Tick-borne Diseases in Virginia

Summer means many things for children. It’s a break from the school-year routine, a chance to spend more time outside, and the opportunity to enjoy a few weeks away at camp. These outdoor activities also mean increased exposure to ticks.

Ticks are most active from April to September. Not surprisingly, the incidence of tick-borne diseases peaks during that time, too. Children are especially vulnerable to tick-borne diseases because they are lower to the ground and spend more time playing in the grass and leaves.

In Virginia, there are four reportable tick-borne diseases: Lyme disease, Rocky Mountain Spotted Fever, Ehrlichiosis/Anaplasmosis, and Tularemia. Virginia also has three non-reportable tick-borne diseases: Southern Tick-Associated Rash Illness, Babesiosis, and Powassan virus.

Reportable diseases are those of greater public health importance, and medical professionals must report diagnoses to local or state health authorities. Reporting helps agencies maintain accurate statistics and respond quickly to disease outbreaks.

This article includes an overview of each disease, a guide to preventing tick bites, and instructions for removing a feeding tick.

Tick-Borne Diseases

Lyme Disease

Annual cases in Virginia (2016) Cases between April and September (2015)




Lyme disease is the most well-known and often-discussed infection transmitted by tick bites. Lyme disease is an infection caused by the bacterium Borrelia burgdorferi. Lyme disease is transmitted through the bite of an infected blacklegged tick (also known as a deer tick). A tick must be attached to its host and feed for at least 36 hours before being able to transmit Lyme disease.

Young, growing ticks known as nymphs are more likely to bite than their adult counterparts. Nymphs can be as small as a poppy seed, making them hard to spot on your child’s body.

The number of Lyme diseases cases has grown rapidly in Virginia, from just 357 in 2006 to more than 1,300 in 2016. The increase may relate to greater disease prevalence in local animal populations. Because Lyme disease is difficult to diagnose, obtaining accurate data remains challenging.


The most obvious symptom of Lyme disease is a classic “bull’s-eye” rash—a red center, clear ring, and surrounding red ring that may grow up to 12 inches in diameter. The rash may appear between 3 and 30 days after the bite, although it most commonly develops between 4 and 7 days. The bull’s-eye rash can appear anywhere on the body—not just where the tick bite occurred.

The bull’s-eye rash is known as an erythema chronicum migrans (ECM). The rash is also referred to as an EM rash. The rash must be at least 2 inches in diameter to qualify as EM; other tick bites create similar but smaller rashes. As many as 30% of those infected with Lyme disease never develop a rash.

Other symptoms of early localized Lyme disease may include fever, fatigue, headache, and muscle or joint aches, symptoms that can mimic a general viral illness.

If Lyme disease is not recognized at this early stage, the disease may progress to early disseminated Lyme disease, which can present with multiple skin lesions, nerve involvement (such as facial nerve palsy), and possibly mild inflammation of the heart. Lyme disease is still treatable with oral or intravenous antibiotics at this stage.

More serious symptoms of early disseminated Lyme disease can include meningitis and more advanced forms of heart block.

Late Lyme disease can present with symptoms of significant arthritis and various neurologic conditions.

Diagnosis and Treatment

An EM rash is the most common way to diagnose early localized Lyme disease, although blood tests may detect antibodies after 3 to 4 weeks. In the absence of the distinctive rash, diagnosis can be difficult. Lyme disease symptoms are similar to those of many other diseases. Lab tests for Lyme disease done at the time of a tick bite will be reported as negative and, therefore, are not warranted.

Oral antibiotics (doxycycline, amoxicillin, or cefuroxime) taken for 14–21 days will treat early-stage Lyme disease effectively. Treatment at the appearance of the EM rash (early-stage disease) will prevent the onset of any late-stage Lyme disease, which is also treated with antibiotics (usually intravenously). However, recovery from late-stage Lyme disease may take months or years.

Rocky Mountain Spotted Fever (RMSF)

Annual cases in Virginia (2016) Cases between April and September (2015)




Two-thirds of all RMSF cases occur in children under 15 years of age. RMSF is caused by the bacterium Rickettsia rickettsii and is transmitted through the bite of an American dog tick. A tick requires at least 12–24 hours of feeding before it is capable of transmitting RMSF. Only 1 in 1,000 American dog ticks carries RMSF.


RMSF symptoms develop within 2 to 9 days and include fever, headache, rash, nausea and vomiting, stomach ache, muscle pain, and decreased appetite. The disease’s name comes from the red, spotted rash that usually develops between 2 and 5 days after the fever begins. The rash first covers the extremities, then spreads proximally to the rest of the body. (Some 10–15% of patients do not develop a rash.)

