.gov/prevent/lyme/lyme_disease.aspx
Virginia Department of Health: http://www.vdh.virginia.gov/news/LymeDisease/
Wisconsin Department of Health Services:
http://www.dhs.wisconsin.gov/communicable/tickborne/Lyme/Index.htm
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