California Physician Response to Tick-Borne Disease Questionnaire
California Department of Health Services, Medical Board of California ACTION REPORT, Vol. 88, February 2004, pps 8-9
At the end of 2003, there were 115,354 physicians licensed
to practice in California, of which 89,025 live in the state.
Only 303 of these physicians responded to
the California Department of Health Service's questionnaire
on tick-borne diseases. Hardly a statistically sound sample,
but since the physicians most likely to respond are those
who have some inkling of what Lyme disease is all about,
the survey results are useful in highlighting that, given
that assumption, most doctors in the state remain clueless
about the likelihood of exposure, diagnostics and treatment
In February 2003, the California Department of Health Services (CDHS) posted a questionnaire on tick-borne diseases in the Medical Board of California's quarterly publication, the Action Report. The purpose of the survey was to assess physician awareness of ticks and tick-borne diseases in California. This information will aid CDHS to develop educational materials on tick-borne disease prevention that physicians will find useful. This article summarizes the results of the survey.
A total of 303 physicians who currently or recently practiced in California completed and returned the questionnaire. Collectively, respondents reported specialty was family practice (63-21%), followed by internal medicine (54-18%), pediatrics (50-17%), surgery (22-7%), dermatology (18-6%) and obstetrics-gynecology (13-4%).
Two hundred fifty-six (85%) of the respondents believed that their patients were potentially exposed to Borrelia burgdorferi, the bacteria that causes Lyme disease (LD), locally or in the county where they practice. Ninety-eight (32%) physicians indicated that they had diagnosed at least one case of LD in a patient while practicing in California. The five most common specialties among those who had diagnosed LD were family practice (26-27%), pediatrics (22-22%), internal medicine (12-12%) and emergency medicine (8-8%). Of 77 respondents who indicated the number of LD cases they had diagnosed in the past five years, 66 (86%) diagnosed one case, six (8%) diagnosed three to five cases, three (4%) diagnosed six to 25 cases, and two (3%) diagnosed more than 25 cases. Of those who had diagnosed LD, 70 (71%) observed the erythema migrans (EM) rash associated with LD. Of the 98 respondents who had diagnosed a case of LD, 78 (80%) were aware that LD was reportable and 49 (50%) had actually reported cases of LD to their local health department.
The questionnaire also focused on knowledge and practices associated with tick bites. In a typical year, 109 (36%) of the respondents reported seeing no tick bite victims, followed by one to two tick bite victims (103-34%), six to 25 (42-14%), and three to five (38-13%) tick bite victims per year. Only seven (4%) physicians, who practiced in Contra Costa, El Dorado, Mendocino, San Joaquin, and Santa Clara counties, reported seeing more than 25 tick bite victims per year. One hundred eighty-six (61%) physicians reported that a patient had presented to them for the removal of an attached tick and 158 (52%) of all the physicians would recommend testing a tick for B. burgdorferi. Several physicians qualified that they would submit a tick for testing only if it had been attached for greater than 24 hours or was a particular species; others noted that they would submit a tick for species identification only, not testing. Most respondents, 234 (77%), said they provided recommendations to their patients to prevent tick bites.
In fact, several respondents indicated uncertainty whether results of tick testing were at all useful in clinical management of patients. Indeed, management of a patient who presents with a documented tick bite should be based on clinical presentation and course, regardless of tick-testing results. Also of note was that while most responding physicians were aware that LD is reportable, only half of those physicians who had diagnosed a case of LD had reported it to their local health department. Reporting LD and other tick-borne diseases to the local health department is not only legally mandated (Title 17, California Code of Regulations) but provides data valuable toward assessing the regional risk of these diseases. Based on the epidemiologic data accumulated through disease reporting, the practicing physician can better judge the likelihood that a patient in his or her practice area could have been exposed to one of these disease agents and thus better direct and interpret their diagnostic workup.
At least seven tick-borne diseases have been described in California. The most commonly reported tick-borne disease is LD (70-145 cases per year in the last five years), followed by relapsing fever (3-17 cases per year), and Rocky Mountain spotted fever (0-5 cases per year). Other tick-borne disease infrequently reported in California include anaplasmosis (formerly granulocytic ehrlichiosis), monocytic ehrlichiosis, babesiosis, and Colorado tick fever. Tularemia and Q fever may be rarely transmitted via ticks, but other routes of transmission (e.g., direct contact, inhalation) are far more common. While some respondents (23%) believed that their patients could be locally exposed to tick-borne encephalitis (TBE), it should be noted that TBE, a viral disease found in European Ixodes ricinus ticks, has not been reported in North America. [It should be further noted that while I. ricinus isn't found in North America, we have several ticks that transmit to humans and other animals organisms that cause encephalitis, thus we do indeed have tick-borne encephalitis in the U.S. - MK]
Several respondents astutely noted that localized skin infections and tick paralysis, and ascending paralysis produced by toxins in feeding Dermacentor spp. ticks, are other rare complications associated with tick bites in California.
There are limitations to the interpretation of the results from this questionnaire. It is unclear how accurately the sample of 303 respondents represents the approximately 60,000 physicians who currently practice in California. Physicians who have diagnosed a tick-borne disease or who have seen ticks on patients may have been more motivated to respond to the questionnaire than those who have not. This may result in a overestimation of the number of physicians who believed that a person can become infected with LD in the county where they practice (85%). Nonetheless, as this is the first statewide assessment of this type to be conducted, the results can offer a rough guide of current knowledge and practices of some California physicians regarding tick-borne diseases and thus will be helpful in further developing informational materials.
CDHS would like to thank the physicians who participated in this survey. Additional information on tick-borne diseases in California may be obtained by contacting the CDHS Vector-Borne Disease Section at (916) 552-9730 or visiting the Web site.
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