Diagnosis and Treatment

RMSF can be fatal if left untreated. Because the disease poses a serious risk by the time the rash appears, treatment may start before confirmation of the diagnosis. Early treatment with the antibiotic doxycycline is very effective in preventing serious illness and death.


Annual cases in Virginia (2016) Cases between April and September (2015)




Both ehrlichiosis and anaplasmosis are caused by several species of closely related bacteria. Ehrlichiosis is transmitted by the bite of a lone star tick. (Lone star ticks are the most common source of human tick bites in Virginia.) Anaplasmosis is caused by the bite of a blacklegged tick, especially a nymph-stage tick.

Both diseases require a tick to feed on its host for at least 24 hours before disease transmission can occur.


Symptoms for the two diseases begin within 5 to 10 days of the bite. Symptoms are very similar to flu and other viral illnesses and include fever, headache, chills, malaise, eye redness, nausea and vomiting, and muscle pain. Some persons can seem confused when they have the infection. While a rash occurs in only 30% of adults diagnosed with ehrlichiosis, it appears in up to 60% of pediatric cases. Rashes are atypical of anaplasmosis infections.

Untreated infections can become serious and potentially fatal, especially for those with weakened immune systems.

Diagnosis and Treatment

Like most tick-borne diseases, ehrlichiosis and anaplasmosis are treated with antibiotics upon suspicion of illness. Waiting for blood tests risks allowing the illness to progress to a more serious stage. Additionally, lab tests for these illnesses will usually be negative during the first 7–10 days of illness. Treatment should be initiated based on clinical suspicion. Doxycycline is the first-line treatment for adults and children of all ages and should be initiated immediately whenever ehrlichiosis or anaplasmosis is suspected.


Annual cases in Virginia (2016) Cases between April and September (2015)




Tularemia is rare. Virginia has recorded no more than six cases per year during the past decade. Bites from the American dog tick and lone star tick can transmit tularemia. The amount of feeding time necessary to transmit the disease is unknown.

Tularemia can also be spread by several animal species, especially rabbits and hares. Tularemia is sometimes known as “rabbit fever.”

Tularemia may be transmitted through contact with animals (e.g. while cleaning wild game or eating undercooked, infected meat). It can even be spread by inhalation of contaminated air. An infection through inhalation is especially dangerous and can lead to pneumonia. Tularemia cannot be transmitted from person to person.


Symptoms commonly appear after 4 or 5 days, although they may appear up to three weeks after the initial contact. They include fever, body ache, chills, and headache. Symptoms vary based on the type of exposure but often include an ulcer at the bite site (for tick transmissions) and swelling of the lymph nodes.

Diagnosis and Treatment

Tularemia is difficult to diagnosis because it is a rare disease with common symptoms.  Once confirmed by lab testing, Tularemia is treated with specific antibiotics (streptomycin, gentamycin, doxycycline, or ciprofloxacin) for 10–21 days. Although symptoms may persist for several weeks, most patients recover fully and without long-term problems.

Southern Tick-Associated Rash Illness (STARI)


STARI is transmitted via a tick bite. It is similar to Lyme disease but caused by lone star ticks, not blacklegged ticks. The underlying cause remains unknown, but the bacterium that causes Lyme disease, Borrelia burgdorferi, has been ruled out.


Symptoms usually appear within 6 days. A rash like the “bulls-eye” rash of Lyme disease often appears, adding to the potential for misdiagnosis. Also like Lyme disease, advanced STARI may lead to neurological issues and arthritis. Other symptoms include fatigue, headache, joint stiffness, and fever.

Diagnosis and Treatment

STARI symptoms typically resolve with treatment by antibiotics, such as doxycycline.



Babesiosis is caused by a parasite transmitted through the bite of a blacklegged tick. The parasite damages red blood cells within the human body.


Symptoms appear within 1 to 6 weeks and include fever, chills, fatigue, sweating, headache, muscle ache, and jaundice. Babesiosis can lead to more serious symptoms such as acute respiratory failure, congestive heart failure, and renal failure. These symptoms are more likely to occur in immunosuppressed patients and those without spleens.

Diagnosis and Treatment

Antibiotics are an effective treatment for Babesiosis.

Powassan Virus


Powassan virus is extremely rare. Virginia has registered only one case, in 2009. Powassan virus is related to other viruses such as West Nile virus. It is caused by the bite of an infected blacklegged tick, groundhog tick, or squirrel tick.


