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TICKS AND TICK-BORNE DISEASE:A MULTIMODAL APPROACH TO LYME

Photo courtesy of NCVP

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Justine A. Lee, DVM,

DACVECC, DABT

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Introduction

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Garret Pachtinger

VMD, DACVECC

COO, VETgirl

Introduction

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Richard E. Goldstein, DVM, DACVIM, DECVIM-CA Executive Director and Chief Medical Officer of U.S. Diagnostics, Zoetis

Introduction

TICK BASICS

Photo by Keith Weller, USDA/ARS 16 |

COMMON TICK GENERA OF U.S. IMPORTANCE� Amblyomma spp.

– Amblyomma maculatum (Gulf Coast tick) – Amblyomma americanum (Lone Star tick)

� Dermacentor spp.– Dermacentor variabilis (American dog tick) – Dermacentor andersoni (Rocky Mountain Wood Tick)

� Rhipicephalus spp.– Rhipicephalus sanguineus (brown dog tick)

� Ixodes spp.– Ixodes scapularis (deer tick or black-legged tick) – Ixodes pacificus (Western black-legged tick)

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Zoetis Atlas of Veterinary Clinical Parasitology.

GENERALIZED HARD TICK LIFE CYCLE

Engorgedfemale feeding

on a host

2

Adult ticks attachand feed on dogs,

humans, foxes, etc.

1Engorged female ticks fall off host and lay several thousand eggs

3

Larvae feed on small mammals such as mice

4

Larvae drop off andmolt into nymphs

5Nymphs feed on mice, dogs, cats or humans

and molt to adults

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COMMON CLIENT OBJECTIONSWe don’t have ticks

where I live

Why don’t Isee them?

We don’t have trees

We only stay onthe trail

Ticks die off inthe winter

� Show them the maps

� Go back to lifecycle basics� Not fleas; short time on host� Pre-adult stages very small

� Ticks quest at host level(grass,bushes,etc)� They don’t drop from trees

� Dermacentor spp. are abundant

� Ixodes spp. adults most active Oct–Feb

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LYME DISEASE(BORRELIOSIS)

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Prevalence Rates0%–1%1%–2%2%–5%5%–8%8%–10%10%–15%15%–100%

� 30K cases per year1

� CDC believes actual cases to be closer to 300k per year2

PREVALENCE MAP – HUMANS 2015 CENTERS FOR DISEASE CONTROL & PREVENTION (CDC)

PREVALENCE MAP – CANINES 2017 COMPANION ANIMAL PARASITE COUNCILTM (CAPC)

� 73.8% increase in positive cases reported since 20123

� 283k cases per year3

� Lyme disease incidence in people was positively correlated with canine seroprevalence4

1. http://www.cdc.gov/lyme/stats/chartstables/incidencebystate.html. Accessed on Sep 20, 2017. 2. https://www.cdc.gov/lyme/why-is-cdc-concerned-about-lyme-disease.html. Accessed Jan 6, 2018 3. http://www.capcvet.org/parasite-prevalence-maps. Accessed Sep 20, 2017. 4. Mead PS et al; Canine Serology as Adjunct to Human Lyme Disease Surveillance. Emerging Infectious Diseases. 2011;17(9):1710-1712.

PREVALENCE OF LYME DISEASE IS INCREASING IN HUMAN AND CANINE POPULATIONS

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� Causative agent: Borrelia burgdorferi

� Vector: Ixodes spp

� Geographic distribution: – Northeast, Midwest and Pacific Northwest– Recently reported in Mid Atlantic, Southern

Appalachia and Southern Canada

� Clinical signs: Fever, lethargy, and shifting leg lameness

– In some cases, potentially fatal glomerulonephritis

LYME DISEASE

Drs. Nielssen, Carr, and Heseltine, VA Tech, 2002, Dr. Craig Greene, Univ. GA, 2003.

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�Causative agent of Lyme disease or Lyme borreliosis

�B. burgdorferi, B. garinii,B. afzelii

�Vectored by Ixodesspp. ticks

�Gram-negative spiral-shaped bacterium

BORRELIA SPP.

