Increase in Ticks and Lyme Borreliosis,Yet Research into Its Prevention on the Wane

There is increased concern about the upward incidence of Lyme borreliosis (LB) in Europe, the United States, Asia, and Northern Africa (Rizzoli et al. 2011, CDC, 2015, WHO, 2015). However, effective measures to control tick populations or vaccines for LB are not yet available. Therefore, behavioral measures including performing routine body checks, using protective clothing, and the application of tick repellents are of great importance. Unfortunately, acceptance and uptake of many of these preventive behaviors are currently low. Hence, effective health education and health communication aimed at promoting the uptake of preventive behaviors regarding tick bites and LB are urgently needed (Beaujean 2013).

In this journal, Mowbray published a systematic review of educational and communicational interventions to prevent tick-borne diseases covering the period 1995–2010 (Mowbray 2012). Mowbray included nine studies, of which the most recent one was published in 2008. Based on the limited number and low quality of studies available at the time, Mowbray recommended that more research should be conducted. Focus should be directed at improving evidence-based insights regarding the promotion of preventive behaviors among those members of the general public that exposed a greater risk of contracting LB. We fully agree with Mowbray's stance and conducted a systematic review on the same topic in May 2015, covering the period 1995–May 2015. Following a literature search, a total of nine studies were included. Surprisingly, our review yielded exactly the same studies as already included in the review by Mowbray. This means no studies were published in the seven years after 2008 on the topic of education and communication interventions to prevent tick-borne diseases.

This raises the question why no new studies were conducted in recent years concerning educational and communicational interventions to prevent tick-borne diseases. In contrast, the annual number of publications concerning ticks and LB in general had increased during the period 1995 to 2015. To illustrate this, when searching PubMed for articles that include the key terms “ticks” and “LB”, the number of articles retrieved increased from 112 in 1995 to 394 in 2010, followed by 659 in 2014. However, it might be that some unpublished results or rejected proposals exist and these would be missed by searching for publicly available output. Furthermore, it is possible that some studies are still ongoing, and it could take some years before these studies will be published. When considering the reasons for a lack of research output, it could be possible that the lack of studies on tick bites and LB is because of competition from other—possibly deemed more urgent—public health topics such as tobacco, alcohol, and nutrition.

Based on the PubMed searches described earlier, we made a pragmatic assessment of trends over time for different research themes related to ticks and LB. Studies were categorized by year (1995–May 2015) and theme, that is, vaccines, diagnosis, treatment, and based on the article's title. It was noticeable that in the initial years covered, most research concerned the prevalence and incidence of ticks and LB. In the years that followed, considerably more studies were published on the topic of coinfections from tick bites and the long-term sequelae of LB. The proportion of studies investigating the theme “diagnosis” decreased from ∼10% in 1995 to ∼3% in the past 5 years, and research on vaccines and vaccination (∼4%) and treatment (∼2%) remained almost constant. This, therefore, implies that a reduction in diagnosis research output has not necessarily been because of an increased focus elsewhere, such as LB prevention work. Hopefully, the increased number of publications on tick-borne diseases—mainly on coinfections and the long-term sequelae—will function as leverage in the call for more research on education and communication interventions to prevent tick-borne diseases. After all, education and communication on (prevention of) tick bites and tick-borne diseases are also needed for prevention of disease because of coinfection and the long-term sequelae of LB (Stanek et al. 2011).

In this editorial, we again sound the alarm bell, just as Mowbray did a few years ago. As long as there are no effective measures for controlling tick populations and there is no vaccine available, we rely solely on health education and communication efforts to prevent tick bites and LB. Since checking one's body for ticks after every visit to nature is not a universally accepted behavior, further prevention efforts need to be established, implemented, and honed on the basis of scientific rigor.

First of all, insight into public perceptions and protective behavior regarding LB is crucial to develop a successful prevention program (Heller et al. 2008). It is important to design and evaluate interventions with different populations in mind, because of variation in pre-existing levels of knowledge and perceptions about LB (Daltroy et al. 2007, Mowbray et al. 2012). Furthermore, future studies should be of a higher scientific quality: application of reliable and valid data collection methods, such as using standardized assessment tools and trained assessors blinded to the intervention. In addition, randomized controlled trials should be conducted to measure the actual behavioral change effect of protective measures against LB. Prevention programs targeting tick bites and LB should aim at influencing those determinants related to preventive behaviors, for example, knowledge, concern about LB and perceived efficacy of wearing protective clothing (Beaujean et al. 2013). To illustrate this, an interactive and practical approach to increase self-efficacy could be applied, such as practicing the search for and removal of a tick on a rubber arm (Daltroy et al. 2007) or enabling individuals by providing tools to check for ticks, to remove ticks, and to apply repellent (DEET) to skin, and permethrin to clothing (Malouin et al. 2003). However, these are just examples; we emphasize the use of the Intervention Mapping protocol for the development of health promotion programs to link determinants of behaviors to appropriate behavior change methods (Bartholomew et al. 2011). Intervention Mapping describes the process of the health promotion program development in six steps, from recognition of a need or problem to the identification of a solution. With such a systematic approach—whereby each step is based on previous steps—evidence-based health promotion programs can be developed, implemented, and evaluated.

We call on researchers and funders to prioritize research in the field of public health interventions for tick bites and LB because, in the words of Benjamin Franklin, “an ounce of prevention is worth a pound of cure.”