Some people infected with Powassan virus do not develop any symptoms. Those who do typically have symptoms within 1 to 4 weeks after the initial bite. Symptoms include fever, headache, nausea and vomiting, weakness and loss of coordination, and confusion and difficulty speaking.

Powassan can also cause swelling of the brain (encephalitis) and swelling of the membranes around the brain and spinal cord (meningitis).

Diagnosis and Treatment

Powassan virus is a serious illness that often requires hospitalization. There is no specific treatment available, but effective general treatment includes intravenous fluids, respiratory support, and medication to reduce swelling in the brain.

How to Prevent Tick Bites

The April–September window accounts for most tick-borne illnesses. While ticks are still active during other months, paying added attention during the summer can help avoid tick-borne diseases.

Ticks cannot jump or fly. Typically, they hide in ground cover and attach to the foot or shoe of an individual. Then, they crawl up the body until they find a suitable place to feed.

Humans are “end hosts” for ticks, meaning that any disease transmission does not reach a sufficient concentration in the host’s bloodstream to pass on to other feeding ticks. Tick-borne diseases, then, are sustained and transferred by smaller hosts, such as mice.

Ticks must feed for at least 10 hours to transmit a tick-borne disease and often require 24–36 hours or more. That makes checking for ticks following an outdoor activity especially critical. Daily “tick checks” at bedtime or bath time are the most effective way to prevent tick-related illnesses.

To Prevent Ticks from Getting on You or Your Children:

  • Tuck pant legs into socks and boots while hiking.
  • Wear long-sleeved shirts that close tightly at the wrists.
  • When possible, avoid wooded areas or places with tall grass and leaf litter.
  • Walk in the center of trails.
  • Children should use an EPA-approved repellent that contains between 20 and 30% DEET; adults may use repellents with up to 50% DEET.
  • Treat outdoor clothing with the insecticide permethrin, which can last for several washings; pretreated clothing may remain protective for up to 70 washings.
  • Wash suspect clothing in hot water and dry fully on high heat to kill potential ticks.
  • Encourage children to bathe or shower within two hours of spending time outside.
  • Complete a full-body tick check of your child, including under the arms, inside the belly button, in the hair, and in other hard-to-see areas.

To Prevent Pets from Bringing Ticks into Your Home

  • A tick-preventive product, known as an acaricide, protects your dog and reduces the number of ticks it brings into the home. (Some acaricides kill ticks on contact; others kill ticks as they feed.)
  • Cats are very sensitive to chemicals; check with your veterinarian before applying any products.
  • Check your pets daily for ticks.
  • Remove any ticks as soon as they’re found.

To Prevent Ticks from Infesting Your Yard

  • Remove leaf litter, brush, and trash from the yard.
  • Keep grass mowed regularly.
  • Create at least a three-foot barrier of wood chips or gravel between grass and wooded areas to limit tick migration.
  • Keep playground equipment and outdoor furniture away from wooded areas.
  • Discourage wild animals from entering the yard.

How to Remove a Tick

To remove a tick, use tweezers to grab the tick as close as possible to its head or mouth, next to the skin. Pull gently but firmly directly away from the skin. Pull slowly to get the tick to let go of the skin one leg at a time.

Do not twist or bend the tick, as this may sever the tick’s mouth and leave it embedded beneath the skin. (Remnants of a tick may cause a minor infection.) Avoid crushing the tick’s abdomen, which may leech infected liquids into the bite site.

If the head of the tick breaks off and remains in the skin, try to remove it with clean tweezers to reduce the risk of a general skin infection. If it does not come out easily, it is best to leave it alone and let the skin heal. An embedded tick head (without the body) will not increase the risk of a tick-borne infection such as Lyme disease or Rocky Mountain Spotted Fever.

Do not try to remove a tick with a hot match, small flame, nail polish, petroleum jelly, or alcohol. These methods are not safe and may cause the tick to regurgitate infectious liquids into the bite site.

After removing the tick, wash your hands thoroughly and apply an antiseptic to the bite site.

Discard the tick by flushing it down a drain or toilet. If you suspect the tick may have been feeding for several hours, drown the tick in alcohol and keep it for three to four weeks. If your child becomes ill, the preserved tick will help identify the species and expedite diagnosis.

If a tick is not removed from the skin, it will continue to feed and get larger. Ticks will usually fall off on their own after sucking blood for about 3–6 days. After falling off, it is common for a small red bump to appear on the skin, which is caused by the body’s reaction to the tick saliva. This area of redness is usually quite small and is distinct from the EM rash that can appear days or weeks after the bite.

For more information, visit the Virginia Department of Health’s resource section on tick-borne diseases or the CDC section on ticks.


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