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� Causative agent: Anaplasma phagocytophilum

� Vector: Ixodes spp

� Geographic distribution: – Northeast, Midwest and Pacific Northwest– Recently reported in Mid Atlantic, southern

Appalachia and Southern Canada– Often a co-infection with B. burgdorferi

� Clinical signs: Acute onset polyarthritis, fever, bleeding, thrombocytopenia

ANAPLASMOSIS(PREVIOUSLY EHRLICHIA EQUI)

Drs. Nielssen, Carr, and Heseltine, VA Tech, 2002, Dr. Craig Greene, Univ. GA, 2003.

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ANAPLASMA SPP.A. PHAGOCYTOPHILUM –GRANULOCYTIC ANAPLASMOSIS� Rodents considered main reservoir � Multiple vertebrate hosts including

mice, deer, dogs, cats, horses, and humans

� Vectored by I. scapularis andI. pacificus

A. PLATYS – CANINE CYCLIC THROMBOCYTOPENIA� Invades platelets� Maintenance cycle not confirmed,

dogs likely reservoir host and vectored by R. sanguineus

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25 | � http ://w w w .capcvet.o rg /parasite -preva lence-m aps/ accessed 12-10-17 26 |

� http ://w w w .capcvet.o rg /parasite -preva lence-m aps/ accessed 2-21-16

� http ://w w w .capcvet.o rg /parasite -preva lence-m aps/ accessed 12-10-17

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C6Detection

Clinical Signs

Weeks After Infection

Prot

ein-

Spec

ific

Antib

ody

Conc

entra

tions

Schematic representation of antibody concentrations to different outer surface proteins of B. burgdorferi. Antibodies to C6 precede the onset of clinical signs and indicate infection.9

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Data on file, Study Report: B865R-US-12-018, Zoetis Inc.

VACCINATION WITH VANGUARD crLYMEPREVENTS DEVELOPMENT OF LYME LESIONS

Synoviallayers

Skin

Vaccinates Non-Vaccinates

Normal neural fiber Nodular lymphoplasmacytic infiltrate present around neural fiber

No inflammatory infiltrates present Nodular mononuclear (lymphoplasmacytic) infiltrate present

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A POSITIVE POC TEST! WHAT HAPPENS NEXT?

LYMEClinical Signs: lameness, joint swelling, polyarthritis, protein-losing glomerulopathy?

Asymptomatic Symptomatic

UA and Urine Protein Creatinine Ratio• UA/UPC, qC6, Chemistry Panel• Antimicrobial therapy• +/- Repeat qC6 after therapy

Negative Positive

Follow UA/UPC 2-3 times+/- Antimicrobial therapy

Antimicrobial therapyFollow UA/UPC in 2-3 wksqC6 of remains proteinuric after treatment

Littman, M.P. (2018) ACVIM consensus updated on Lyme borreliosis in dogs and cats. JVIM; 1-17.

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A POSITIVE POC TEST! WHAT HAPPENS NEXT?

ANAPLASMA/EHRLICHIA

CBC

Treat to avoid progressionOR

Choose not to treat

CBC WNL CBC abnormal

Treat

Greene, E.C. (ed.). Infectious Diseases of the Dog and Cat (4th ed.) St. Louis, MO. ElsevierLittle, S. 2010. Veterinary Clinics of North America Small Animal Practice 40: 1121–1140.

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TREATMENT!

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Borrelia burgdorferi1

� REVISIT TICK CONTROL WITH DOG OWNER

� Immunity from natural infection not protective against subsequent infections

� Borrelia burgdorferi localizes in tissues and infection can recrudesce

� Incubation period for Lyme arthropathy can be prolonged, painful and under-reported/underdiagnosed

– Median 68 days2

� Perform GPE, UP:UC; consider 4-6 weeks antimicrobial treatment

� Renal failure is progressive and terminal (mycophenolate preferred tx)

� Labrador and Golden Retriever dogs are at increased risk of Lyme nephritis3

– Impaired removal of immune complexes from glomeruli?1. Littman, M.P. (2018) ACVIM consensus updated on Lyme borreliosis in dogs and cats. JVIM; 1-17. 2. Straubinger et al., 1998 Wiener Klinische Wochenschrift 110(24):874-81.3. Littman et al., Journal of Veterinary Internal Medicine 2006;20:422–434.

