2016 Lyme disease conference breakout session 1: surveillance part 2

Conference to develop a federal framework on Lyme disease

May 15-17, 2016, Government of Canada Conference Centre, 111 Sussex Drive, Ottawa, ON

Conference day 2: Monday May 16, 2016, Rideau Falls room

Transcript

Alain: [00:01]

Ladies and gentleman, we will get back underway and I will take your gratitude for having liberated you out of this room first, so you had a first crack at the cookies. That was all part of my plan. We will continue with our next speakers, and I'm just going to encourage Curtis and Vett for-as next speakers. Please feel free to slow down. Because the interpreters of course in the interpretation booth have a devil of a time keeping up. But thank you for that, Natasha. So our next presenter and the title is on the slide there, is Vett Lloyd, who's a professor in the department of biology at Mount Allison University. Welcome Vett. Over to you.

Vett: [00:56]

Alright, now that I've adjusted it for short people. Okay, so thank you guys all for showing up. I'm going to be talking about my favourite research organism here, which is the fluffy thing. But I'm also reasonably fond of humans. So, let's see how this works. We'll start with the usual somewhat boring disclosures. I'm an academic, so no one actually cares about me. The research in my lab is funded by EM Search, so basic research funding. And that's about all that I have to say about it. There's no commercial-I do have other grants for other projects, but I'm not talking about them here.

So in terms of what I am going to talk about today, the talk comes in two chunks. They're quite closely related. The first is a compare and contrast. Not only do I like dogs, I think they are absolutely phenomenal ways to use as a sentinel to see what the risk is of human Lyme disease.

So I'm going to be talking about surveillance approaches, and I might as well tip my hand now and say that I'll be suggesting that using dogs as a sentinel species is a very powerful approach. The second thing I'm going to do is demonstrate why that might be the case, using New Brunswick as a case study because we have very good, high-quality tick data as well as dog seropositivity data from New Brunswick. Alright, before I go on, I'm going to mention that most of the work I'm talking about is published or in press. It's based on a canine seroprevalence study that's in press right now in the Canadian Veterinary Journal, published work from the National Microbiology Lab and unpublished work which will get published soon-sorry-on our passive surveillance of ticks in New Brunswick.

Okay, so Dr. Ogden gave us a really good background on how we can use tick surveillance to assess the Lyme disease risk, which is great, because then I don't have to spend a huge amount of time doing that. So the picture at the far end, far left, shows some students from the labs doing active surveillance. And that's approach where you go out and you're dragging things around or poking shrubbery with little bits of flannel. You're hoping to catch the ticks that are up and about and actively questing. There's also passive tick surveillance where you get veterinarians to peel the ticks off dogs, children and their client and mail them in to you. That's our mail supply from one day.

The drawback with both of these tick surveillance methods, as Dr. Ogden mentioned, is that they are very labour-intensive. Even if you're using students or you're partnering with community groups, which is something I find a wonderful thing to do and a very, very powerful way in terms of education as well as getting extra help, it's still expensive, because you have to get people to different areas and you have to then wander around in the field getting bitten by mosquitoes, black flies and almost everything else searching for the one tick that might or might not be questing at that particular time. And it's fairly low sensitivity, because ticks' activity, sometimes they come up, sometimes they're down. It depends on the time of the day. It depends on the humidity in the air. It depends on the season, whether or not that stage is actually questing at that point. It depends on what you've treated your flags with. We determined empirically that if you rub your crag blanket over a wet, smelly dog, you get four times the recovery rate, which is great until you think about what happens if you travel in a car with wet, smelly blankets for a few hours to a field site. So it's not an ideal approach, and it's certainly intensive, expensive and low sensitivity.

The other end of the spectrum is human case reports. With human case reports, I don't think that there's much question that it's under-reported. There are many reasons why the difference with them-we don't have to get into that. That's something for the clinicians. So I'm going to suggest that canine seroprevalance is a very nice middle ground. It's less labour-intensive. There's very well-established methodology. And the beautiful thing is, it's already been done. So there's actually not a whole lot to be done there. In Canada, there've only been a few studies using canine seroprevalance as a sentinel species for human risk. It's been used very extensively in the U.S. It's been used in Europe and Asia, and perhaps Canada should jump on board here.

The reason why canine seroprevalance studies works is very simply because that's a typical family, and generally dogs live with people. They go out with people or people go out with them as the case may be. And so you're spending time with your dog. Your dog lives in the same area as you do. And for a dog to become infected-dog, tick-requires exactly the same thing for a person to become infected. It means the tick has to find the animal. The tick has to get onto the animal, and then bite and feed for long enough to transmit infection. So the mode of infection is the same, and as your dog is with you, there is a-that indicates that if your dog gets infected, you are at risk of infection as well.

Okay, so to the last advantage of using canine seroprevalance studies that I'll mention is that the fact that it's already being done and the information on canine seroprevalance is already freely available online. It's a beautiful-it's the pet disease report by IDEXX. They're the major-they have 95% of the market share in veterinary diagnostics. So mostly this is up there. This is Ottawa. All you do is type in your postal code. If you want to get really local, I thought Ottawa would be appropriate because that's where we are. And you can see the number of positive cases in your area. And that will give you a very effective way of assessing your risk, and it's quite useful in terms of public education and awareness.

And again, the methodology for canine seroprevalance is very highly standardized and highly validated. Okay, so that's my 'dogs are great' approach. Now I'm going to go through our New Brunswick study as a case study for the use of canine seroprevalance as a predictor of human Lyme disease risk. And I am using New Brunswick just because that's where we live, so that's where we have the most data. Presumably this approach would work anywhere in Canada as there are people and dogs in pretty much everywhere in the country.

Okay, so why New Brunswick? Because we have data from New Brunswick. That's a tick-our tick map with New Brunswick divided into our seven health districts. And each district, we've got passive tick collection data from it and the colour-coded, it depends on the incidence of risk. And in that case, the highest tick risk is in the south and the areas bordering Maine and Quebec, which is hardly a surprise. We also have, courtesy of the work done by Public Health Agency of Canada and Dr. Ogden's work, we have his very nice modeling. We have similar modeling using a slightly different system by one of my colleagues. So we have another source of modeling data.

So, superimposed on that we can now start-seeing as how we have tick data and climate data, we can now ask what's happening with the dogs. So just to reiterate why this is a good idea, dogs live with people. They have a robust immune response to Lyme disease, so it can be detected quite readily. And detection is detected with point of care commercial kits. Essentially, you take your dog in to the vet. Eight minutes after they get blood out of your dog, you'll have a yes or no answer. And it's the same C6 ELISA that's the first tier of human testing.

So what we did, we phoned up all the vet clinics in New Brunswick, which is the first time I realized exactly how many of them there were. And we asked-we were aiming for 100 blood samples from each of the seven New Brunswick health clinics. We got 699 samples because our 700^th dog died. It actually died of Lyme nephritis, so we decided to exclude it. We ran a SNAP for C6 ELISA test and then immunoblotted afterwards. And then we did some other stats, statistical stuff that I'll ignore. So the results, what's shown in the map here are the percentage of infected dogs in each of the seven health regions. We're seeing similar results. The south is the highest and pretty much everywhere else. So we're in fact finding seropositive dogs throughout, and we had a good sample size in each. For relevance for the people in New Brunswick, this actually indicated a very rapid increase in canine seropositivity because the test-the same survey was done six years ago and found less than one percent. So a lot has happened. There are a lot more infected dogs since this survey was last done.

We did Western blotting. The results were generally consistent. Both tests had false positives and both had false negatives. Seeing as how the veterinary community doesn't have an established algorithm for interpreting Western blots, we basically figured, "This is complicated and yes, veterinarians are right. It's too complicated. Let's just forget about it." So moving onwards, a quick correlation between what we see with the ticks and what we see with the dogs and what we see with the climate models. Yes they are quite similar. There's one point I'm going to point out, which is emphasized by the red oval up there, which is that we see along the coast a higher incidence of canine seropositivity than we would expect from the climate models. So we're picking up a lot of infected dogs in areas that you wouldn't expect to be conducive to established tick populations. This is a bird flyway, it's a major migratory route. So presumably we're picking up adventitious ticks, and I would actually argue the ability to take up adventitious, non-established, non-endemic populations is an advantage, because if dogs can get infected there, so can humans.

Okay, so running through what this means for humans. We can go to the literature and there's a study from Massachusetts which looked at the ratio of human Lyme cases and canine Lyme cases and came up with the fact that there's a ratio. For every six infected dogs, there was one infected human. I applied that to the population of New Brunswick and came up with the rather startling number that there would be over 6000 humans in New Brunswick infected with Lyme disease. And when you compare that to the public-excuse me-the Public Health number of five people, yeah, there's a bit of a discrepancy.

So I wanted to reassess these calculations and see if they-what we would come up with. So the reassessment approach is pretty straightforward. It actually came, I believe, originally from Robin Lindsey. And the idea is that the number of infected people is going to be the product of your proportion of infected ticks, which I called I instead of P, the proportion engorging on the host, that's shown in the second column, and then the number of tick bites. Now the problem here is that most people don't detect a tick, so there's no way of quantifying the number of tick bites until we take advantage of our friend the dog. Because when a dog gets infected, it's again a function of the number of infected ticks, the proportion engorging on the dog-and that's a typo; it should say dog, not human. And the number of tick bites, and that'll give you the number of infected dogs. We know the first number. We know the second number. We know the last number. So we can work out the third number. And from that, we can then go back to humans.

So with apologies to the people who have just gone through their tax returns, this is going to seem like a bunch of calculations not unlike filling in your tax return. Go to Schedule A. I'm going to go through all of these numbers. So the proportion of infected ticks-that's actually-we've got good data on that. We've got data from the Public Health Agency of Canada, published data, our own data, the rate-in the published data range is from nearly 7% to nearly 16%. We used our data because it had the highest sample size at 12.3%. So it's a midrange value nicely between the published values.

The proportion of fed ticks is actually quite easy to assess because ticks get bigger when they feed. So if you do a lovely little graph of how big your tick is relative to how long it's been feeding, you can then say, "How many of the ticks that were recovered from dogs had fed for more than three days? How many recovered from humans had fed for more than three days?"

And as a note here, I picked three days. I realize that ticks can be infective less than that. I decided in all these calculations, I went for the most conservative possible estimate for any number of reasons. So our fed ratio is that in humans we had-8% had fed for more than three days, or 60 on dogs. The numbers before the slash are the numbers from the NML data, which I didn't want to choose because it was higher. So I went again for the more conservative numbers. Okay, number of tick bites. This is where it gets interesting. The first-when I first thought about this, I figured, well one reason we couldn't do this is because no one knows how many dogs there are in New Brunswick. Wrong again. Dogs are big business. So Ipsos Forward has-on a very regular basis surveys the number of dogs out there so they know how much dog food they can push. So in 2014, there were apparently a 111,000 some odd dogs. And they say that this is accurate plus or minus 50 dogs, which is astonishing.

Anyway, with a 6% Borreliosis positivity, that means just shy of 7,000 dogs are infected. To produce 7,000 infected dogs, given a tick-infection rate of 12% and 60% feeding for three or more days would give you 90,000 and a bit tick bites. There're a bunch of calculations here which I'm aware of; I didn't take them into account. We got multiple ticks for most dogs; the average is 1.3. Not all the ticks are found by dog owners by any means and the tick infection rate is slightly inflated. All of that means that there're actually more tick bites than shown here, but again I went for the conservative estimate.

