Addressing Climate Change-Induced Tick-borne Lyme Disease Patterns Through Data-Driven ‘One Health’ Policy

Background Climate change presents unprecedented challenges to health care. It has already exposed previously unknown interdependencies between public, animal, and environmental health. For instance, opportunistic animals and microorganisms adapt behaviors to new climatic conditions, and these ecological changes can have severe effects on human disease control and prevention.1 Of all known infectious diseases in people, 60% can spread from animals.2 Furthermore, 75% of newly emerging and potentially human life-threatening infectious diseases have zoonotic origins.2 As non-human, abiotic factors (eg, climate change) drive ecological and geographical changes, new environmental conditions will spawn changes in zoonotic disease. Unfortunately, our current health system and public health data infrastructure does not appear prepared to contextualize, predict, and react to these interdependencies.3 Here, we discuss tick-borne Lyme disease as a public health challenge in the state of New Jersey and describe how a One Health approach can be useful to understand and predict climate change-induced tick-borne Lyme disease infection trends in the state. One Health is a concept that expands the traditional cast of health care and public health stakeholders to include untapped expertise (veterinary, environmental, and agricultural sciences).4 Lastly, we provide policy recommendations that may help strengthen our health system and public health data infrastructures for climate-driven changes infectious disease. Tick-Borne Lyme Disease as a Public Health Challenge in the State of New Jersey Tick-borne Lyme disease, for which New Jersey ranks among the highest states in absolute and per capita cases, is among the Center for Disease Control and Prevention's (CDC's) eight priority zoonotic diseases of "greatest national concern."5,6 Lyme disease is caused by Borrelia bacteria, and it is transmitted to mammals primarily via blacklegged tick species.7 Lyme disease is treated with oral antibiotics doxycycline (Monodox, Doryx, Vibramycin, Oracea), amoxicillin (Amoxil), and cefuroxime (Cetrin, Zinacef).8 The intravenous antibiotic ceftriaxone (Rocephin) is also used for neurologic Lyme disease.8 Additionally, benzathine penicillin and macrolide antibiotics are given if frontline antibiotics do not work, and prophylactic antibiotics may be administered if certain criteria are met in the absence of Lyme disease symptoms.8 Still, up to a quarter of patients report Lyme disease symptoms several months past infection, and there is no evidence of long-term antibiotics, or any other treatment, resolving poorly defined and understood phenomenon of chronic Lyme symptoms.9 Lyme disease is on the rise; a 25-fold increase of annually reported cases has been observed nationwide since 1982, including in New Jersey.10,11 Cases tend to peak in the summer months of June and July, which concentrates demand for testing and treatment resources during those months.12 The state endorses the CDC's two-step process for diagnosis, which entails an enzyme-linked immunosorbent assay (ELISA) or indirect fluorescent antibody (IFA) test and potentially a Western immunoblot (WB) test.13,14 Polymerase chain reaction (PCR) tests and Borrelia cultures can also serve as the initial laboratory test, but these are considered unreliable and unstandardized.15 ELISA, which is the most common test, can take weeks to yield results and is known to present false negatives in as many as 50% of instances.16 Overall, these blood tests are neither fast enough nor dependable enough to yield a sufficiently prompt diagnosis in the absence of the iconic bullseye rash, which itself only appears in 70% of cases—sometimes only after multiple weeks.17 This is especially problematic since ticks most frequently bite the back of the neck, scalp, and other areas where non-irritating rashes may go unnoticed.18 A One Health Approach Amid Climate Change One Health approaches to predicting and mitigating infectious zoonotic disease outbreaks amid the steadily growing effects of climate change can be useful in the case of tick-borne Lyme disease in the state of New Jersey. Climate change is altering the ecology of Borrelia-infected ticks, which changes human–tick interactions and Lyme disease transmission. For example, ideal tick habitat is shifting northward, which changes both the location and months affected by local tick seasons.19,20 New Jersey is in a particularly critical situation among high Lyme disease rate states. As both the most densely populated state in the union and hosting some of the greatest percentage of parklands, it faces unique challenges regarding host and vector interactions (ie, humans, deer, ticks, etc).21,22 Therefore, preventing tick-borne Lyme disease depends on an accurate understanding of an area's tick population, tick density, human behavior during peak tick season, and other key factors. It is especially opportune to address surveillance