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Littman, M.P. (2018) ACVIM consensus updated on Lyme borreliosis in dogs and cats. JVIM; 1-17.

Borrelia burgdorferi

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PREVENTION STRATEGIES

Tick Removal

Tick Control

Vaccination

TICKCONTROL

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� A novel isoxazoline parasiticide that kills fleas and ticks*

� A monthly liver-flavored chewable that can be given with or without food

� Fast acting– Starts killing fleas in 3 hours– Starts killing ticks in 8 hours1

� Persistent – doesn’t lose efficacy at the end of the month– ≥ 96.2% effectiveness within 8 hours after flea infestation through Day 35– ≥ 96.9% effectiveness for 35 days against all labeled ticks2

� Kills fleas before they lay eggs for 35 days

� In a simulated home infestation, >95.6% reduction in adult fleas within 14 days after treatment and 100% by day 60

WHAT IS SIMPARICA (SAROLANER)?

*Indicated for: Ixodes scapularis (black-legged or deer tick), Amblyomma americanum (Lone star tick), Amblyomma maculatum (Gulf Coast tick), Dermacentor variabilis (American dog tick), and Rhipicephalus sanguineus (brown dog tick).1. Evaluation of the speed of kill of sarolaner (Simparica™)against induced infestations of three species of ticks (Amblyomma maculatum, Ixodes scapularis, Ixodes ricinus) on dogs; Robert H.Six, et al; Veterinary Parasitology; http://dx.doi.org/10.101 6/j.vetpar.2016.02.014.2. Six RH, et al. Efficacy of a novel oral formulation of sarolaner (Simparica™) against five common tick species infesting dogs in the United States. Veterinary Parasitology 2016 May 30(222):28-32.

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SIMPARICA CHEWABLE TABLETS DEMONSTRATED ≥ 96.9% EFFECTIVENESS FOR 35 DAYS AGAINST 5 COMMON SPECIES OF TICKS FOUND IN THE US

Efficacy of a novel oral formulation of sarolaner (Simparica™) against five common tick species infesting dogs in the United States, Robert H. Six et al, Veterinary Parasitology, Volume 222, 30 May 2016

I. scapularis � (Black-legged tick)

A. americanum � (Lone Star tick)

A. maculatum � (Gulf Coast tick)

D. variabilis � (American Dog tick)

R. sanguineus � (Brown Dog tick)

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SIMPARICA IMPORTANT SAFETY INFORMATION

IMPORTANT SAFETY INFORMATION: Simparica is for use only in dogs, 6 months of age and older. SIMPARICA may cause abnormal neurologic signs such as tremors, decreased conscious proprioception, ataxia, decreased or absent menace, and/or seizures. Simparica has not been evaluated in dogs that are pregnant, breeding or lactating. Simparica has been safely used in dogs treated with commonly prescribed vaccines, parasiticides and other medications. The most frequently reported adverse reactions were vomiting and diarrhea. See full Prescribing Information at www.zoetisUS.com/SimparicaPI

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SIMPARICA IS EFFICACIOUS AGAINST TICKS THAT CARRY INFECTIOUS ORGANISMS

Simparica kills ticks quickly, which may reduce the likelihood of transmissionof the pathogens that cause disease

Ixodes scapularis(Black-legged“Deer” Tick)

� Borrelia burgdorferi – Lyme Disease � Anaplasma phagocytophilum – Anaplasmosis� Ehrlichia muris / EML agent – Ehrlichiosis

Rhipicephalussanguineus

(Brown Dog Tick)