Okay, so now we know how many tick bites there are. The last thing we have to worry about is the fact that that is your furry friend, and that is you. And your furry friend is actually more attractive to a tick than you are, because your furry friend is furrier than you are. At least, that's the case for most people. The other thing is generally humans bathe more frequently than dogs. So we smell better to ourselves, less so to a dog. So again, humans are less attractive to a tick than a dog is. Now, we have to calculate in the relative attractiveness of hosts in these calculations. That can be done from the literature. So we go back to the Lindenmeyer study, which would give us 14%. I decided to take a direct measure because this is confounded with other variables, which is if we took the data from the NML, their 2014 paper, they showed that they got only slightly more ticks from dogs than humans. But that's an ascertainment issue, because they're getting ticks primarily from the medical system and less so from the veterinary community. In contrast, I get ticks almost exclusively from the veterinary community, rarely from humans; those are independently submitted. However, those are really the only two ways you can test ticks in New Brunswick. You can send them to IDEXX to get tested for 150 U.S. But people don't do that because they can get them tested for free. So if you add that up, you end up with a total number of ticks from humans and dogs in New Brunswick, and roughly one in five bites a human versus a dog.

So we do all this together and we get an estimate of the number of tick bites. We multiply that all together and what we end up with is a conservative infection rate of having 173 predicted human infections in New Brunswick for two years ago. So in many ways, this is a very nice and Canadian number. It's almost exactly between the high number and the low number, so that's lovely and Canadian and compromisey [sic]. There are certain-it is nevertheless-go back here. There is a significant discrepancy. Five to 6000 is a big difference, but saying that instead of five people with Lyme disease in New Brunswick there are 173 is still a significant discrepancy.

Alain: (Inaudible).

Vett: Thank you. So why the discrepancies? There are a whole host of reasons that could give it-we talked about these in detail this morning. They were well covered. Testing at inappropriate time, the clinician's not thinking about Lyme diagnosis when someone goes into the ER or their family doc, sensitivity of testing and so forth. And certainly that's something we can talk about.

In terms of general conclusions, I would again support the idea that canine seropositivity studies using dogs as a sentinel species to assess the risk to humans is a very powerful approach and a lovely complement to the tick surveillance that's being done. It's inexpensive because it's already been done. It's standardized, it's wonderful. The national infrastructure is already in place and it feeds beautifully into the education and community engagement initiatives that have to be happening. It is directly relevant to humans because people live with dogs and it's able to pick up issues of adventitious ticks being infective. So it's insensitive to tick endemnicity, which I think is actually an advantage. So that's it for me. Thank you.

Alain: [20:56]

Thank you very much, Vett. Can we switch the PowerPoint presentations please? Our next speaker is Curtis Russell, who's a senior program specialist with Public Health Ontario and its Ontario Lyme Disease Surveillance Program. Curtis.

Curtis: [21:16]

Great. Thank you for having me. I do realize I talk fast, so I made sure I didn't have a coffee at break. So hopefully that will help, but I'll try and keep it in mind. So my presentation today is going to spill off a little bit from what Dr. Ogden did. I'm kind of giving you an update of what we do in Ontario. How do we look for ticks, how do we do human cases, just what the Public Health Ontario Program is.

Alain: I'm just going to put it in PowerPoint (inaudible) moment.

Curtis: Yeah. I won't touch.

Alain: (Inaudible).

Curtis: I'm not touching anything.

Alain: If we could put them in PowerPoint presentation mode, please. And that's one.

Curtis: There's always that hope as a presenter that it'll crash and you can just run away, but it looks like it's going to work.

Alain: No, no, no, no, no. Download, download, down.

Curtis: Next time we'll bring sock puppets. I'll bring tick puppets.

Alain: There we go.

Curtis: Great, thank you. Thank you at the back. So again, I'm going to give you an overview of Ontario's Lyme Disease Surveillance program. So, not that interesting. If I'm not sitting in a cubicle in downtown Toronto, I'm usually running around the woods looking for ticks. So I have nothing to clear for conflicts of interests. I have no commercial support and nothing there as well.

So what am I going to talk about today? I'm going to talk about-overview of what Public Health Ontario, or PHO, what do we do for our Lyme Disease Surveillance Program. The areas that I will cover are human surveillance; tick surveillance, what do we do, how do we know where the numbers are; give a little bit of insight into our epidemiology in Ontario and some of the initiatives. What is PHO doing about Lyme disease in Ontario for our aspects about our mandate - what we cover.

So what is it? What does PHO do? So we work closely with the Ministry of Health and Long-Term Care. So, broad paintbrush, Ministry of Health and Long-Term Care is program and policy; Public Health Ontario is science, technical aspects. So we work a lot closely with other agencies and look on the science and technical aspects of that. So the things we have for that to have that data to do the science and technical (inaudible)-you know, have the human data, have the tick data. We also work closely with the public and physicians for some education. Education-wise, our mandate is more to the physicians and, you know, public health units. That's our mandate, who we're supposed to educate and work with, but bearing in mind, because ourself [sic], we do have a public …

Alain: Just be mindful that as you turn to look to the slide, you lose your audio. Okay?

Curtis: So, good thing to know. I'm getting real intimate with the mic there, if people can't see.

Alain: He turned into a yoga instructor.

Curtis: I'm now stuck in this pose. Yeah, so public, we talk about public education. That's more-we do have a public facing website, so we do know the public goes to that. However our mandate more is to the health units and the health care providers, and then we do do research, which I'll go into in the slides.

So just for a bit of background, Ontario-I know each province has, you know, health districts, health regions. In Ontario, we call them public health units; for short we just say health units. Again, there are 36 of them, so each one of those has their own local medical officer of health. They're different regions, you know, as you can see by the map, varied differentiations in size, habitat, biology, population. You know, you have down in Toronto with millions of people or you can have ones up in, say, you know, northwestern Ontario where you're talking about tens of thousands of people and, you know, people from different areas. Very different dynamics, which is also the case for a lot of the other provinces.

Big thing that we do, a lot of the work we do really directly with the health units and they're the, you know, feet on the ground. They're the ones that do a lot of the hard work, they're really great to work with, really passionate. But they're the ones that do a lot of the work. (Inaudible), they're the ones that do the tick surveillance. We will educate them how to do the tick surveillance, but they're the ones, so they actually can go out and do the tick dragging. They're also the ones that investigate the human cases. They're the ones, you know-get reported, you get the lab work. They're the ones who go out and investigate in the cases and look whether they should put it into our provincial reporting system. You know, they do their risk assessments, they look at what's happening within their area, they use their data, the data we provide them to determine what they should do with their health unit, and they do that for all kinds of different pathogens, but they also do that for vector-borne diseases. And then based on that information, they will create local programs and they also do their own local public and physician education.

Role of Public Health Ontario. What do we do? We work with them. So we provide expert scientific (inaudible), so a lot of the medical stuff, we have an aspect of that. We have physicians within Public Health that we can help with. And then with the health units, we provide the science and technical expertise. So, you know how do you do tick surveillance? How do you tick drag? How do you get that really awesome outfit on and go out into the woods and look for ticks? You know, when we're dealing with human cases, what should we do? We provide our own guidelines. You know, how should you standardize your best practices? You know, how should you conduct a standardized human case investigation? How do you do your tick dragging? Even though the health units do a lot of the work for tick surveillance, we will actually go out with them sometimes as well and do that and provide some training. And again, we also spy with their risk assessments and we are also the public health lab. So all the lab samples that come into Ontario, they come into the Public Health Ontario laboratory. So we provide the tick identification; once identified it goes off to the national lab. We also do all the in-house testing; we do the testing in Ontario for all the Lyme disease possible cases.

We also do research, so we take the data we have, we work with colleagues and try to produce some different things. So for example, one of the papers we just had out, it was just in public in press, one of our colleagues did this, is human pathogens. So we looked at, you know, what pathogens are associated with blacklegged ticks? So we did a survey, a lit search, tried to see what's in the different pathogens and looked-you know, what's happening within kind of Ontario/North America setting. You know, we did some population-based stuff, looked at ticks, you know, where are they? Where are they occurring? Where's the Borrelia? What's the prevalence in the different parts of the province based on the tick data we get?

And one of our other colleagues is looking at healthcare costs associated with Lyme disease. So it's a population-based study about, you know, what are the costs to the system, the people having Lyme disease and following them through? That's an ongoing study, but it's a very interesting work.

So what do we do in Ontario? So we have different aspects of-you know, Dr. Ogden did this really well, so I won't get into the nitty gritty of it, but, you know, we have passive surveillance. So right now if you have a tick on you, you can take it into your local health unit or to your local physician and you can submit it off to us. So at our public health laboratory, we will identify it. If it is a blacklegged tick, it goes off to the national lab in Winnipeg where they then will do their testing and confirm whether or not it has different pathogens in it.

Also we have our surveillance system, it's call IFIS, and we use that for all our reportable diseases. So if someone has Lyme disease, that's where we're coming to that and that is reported into our system. So, you know, if we have a human case with no travel history, they had to get bit by an infected tick, so that's also another way of saying there's probably some ticks in a different area. And then the health units, you know, they're the ones that do this. They look for the ticks, they monitor these human cases, so they get lab reports or reporting from physicians that they think someone has it. They can go out and investigate that case and determine whether it fits our case definition.

Again, the active stuff, we actually go out and look. So (inaudible) two, you know, if we have passive data, humans, ticks, people complaining, telling us that there's something going on in the environment, we will actually go out and look for the ticks in the environment. So that, you know, the ones that you've seen before, the tick dragging, small mammal trapping. Small mammal trapping, we usually do in collaboration with the National Microbiology Lab. You know, they have the expertise, they have all the traps. So we do that with them. The tick dragging, more us and the local health units that we can do that. Again, you know it's really high-tech equipment; it's another good use for duct tape.

So what do we do with all that data? You know, going out, looking for the ticks, finding the ticks, getting that passive data (inaudible), getting all those human cases, we're now going to use that information to tell us where there might be problem areas and where new things are expanding. So example, we produce annual reports. This one is showing for 2014. Where we see local acquired cases, which kind of lines up to certain things, the colours look a little off but you can see, you know-wish I had a pointer-but you can see, you know, St. Lawrence region, you know, Kingston, Leeds health units, you know, they have a large number of cases. And there are more there occurring within those certain areas. And this is based on the most likely exposure, wherever we think that person got it. So, you know, I don't remember what I had for lunch yesterday, but, you know, where do people think they got it? Where was the exposure? And there's different levels of that as well. But again, this is where we're seeing them. And then we can try to look at that with our passive tick information. Does that line up? Is there areas where the ticks are coming where we don't see humans? Is there humans coming from areas where we don't see ticks?

So this is (inaudible) again. So these are ticks based on the submitted location of residence, so where they live, not acquisition. But again, you can see large numbers of ticks coming from the St. Lawrence down along the north shores of Lake Erie, Lake Ontario. However as you do know, we do get other ticks up in northern Ontario. If you're looking more around the northeastern ones, we think those are more the adventitious ticks, but we do know that, you know, you can get these ticks through the migratory birds almost anywhere in the province. But we still do seem to get somewhat focal areas, and we do have more kind of coming up around that northwestern (inaudible) River area, which is an area we have identified as a risk area.

So this is one of the papers we showed, where, you know, we looked at, you know, where the tick's coming from, where's the positivity rate. So again, this is both by exposure, but again, getting large numbers of ticks coming from that St. Lawrence area down around Lake Erie a little bit and then, you know, we're getting a little bit up in the northwest here. And the rate of positivity can be quite variation. But you see, you know, where we're getting the large number of ticks is also seems to be the areas where we're getting, you know, higher positivity rate, which is usually explained because those areas have been established longer, more ticks there. That's where we usually get the higher positivity rates.

Again, not to really get into detail with this map, but, you know, we also do get other species coming into province that we do identify and we do have a location where people, you know, the residents, of where they come in. So we do look at that just to see, what are we getting? Where are they coming from? Is there anything associated with that? So, you know, we can see where the blacklegged ticks are, you know, we see most of them coming from, you know, the St. Lawrence area, American dog ticks, you know, we get more, you know, they're there as well. But we get them kind of across the whole bottom. You know, woodchuck ticks, you know, we don't see a lot of those on people; we don't get large numbers of them, but where are they coming from? And again, the lone star tick, most of the ones we see, we get a very small number of them and again, most of them are being, you know, they're adventitious, they're being brought in. But we can look at numbers and see if there's any trends or if there's something occurring that might raise alarms. Again, if you would go to PLoS One and search Nelder, that's where this paper is. I know a couple of people taking pictures. So PLoS One, Google the author Nelder, that's where this paper is.