and resiliency strategies today, as very recent reports from the CDC indicate that more modernized approaches Lyme disease case data collection (ie, reporting of labs data) among states, including New Jersey, led to a higher level (>70%) of confirmed Lyme disease cases that would have otherwise gone undetected and thus untracked.23 One Health Policy Effective allocation of data infrastructure and other critical health care resources will be crucial as the climate changes. Ticks are very sensitive to habitat change, and they will adapt their range and behavioral ecology to new climatic conditions—including places where resources may not have previously been prioritized.24 This will inevitably mean that resources must be ready and mobile across high-risk localities like those found in the state of New Jersey. Tick mitigation research in the Northeast United States has concluded municipal approaches, rather than individual citizen efforts, are far more cost effective.25 In June 2021, the state of New Jersey legislature passed bill A-1992/S-347 to create a permanent "New Jersey One Health Task Force" to promote "communication between state agencies and scientists who study human health, animal health and the earth sciences."26,27 This legislative effort, informed by the Rutgers One Health Steering Committee, which was started in 2016 by leaders at the Rutgers Robert Wood Johnson Medical School, made New Jersey the very "first state to legislate a task force to fight disease transmission from animals to people."28 To date, the New Jersey One Health Task Force is one of several government and intergovernmental organization initiatives working to further One Health.29 A One Health approach to facilitating coordinated, cross-sectoral strategies at local levels could exemplify the goals and recommendations of CDC's Public Health 3.0 initiative.30 The guidelines name environmental factors as key, non-medical and social determinants of health, so collaborative, community efforts that integrate new types of actionable environmental data (eg, geographically granular information relevant to tick populations) can advance the "essential definition" of public health. Examining integrated data systems is core to taking a One Health approach, and combined evaluations of environmental and human health can streamline efficient ways to improve both. Leveraging One Health to Address Tick-Borne Lyme Disease in New Jersey Moving forward, we recommend the New Jersey One Health Task Force contemplate data surveillance measures that combine environmental data relevant to tick ecology with robust patient data on Lyme disease. We also recommend the One Health Task Force work with local health systems in New Jersey, relevant local governmental agencies, patients, and industry to modernize and improve data infrastructure and foster cross-sectoral collaboration for public health surveillance and responses to Lyme disease risk. Together, these strategies can potentially inform where Lyme disease risks are highest, how Lyme disease is spreading, and what is needed to initiate an effective and disease-preventive public health response. Like most states, New Jersey requires health systems to report Lyme disease cases to a state surveillance program, which is in turn shared with CDC. The New Jersey Department of Health's (NJDOH) Communicable Disease Service (CDS) has a particularly robust "Communicable Disease Reporting and Surveillance System."31 CDS monitors several risk factors and trends for vector-borne diseases, but it is not clear how well-integrated continuously collected public health and environmental data are.32 Augmenting an existing Lyme disease registry with reported real-time information from other stakeholders, such as learning health systems, may elucidate currently inscrutable case trends.33 One issue for Lyme disease data tracking, however, is that registries may report where a Lyme disease case was recorded, but not where the tick bite/exposure occurred. When a state-wide registry is configured, hospitals can include this type of information. Therefore, we also recommend that future research explore nearby environmental correlations that inform which risks are contributing to local Lyme disease cases. Incorporating climate change considerations into government health strategies, such as limiting human-wildlife vector interactions, is suggested in World Health Organization guidance on nature and health as well as climate change.34,35 Municipalities, health systems, and agencies should be able to review linked, geographic data on where environmental conditions have been most ideal for a rise in tick populations/density (eg, winter snowfall, humidity, temperature trends, recent tick population patterns, deer density, etc) as well as data on human activity in different geographic areas (eg, public park usage). Altogether, this could help health systems better prepare and dedicate actionable and preventive resources and efforts in areas with an anticipatedly high rate of Lyme disease due to shifting climate patterns.