Life After Lyme Disease

DNA sequencing test results

Diagnosing Lyme disease has always been a problem, as many of the symptoms are similar to a whole host of other conditions and traditional serological testing methods are unreliable in the early stages. Doctors have to rely on combining a list of symptoms with identifying the risks of patient exposure to ticks (which carry the bacteria responsible for Lyme disease), and as this condition can incubate in the body for months or even years before it manifests this can make diagnosis even more difficult.

A recent report published in the latest April 2010 edition of the American Journal of Clinical Pathology may bring some hope to medical staff dealing with Lyme disease around the world, as a team at the Milford Hospital, CT (headed by Connecticut physician Sin Hang Lee, MD) have now revealed a new way of diagnosing  this disease by using DNA testing to identify whether or not the patient has any of the bacteria which cause Lyme disease present in their blood. In clinical testing this DNA procedure proved to be highly successful at identifying low levels of the Lyme bacteria, which were often missed by the previous methods of serological testing.

Early Lyme Diagnosis

Lyme disease can easily be treated in the early stages by using standard antibiotics, but if left untreated this bacteria can spread through the body causing a whole host of painful and potentially debilitating conditions such as Lyme arthritis, chronic fatigue and even serious problems with the central nervous system and heart such as neuro borrelia and arrhythmia.  This is why it is so important to diagnose Lyme disease as quickly as possible, as it can save months of unnecessary pain and discomfort for patients and can prevent any serious complications from developing.

Model of DNA Strand

The DNA test discovered by the Connecticut research team is highly sensitive and specifically aimed at identifying Lyme disease, and is most effective in the early stages of the condition when the bacteria are circulating freely in the blood system. Several leading medical insurance companies have already recognized the potential of this new testing method and have provisionally agreed to cover the costs of this procedure for their members.

What Causes Lyme Disease?

Lyme disease is spread by the bite of infected black legged ticks, which are common in many areas of Europe and throughout the mid and eastern United States. Lyme disease is caused by the Borrelia burgdorferi bacteria which is transmitted through tick saliva into the body of the host, where it typically has an incubation period of around 3 to 30 days (although it has been known to remain undetected for years before manifesting symptoms in the host). The Lyme bacteria infection can spread through the body via the blood stream and also lymph nodes, and can be carried to major organs and other areas of the skin.

As well as preventing under-diagnosis of Lyme disease and ensuring that sufferers are treated as quickly as possible this new DNA technique could also help to prevent over-diagnosis of this condition, and this can reduce the unnecessary use of strong antibiotics in patients who have been misdiagnosed with Lyme disease.

Olive Branch with leaves and ripe fruit

Phytochemicals are found abundantly in nature and can be extracted from the roots, leaves, fruits, seeds and stems of plants, and have many applications when it comes to medicines and treatments. Oleuropein is a natural substance found in the olive leaf, which has been used as a herbal remedy for many years to treat a number of conditions including bacterial and fungal infections, fevers, fatigue and allergies. The benefits of phytochemicals such as oleuropein have been the subject of intense scientific research in recent times, as many people believe these powerful natural substances may hold the key to fighting many of the diseases that persist in modern society despite the advances of medicine.

Insect-Borne Diseases

The first recorded use of olive leaf extract to fight insect-borne diseases occurred around 150 years ago, and was mentioned in account which detailed cures for tropical fevers and one of the biggest threats to human health, malaria, which is transmitted by the bite of mosquitoes. The Pharmaceutical Journal listed a recipe by a Daniel Hanbury, which showed a simple healing concoction against tropical fevers, which was found to have much success when treating colonial Britons who contracted symptoms of malaria whilst out in the more exotic parts of the Empire. The recipe is a straightforward tincture of olive leaf, creating by simply boiling the leaves in water and then administrating the liquid orally until the symptoms of fever ease, and Hanbury believed that it was the bitter part of the leaves in particular that the key healing ingredient. Scientist are now discovering that Hanbury was right in his analysis of the healing power of the olive leaf, and this bitter ingredient thought to be so important is now known as oleuropein, which is a key chemical compound that has been shown to have a number of effects on the body such as increasing blood flow in restricted arteries, relieving intestinal muscle spasms and also easing heart palpitations and arrhythmias.