You know, and then other things we do. You know, all the good work that those health units do, and they do do the tick dragging and, you know, they go out spring and fall and they do find blacklegged ticks, we can then use that to call it risk areas. And again, because most of our mandate is to the health units and to the physicians, they can use this so the health units can get case investigations. You know, because right now in our case investigation, it doesn't say that they have location to an endemic area or to a risk area. So, you know, someone falls within that, health unit can use that to kind of classify for when they're looking for their cases, again, for provincial surveillance. And most of those areas are known, you know, where we're seeing those ticks come from in human cases. So as you know, the Rouge Valley is now one of our risk areas, which is along the eastern part of Toronto. Basically the work was done in Nova Scotia and through (inaudible)). We do put up 20 kilometre buffers around our known areas just to kind of give that buffer effect of where the ticks can maybe expand to.

So same thing in Toronto. They weren't at the Raptors' game last night, but, you know, they could be, you know, any of the wooded, brushy areas, you know, there's a possibility of them being in those different habitats. So that's what we do with the buffers and try to give that … And we also see, you know, we know right there on their disclaimer that, you know, ticks can be in brushy, wooded areas, they can be in other parts of the province, but based on the surveillance, this is where we're seeing them now. This also helps the health units so they can go and look, you know, areas where they don't have a risk area yet, should they go out and look there to see if there's something occurring. And then from a public point of view, sometimes people say, you know, "There's no line." In Ontario, you can quickly show them this map and say, "Here's where the risk areas are. Here's where it's occurring."

Some new updates, some things we've done. We changed our case definition in 2015. The main thing we did there is, we used to say, you know, "Did you have a location exposure to an endemic region?" And endemic was that focal point. So, "Were you at Long Point? Were you at Turkey Point? Were you at Thousand Islands National Park?" Now we've gone to that risk area term. So now you look more at that map and, you know, it can encompass more cases, so we will find more cases that way. And the other thing we have them do now is we have the EM rash, if it's clinically confirmed and you kind of came from a risk area, that's indicative of a case now in our new case definition.

Some of the things we do. So those health units, you know, so that they know how to do tick dragging, we actually go out and do training sessions. I usually do the southwestern one and then an eastern one. Actually go out, put a whole bunch of people in awful looking Tyvek suits. You know, when the dad pulls up in his minivan and we're all in Tyveks and gloves, he kind of goes, "Should I be here?" And then he turns around. But pretty much, we go out, we actually go to areas that are, you know, highly endemic, high risk areas where we have lots of ticks so they can actually go into the environment and actually see what it looks like, know what they should be dragging and then showing them in the visuals of actually what the ticks look like.

And you should note too on the right here, we actually do have active tick dragging SOPs with, you know, what material should you bring with you, what should you do so that everybody is doing the exact same way. Even on our website we have a little video where I actually go out and show you how to tick drag, what you should do. It really shows you why I'm in science and not in media. But it gives you an idea of what you should be doing.

Other thing we do, you know, there will be a quiz on this later. But standard questionnaire, again, given to the health units so that they're all asking everybody somewhat the same questions so we can standardize again where the cases are occurring and what's happening. And we do have some canned exposure so, you know, the same areas where it's always coming up, we can have that captured in our information.

Yeah, so other things, you know, we've done some lit reviews, you know, again, when we do that stuff, we do tick dragging or we do human surveillance, are we doing the best things possible? So, you know, we did surveillance, you know, systematic review. What are the different methods for tick dragging? Is your tick surveillance in field, you know, is that the best way to do it? And, you know, going through the literature based out of our provincial programs, tick dragging is a very effective method and that's what we've been showing by doing that. Same thing too, human surveillance. You know, what are the different aspects? What can we do? You know, we are governed by IFIS and we're under reportable diseases. But it is a good way for capturing human information, and, you know, there are some other aspects that we can use to maybe accentuate that.

Our partners, you know, we don't do this alone. We have a lot of people that are really good and really big help. So Ministry of Health and Long-Term Care, they're really good for the public education, program and policy. OMAFRA, they do, you know, they have a lot of the animal stuff, they're dealing with the vets and that. They are a big help for what's happening within those. MNR, they look after all the provincial parks, so they're really good at, you know, giving us information of what's happening within those parks but also letting us go into the parks for our surveillance. The MOE climate change, you know, get the climate anomalies with the temperatures, where things are going. The Canadian Wildlife Health Cooperative in Association with the Ontario Vet College, again, that association, that link to the vets and things, what's happening in those. Big thanks to the public health units, they're the ones that do a lot of this hard work. And also to the Public Health Agency of Canada, because they're the ones that help us with the testing and give us our provincial view.

And then webpage. You can't really read it, but we do have a webpage, so if you go to publichealthontario.ca, we do have a webpage with all our different resources. So depending on what you're looking for, you know, if you need to do laboratory testing, we have our lab (inaudible), we have a requisition. If you want to submit a tick, we have our forms there. Those publications I'm going to talk to you about, there's actually research links. We have our annual report, so we have an annual vector-borne disease report where we post our numbers where things are occurring. And some of our different resources such as case management tool or how to do the proper tick dragging. And that's it. Thank you.

Alain: [37:33]

Thank you, Curtis. I can suggest a very good chiropractor to get you straightened out after being in limbo for the last 15 minutes. I'm going to ask our presenters to come forward and sit at the panel table. So, Nick Ogden, Natasha Rudenko, Vett Lloyd and Curtis Russell, to just join us at the front of the room. The question came to me, just at the break, will we have time to ask questions? Well yes we do. And this is the time to ask questions. I know that-George, I think you've got a whole list of them, right? I count a couple of them on your page there. There may be several of you that have questions. I'm just going to invite you to go to the microphone and ask our panellists your question. We've got a fair amount of time in front of us to do this, so I don't think that we're rushed. I will pause on occasion to check in with the folks that are joining us via WebEx to see if there are any questions via WebX. So if we could start, if you could be brief with your questions so that we can get as many questions answered. Go ahead.

Female: [38:38]

Hi, I'm sorry, I forget your name, to the last speaker there. On the questionnaire, I couldn't see from the back. Is that to the patient or to the doctor to fill out?

Alain: So if you just drag the microphone to you.

Curtis: That's for the health units to use, so when they get, you know, a lab report or something that there might be a human case, that's so that everybody's asking the same questions when they're doing our provincial case investigation.

Female: Oh, so it'd be based more on test results rather than symptomology then.

Curtis: Well either one is-they're just looking and asking all the questions, you know, where were they exposed? What was the diagnosis? Was it lab? Was it clinical? Not so much just, what were they doing to figure out what it was?

Female: Right, and those are in use now already?

Curtis: Yes.

Female: Okay. Thanks.

Louise: [39:21]

My name's Louise Billings and I'm from New Brunswick. And so my question is for Dr. Lloyd. And I can't understand the discrepancy between the five people that Public Health says we have in New Brunswick in the last year with Lyme disease and what you're saying. Is there anything that we can do to change that? Because anytime we try to make progress, it's, "Well it's not a priority because we only have five cases in New Brunswick."

Vett: Yeah, that's a really significant problem, and it's politics and I'm a scientist, so I'm not the person to ask. I'm not good at that. But as an advocate, what do you see? Do you see five? Do you see …

Louise: I think they should be listening to you with what you've done and at least looking at the dogs that we have that are infected in the areas, because we're still talking about endemic areas in New Brunswick. We're still saying, "If you haven't been in those two areas, you've proven that these infected ticks are all over the province."

Vett: Yeah, I think-so from a biologist's point of view, there's no question that you can get infected anywhere in the province. I think the problem there would be that frequently I hear from Public Health officials and physicians, they look at a map, they see the red dot. The person isn't in that red dot, so there's no understanding of what endemic means. It's just a gradation of risk and it's biologically very interesting. And I think that's a question of messaging, that our Public Health people could probably do a better job on.

Louise: So will they-will Public Health-could you do a presentation with Public Health in New Brunswick?

Nick: Would you like to set it up for her?

Louise: I'd love to (inaudible).

Nick: I'll just add a couple of things to that. I mean, it's really clear that going out and looking for the risk in the environment be it with sentinel animals, be it with passive surveillance and all this sort of thing, it's what we should be doing, I believe, as a Public Health person, because it's a little bit like testing-you don't wait until people are keeling over with E. coli before testing the water. And what we should be doing is testing what's happening out in the environment rather than before people start keeling over. There is a lot of issues with human cases in terms of-we know pretty much always that the number of reported cases is less than the cases that are occurring, and that's for every kind of surveillance. So it kind of breaks in the kind of chain that means that we're only going to get a proportion of the cases. Surveillance for human cases is still worthwhile as long as all of those breaks in the chain are all kind of, like, equal wherever we go. Because then we can compare from one time place to another and one geographic place to another. But it is certainly a work in progress, getting that human case surveillance right.

Louise: (Inaudible) did forget to say that I …

Alain: Could you go back to the microphone so that we can capture that please?

Louise: I'm sorry. I do see-I have a support group in Fredericton and we've had over 100 people just in our greater Fredericton area now that are being treated for Lyme disease.

Alain: Thank you. Next question, please.

Female: [43:09]

My question is regarding surveillance, so I guess the last speaker. So since last summer, Morningside Park, which is part of the Rouge Valley system, is listed as an area of concern. I was actually just diagnosed last year after being ill for almost 30 years and I grew up down the street from Morningside Park. So I frequented that park frequently in school, class visits, you name it. And I had the large red rashes, which were dismissed back then. So my question is, the reliability of the tick surveillance and then putting it on your map as an area of concern, considering I don't think surveillance really started until-I think you mentioned the '90s and-period or 2009?

Curtis: Like, the tick surveillance or (inaudible)?

Female: Tick surveillance, dragging and-yeah.

Curtis: Yeah, since the late '90s, but, you know, based on that information, where are areas we should look at. And again, that risk map is to show those areas. But it's also for the health units to do their case investigations. It's not for just clinical diagnosis, which is definitely not my specialty, so I won't allude to that. But, you know, we have to do tick surveillance to show where those areas could be, you know. And that map is not static. You know, as we find new areas, we will add to that map and the health units are doing that work to look into new areas. So Morningside Park, Toronto has added that as now risk area as well.

Female: Yeah, because Public Health has to remember that doctors look at these maps. And if they see that you don't live in that area, they're not going to consider you as a possibility for Lyme disease. So the map has to be constantly updated and their surveillance has to be constantly done everywhere.

Curtis: We will constantly update that map and then same thing too, the disclaimer on that map is, you know, tick exposures can happen anywhere in the province. This is areas where we definitely know it's happening and where there can be other areas. So we try to note that on the map.

Louise: Thank you.

Alain: I'm seeing a lot of people line up. By the way, we're not, like, rushed earlier before lunch. We've got plenty of time. So we can go right up until five o'clock if you want with just questions. So please relax. If you feel a need to sit down before you ask questions, we're good. Go ahead.

Female: [45:14]

Thanks. And thanks very much for your presentations. They are very interesting. I have one question for Dr. Ogden and then another question for the whole panel. And one of the things I've noticed with the surveillance that Health Canada does, and particularly Dr. Ogden and Dr. Lindsey, is that you go from Newfoundland to Alberta, but you often don't include B.C. And so that's the one question. And the second question is, given the genetic diversity of Borrelia in Canada and the impacts that can have on a patient being diagnosed with Lyme disease and on surveillance criteria, what would you suggest changing in our surveillance guidelines and in our diagnostic guidelines because of the genetic diversity of Borrelia?

Nick: So the first question is, why do we not go into B.C. And the reason is that, well like everywhere, we generally go and participate-we're a federal organization. We can't just arrive and do stuff, you know. Secondly they've got a very competent B.C. CDC who are going out doing what I think is important and it's really a big difference between Ixodes pacificus in the west and Ixodes scapularis in the east. Ixodes scapularis is easier to detect. I mean, finding it is just easier. It's hard work to detect that in B.C., and so they use kind of a risk model approach to map out areas of the highest risk.