� Ehrlichia canis – Ehrlichiosis � Babesia spp. – Babesiosis

Dermacentorvariabilis

(American Dog Tick)

� Rickettsia rickettsii – Rocky Mountain Spotted Fever� Francisella tularensis –Tularemia

Amblyommaamericanum(Lone Star Tick)

� Ehrlichia chaffeensis – Human monocytic ehrlichiosis� Ehrlichia ewingii – Granulocytic ehrlichiosis� Rickettsia amblyommii – Rickettsiosis � Francisella tularensis –Tularemia

Amblyommamaculatum

(Gulf Coast Tick)

� Hepatozoon americanum – American canine hepatozoonosis

� Rickettsia parkeri – Rickettsiosis

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Comparative speed of kill of sarolaner (Simparica™) and afoxolaner (NexGard® ) against induced infestations of Ixodes scapularis on dogs; Robert H. Six et al; Parasites & Vectors (2016) 9:79.

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RESULTS – 24 HOURS

SIMPARICA COMPARATIVE TICK (I. SCAPULARIS) SPEED OF KILL VS NEXGARD® (AFOXOLANER)

PERCENT REDUCTION IN GEOMETRIC MEAN LIVE I. SCAPULARIS COUNTS – 24 HOURS

99.7 99.1 100.0 98.8 96.699.5 95.1 95.1

77.971.8

0102030405060708090

100

Day 1 Day 8 Day 15 Day 22 Day 29

Per

cent

Red

uctio

n

Day of CountSaro laner Afoxolaner

* * *

* Simparica significantly different than NexGard (P≤0.0278).Comparative speed of kill of sarolaner (Simparica™) and afoxolaner (NexGard® ) against induced infestations of Ixodes scapularis on dogs; Robert H. Six et al; Parasites & Vectors (2016) 9:79.

NexGard® is a trademark of Merial Inc.42 |

Six RH, Geurden T, et al. Evaluation of the speed of kill of sarolaner (Simparica™) against induced infestations of three species of ticks (Amblyomma maculatum, Ixodes scapularis, Ixodes ricinus) on dogs. Veterinary Parasitology 2016 May 30(222):37-42

* Simparica significantly different than Placebo (P≤0.0234).

IN EXISTING INFESTATIONS, SIMPARICA HAD 98.8% EFFICACY WITHIN 12 HOURS; FOR RE-INFESTATION ³95.7% AT 24 HOURS AFTER INFESTATION THROUGH DAY 29

PERCENT REDUCTION IN GEOMETRIC MEAN LIVE I. SCAPULARIS COUNTS

0.015.0

20.7

0.0 9.5 0.0

56.5

0.0 0.0 0.0 9.6 0.0

98.891.7

68.874.0

62.0

17.6

100 100 98.795.7 97.2

74.9

0102030405060708090

100

Day 0/1 Day 7/8 Day 14/15 Day 21/22 Day 28/29 Day 35/36

Per

cent

Red

uctio

n

Day of Count

4 Hours 8 Hours 12 H ours 24 H ours

*

* **

*

*

*

*

*

*

*

*

*

*

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IXODES SCAPULARIS(BLACK-LEGGED/DEER TICK)

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3 GROUPS OF 8 DOGS EACHSTUDY DESIGN

Group 1Placebo Given

Day 0 and 7

Group 2Sarolaner Given

Day 0

Group 3Sarolaner Given

Day 7

� Adult ticks were obtained from Rhode Island � PCR prior to infestation (tick infectivity):

– 57% were positive for B. burgdorferi – 6.7% were positive for A. phagocytophilum

� Each dog was infested with 50 (±5) I. scapularis ticks on Day 28.– Day 29 – Tick counts without removal were performed (24 ± 2 hrs after infestation) – Day 30 – Tick counts without removal were performed (48 ± 2 hrs after infestation)– Day 33 – Tick count and removal

� Blood was collected on Days -6, 27, 49, 63, 77, 91, and 104

� Skin biopsy was performed on Day 104Honsberger N et al, Efficacy of sarolaner in the prevention of Borrelia burgdorferi and Anaplasma phagocytophilum transmission from infected Ixodes scapularis to dogs; Veterinary Parasitology Volume 222, 30 May 2016, Pages 67–72.