Antibacterial Powers of Olive Leaf Extract

One of the main reasons why researchers are interested in olive leaf extract when it comes to insect-borne diseases it the powerful anti-bacterial effect of an ingredient found in oleuropein, which is called elenolic acid. This acid has been shown in clinical testing to inhibit not just a number of different types of viral and bacterial growth, but also the growth of parasitic protozoans, and is thought to work by dissolving the protective outer lining of the harmful microbes, effectively preventing them from multiplying and spreading.

Close up of olive leaves

Elenolic acid also works effectively without exhibiting any harmful effects on host cell mechanisms, and this means that oleuropein could potentially be a very safe, non-toxic substance which could be used to treat a whole host of infectious diseases including Lyme disease, which is a rapidly spreading condition that is caused by the Borrelia burgdorferi bacteria. Lyme disease is transmitted by the bites of ticks, and can be difficult to diagnose since there are no reliable tests for this disease in the early stages. Lyme disease can be treated successfully by antibiotics, but these strong drugs can be unsuitable for some patients, especially those with existing conditions, and have been known to cause a number of unpleasant side effects such as digestive upsets and a weakened immune system. Researchers are keen to develop the research on olive leaf extract further, as this could prove to be an important weapon in the future treatment and prevention of insect-borne diseases such as Lyme disease and other infectious conditions.

Actor, Ben Stiller

Hollywood funnyman Ben Stiller may be among one of the thousands of people around the world who have contracted the chronic condition Lyme disease. Like many other sufferers Stiller, 44, discovered he may have this potentially harmful disease after seeking treatment for another ailment, in this case an inflamed knee which never healed after he injured it whilst on a charity related trip to Mozambique. Stiller explained that "I was in Africa about three and half weeks ago and I stepped in a ditch in Mozambique", but after a few weeks his knee was still very painful and inflamed, causing Stiller to walk with a limp at times and so he sought further medical assistance. Despite numerous tests doctors could not identify the cause of the inflammation and infection and this painful condition was exacerbated by some arthritic elements that were revealed on MRI scans.

Lyme Disease Suspected

Stiller’s knee injury grew steadily worse over the following weeks and was so painful at one point he almost had to pull out of a high profile interview with one of America’s premier TV talk show hosts David Letterman, which had been scheduled for March 23. However recently a breakthrough in Stiller’s mystery knee complaint came through when one of his doctors queried whether or not he had ever had Lyme disease. Stiller had been on the East Coast during the height of the tick season the previous year (ticks are prime carriers of Lyme disease) and that at this time his son had actually contracted the disease. Lyme disease is well known for causing severe joint pain and arthritic conditions, and Stiller’s doctors finally diagnosed Lyme disease as the most likely cause of his painful knee condition. As Stiller explained to Letterman in his interview this breakthrough came just at the right time, as the next stage of his treatment would have been orthoscopic procedures followed by possible invasive surgery, and as he said “…if it is Lyme disease, I won’t have to have the procedure done, which is great", as this treatment could have seriously restricted his mobility for months and prevented him from working on any new movies or other projects.

Confirming Lyme Disease

Lyme disease is a difficult condition to properly diagnose, as it can in some cases take months or even years for the symptoms to appear, and standard testing can not always identify positively whether or not the bacteria that causes Lyme disease, Borrelia burgdorferi, is actually present in the system. Although there are still more tests to go ahead before Stiller can be confirmed with Lyme disease, he could be among thousands of patients around the world suffering from this potentially debilitating condition who are initially misdiagnosed, and undergo months of futile tests. Lyme disease is easy to treat in the early stages with antibiotics, but if left to develop it can cause a number of painful symptoms such as inflammation and swelling of the joints, and it can also be much more difficult to treat once the bacteria has spread throughout the body’s system.

If you spend a lot to time in areas with a high risk of ticks and other biting insects then you should learn as much as you can about how to prevent these insects from attacking you, as not only can this result in painful and irritating bites but many insects can also carry harmful pathogens that cause nasty diseases, such as the tick-borne condition Lyme disease.