Female: And how does that differ from what you do?

Nick: Well, we're doing a lot more of the kind of-the risk model can then guide us to go out with a tick sample....

Female: On the ground? Yeah.

Nick: … and that sort of stuff, which is relatively easy to do compared to tracking rodents, which is hard work and it is very, very resource-intensive. So it's kind of tough to do the surveillance. It's tougher to do the surveillance out in the field in the west than it is for scapularis in the east or the upper Midwest.

Female: And I got the impression that you said before that you don't do all the surveillance and often it's provinces that are sharing the data with you.

Nick: Yeah.

Female: And so it just has not been shared from B.C.?

Nick: Well, it has been shared but they only did the last tranche or work I think about a couple of-either last year or the year before. And that was essentially validation work for their risk model. So they're not going to be able to, you know, to go out there and really kind of do the same amount of surveillance on the number of sights that has happened in the east because they can't just do black drag sampling. But, you know, this is a work in progress. You know, this is a work in progress. And then you asked a question about the strains.

Female: Yeah.

Nick: The impact of the strains remains-I mean, what we've done is to discover that they're there and that there are geographic variations in where the strains are occurring. We don't have any information at all really using the same method of what's happening in B.C. I think we need to understand what that means for, if anything, for diagnosis, for pathogenisting. But I think that work has to happen first before we start to change surveillance cases definitions on this, but I think, you know, if it's going to have an impact on anything, it will downstream have an impact on diagnostic methods.

Female: And thank you very much. I'd love to hear the rest of the panel, because I have done some freedom of information requests provincially and federally. And one of the things that was brought up in the freedom of information request is that the surveillance guidelines and the diagnostic guidelines should be revisited because of the genetic diversity. And it just seemed that every six months, you're finding a new strain or something that wasn't anticipated that is also pathogenic to humans.

Male: (Inaudible).

Alain: So if I could ask you to go to the microphone.

Male: [49:30]

(Inaudible). Very quickly, I'm a tick biologist. So I've had the occasion to sample ticks in B.C. And the one thing-and it's passive surveillance. I get them from pet owners and so forth. The one amazing difference in addition to everything that's been mentioned, the height of the season for Ixodes pacificus ticks is December, January, February. I get zero ticks in June, July and August. So it's exactly the opposite from the rest of Canada. And this, I think, complicates some of the comparison.

Female: Thank you.

Alain: Thank you very much.

Natasha: I would like to comment on your question from European point of view. I guess we are less affected with American dogma that was stated 30 years ago, that sensu stricto is a single causative agent of Lyme disease in North America. So that's why for us was normal to be a little bit more open-minded. And tests that are developed in Europe, actually directed to detection of, let's say, sensu stricto (inaudible), first of all, then Borrelia (inaudible) was added and Borrelius (inaudible). But it's not the whole spectrum of (inaudible) that should be checked. Because you know, it's, like, hard to find a black cat in a dark room especially if you don't search for it. So the main problem of all those diagnostic tests, it's my opinion, is that they're very narrowed. They're directed to a very small group of strains that might be successful if you are likely to be infected with this exact strain. But one step aside and the test will fail. So this is my thing. I think that the use of money needs to be turned in a way to provide significantly wider spectrum or number of tests that will be able to define or detect more (inaudible) conditions, at least those that are proven to be in one or the other way involved in human Lyme disease.

Female: Thank you. Thanks very much.

Rob: [51:58]

Hi, I'm Rob Murray. I'm with CanLyme and I'm one of maybe two people in Nova Scotia that's doing tick surveillance, and I was a volunteer. And I'll correct Dr. Kaufman here a little bit. Ticks can't be found across Canada in July and August. It's not just B.C. In fact, I'm suspecting it's probably from mid-June to mid-September, but I'm watching some of these-I prefer to call them hot spots now. Hot zones rather than endemic areas, because I can step out of one field into an adjacent field-I shouldn't have stepped away from the microphone-and find ticks, hundreds of them, and no ticks, and not know why. But I'm still trying to figure that out in tick biology because I don't want to waste my time. So I'm not doing scientific surveillance; I'm going for volume here. Now Dr. Lindsey left some tokens behind in some of our fields for deer baiting. So the question has come up from the locals. These are just outside of Lindenberg. I've lunch near some and collected ticks near others. Was any useful data ever obtained from those deer bait stations where they just fed for a couple years? Because the stories vary, but essentially it seems that it might have been budgetary. It's supposed to be three levels of government supporting that research and the ball of it dropped somewhere along the way. But they were fed for a couple of years and then things were let go.

Nick: I think that work is being written up right now. I think that work is being written up right now.

Rob: Okay. And do you have any knowledge, because I think I've got some, of why we can't get Permethrin easily in Canada? Why there's such a problem with it?

Nick: There were some issues with the kind of regulatory organization and-but that was some time ago. And what's happened subsequently, and I put your finger on what is potentially a very good method of protection and that the military are allowed to use. And that is that Canada has been deceived as not being a market for stuff that is available in kind of the public health and prevention toolbox in the U.S. that's not available to us because it's not licensed for use here. And those products are not being brought forward. The companies are not coming to Canada and saying, "Okay, we want to try and license this." And that's something we're going to have to do something about. So you …

Rob: Okay, I've got the answer from the company. It's indirect because I don't have it even electronically anymore. They have been asked repeatedly to come up with more and more bigger sums of money for safety testing in Canada even though it's internationally accepted. Hundreds of thousands of dollars (inaudible) request for another seven, 800,000. And the company owner said, "Look, you know, we know that you can benefit from it (Inaudible) in the field." So it's a question of one department-you know, the left hand not knowing what the right is doing and being asked to operate the department probably at a profit. But that's just my own personal opinion. The story is not complete yet. Thank you.

Nick: Thanks. That's good to know.

Jill: [55:26]

Hi there. I'm Jill from Alberta. A word on the Permethrin, I was able to order it last year. Amazon.ca and it's gone this year. But there is another avenue. I'll let you all know how to get some Permethrin in Canada. I do have a question. Based on Health Canada, Health Ontario and every province, I guess it would be, your surveillance data is based directly on health data provided to you, right? So if we have a country that's chronically under-diagnosing Lyme or recognizing, they say, the bull's-eye rash, you nailed it. You're diagnosed with Lyme disease. But that's not true in Canada. Nobody-very rarely do people get diagnosed, even if they have a tick holding a sign saying, "I have Lyme and I just bit her." The doctor still does not acknowledge that. So all this mapping and data you've collected is terribly inaccurate and has been for years and years because you're not going to the provinces, like Alberta who, "We have no infected ticks. They're in B.C. and Saskatchewan." And Saskatchewan government says, "We have no infected ticks. They all came from Alberta." When we going to straighten this out? We need surveillance in every province, pick a zone, every year. Hire the people, go out and do the surveillance. I personally do surveillance in my area. I capture as many hunted animals, I stop at every road kill I see. I have my tick kit and I will pick ticks and send them off to be tested. It turns out I actually found a species of tick Alberta didn't know they had. But my due diligence hopefully is going to pay off, and I need Health Canada and each province to do their due diligence.

Nick: Can I respond to that?

Jill: Yes.

Nick: Yeah, so I agree with you. What ideally we should be doing is systematic surveillance in every province in order to … We do have information from Alberta. There is a passive tick surveillance system; in fact, I think there are two. One is run by agriculture using the kind of (inaudible). The other is from Hugh Clinics run by Alberta Health.

Jill: Alberta Health throws a lot of ticks in the garbage, I'm afraid to say. They don't make it to surveillance. And how the receptionist at the doctor's office can identify that species of tick. I can't do that yet, and I've been playing with them for a couple years now. They're making the call on a level they're not-they shouldn't be making a call on. And ticks have physically in front of my eyes hit the wastebasket.

Nick: So I can't comment on that, because … I say, it should be being done systematically. One of the things that is, I think, an issue for all federal, provincial public health, municipal health unit level, is the-we haven't got a whole lot of resources to deal with this. And that is an issue (inaudible).

Jill: Well didn't Zika virus and a couple others just get $748 million worth of funding? Let's claw a little bit of that back and give it to the Lyme research.

Nick: Go and talk to my bosses.

Jill: What is your boss' name? But seriously.

Nick: You may regret giving any. I think now that you know who they are, because they're at this meeting, and I think now things are changing from this. But you see what I presented is what we've done over the last sort of couple of decades essentially. By and large kind of resource-wise not far off the corners of our desks. So what happens in the future is another thing.

Jill: We need accurate data. Accurate surveillance.

Alain: Jill-and I'm going to foreshadow part of the conversation that we intend to have tomorrow.

Jill: Get it right.

Alain: The part of the conversation tomorrow will be, in an ideal world, in an ideal Canada, what would a surveillance system look like? That's one of the questions. I think you're going to drive to an answer to that very question. And with follow-up questions, how do we make that happen? What's necessary to make that happen? So I'm going to encourage you to continue mulling over that, collectively let's continue mulling over that, because we want to hear about your ideas on that tomorrow. Alright?

Jill: Okay.

Alain: It's absolutely essential. And I didn't mean to interrupt, but I just wanted to flag something. We touched …

Natasha: I just want to give you just very general remark. You know, it's, like, it sounds so easy to collect ticks. I mean, we'll take flags, we'll go out, we'll just flag some area and we'll find that there are no ticks. Actually this is not an easy task. Professional, or trained people, should do this because collecting Ixodes scapularis for example in northeastern United States, the technique cannot be applied in southeastern United States. And a couple of failures were overly recognized because people from northeast went to southeastern United States, went out and said, "We can't find any. They are not there." But no, it means only one thing that you can't find it because you don't know how. Ticks in southeastern United States should be collected by couple. Single person will not be able to do tricks to get ticks out of the land. So that's why it's, like, you have to be sure the people who go out know how, first of all, and that they know definitely what they should do, how they should do and what they're looking for. Otherwise it will be just a wasting of time and human power. This is extremely important process, but it needs to be done by professional. You cannot just hire people and say, "Let's go out, collect some ticks." They might be there; they might not be there. But this is just a serious thing that needs to be taken as seriously as diagnostic of Lyme disease.

Jill: Yes. But if I'm collecting them off of host animals, they're there.

Natasha: Yeah, they're there.

Jill: They're there. I collect them.

Natasha: But it's a little bit different when you're going outside. Yeah.

Jill: Yeah.

Alain: Joanne, did you have additional questions?

Joanne: No, I'm good. Thank you.

Alain: Okay. Thank you very much.

Female: [01:02:11]

No disrespect, ladies, but my question is for the two gentlemen. Sir Ogden, I think I've memorized your work. I have read it through Journal of Applied Ecology. I'm nervous. On the summary of number five, it states there that the ticks expands 46 kilometres per year over 80% in 2020. So we're 2016. Four years from now. So I'm thinking maybe we're now 60% and my question is, I was bitten outside of Toronto. It was identified by Ministry of Public Health that it's a blacklegged tick, May 14 of 2011. My question is, if it is expanded for 46 kilometres per year, why my-it's hard for me because I was denied from my Workers' Compensation because the area that I live, it's one hour away from Toronto. And it says that it is not endemic. And I assure you it is, because according to your paper, it is expanded 46 kilometres every year. Outside of Toronto, Dr. Russell, I'm one hour away. Do you think I am not in the endemic area? I am, and I've got the tick bite to prove it. I have the bull's-eye rash, and I still get denied by my Workers' Compensation for two reasons: I am not in the endemic area, and the ticks should be 36 to 48 hours. And you have to-all I am asking is to add the map. Because this doctor who denied me says that I am not living in an endemic area. And I believe, doctor, that your study was done in 2010 and it was published in 2012. And now we are in 2016. Please correct me if I am wrong.

Nick: Whatever the reason is for-it seems to be a wholly inappropriate use of the information that we are providing, to be honest with you. This is risk information to guide Public Health, target Public Health action, towards those communities, those regions we think are the best so they should have the-those are the places where people really need the information right now. But to be used for the purposes that you have identified rings for me a lot of concern.