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“EFFICACY OF SAROLANER IN THE PREVENTION OF BORRELIA BURGDORFERI TRANSMISSION FROM INFECTED IXODES SCAPULARIS TO DOGS”

The number of dogs ‘Ever Positive’ for B. burgdorferi was significantly differentthan the placebo group (P=0.0002)

TREATMENT GROUP

DAY OF TREATMENT

DAY OF TICK INFESTATION ANTIBODY PCR CULTURE

Placebo 0 and 7 28 6 of 8 (75%)

7 of 8 (87.5%)

7 of 8 (87.5%)

Sarolaner 0 28 0 of 8(0%)

0 of 8(0%)

0 of 8(0%)

Sarolaner 7 28 0 of 8(0%)

0 of 8(0%)

0 of 8 (0%)

Results: Borrelia burgdorferi Transmission

Honsberger N et al, Efficacy of sarolaner in the prevention of Borrelia burgdorferi and Anaplasma phagocytophilum transmission from infected Ixodes scapularis to dogs; Veterinary Parasitology Volume 222, 30 May 2016, Pages 67–72.

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In this well-controlled laboratory study, a single oral dose of 2 mg/kg sarolaner

blocked transmission of Borrelia burgdorferi in dogs exposed to infected ticks

21 or 28 days after treatment

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CONCLUSION

Honsberger N et al, Efficacy of sarolaner in the prevention of Borrelia burgdorferi and Anaplasma phagocytophilum transmission from infected Ixodes scapularis to dogs; Veterinary Parasitology Volume 222, 30 May 2016, Pages 67–72.

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Although not statistically significant (P=0.0769), none of the sarolaner-treated dogs were ‘ever positive’ for A. phagocytophilum, indicating 100% blocking of

A. phagocytophilum transmission

Results: A. phagocytophilum Transmission

TREATMENT GROUP

DAY OF TREATMENT

DAY OF TICK INFESTATION ANTIBODY

Placebo 0 and 7 28 4 of 8 (50%)

Sarolaner 0 28 0 of 8(0%)

Sarolaner 7 28 0 of 8(0%)

“EFFICACY OF SAROLANER IN THE PREVENTION OF ANAPLASMA PHAGOCYTOPHILUM AND TRANSMISSION FROM INFECTED IXODES SCAPULARIS TO DOGS”

Honsberger N et al, Efficacy of sarolaner in the prevention of Borrelia burgdorferi and Anaplasma phagocytophilum transmission from infected Ixodes scapularis to dogs; Veterinary Parasitology Volume 222, 30 May 2016, Pages 67–72.

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In this well controlled laboratory study, a single oral dose of sarolaner successfully

blocked the transmission of A. phagocytophilum from infected wild-caught I. scapularis to dogs for 28 days

CONCLUSION

Honsberger N et al, Efficacy of sarolaner in the prevention of Borrelia burgdorferi and Anaplasma phagocytophilum transmission from infected Ixodes scapularis to dogs; Veterinary Parasitology Volume 222, 30 May 2016, Pages 67–72.

VACCINATION

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BORRELIA SPP. TICK ATTACHMENT → <24–53 HOURS LATER

� Borrelia transmission occurs� Outer surface protein A (OspA) in midgut ↓

– Required for Borrelia to infect ticks– Found in tick midgut and switches off soon after tick attachment to mammal

� OspC ↑– Required for Borrelia spp. to infect mammals– In tick salivary glands and is the main immunogenic protein of Borrelia

– Approximately 15 OspC’s in the USA, 30 worldwide

IMMUNE RESPONSE TO NATURAL INFECTION WITH BORRELIA SPP� Dogs have no natural exposure to OspA → Anti-OspA antibodies not

reliably produced

� Anti-OspC antibodies are short-lived and highly type specific� Borrelia spp. are relatively insensitive to canine complement

� Vaccination with annual OspA + OspC vaccine helps prevent further transmission of Borrelia from ticks feeding on vaccinated dogs

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1. Schwan TG, Piesman J., et al. Induction of an outer surface protein on Borrelia burgdorferi during tick feeding. Proceedings of the National Academy of Science. March 1995; 92:2909-2913.2. Rhodes D., et al. Identification of Borrelia burgdorferi OspC genotypes in canine tissue following tick infestation: Implications for Lyme disease vaccine and diagnostic assay design. The Veterinary Journal. 2013;198:412-418.