Prevent Tick Bites

Tall grass and woodland boundary

Prevention is better than the cure when it comes to tick-borne diseases, and although these old fashioned tick prevention measures are not guaranteed, they can help you to prevent tick bites when you are moving through high risk areas such as dense undergrowth and tall grass at forest and woodland boundaries:
• Clothing – ticks lay in wait for their prey in low level grass and undergrowth, and most people pick up ticks around their feet, ankles and lower legs. Ticks need a soft, safe place to feed from and will typically grab onto your trousers or legs as you brush past, and then crawl up your clothing to find a more secure area to bite you from such as the backs of your knees or your stomach and lower torso. By making sure you wear long trousers with the hems tucked into thick socks you can prevent ticks from finding easy places to bite you, and if you wear light colored clothing when you return home or get back to your car you can quickly check for any ticks that have clung onto you and brush them off before they find a vulnerable spot to bite you. It is also a good idea to wear long sleeved tops as well and gloves if you are gardening or clearing brush in high risk tick areas, and always wash your clothes and footwear as soon as possible when you get home just in case  there are any ticks still lurking.
• Avoid Long Grass – ticks mostly feed from small mammals such as mice, rabbits and deer, and will target key areas where these animals live and feed such as long grass and dense undergrowth. Therefore if you are going out hiking try and avoid moving through these high risk areas if at all possible, and stick to clear open ground where it is less likely feeding ticks will be present.
• Insect repellent – if you do need to go into high risk areas an added measure of protection can be offered by treating your clothes with an insect repellant such as citron oil, and a more modern equivalent would be a chemical such as permethrin, however these treatments are not guaranteed to work and toxic chemicals should not be used regularly close to the skin, as the long term exposure risks are not yet fully understood.

New Research into Old Fashioned Remedies

For centuries the American Beautyberry (Callicarpa americana) has been used in northeastern Mississippi by farm workers to repel ticks and prevent tick-borne disease, and recent research from the US Department of Agriculture’s main scientific research unit, the Agricultural Research Service (ARS), has revealed that there could actually be some scientific evidence to back up the effectiveness of this old fashioned tick prevention remedy.

American Beautyberry (Callicarpa Americana)

Researchers tested the American Beautyberry plant and found that compounds released from the crushed leaves actually repelled biting insects such as mosquitoes and ticks in clinical tests. Two compounds in particular, callicarpenal and intermedeol, were isolated as being effective against the blacklegged tick (which carries a number of diseases including Lyme disease). Although this research is still only in the early stages, researchers believe that the compounds isolated from the American Beautyberry could prove to be important substances in the fight against tick-borne disease in the future.

Insects that feed on animals are primary carriers of a number of unpleasant diseases, and many of these can be transmitted from animals to humans such as Lyme disease, which is caused by the bacteria Borrelia burgdorferi.

Humans have a significant impact on fragile ecosystems all around the world, and research suggests that increasing urbanization and modern forest management techniques can all have a significant impact on the spread of tick-borne disease.  We often think of dramatic environmental disruptions happening in far away places such as the rainforests or Arctic glaciers, but similar problems are occurring with ecosystems right in our own backyards, and this can result in a number of problems such as an increased risk of exposure to infected ticks carrying the bacteria which causes Lyme disease.

Urbanization spreading into wild areas

Urbanization

Ticks mostly feed on woodland mammals such as mice, rabbits and deer, and because their chosen prey is more abundant at woodland and forest edges this is also where the population densities of ticks are the most concentrated.  Spreading urbanization has put woodland and forests under threat and pushed the boundaries between residential and wild areas even closer, and this means that there are more and more people living and working in high risk areas for Lyme disease.

Forest Management

Both ticks and their prey need certain habitats in order to survive, and researchers at the Washington University’s Tyson Research Center discovered that in the Missouri Ozarks (predominantly oak and other hardwood forests) those areas which were managed by the Missouri Department of Conservation and the Nature Conservancy were actually more at risk from tick-borne diseases crossing to humans and domestic animals, as selective logging and managed burns of the woodland created much more sustainable habitats for the prey ticks fed from, in particular deer and small mammals such as rabbits which both prefer the tender fresh green growth that is abundant in newly cleared woodland areas.

Woodland management can create ideal habitats for ticks

Researchers were keen to determine exactly which species were the main feeders of infected ticks in a typical woodland enviroment, and so collected ticks from a variety of sites in the managed woodland and wilder areas, and analyzed the DNA in the blood the ticks had fed on to identify which animal the blood came from, and whether or not any pathogenic bacteria were present.  This research provided some interesting results and it was found that stable deer populations did not significantly effect the spread of tick-borne diseases, but that concentrated populations brought about by plentiful food and protected habitats caused a dramatic increase in the impact and spread of tick-borne diseases such as Lyme disease.