Female: It was already now sir in Barrie, it was found already in Barrie. And I have all the documentations given to the Workers' Compensation that I am in an endemic area and it's still denied.

Female: Maybe a letter from Public Health Canada would be to your (inaudible).

Female: That's why I'm here, for Mr. Russell. Thank you, gentlemen.

Curtis: Yeah, I can't echo much more than what Nick said. Again, it's for risks, you know, look, we're here. But compensation, I'm not privy to that information, but that's not the intent of that. It's to know where the most likely areas are, where the greater risks are. Again, I'm not a physician but the physicians (inaudible) an idea of where those areas are, again, based on what they see and what they know. And we note on that map, they can be in other spots and the same thing too, you know, the closer you are to a risk area, you know, right on the paper, the closer you are to a risk area, the greater the chance; the farther away, you know, but you can (inaudible) to a tick. Again, as Nick was saying, it's to give people an idea-and a lot of it is for the case investigation for the health units. And same thing too within the health unit, they are not restricted to that 20 kilometres. Based on their local experience that they say, "Look it, this person has a tick, they've got the rash, the doctor says they have something in that area," they can use that information. They don't have to stop at 20 kilometres. That is a buffer to give them an idea. Again, it is not meant to use for compensation or those other aspects. It's to know where those areas might be.

Alain: Thank you.

Female: I don't intend to use it as in compensation, but I'm just giving you just a general that they are not using your data, anything at all. They're just blowing it out. That's my point.

Alain: Thank you, appreciate that.

Female: [01:06:41]

I have little questions that might get to all four of you. One, where is the surveillance done of Canadians who were infected in Europe? As one of 23 million that has a passport, I was infected in Europe and no doctor could recognize Lymphocytoma and it took me eleven years to get my blood to Winnipeg. So that's ridiculous. Even though I was in endemic areas and there's no paperwork for me to fill out to get logged as a Canadian infected abroad. And ticks are real vampires. Dr. Dieter Hassler in University of Heidelberg was actually discussing how he was able to get an infection rate in his area down from 17% to 1.5 due to education and early treatment. Hopefully Public Health people can look into this, because that was in 2000 that he was actually on record for saying that. And because dogs have a six to one ratio of picking up ticks, either is there a breed of short-haired dogs that can be put with a tracking collar to run around-no, seriously. Or a little coat that's got all the smelly, dog, whatever attracts ticks, and that way you can load it and we can do the studies about where racoons go in the city of Toronto to find out where their little zones are and garbage bins. This way you'd be able to dump in the data of, where did the dog go? How many ticks did it pick up? And collect the data that way. You don't have to have an army of people dragging ticks. And dogs can get into the areas that humans might not think to look. So just as a suggestion. So question one, Europeans.

Nick: Lyme's been nationally notifiable since 2009.

Female: I was infected December 2000.

Nick: Yeah, so that predates the … We do capture the travel required cases of Borrelia, (inaudible) and so on. All that testing is done at the National Microbiology Lab. So if anybody has a travel history and shows symptoms of Lyme, they should be getting their samples sent off to the National Microbiology …

Female: It took me eleven years to get my blood there and they told me the results were due to the fact I had early antibiotic treatment in Ireland and that so much time had passed since infection, hence the borderline results, right? So that needs to be documented somewhere so that people like me are not falling through the cracks. And you know how many Canadians-think of all the university and college students that are taking courses one term abroad. We're sending Canadians over, and when I got sick at York University, I was a student. There was a student from Wales doing a masters who was infected in Killarney Provincial Park and we just sent her back to Wales. So …

Nick: These cases should be captured now.

Female: They're not. And has anyone, Dr. Russell, has anyone ever thought about looking at what's been done before in the '90s to see what worked?

Curtis: Well, we have been doing some ongoing studies. And I don't know whether they're complete or not, but I think they probably are. I've seen what happened in European countries, particularly Switzerland, and understanding how kind of people are changing their attitudes in response to the information that's been provided and how that's different here than there, and whether these sort of methods are transferable. But getting that information to people that makes them change what they do is actually really difficult.

Female: Part of the issue is, for example, Toronto Public Health will only have things in French and English, and they've identified 15 cultures or languages outside of French and English, and none in that top 15 are Caucasian skin tone. And as I wrote to Toronto Public Health, people aren't going to know what to ask for if they can't read the material. And if you're not showing them rashes, as I've also asked Dr. Patel in your lab several times, what does a rash look like on you, Dr. Patel? Because if doctors couldn't recognize multiple blotchy rashes on me and Lymphocytoma, what does someone who's darker, what are there chances. It's not there? And we're doing a disservice right across the board. It's very frustrating on the public side of things, and when you're trying to help people that think that they might have something, they're being told, "Oh it's a bruise. It's eczema, it's ringworm, just ignore it." And these people, if it's hard enough for a Caucasian Canadian to get a diagnosis, these are the people that we're now encouraging to go to parks and use provincial parks and explore the great outdoors and become good Canadians, and we're not giving them the skills and the information to protect themselves. So I hope that ends up on your data somewhere.

Alain: Good thoughts.

Female: Yeah. So hopefully the dogs with the little trackers.

Vett: I love the idea. I'm not sure what the Animal Care Committee would say about it, but to some extent that's already happening. I do have community members who for various reasons don't treat their dogs with tick repellents. And they are an excellent source of ticks from their region.

Female: Because they do it in migratory seabirds, because they published studies in the '90s that migratory seabirds along the Atlantic coast were found to have European infections.

Vett: Yeah.

Female: They've been doing studies on puffins.

Vett: Yes.

Female: And they've got the tracking devices on them, and especially along Atlantic Canada, because of the whole issues of night lights, they actually have people going out, rounding up the puffins at night, keep them caged into garages and releasing them in the morning so that they're safely in the waterways, because they're getting confused that the night lights in communities are actually stars reflecting on the waters. So here puffins, they're already collected, like, you know, it's already being done in so many different areas and it just seems like everyone's stand alone and ignoring everyone else's research.

Vett: I think that's a very important point that we need to coordinate these research efforts.

Female: Thanks.

Alain: Thank you.

Female: [01:13:23]

Hi there. I'm here to muddy the waters a whole lot, particularly because I've been sick for over 25 years and now being treated for Lyme and Babesia and Bartonella. So my question is about co-infections, and I noticed, Dr. Ogden, that your last slide you left up for us all to read, and I thought there were a list of them there and that there's no discussion around it today. And I'm finding that particularly frustrating because I see us having the opportunity of all these ticks being brought in and I don't know, are they all being tested for co-infections? And if not, is it that difficult to do? Then we can get a massive-I mean, everybody's talking about the ability to collect data and analyze data now in great quantities. Why not do all these huge number of co-infections that many of us are being treated for? Q fever,Bart-you know, all the others. (Inaudible), Anaplasma and Mycoplasma and the whole deal. So do them all so that then … Like, I see-I come here and I think, "I'm so excited that we're doing this. It's so wonderful, we're all working together. We're going for this common goal." And then I see, well there's people that are going to be diagnosed in the early stages and get better and get well. And then there's those, the few of us, that don't get better, and it's because of the co-infections or possibly other things as well, but because of the co-infections. And there will be no data. So is there data? And I would love to hear.

Nick: Yes, obviously for Lyme disease, it's nationally notifiable. But none of the other tick-borne diseases are. Some of them are provincially notifiable. But nationally notifiable, no. With the tick surveillance, the environmental surveillance, yes we do test for a range of pathogens because of course we're interested in Anaplasma, we're interested in Babesia, we're interested in (inaudible) virus, we're interested in all of the tick-borne pathogens. And we're also interested in finding the tick-borne pathogens that we're not aware of at the moment too.

Cheryl: [01:15:42]

Hi, my name is Cheryl, and I represent a support group that we just founded a year and a half ago in the most southern part of Canada, in Essex County. I am coming today to ask a question about surveillance. It seems to be the topic of the day in here today. I'm actually asking what the responsibility is of local health units with regards to surveillance. I know, Dr. Russell, you had mentioned earlier that you actually would go down and teach individual health units on how to perform an accurate one. And do we have records of surveillance initiatives actually taking place in all of our counties throughout Ontario? Are they obligated to perform tick drags, flags or live trapping in order to determine the risk to the public and if they do find Lyme disease and/or other infections in the local tick population, are they obligated to inform the public and at what point are they supposed to inform the public? Sorry, that's a big question.

Curtis: (Inaudible). So, you know, each of us obviously has their own different bylaws and rules.

Cheryl: Right, right.

Curtis: With tick surveillance, so broad paintbrush. You know, if a health unit goes out and does the active tick dragging and the surveillance, that data then, we send that off to the National Microbiology Lab where they will then identify the ticks, and if they're blacklegged do the testing. That information will come back to us and to the local health units so they do know what they found, you know, if there's something going on. And at the local level too, they have the human data, they have the passive data to tell them, you know, hopefully to indicate to them that there might be something there. If there's something warranted, they can and do look. And they are, based on the IED protocols and what's happening with Ontario, they are supposed to do a local risk assessment for vector-borne diseases to determine what is needed within their area.

Cheryl: Okay. Is there a place that we can access online with regards to the results of those reports?

Curtis: We do do an annual vector-borne disease report. So publichealthontario.ca where we would post, you know, where our human cases are, what our, you know, tick surveillance numbers. And that's on our Public Health Ontario website.

Cheryl: Will it also show where exactly tick drag surveillance initiatives have taken place?

Curtis: That would be more at the actual local level for them to show where they're doing.

Cheryl: Okay.

Curtis: However if we did the tick dragging and found information to say we had a new risk area, that would then be added.

Cheryl: Okay. The reason I bring this up today is because one day in 2015 last year, one of our members phoned the local health unit and spoke with a medical officer there with regards to a question about how many drags they are doing every year. And our local medical officer stated that they don't have funding for that. And that was a big concern for us because we know that in the year 2015 we only had one case of Lyme disease diagnosed, and we happen to know that Point Pelee National Park is included within our county, which is known to be an endemic area. Parks Canada may be done totally separate from the county, I would imagine as far as the statistics (inaudible) …

Curtis: So we do recognize Point Pelee as a risk area, and you can probably (inaudible).

Cheryl: Right. That's where I was infected in 2007.

Curtis: Right. So yes, it's an area we know of well. As for their municipal budget, I wouldn't have the privy to know what they're doing with that.

Cheryl: Okay. Is there a way that we could bring it up to the local medical officer to say, "Hey, look it. We have this many patients that we know of with Lyme. You need to be doing a bit more tick drags and flags.

Curtis: Yeah, and I think that would be a conversation with your local MOH as to what needs to be done.

Cheryl: Okay. Thank you.

Ryus: [01:19:38]

Hi, my name is Ryus from Winnipeg, Manitoba. I've actually done some of my own surveillance, and I haven't found it actually that hard to find blacklegged ticks in areas that aren't known to be endemic. But my question actually is about reporting issues and, you know, significantly underreported cases. Regarding, like, the EM rash and in the Health Ontario presentation, you mentioned that now an EM rash along with someone being in an endemic area is now reportable. But you say you can get Lyme anywhere in the province. So shouldn't-regardless of where you are, if you got an EM rash within Ontario and for the rest of Canada, should that not be reportable?

Curtis: That's for, like, confirmed and probable cases. So, you know, a confirmed case, someone's got an EM rash and they are from a risk area, they are a confirmed case. However we could also have probable cases, so depending on where they fit in the criteria, we could capture that as well.

Ryus: But the thing is, an EM rash is 100% confirmation of an infection. So regardless of where you are in Canada, that should be a confirmed case.

Curtis: Again, there's a difference between our surveillance and what a case is and what clinical aspects are. So based on the information we have to try to standardize so that we can look across the provinces to see where things are occurring.

Ryus: That still doesn't make sense. I mean, we know there's a major issue with cases being underreported, and if someone has an EM rash, that's confirmed by a doctor. But they're-you know, in somewhere that's not endemic. And they say, "Well, we don't have to report it because that isn't what the guideline says."