ADVANCEMENTS IN RECOMBINANT TECHNOLOGY WERE NEEDED TO ADDRESS OSPC DIVERSITY

� Allows for a wide variety of antigens (OspA and multiple types of OspC) to be represented in the vaccine

� Minimizes the amount of extraneous material administered in the vaccine� Thanks to the use of the OspC chimera only two proteins are included in

VANGUARD® crLyme vaccine, one for OspA and one for OspC

Manufacturers could not design a single vaccine which included an OspA protein and a chimeric protein containing antigenic material from seven types of OspC2

� Immune responses elicited by OspC are type specific, meaning a broadly protective vaccine should include multiple OspC variants most commonly associated with mammalian infection1

� Simply adding multiple, whole-length OspC proteins to a vaccine is not immunologically feasible2

CHALLENGES OF EXISTING RECOMBINANT TECHNOLOGY

UNTIL NOW…

CHIMERIC RECOMBINANT TECHNOLOGY…

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ENGINEERED INTO A SINGLE CHIMERIC RECOMBINANT PROTEINImages courtesy of Dr. Richard Marconi.

SEVEN COMMON TYPES OF OspC11

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INTRODUCING VANGUARD® CRLYME

� 1 mL subcutaneous vaccine

� For vaccination of healthy dogs at 8 weeks of age or older as an aid in the prevention of clinical disease and subclinical arthritis associated with B. burgdorferi

� Dogs should receive 2 doses administered 3 weeks apart

� Approved 15 Month Duration of Immunity

� Annual Revaccination Recommended

� Field Safety Study

ROUTE

LABEL

SAFETY

� Helps provide broad coverage to Outer surface protein A (OspA), found in the tick, and contains multiple types of Outer surface protein C (OspC), found in the tick and the dog

� Recombinant technology can help provide low reactivity

FIRSTANDONLY

CHIMERIC RECOMBINANTLyme vaccine onthe market

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� Study included (all 8 weeks of age at start)– 16 dogs vaccinated with Vanguard crLyme on

2 occasions, 3 weeks apart– 16 dogs placebo vaccinated– 7 sentinel dogs (no treatment or challenge)

� All dogs were seronegative to B. burgdorferi at the study start and all dogs were negative for C6 antibodies via IDEXX SNAP® 4Dx® Plus test on day 477

� On day 480 controls and vaccinates were challenged with B. burgdorferi infected wild-caught ticks

NOW WITH 15-MONTH DURATION OF IMMUNITY

Data on File, Study Report No. B864R-US-12-037, Zoetis Inc.

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� The first and only canine Lyme vaccine with two proteins, OspA and a chimeric protein containing antigenic material from seven types of OspC

� The first canine Lyme vaccine with an approved 15 monthDuration of Immunity (DOI) study

� Less extraneous protein

� Safe, low reactivity

� Backed by the Zoetis Companion Animal Immunization Support Guarantee

VANGUARD® CRLYME SUMMARY…

Rhodes, D.V.L. et al., Identification of Borrelia burgdorferi OspC genotypes in canine tissue following tick infestation: Implications for Lyme disease vaccine and diagnostic assay design, The Veterinary Journal 198 (2013) 412-418.Data on file, Study Report No. B961R-US-12-009, Zoetis Inc.Data on File, Study Report No. B864R-US-12-037, Zoetis Inc.

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Thanks to Zoetis for sponsoring tonight’s VETgirlwebinar!

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