The Importance of Tracking Emerging Diseases

With Lyme disease and other insect-borne diseases it is important we fully understand under what conditions the carriers of these pathogens can multiply and spread, as this will help health authorities and governments to identify and track emerging patterns of these potentially harmful diseases and put measures in place quickly to minimize the impact on humans.  For example the research from the Ozarks showed that managed environments caused explosions in deer populations, which in turn led to the increased risk of Lyme disease passing to humans and other animals, and this could be a significant piece of evidence to drive measures against the spread of ticks in the future, particularly when you consider that some state agencies actually encourage deer populations by planting out food for them.  In Missouri alone it was estimated that there were over 1.4 million deer, and this seems to be a similar pattern in woodland across the US, and researchers have estimated that there could be as many as 30 million deer currently living wild in the the mid and eastern United States.  It is likely that alongside these increasing deer and rabbit populations levels of other small mammals such as squirrels, shrews and mice are also booming, which can also be key prey sources for ticks, and all of this could explain why tick-borne diseases are spreading despite many efforts to hold them in check.

White footed mouse - Peromyscus leucopus

The Borrelia burgdorferi bacterium responsible for Lyme disease can infect humans, birds and mammals, and is transmitted to different hosts by tick bites. There are a number of animals that can carry the Borrelia burgdorferi bacterium and they can pass this on to uninfected ticks, but in many cases of zoonotic diseases (those transmitted from wild animals to domestic animals and humans) there is one natural animal host in particular responsible for incubating the bacterium. In the case of Lyme Disease researchers had historically considered mice (in particular white-footed mice) to be the main animal reservoir for this disease in North America, as past studies have shown that almost 90% of all ticks feeding on infected mice pick up the Borrelia burgdorferi bacterium, which is an infection rate almost double of any other species. Also mice are very common animals that occupy diverse habitats from woodland to residential districts, which would increase the spread of this disease across a larger area and this combined with the high infection rate would support the assumption that mice were the primary reservoir of Lyme disease.  Current vaccination strategies aimed at bringing Lyme disease under control throughout northern America have been based on the assumption that white footed mice are the main source of the Borrelia burgdorferi infection cycle.

New Studies

However new evidence from studies undertaken by biologists from the University of Pennsylvania have revealed that Lyme disease may have a much more complicated host pattern than first thought, and that there are actually a wide number of vertebrate species that contribute to transmitting the Borrelia burgdorferi bacterium. In a recent in-depth study carried out in the high risk tick infection area of the Hudson Valley, researchers discovered that both mice and deer (another species that is commonly linked to Lyme disease), did not actually factor very highly in the cycle of transmitting the Borrelia burgdorferi bacterium infection. The research revealed that just 25% of infected ticks were fed by mice, much less than the 55% of infected ticks discovered to have been fed by shrews in the same area. This evidence indicates that other factors such as animal population density had a huge influence on the spread of the Borrelia burgdorferi bacterium, and that focusing on just one species such as the white-footed mouse was not an effective way to combat the spread of this disease.

Combating Lyme Disease

Zoonotic pathogens (such as the Borrelia burgdorferi bacterium that causes Lyme disease) that can cross easily between human and animal species are a major threat to ecological systems all around the world, and areas where residential and wild land converge such as at forest and woodland boundaries are particular high risk zones. It is very important that researchers understand exactly how the diseases spread to

Woodland edges are high risk areas for Lyme Disease

different species and across to humans, so that they can work with governments and health authorities in finding new strategies to help protect the public and minimize the spread of infection both in wild and domestic animals. Identifying the main animal host or hosts of pathogens such as Lyme disease can be a key weapon in combating the impact of zoonotic emergences, as strategies can be implemented that interrupt the transmission of infection such as between the ticks and the primary animal hosts, thereby breaking the infection cycle and preventing the disease from spreading to new areas.

Lyme disease is a condition transmitted by the saliva of ticks when they feed on a host (human or animal), and is caused by the Borrelia burgdorferi bacteria.  It is thought that the Western blacklegged tick and the deer tick are the primary carriers of the Borrelia burgdorferi, and these are common throughout northern America and southern Canada, and high risk areas of infection for humans include forest and woodland edges and open grassy areas.