Nick: I'd just like to point out again that the-with our objective, it would be nice if we could capture as many cases as possible. But actually capturing as many cases as possible is not necessarily the first and foremost objective. The objective is to be able to compare from one time place to another. When we started to develop the national surveillance case definition, it's recognized that EM is an important clinical manifestation and we want to be encouraging people to be reporting at that stage. But actually a relatively small proportion of EMs are this sort of, like, classic kind of bull's-eye target appearance, which you can probably go, you know, if that were present in every case, well fine. It would be much easier to say that this is a case anywhere. The reality is that the erythema rash is relatively infrequently like that and more frequently are the type of rash which can be confused with a lot of other types of rash. So there is-we had a lot of discussion about it. And the conclusion at the end of it was that trying to capture all of those kind of rashes that might be but could be something else would kind of bring Public Health to its knees and would lead to a lot of false kind of positives, if you see what I mean. So that was our main concern about that. But I recognize that's a problem; I think we all recognize that that's a problem.

Ryus: Thanks.

Vett: Can I throw in one comment?

Alain: Please go ahead.

Vett: I realize this will make those doing the surveillance and the epidemiological maps cringe, but I do think that we need a paradigm shift in how we interact with community groups. I've benefitted enormously from community members going out and doing tick dragging. And I know that's going to be an issue in terms of integrating it with your data, and you probably don't want to. But that is still tremendously valuable from a research side, and thank you for doing it. It's also incredibly valuable in terms of educating the public. There's nothing like seeing your neighbour wandering around the park with a tick drag to get someone asking, "What's going on? What's the problem?" And I'd really like to get away from the current dynamic we have, which is, patients as the enemy or the patronizing, sort of, "Don't worry, we'll deal with it all and you people run along." Perhaps this is an academic thing, but interacting with the community, partnering with the community is incredibly important, and I'd love to see more of that. So I know I get ticks from Rob Murray and Reuben Kaufman, and I hope your ticks go to a good home.

Ryus: (Inaudible).

Vett: Good. So thank you for doing that and I'd like to see that as somewhere we would go in the future.

Alain: Next question please.

Veronica: [01:24:42]

Hi, I'm Veronica. I'm from Tecumseh and my question is for Curtis. The Lyme disease standard questionnaire and the EM rash reporting, can that submitted by the patient themselves or does it have to be reported by a doctor?

Curtis: So that standardized case investigation questionnaire, that's for the health units, so the case investigators, when they're looking at a case. So, you know, it depends on them and who they're interviewing. They could be interviewing the patient or they could be interviewing the physician.

Veronica: So the patient can complete it themself.

Curtis: Well when they are doing the investigation and asking them those questions, they can ask them those questions as well.

Veronica: And then the EM rash, I've seen a couple lately. And it's kind of upsetting because they went to the doctors and the doctors didn't recognize it. And the one woman ended up in the hospital, fatigue. Like, my son has Lyme disease; I knew nothing about it. But with her, now that I have a little bit of education, she got bit and she doesn't know by what, but she took off her Band-Aid and there's the rash. And she has a metal taste in her mouth, a stiff jaw, stiff neck, fatigue, seeing black floaters in her eyes. And I'm, like, "Go get antibiotics." And it's not being recognized as a bull's-eye rash. And she's not getting her antibiotics. She's been diagnosed with lupus and now she's been diagnosed with rheumatoid arthritis. And it's probably been a month now and there's no-nothing. No antibiotics. And can she report it, like, the EM rash to the public health unit? Like, does she need the doctor to do that?

Curtis: Well it's usually based on, you know-for us for our case investigations, you know, it's the clinical and the laboratory aspects. Again, like, sorry about your friend. That doesn't sound very nice at all. But again, that's, you know, it's a case investigation for standardization, so again, it's through clinical diagnosis and laboratory testing. However if they do have issues, they can bring them towards their health unit.

Veronica: Okay. And Natalia, I wanted to ask you, just my last question, about-you were talking about the host of ticks and you said, "Rabbits," and I missed it. Can they carry Lyme disease?

Natasha: No.

Veronica: They can't

Natasha: This is actually an extremely interesting controversial thing. To be able to culture Borrelia in any liquid media, you have to add rabbit serum. Borrelia will not grow without rabbit serum. But from the other side, rabbit is one of few animals that resist anyBorrelia from sensu lato family exceptBorrelia andersonii So the immune response of rabbit to sensu stricto garinii afzelii is so strong that Borrelia can't survive in that animal.

Veronica: Okay, because we had pet rabbits and they died. And I was worried if they had Lyme disease because one of them was paralyzed in the back end. And they've scratched us. And I'm, like, "Could we …" Like, I was worried about that. And one of the rabbits died and the rabbit with it had ticks on it, and then my daughter was holding the rabbit. And I'm, like, "Could those ticks (inaudible)."

Natasha: Yeah I know from-I'm not a veterinarian. But I know from my grandfather that rabbits are very susceptible for different infections. But working in the lab, we actually use the rabbits to feed ticks on them. And some rabbits respond to tick bite, developing a rash on its skin. But whatever we were trying to do to prove that any other strain of species of sensu lato borrelia can infect rabbit failed. I mean, there is definitely something in complement of rabbit that kills Borrelia as it cleans it completely. So I'm sure that as long as the rabbit didn't crush infected tick with nail that scratched you, you shouldn't be worried about transmitting Borrelia from this animal because it's deeply and strongly resistant to infection. And this is actually very interesting thing, because the people who are searching for anti Borrelia candidates should look on a complement of those animals that are resistant to infection, because there are definitely some compounds in the compliments that kills Borrelia. This is what needs to be targeted.

Veronica: Okay, thank you.

Natasha: You're welcome.

Alain: I want to be careful in managing your time. It's four o'clock. I said we've got plenty of time, and I stand behind that. But I don't want to really exhaust our energies because we still have tomorrow to go. So carry on.

Female: [01:29:33]

I'll be quick. And this is to anybody who can provide with the answer for me. Basically a follow-up to the last two questions. I pulled a tick out of my head myself. I had the rash on my head, hair fell out. Every symptom almost in the book. My doctor basically fired me, told me never to mention Lyme again. He admitted that I was the third crazy in his office that week trying to claim Lyme. I know it's too late for me; I'm here. But I would really love to educate him. So how do I provide his office with some paperwork so that he doesn't send somebody else out as a crazy, like he did to me? Where do I get this paperwork to drop in on his office? Uh oh, the silence is scary. Sorry?

Nick: We've got loads of stuff on Lyme. There's loads of stuff published.

Female: He hopped on the Internet while I was sitting at his desk and he started to read the symptoms of Lyme, furiously typing and reading, "Do you have this? Do you have that? Do you have this?"

"Yes. Yes, yes, yes."

He said, "Lyme stops at the Oregon border." I live four and a half kilometres off that Oregon border on a ten-acre property screaming with rodents and birds. I don't think they're stopping them at the border. He is in complete denial, as is the rest of his office. So your sources online, he is not looking for or he is simply ignoring. So I would like to do his work for him and hopefully save some other people. So could you direct me or whatever-like, where do I get the information that he will find legit and not me as a crazy person pulling stuff offline?

Nick: So as I mentioned, there should be something on the Public Health Agency website, Healthy Canadians. And there should be something on-I'm presuming Alberta?

Female: He went into B.C. I'm from B.C., Surrey.

Nick: Yes. B.C.

Female: And he went on to CDC's site and, "No. No, no, no, no, no. We don't …"

Nick: There is a map of risk in southern B.C. of where the …

Female: He was-and this was the thing. This is why I want to get him information. When he fired me, I went to get my file back from him. None of my visits are in there, none of my symptoms are in there. He never reported me. My reference to CDC, somebody mistakenly let me see it, and it said, "Patient is insisting that I refer her to you, though I don't think she needs you." So of course they phoned me and said, "No, we don't need to see you." So he needs this information and obviously if it's online, he's not getting it. And I've tried to provide him with some, but he doesn't think it's good enough. So maybe tomorrow, because I know it's, like, tough question to answer right now. Maybe tomorrow that can be part of the thing for the future, is to provide us who are here, who want to educate those who are not willing to listen, with the proper source of information to provide them so that I don't just look like some crazy lady pulling stuff offline.

Nick: So just hold that thought, because we're here in the surveillance session.

Female: I know.

Nick: There's actually a communication session as well, and I know that kind of, like, you can't just separate that stuff out. (Inaudible).

Female: I don't want to run to the other room just for a question.

Nick: Just maybe it's worthwhile bringing that point up tomorrow about how you-finding the information then communicating it out.

Alain: It'll be interesting-it's me. It'll be interesting to hear what will come out from that other break-out group that's looking at public education and awareness, whether or not that aspect of communicating about Lyme disease will be touched upon. And by the way, at some point tomorrow right after lunch we'll be hearing back from the various break-out groups in terms of the tenor of their conversation. So one of two things. You may get some feedback then and there. Or you can infiltrate that group tomorrow morning, alright?

Female: Thank you.

Alain: So it certainly is very, very topical. So, absolutely. Thank you for that.

Kami: [01:33:45]

Hi, Kami Harris. I'm a PhD student with the Atlantic Veterinary College as well as at Olsen in collaboration. My question was kind spurred by-and I'm kind of paraphrasing here, Ogden, you said, "You can find a tick on a dog, but that's not necessarily a reproducing population," which I agree with. However in terms of hundreds of dogs, it could be very likely a reproducing population in that area. And so my question sort of directing back to this developing a framework, somewhere we can move forward, something we can put down on paper and have strategies to develop. And in vet school we're taught extensively one health, one health, one health. And that is, for anybody who doesn't know, collaborating with researchers, veterinarians, medical communities, and making a one health initiative to really push particularly zoonoses diseases. So we know Lyme is an arthropod vector of zoonoses, and so what can Public Health and the NML and the researchers do together and also in collaboration with veterinarians to increase surveillance in a way that is effective and it's done by professionals and validated and in this one health spirit?

Nick: Couldn't agree more. We have been doing it. I mean, it is quite a data set actually. I mean, it's probably the longest data sets on ticks pretty much anywhere in the world; I think it's been systematically collected. So we started off in 1990 or 1989, and it's still going today. I identified a problem or a weakness of the passive surveillance, which is that you find a tick on a dog and it doesn't necessarily mean that there's a population here. So we're working on ways of, and have worked on ways, in which that information can be assessed in exactly the way you're suggesting. In other words, you know, what's the number of ticks submitted per unit population? Can we see changes in the tick infection prevalence? Are we continuing to look at other signals that are coming out of passive surveillance? Will increase our ability to say, "Yeah in this place we've probably got a tick population and this place we haven't." So, you know, I'm probably preaching to the converted on that.

Kami: Great. And just, I guess maybe, like, a follow-up is that veterinarians in our area and with our research prior to us taking their ticks very willingly and their data sets and information from the animals that they were seeing had nowhere other than the veterinary community to give that information to. And so what can you do to collaborate with them and grab their data sets?

Nick: I say this has been going on for a long time, that there's been a collaboration between the veterinary clinics across the country, the provincial public health and those other (inaudible) sometimes it's natural resources and so on, who kind of manage and collect the ticks, dispatch them for appropriate identification and testing. And that has been going on for, kind of, really since the outset. Some places, there may be a kind of I guess patchy occurrence because-as well as the-you've got to have a dog to pick the tick up. You've got to have an owner of the dog to take the tick to the vet or take the dog to the vet. So there is a sort of, like, a patchiness in terms of the human population occurring. But, you know, we need to account for that in the analyses of the data. But I say, you're preaching to the converted.

Kami: Thank you.

Vett: Can I add something to that? Just to add to that, and actually this is a question for Curtis and for you, the NML tick data is phenomenal, but certainly in terms of the passive surveillance, there are holes in it. My understanding is that no more ticks are being accepted from Nova Scotia dogs. I hear frequently from Ontario veterinarians that they can't get their ticks tested. And I don't know if this is correct. You talked about Ontario people testing their ticks and then the last thing is-I know P.E.I. has cut off sending their ticks for a variety of reasons. So can we do something nationally so that you can get ticks tested from everywhere?

