By Cristina Cuomo
PURIST: I’ve read that this is the biggest tick season in the last 10 years. What does that mean for you, as someone treating tick bites and Lyme disease?
DR. ANDREW HANDEL: I am a pediatric infectious disease doctor at Stony Brook, and so I do see children throughout the entire year, but certainly more so in the heavy tick seasons with tick-borne disease concerns and Lyme disease. So, I know the entomologists are reporting that in the field they’re seeing more ticks than they have in the past. The CDC also has a tick bite data tracker, and it’s showing that this year more people are presenting to the emergency departments for evaluation of tick bites than they have in past years. That said, every year on Long Island is a bad year for ticks. So, what that means for us is again, seeing more patients in our clinics, in our emergency departments, with concerns again of recent tick bites. Of course, following that, we start to see more diagnoses of tick-borne diseases.
I’ve been reading about the Bourbon virus, a rare and potentially lethal illness transmitted by the Lone Star tick. Are you seeing that on Long Island?
Yes. Bourbon virus is a tick-borne pathogen. It’s a virus that gets transmitted by the Lone Star tick. It’s been previously described in other parts of the country, but we had not yet found cases here on Long Island, though we have suspected that they’re occurring. The case that was recently published in the media involved a patient who was infected with it years ago, but the research sample that had been drawn was just tested for it and found to be positive. So, although it can be lethal, honestly, we don’t understand enough about the virus to know how often that happens. The patient who was infected with it fortunately survived.
How lethal is it?
There have been deaths as a result of it, but it’s not something that is readily testable. There are tests that we can order through the New York State Department of Health where they can do specialized testing to look for it, but unless you go out of your way to do that diagnostic test, it’s not something that’s orderable at most of the commercial laboratories. And so the thought is that these cases likely are happening and many of them may not be diagnosed—either they’re not getting diagnosed, or they’re not all that severe. But the overarching idea is that we don’t know enough about the virus, which is one of the things that our symposium was focusing on: We need to learn more about these emerging pathogens.
How are you doing that research?
A study that I oversee collects blood samples and clinical information from children who have been recently bitten by a tick. We identify children who’ve been bitten by a tick within the past two weeks, and we collect a blood sample through a device sent directly to their home. Then we monitor their symptoms through electronic surveys over the next month, and then collect another sample a month later. What we’re able to do is to test and look to see if they develop antibodies against one of these emerging pathogens to show that they’ve been infected with it. Again, for many of these infections, they seem to be subclinical, where you don’t necessarily have severe overt symptoms. For our study we’re not looking at Bourbon virus yet, but once we have additional funding, that is part of the plan.
Has funding increased as Lyme disease gets more attention?
It’s a mixed picture. The NIH seems to be decreasing funding, and the Department of Defense has a line item for research in tick-borne diseases, but very few submitted proposals are actually funded. Overall it’s still very difficult to obtain funding from national research funders.
Let’s talk about alpha-gal syndrome. I had it, and I notice more people around me are getting it—then it seems to just disappear after a year or two without a treatment plan. How does it differ from Lyme, and why are we seeing such a spike?
First off, alpha-gal syndrome is an allergy to red meat. It’s always important to make a distinction between having an alpha-gal IGE and alpha-gal antibody and alpha-gal syndrome. So, many people we know have the antibody, but only a subset of them will actually have symptoms as a result of it. Some people are only positive in blood tests but actually don’t have any relevant symptoms as a result of it. But without question, Suffolk County is seeing a huge boom in the number of patients with alpha-gal syndrome. There’s a study from the CDC a few years ago that described the distribution of alpha-gal syndrome diagnoses across the United States, and 4 percent of the cases in the entire U.S. occurred in Suffolk County alone. So, we know that it is a massive problem here. The Lone Star tick was not all that common on Long Island 20 years ago, but since then it’s become by far the most common tick to get bitten by. They’re very different diseases. Lyme disease is an infection you get that’s transmitted by the tick, whereas alpha-gal syndrome is an allergy that you get not because you have an infection, but because you’re having an allergic reaction to something within the tick saliva that then causes you to also have an allergic reaction to red meat and other mammalian products.
Alpha-gal is a carbohydrate, right? And this is not Lyme disease.
Exactly, yes. But we don’t know exactly what it is in the tick saliva that’s causing it. We’re putting in a proposal through Stony Brook to study that. Lyme disease is an infection caused by the bacteria Borrelia burgdorferi, whereas alpha-gal syndrome is not an infection. It’s an allergic reaction to the tick saliva.
And it can fade over time?
It does, absolutely. Over time—it varies from person to person—but generally on the order of years people stop having allergic symptoms from red meat. For some people, it doesn’t fade. It really is quite variable, but for somebody who’s had it in the past, once they’re bitten by another Lone Star tick, the allergy can rev right back up.
What is Stony Brook’s treatment approach for Lyme disease?
We follow the IDSA—the Infectious Diseases Society of America—guidelines. It depends on the patient’s specific symptoms and the specifics of their case. For prevention, we talk to people about avoiding tick bites altogether—different insect repellents, the importance of doing tick checks, all those preventive measures. Then for people who meet certain criteria we recommend a single dose of doxycycline, which has shown to be about 90 percent effective at preventing Lyme disease. Then after that, it depends on the symptoms the patient is experiencing—generally patients will be treated with either a course of doxycycline or amoxicillin.
For chronic Lyme, do you employ a more holistic or integrative approach?
The term we tend to use is post-treatment Lyme disease syndrome, because the studies have demonstrated that prolonged antibiotic courses are not effective at reducing those symptoms. For patients in those circumstances, we focus on symptom management. We’ve learned a lot about this from long COVID, which seems analogous to post-treatment Lyme disease syndrome—dealing with specific symptoms and having patients seen by specialists who may be experts in those symptoms is the most effective approach.
Where do things stand on a Lyme vaccine? Is it imminent?
There is one making its way through the research process, and it seems to be doing quite well. That’s the Pfizer-Valneva Lyme disease vaccine. At Stony Brook Children’s Hospital, we were a clinical trial site for the pediatric study. Recently some of the preliminary results came out on their Phase 3 trial—the largest trial generally done before going before the FDA. They found the vaccine was about 73 percent effective at reducing Lyme disease. From the preliminary data, there were no unexpected side effects.
When could it be available to the public?
My understanding is the Phase 3 clinical trial is completed; they just haven’t published the actual data yet. They released some findings through a press release, but the peer-reviewed paper has not yet been released. We are curious to see how it really looks once we have the actual scientific paper, and then it goes before the FDA, which reviews all the data submitted by the pharmaceutical company and can make a decision about whether to license it for use within the United States.
Ticks breed and feed on rodents—mice especially. There’s a company called EcoTick developing lure boxes that treat rodents with an anti-tick solution to kill ticks at their source. Is that a promising approach?
I would have to defer that one to the entomology expert. On Fire Island, for example, they had deer posts—boxes with feed lined with rollers coated in tick repellent, so when deer came in to eat, they’d be coated with the repellent. Unfortunately that doesn’t seem to have been all that effective. The bigger point is we absolutely need better approaches to tick control. There’s a whole world of research into this, whether it’s vaccinating mice or other approaches, and we need to study which is most effective. As of now, the jury is still out.
How can readers with chronic Lyme get involved in clinical trials?
We’re looking for ways to get the word out, so we can find more patients, and understand what’s happening. We’re happy to pass that information along. southampton.stonybrookmedicine.edu
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