Diagnosing Lyme Disease

Testing for the Borrelia burgdorferi infection

Lyme disease typically manifests in the early stages as a skin rash, often with a characteristic ‘bulls eye’ inflammation pattern, which can take between 3 to 30 days to develop.  However it has been estimated that in as many as 30-50% of cases no rash will develop at all, and this can make diagnosis in the early stages very difficult.  If left untreated Lyme Disease can develop into more serious symptoms, which can include meningitis, heart problems, arthritis, nerve damage (peripheral neuropathy) and inflammation of the spinal cord and brain (encephalomyelitis).  Lyme disease can be challenging to diagnose, as many of the symptoms are common across a wide range of other conditions, and there are as yet no conclusive tests for identifying the disease in its early stages (serological testing is only useful when the disease has progressed further). Many patients with Lyme disease are not correctly diagnosed in the early stages, and this can lead to months and even years of unnecessary suffering.  Lyme disease can actually be treated very successfully with either oral or injected antibiotics if caught in the early stages, but if left untreated the condition can become very serious and then it can be much more difficult to combat the disease and its symptoms once it has turned chronic.  Many physicians are still relying on serological testing to identify the condition, but this is simply not reliable enough and has been shown to fail to detect the Borrelia burgdorferi infection in as much as 20% of clinical tests.  One of the reasons current tests are ineffective in the early stages of the condition is that it can take as much as six weeks after the initial infection for the Borrelia burgdorferi bactera in the blood to reach large enough levels to show up in testing.  Also this bacteria can sometimes lie dormant for long periods of time, and this can make a diagnosis difficult if it emerges later on, as the patient may not connect the condition with any exposure to ticks that occurred in the past.

Blood test for Lyme Disease

This is why it is so important that physicians are educated in the process of identifying and diagnosing Lyme disease in its early stages, and the key to this is not clinical tests but possessing a good epidemiological understanding about the risks of patient exposure to infected ticks.

Surveillance

Physicians also play a vital role in the surveillance of ticks and can help to identify new endemic areas quickly by being able to diagnose the disease effectively, and also by reporting all suspected and confirmed cases to the local Health Authority.  This process has helped researchers to pinpoint infected tick emergence in Canada, and has shown tick populations spreading in Ontario, Nova Scotia, Manitoba, Quebec and British Columbia. Through enhanced surveillance and increased awareness of symptoms and treatments, physician can play a crucial role in minimizing the impact of Lyme disease as it spreads to new areas.

Not all ticks carry the Borrelia burgdorferi bacterium responsible for Lyme disease, and if you live in, or intend to travel through an area with a risk of Lyme disease it is important you understand which species of ticks are potentially harmful so that if you do get bitten you can take the appropriate action. 

Ixodes scapularis - The Deer Tick

Deer Ticks

Those ticks that primarily carry the Borrelia burgdorferi bacterium are blacklegged ticks (Ixodes scapularis), also known as deer or bear ticks, and these are very small when they are not engorged (around the size of a pinhead), and when they have fed they swell to around the size of the tip of a pen.  The female is slightly larger and reddish brown and the male darker brown in color, and they are very difficult to spot on household pets.  Deer ticks live in the woodland and forest in dense, cool underground, leaf litter and brush and feed mainly on mammals such as rodents and deer, and because they predominantly live on the woodland edges and in densely landscaped residential areas they can regularly come into contact with humans.  Deer ticks wait near ground level for passing prey, and can latch onto your feet, legs and ankles as you brush past, crawling upwards until they find a spot to bite you.  Lyme disease can be treated with oral or injected antibiotics, and early diagnosis and treatment is essential as this disease can cause serious complications such as Lyme arthritis and problems with the heart and nervous system.

Western blacklegged Ticks

Western blacklegged ticks (Ixodes Pacificus) are physically very similar to the blacklegged deer tick, and are also known to carry the Borrelia burgdorferi bacterium that causes Lyme disease and are found in the same kinds of habitats and also throughout more open grasslands.