Curtis: We have a national team. But right now in Ontario-we used to take ticks off of everything, vets and humans. We came to a lab (inaudible) the number of ticks that we were getting. So our labs, since 2009, takes ticks off of humans only. We do, you know, some of the health units, they do talk with their local vets, can they do some sentinel surveillance? And some of the vets do have some sentinel stuff set up with the national lab for some Ontario data. We are looking at other things. We do work with the vet college to see, you know, is there some information there that we can use as well? And those are some of the avenues we're exploring. But as of right now the tick submissions are off of humans.

Nick: Some jurisdictions have had problems with that. I mean, it is a partnership between the vets and the medical clinics who participate in the passive surveillance and the provincial organizations and the Public Health Agency. And sometimes the provincial public health organizations for some reason don't have the resources they need and there's been some glitch. And that does happen, I'm afraid. The other thing that is a bit more systematic is that this was originally intended as a surveillance system, kind of a bit of a canary in the coal mine kind of system. And it's kind of become a bit more of a sort of first view surveillance system to say, "Okay, do we have the likelihood of emerging risks?" And we find that where the ticks are really setting up home. Then suddenly you're starting to get tens of thousands of ticks submitted, and it's actually completely swamping the passive surveillance program. So from those areas, what generally is happening is that we're actually closing down the animal part of it, which I understand we have to do because otherwise Robin Lindsey won't be able to get into his lab because, I mean, he has literally tens of thousands of ticks to examine every year. But I still believe that there are other data that we could get through maintaining that. But it is really tough, because we're moving from what was a sort of light touch sentinel surveillance to something that is really trying to cope with something that is really quite a complex environmental problem.

Alain: Alright. I know that there are three of you that would like to ask a question-no, that's alright. There's two of you right there; I know that somebody's sitting here at the front that wants to also ask a question. It's 4:15, I'm worried about managing our energy and time. But more importantly, tomorrow morning when we start up, I'm going to be asked on your behalf to tell the other two break-out groups, what were some of the big messages that came out from our conversation this afternoon? I've been tracking some, but I will guarantee you that I've got them wrong. So I need you to tell me, before we walk out of this room, what are the big messages that you want me to report back in plenary tomorrow on your behalf. I need to keep some time available for that, so I'm going to go with the last three speakers to ask questions. And then I'm going to give you a short task on the big messages that emerge from our conversation this afternoon. Over to you, sir.

Reuben: [01:42:23]

Thank you. Reuben Kaufman, a former professor, so I can't guarantee to be quick, but I'll try. And this is just a general comment about EM rash, and unfortunately sometimes a loose use of language. Very frequently you read that an EM rash does not appear or it does not occur some percentage of time. It's not always clear to me, that the EM rash has not occurred in a case of Lyme or simply it hasn't been observed because of where the tick was and so forth. Also in the same line, very many people might say, "I have an EM rash," but of course there are other sorts of just local routine reactions to a tick bite, which I imagine many people might misinterpret as an EM rash. And so this is a difficulty and there's no answer here directly. But this is a difficulty that we all have to realize that the Lyme disease situation, like any other aspect of biology, is biology; it's not physics. And we do not have black and white answers for things. And I think all of us should probably keep that in mind with so many of the questions that have arisen during this conference.

Alain: Thank you. Madame.

Female: [01:43:44]

Hi there. I would like to ask, seeing as I live in Dundas, right smack in the center of the area that was studied by John Scott in his latest article that was published in the journal of, what is it, Scientific Medicine in the month of May this year, and where it showed that 40% of the ticks were positive in the area of the ticks that he collected. Realize it wasn't a great, huge sample size, but that's significant to me because literally I am smack in the center of the area he studied. So my question is, why the discrepancy between what Public Health is saying in Hamilton, where they're basically saying there is no Lyme, or up until just recently, they're saying, "There is no Lyme in Canada." Were they not testing at all? And if they were, were there two different-like, I think he sent his ticks to the States to be analyzed. Is there a different methodology or, you know, a test that they're doing? But to have such a discrepancy in the science and such inaccurate information being given out to the people of Hamilton and the surrounding areas, it's terrible. Someone posted a picture just the other day of a tick nest this big with thousands of ticks in that one little spot in the park where all my kids play t-ball and all those things. Those are stressful things to see online and I'm wondering why it is that there's just such a gap between that research and what we're hearing from Public Health. He is a Lyme patient, so he's got a vested interest to do the work. But I don't know if those who don't have Lyme disease are as interested as us.

Curtis: So the part about, like, testing with the Americans, I think that's more his colleagues and who he's working with. As for-again, I'm not a microbiologist. So the protocols of what they used-but I think it was more just that those are his colleagues, they have the lab capacity to test, so that's why they were-that's who he was working with for lab testing. As for the information he's gathered, that was him actively going out and finding them based on his surveillance. You know, Hamilton, yes, we will take that into consideration. We are in consultation with Hamilton. You know, it's another data, it's another piece-you know, we take everything, human, passive, tick, you know, it's another piece. The word's used too much, but it's another piece of the puzzle, you know, as to what's going on in that area. We recognize that we can get ticks in new areas, and that's why we keep doing the surveillance. So we will be talking with Hamilton (inaudible) what does that mean and where do we go forward with that?

Female: It's just so frustrating because Public Health (inaudible) ticks and meanwhile teachers are pulling ticks off the kids that are playing (inaudible).

Curtis: Yes, from the data that Hamilton has, you know, a lot of the data that Hamilton has, a lot of it, they do get a lot of dog ticks as well. That's another story, but they do get a lot of dog ticks. So the data, you know, they're working with the data that they have and this is another new data that's been shined [sic] on us, so we'll looked at that data and see what we can do.

Alain: Alright. Over to you.

George: [01:46:57]

Thank you. My name's George. This is for Dr. Natasha. (Inaudible). I was diagnosed with Lyme disease (inaudible). And I'm just wondering which, is the worst one for neurological problems? Or are they all the same?

Natasha: No. Actually (inaudible) it's, like, I always was wondering, why do we have to have a couple of Borrelias in Europe to cause a different clinical manifestation but in North America sensu stricta is so capable of causing everything? You are counting on (inaudible) manifestation, whatever. If you go deeper, at least do a study of clinical manifestation by different Borrelia in Europe, you will find that an (inaudible) actually is the priority forBorrelia afzelii. Arthritis, mostly caused by Borrelia burgdorferi sensu stricta and neuro Borreliosis generally by Borrelia garinii. But Borrelia garinii was separated into two different species. It's still garinii and it's in a new species Borrelia bavariensis. And actually Borrelia bavariensis is the severest amongst them two, causative agent of neuro Borreliosis in Europe. Because all strains that are known to belong to this species were isolated only from humans. So that's why it's, like, you have to be very careful when-somebody will tell you-at least when somebody tells me that (inaudible) didn't appear for me, the normal reaction will be, "So it means that you have a species in Borreli afzelii that will be (inaudible) for European scientists. But in North America, it's, like, you shouldn't count on (inaudible) in 100%. And in neuro Borreliosis, this is worst, I guess. Because the disease needs to be developed really deeply to cause those symptoms, but among garinii and bavariensis, bavariensis is the worst.

George: Okay. The garinii that I had was neuro, cardio and arthritic.

Natasha: Yeah, yeah, yeah. For a long time it was the same group. When you were talking about neuro Borreliosis it was alwaysBorrelia garinii and Borrelia bavariensis was a part of garinii. So it's, like, right now they're separated. But they're of the same-very similar family, but a little bit different features.

George: Okay, one quick question. Is there any chance in the future that they can work a Phage virus versus the bacteria as they do in Georgia?

Natasha: The what?

George: Phage. P, H, A, G, E. Phage.

Female: (Inaudible).

Natasha: (Inaudible) yeah. I have no idea.

George: Okay.

Natasha: It's, like, (inaudible) if people ask me, do I believe if there will be a (inaudible).

George: (Inaudible).

Natasha: Yeah, vaccine against Lyme disease.

George: Okay, great. Two last quick questions. In Ontario especially, are there any signs placed in the endemic areas, as you were mentioning, that your surveillance has checked out and to warn people placing signs in both official languages that people should be aware of?

Curtis: So within those health units, they're responsible for signage. But most of the ones-you know, the areas where we know, you know, those risk areas, there is signage usually put up. So for example, the Rouge Valley, one of our newer ones, Toronto Public Health, Durham, York, they've all developed a joint sign that is placed on entrance ways into Rouge Valley to let people know. And so, like, Long point they always have one at the main entrance. All the other parks do have signs and notification to let people know.

George: So you say it's pretty well identified all over Ontario where it's endemic?

Curtis: (Inaudible) different levels for who's in those different (inaudible).

George: There's no problems with golf courses, camps, public parks, things to that effect?

Curtis: Depending, you know, what they have at those levels and what's being communicated to them. You know, if you're a golfer like me, you're probably in the woods most of the time. But, you know, it's at different levels.

George: Okay. And the last thing I was going to say is that, is anybody aware that there's a letter from the College Order of Ontario Physicians to treat symptoms by the doctors just by the symptoms themselves? Alright, is anybody aware of that? Okay. Well the thing is I saw the letter.

Vett: (Inaudible) wrong panel for that.

Alain: Yeah, that's across the hall, Algonquin room.

George: Is it?

Alain: I would suspect that that's where that's come up. I can't tell you for sure.

George: Okay. I guess that's about it, unless there's some other stuff, there's mycoplasma, sexual transmission, (inaudible), panic attacks, (inaudible), chronic Lyme. Does the bacteria co-infections stay in the body as does malaria and things to that?

Natasha: Unfortunately, I don't like (inaudible). In a room across the street there was a very-supposed to be very interesting discussion about persisting bacteria. To survive, even response of human being, actually bacteria goes deep in the tissues and trying to hide from your immune response in your tissues. So normally if it gets to joints or spleen or heart or any other place where antibiotics can't reach it, it will persist.

George: Okay.

Natasha: And they're little bit different things, resistant bacteria and persistent bacteria, and you definitely should be aware of this.

George: So it's in your musculoskeletal structure and where the …

Natasha: Can be.

George: So in other words, if I still have it and I get a chronic illness or something to that effect or as age passes on, this could come back out again.

Natasha: Actually, again, this is not discussion for this panel. But I will tell you that persisting means that as soon as the danger of pressure from antibiotics, from any other treatment, from pH difference, from starving will pass, Borrelia will make up.

George: Okay. Alright, thank you kindly.

Alain: Thank you very much. I now need to put you to work, and I've asked Eric our technician to lock the door so you can't leave this room right now. I'm just looking back and somebody's walked out. So there you go, that's the power I have. But before you leave this afternoon, I've mentioned this now, this is the third time. Tomorrow morning when we start up, you'll get a glimpse of what happened in the three break-out sessions. You need to commission me in terms of tomorrow morning, what are the big messages that you want me to report back? I'm not going to have a lot of time, I'm not going to be able to do complete justice to the two hours that we've had in our interaction and our question period. But what are the big messages that have come out in this conversation this afternoon? That's what I'm commissioning you to do.

Let me give you an example of what I heard and I can guarantee you I will get it wrong. But I heard things around the risks map that we've seen and the need to update them continuously. We've also heard some inappropriate use of those risks maps that is very worrisome because many of those risks maps are being used to determine testing, diagnosis, insurance claims. So that's a worrisome-that's a big message that I'm hearing from today. There are other ones. We talked-I heard a gap that there may be a gap in our surveillance. What happens when people contract the disease outside of Canada and come in? Do we factor that? Do we know what's going on? So those are the kind of big messages that I'd like to report back tomorrow and you need to tell me if I got it right or wrong in the two examples I gave you.

But this is what I want you to do in the next five minutes, no more. If you're sitting beside somebody you like, somebody that you trust, and I can see that over in some corners, I want you to have a mini caucus, a mini huddle and say, "So for us, what are the big messages that come out from this afternoon?" If you're alone, find somebody in the room that you like and have that very same conversation. Or if you do not wish to engage with a colleague or somebody in the room, you may have a monologue with yourself-it's okay to speak to yourself-in the next five minutes. But in five minutes what I'm going to do is I'm going to reach over to that microphone over there and I'm going to simply hand it to you so you can tell us what are the big things that have resonated for you over the course of the afternoon. So that's the task. That's the second task that you will do. Your first task is that we will say thank you to our speakers this afternoon for all of the information. Thank you very much. We now need to engage, what are some of the big messages that you've heard, that we've discussed over the course of the afternoon? I'm going to give you a couple of minutes to discuss amongst yourselves and then we'll circulate the mic. Go.

[Task is performed]

Alain: [00:00]

Several that have been scribbled, give me one, and listen for others who may have the same key message. And if you don't strike it off your list, I'll come back for a second round, okay? I'd like to do this fairly quickly. Who would like to start us off? I was going to go there, but she was faster. We'll get to you, okay? So I'm going to hand this to you, because I want to take notes.

Female: [00:24]

One of the things that we were talking about a little bit is that the limitations of the data is getting lost in translation when it's going to laypeople or doctors or other people on the front line.

Alain: So the translation getting lost as it goes through …

Female: Or the limitations of the data, that there's certain things that it's not useful for or there's some narrowness to it in terms of strains being looked at.

Alain: Perfect, alright? Great message. Who wants to go next? Raise your hand. We've got a hand right up there, perfect.

Female: [01:03]

Sorry, I have a few, but I'll just go with …

Alain: Give me two. Okay, give me two.

Female: Okay. So first, I think to emphasize what she was saying, we aren't recognizing all of the different species of Borrelia that are present here. As a result, we aren't-our testing, which we know is inaccurate for Borrelia burgdorferi, is not at all picking up any of the other species that are present. So we need to first recognize that they are here-to jump from that, related to that, the data collection, if we're collecting accurate data, then we certainly need not cut off the collection from dogs and other species. If we're going to get an accurate data set, and it may be true that there aren't enough resources, then we need to devote resources to those things because if you're cutting out all of those things, you're not getting an accurate picture of what is actually represented.

Alain: So I'm hearing three. Good.

Female: Okay.

Alain: Well done. It's not going in there.

Female: [02:30]

The other thing would be, just to echo what Jess had said, the role that community involvement can play in the more accurate representation of the data, if people are out dragging and finding the ticks it just an even bigger and better and clearer picture for researchers.

Alain: It also is, as we were told, it's also a very good way to leverage community involvement and raise awareness.

Male: [02:55]

In regards to the tick risks maps and Lyme endemic areas, obviously everybody's in agreement that they need to be updated. But they need to be updated with an integrative set of data, whether that's passive surveillance, active surveillance as well as veterinary data.

Alain: Okay, very good. So just-who wants to take it next?

Female: [03:21]

Hi everybody. Actually, I'm just going to touch a little more-because we noted the same things that were already noted. One of the things that I heard indirectly was that we do need some more money and resources in terms of the testing, so that it's more inclusive of more than humans but also the animals. It sounds like not all those specimens are being tested, and I think in order to be having accurate surveillance we need to do that. Also, we heard from Ontario, but we haven't heard from any of the other provinces in terms of surveillance that they do for their own vectors. And I think that needs to be developed across the country.

Alain: Perfect, thank you very much.

[Inaudible]

Alain: It's okay to argue over the microphone, but please, no violence.

Female: [04:12]

One of the big issues raised is-hang on a second-big issue is the area to deny diagnosis. If in a specific province an MD submits too many case studies, they are then hassled by their College of Physicians and Surgeons. Also one of my pet peeves is with the variety of demographics in Canada, why is-because we've got so many levels of health authorities, why can't we have at least some of the groups translate the information into different languages? So that that way, say these provinces, whichever can pick from the same general library source of accredited and consistent information across the board from coast to coast to coast.

Alain: So the information has got to reflect the diversity in this country, great point. Okay, anything else? Okay, let's keep migrating that microphone. Maybe it needs to go on the other side, perfect.

Female: Hi.

Alain: I see hands being raised in the back. It'll get to you. Carry on, please.

Female: [05:19]

I actually have a couple of things. One was a take-off off of what you had said about when you had spoken with your local (inaudible) health and said they weren't funded for conducting surveillance and, you know, vector-borne Lyme disease specific surveillance, that's true. So I guess-sorry, sorry. I guess I would put the plug in there that if surveillance at the local health unit level is to be continued and carried on, that we should look at funding sources around that. And then the other piece of it is the recognition around human disease surveillance, and that is that the gap, when a clinical case is diagnosed by a physician, it's reported to local public health and we would report that to the province and that's fine. But I would guess there is a huge variation across the province in terms of physician knowledge. So this one really actually has both feet in both surveillance as well as education streams. So just really bringing the health care providers across the province up to speed with some of the more current information.

Alain: Great points. Alright, thank you. If the microphone can-carry on.

Female: [06:34]

Okay. Further to the point about the surveillance, we know that most people are not going to go to the Internet and investigate websites as they're walking down a trail to find out what they should be looking for. The fact that perhaps signage should be a lot more visible, more prevalent and even more than bilingual; multilingual, depending on the area you're in just so that people can be made aware. But the other thing though, with regards to proof of surveillance, I think it would be of great benefit if the health units for each specific county posted whether it be in the newspaper or some other way for the public of that area to become aware, to know exactly what the risk factors are so that they can then take the appropriate precautions. It would save a lot of people a lot of trouble and a lot of suffering.

Alain: Great points, thank you. If we can maybe make the microphone make its way in the back, that'd be great.

Male: [07:41]

Hi. Something I forgot to mention. I walked into the Department of Environment just up the street from me last week and there's a tick poster in there. And big black X with a marker pen to Nova Scotia surveillance crossed off, not done. The sign was there would mean to me, "We're not accepting any ticks. Don't bother us. We get too many. You people are taking too much time with it." Nowhere to send them to, nothing ever happens to them. So that has to be sorted out at the other end too. And the other thing we brought up in here was this reliance on endemic zones to exclude people in diagnosis. My preferred term was hot zone. And I think that's probably enough points from me. Who else would like a …

Alain: Needs to make its way to the front. Oh, looks like it needs to make its way to the back. Jim?

Jim: [08:38]

Yes, there's certain different standards, I think, between reporting tick infection rates, and I'm going to use British Columbia as an example. In poster presentations given by individuals from the B.C. Center for Disease Control, there indicates that there is variation within region by region of tick infection rates. Yet when it's reported to the public, it's repeatedly said to be.56% of the tick- Ixodes tick population, which is very, very low. Now our ticks come from California and regions which report regularly that the tick infection rate varies wildly from county to county. You can go from a very low tick infection rate to a very high tick infection rate. So how is it the public is consistently given one flat rate and we're never given the data region by region? What is the tick infection in Cultus Lake? What is the tick infection rate in Langley Park? What is the tick infection rate at Shawnigan Lake where the kids go to their camp every year? That's the kind of data that the public needs, not this one flat rate tick infection rate. And I think that has got to change or the public and the doctors are being misled.

Alain: Great stuff. So the granularity and precision of data is absolutely key for informed public and informed activity outdoors. Okay, go ahead.

Male: [10:26]

Very quick comment related to that, Jim, is if you look at the maps given by the CDC, they do show different-based on their sampling, different rates. But I suspect if they're giving some global number, they're giving some average, I don't know. But the-whether or not-one has to actually look at the maps that they provide to show how variable the rates are, as it is in California and other places. Or am I misunderstanding something?

Male: [10:58]

Every time the public asks that question and a reporter asks that question, it is.56% province-wide. There is no regional variation and so the doctors, the information that's going to the doctors in Kelowna, in Cranbrook, in all those areas is basically the same representative value. And so that has got to change.

Alain: Okay, good. Thank you. Can we make the microphone migrate towards the front, please?

Female: Yeah, I'm sorry, it's me again. I forgot to say something.

Alain: (Inaudible). How did you intercept that? Go ahead.

Female: [11:41]

Good. One of the things we identified in our little group is actually hopefully something that will change. And that's who actually reports the surveillance. I know myself and I know a lot of people who have spoken last night is that a lot of the medical doctors haven't really been supporting us, they haven't recognized us, they haven't diagnosed us. Often we have to go to naturopathic doctors. They do recognize it. We have to go to the States' doctors. I would like to actually see those people reporting. I think our numbers would be more accurate.

Alain: Okay, good point. Thank you. Have the microphone come to Jill please. Jill?

Jill: [12:25]

And that was going to be exactly my point. We have a full circle of-Health Canada's data is based on health reporting data, there's no reporting getting done in all the provinces therefore Health Canada data is not accurate. So it's a vicious circle of inaccurate data. That has to change.

Alain: Okay, alright. I'm going to take a couple more points because we're running fast out of steam, okay?

Female: [12:57]

I'm just going to quickly throw this in, is one thing you can do with the CDC website is-very easy to access the data for breakdown by year, breakdown by state. And it's hard to get that data for Canada. It would be lovely to see Public Health Agency of Canada just mimic that information so everyone can actually find out what the risk is in their area and by region of province.

Alain: Yeah, great point. Okay, we're going to bring the microphone over to the back there, thank you very much.

Male: [13:27]

So we had a discussion about risk maps. So one thing that came out was that it's impossible to have perfect information everywhere, and that's just something that we're going to have to deal with. But obviously more resources devoted to surveillance would help improve that. The correlator with that is there's also no ideal risk map, but the type of-there's a problem with the interpretation of areas that have no data as indicating no risk. And I think that's something that in the way that these maps are being used and misused needs to be taken into account. And so ideally we would have risk maps that were based on complete geographically representative data. And so there are different ways of achieving that, but some form of a strategy for standardizing the way that data's being collected among provinces and having sort of an overall strategy for generating maps that will be useful, which these initiatives that are already underway with Public Health Agency and different provincial agencies, I think really needs to be promoted and supported both financially and with these kinds of initiatives, because that's going to be what's going to provide the type of information that people are looking for in these maps. Were there any other points, you guys?

Alain: Good, thank you very much.

Nick: Can I just-(inaudible).

Alain: Nick.

Nick: [14:58]

The things that I heard but I didn't hear repeated just now, and correct me if I'm wrong. One was systematic, that we should be doing something a bit systematic. Did I hear that? The other word is one health, continuing to do stuff with vets. Am I right? Yeah? And the third was citizen surveillance, citizen rates.

Alain: We talked about that, yeah. Absolutely. Okay, thank you very much. Ryus, you want one more point? Can we just run the microphone quickly and we're going to adjourn right after that. No pressure, Ryus. No pressure.

Ryus: [15:43]

On the same point as, you know, identifying areas that have higher infection rates and that, it would also be useful information to-this'll be tougher because in many of the provinces they don't actually analyze them. But for the different species of the bacteria, like, I know Miyamotoi has been confirmed in Manitoba, but that's not mentioned anywhere. So if you have a park that, you know, say, somewhere in Manitoba or whatever province that has confirmed infection rates of, you know, a European strain or, you know, whatever other strain it might be, that's important information to know. Because if you're in a risk area that has an infection that you can't actually get a test for here in Canada, you need to know that.

Alain: Okay, good. Thank you. Ladies and gentlemen, thank you for your time today. Today we've spilled into part of the discussion for tomorrow, but that's okay, because tomorrow what we want to explore is, what does an ideal surveillance system look like for us in Canada? So think about that tonight. Let your dreams evolve and over the course of the conversation tomorrow, it's going to be all around, how do we do that? Very important announcement: I found a wallet with $200 in it. Now I've got your attention. There's a shuttle bus that will leave-it's probably left already, but if you're in the mood to sprint to see if it's left, it was to leave at about quarter to five. There is another shuttle bus leaving at quarter past five. And we resume tomorrow in the room next door, Algonguin, at 9 am. Good evening folks, and thank you for your sustained effort.