Rhipicephalus Sanguineus - The Brown Dog Tick

Brown Dog Ticks

Brown Dog ticks (Rhipicephalus Sanguineus) are a slightly larger species and are much easier to spot, and when they are engorged they form a visible, grey/green color blob, about the size of a fingernail.  They are not known for carrying the Borrelia burgdorferi bacterium, but they can transmit Ehrlichiosis to both pets and humans, which can cause fever, fatigue and lameness. Ehrlichiosis can be treated with antibiotics, and it is important to diagnose the condition early as it can cause serious blood related problems in vulnerable people such as young children and older adults.  Brown dog ticks can be found in grassy and wooded areas and anywhere dogs are kept including kennels and barns.

Dermacentor variabilis - The American Dog Tick

American Dog Ticks

American Dog ticks (Dermacentor variabilis) do not carry the Borrelia burgdorferi bacterium, but they can transmit other diseases to both pets and humans such as Rocky Mountain Spotted Fever (RMSF), which is caused by the Rickettsia rickettsii bacterium, and symptoms include fever, nausea, vomiting, and severe headaches, and this can be treated effectively with antibiotics. American dog ticks can be found in grassy areas, meadows and woodland.

Amblyomma Americanum - The Lone Star Tick

Lone Star Ticks

Lone Star ticks (Amblyomma Americanum)  are also known as seed ticks, and are similar in size to dog ticks but they have a distinctive white blob on their backs.  There is some debate over whether or not Lone star ticks carry the Borrelia burgdorferi bacterium, but they have been confirmed as carriers for Ehrlichiosis and RMSF.  Lone star ticks live mostly in wooded areas with ground cover and brush, and are also found along creeks and rivers

Image of adult blacklegged tick

Lyme disease is a tick-borne infection, and is primarily spread to humans through bites from deer ticks, Western blacklegged ticks and possibly lone star ticks.  These tick species carry the Borrelia burgdorferi bacterium which causes Lyme disease, and feed on a number of small to medium size mammals and birds including small rodents, deer and household pets.

Birds

Birds play a major role in the spread of Lyme disease as they can pick up a tick carrying the Borrelia burgdorferi bacterium in one location, and because it takes a long time for ticks to feed they could be hundreds or even thousands of miles away before the tick finally drops off.  The seasonal migration of birds in Northern America is key to the spread of Lyme disease and over 650 species of bird migrate to different parts of the world annually, either taking part in long distance migration to places such as Africa, Eastern Europe and South America, or short distance migration of just a few hundred miles.  Many birds such as White-throated Sparrows and robins spend the winter in Northern America before moving on to summer feeding grounds in Canada, and there are also a number of transitory birds that pass through Canada as a stop over on the way to other feeding grounds, and many of these could potentially be carrying infected ticks or the Borrelia burgdorferi bacterium itself, which they could pass on to uninfected ticks in the areas they feed in.

The spread of ticks carrying Borrelia burgdorferi bacterium into Southern Canada

Reforestation

A number of factors can influence the spread of any insect species, but the main culprit for the spread of ticks is thought to be reforestation.  Ticks are hardy creatures, but they do require the right habitats to live in. For example the blacklegged tick thrives in cool, moist conditions and the majority can be found in forested areas with dense shrub layers to provide shade and moisture, and tend to condense along the forest and woodland edges, where food is most abundant.  They can also survive in denser underground planting in some landscaped residential areas.

In recent years many areas that were previous cleared for farmland in northern America have been reverted back to small patches of woodland and forest, creating ideal environments not just for ticks, but for the animals they feed on such as deer and small rodents.  This increase in wild tick populations would not normally be a major problem but as urbanization is also increasing, with residential developments encroaching on wild areas, more and more infected ticks are coming into contact with humans, and these woodland border areas in which ticks are prevalent are now coexisting alongside residential areas, creating high risk zones for Lyme disease crossing to humans.

Reforestation is thought to be having a significant impact on the increasing spread of Lyme disease from North America into Canada, and studies by the Public Health Agency of Canada have so far tracked new infected tick emergence in Ontario, Nova Scotia, New Brunswick, Quebec and Manitoba. 

Steps to Prevent the Spread

The Public Health Agency of Canada and other organizations are calling for national surveillance to be put in place to monitor the changing patterns of tick behavior, to identify new endemic areas quickly and effectively in order to notify the public and local health authorities and ensure education is put in place to minimize the impact of Lyme disease.  Doctors are now required to report any suspected and confirmed cases of Lyme disease to the Public Health Agency, and this enhanced surveillance combined with greater physician and public awareness are crucial steps to help mimize the impact of the disease as it spreads into Canada.