Human ehrlichiosis epidemiology and demographics
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Epidemiology and Demographics
United States
During 1986 to 1997, health departments and other diagnostic laboratories reported over 1200 cases of human ehrlichiosis to CDC. Approximately two-thirds were cases of HME. CDC compiles the number of cases reported by the state health departments. Ehrlichiosis is a nationally notifiable disease; however, not all state health departments have reported cases of ehrlichiosis to CDC (Figure 1). To ensure standardization across the country, a consistent case definition is used by all states when reporting cases to CDC.
- Figure 1: Reported Cases of Ehrlichiosis in the United States
The occurrence of these diseases mirrors the geographic distributions and seasonal activities of the tick vectors. Most patients with ehrlichiosis are infected in the spring and summer when they are more commonly exposed to vector ticks. Accordingly, 80% to 90% of all ehrlichiosis cases occur between April and September, and approximately 55% to 70% of all cases occur during May through July (Figure 2). This period is the season for adult Amblyomma americanum and nymphal Ixodes scapularis ticks. A history of tick bite or exposure to tick-infested habitats is reported in 50% to 90% of cases.
- Figure 2: Approximate seasonal distribution of HGE in the United States
Ehrlichia chaffeensis infections are most frequently reported from southeastern and midwestern states with abundant lone star tick populations, especially Arkansas, Florida, Georgia, Missouri, North Carolina, Oklahoma, Tennessee, Texas, and Virginia. Cases have been reported from almost every state in the United States, although some of these may have been imported from states where the disease is highly endemic.
The types of ehrlichiosis are distinct from several other well-described tick-transmitted diseases in the United States with respect to age-specific incidence (Figure 3). In general, reported rates of ehrlichiosis increase with age; most patients with disease appear to be older adults (most often >40 years old). This pattern contrasts with age-specific incidences of Lyme disease and Rocky Mountain spotted fever, which occur most frequently in children. Age-associated host factors may account for severity of disease; however, severe and even fatal ehrlichial infections have occurred in otherwise healthy young adults and children.
- Figure 3: Average annual reported HGE rate (per 100,000) by age group, in NY and CT, 1995-1997
Most of the recognized HGE cases have originated from states that also have a high incidence of Lyme disease, particularly Connecticut, Minnesota, New York, and Wisconsin. This distribution is consistent with the fact that the vector of HGE, Ixodes scapularis, also transmits Borrelia burgdorferi. A number of other states have also reported HGE cases. In the western United States, the HGE agent is transmitted by the western blacklegged tick, Ixodes pacificus (Figure 4).
- Figure 4: Areas where human ehrlichiosis may occur based on approximate distribution of vector tick species
Relatively few population-based investigations have pursued the fundamental question of how many persons become ill after infection with ehrlichiae. A study conducted in southeastern Georgia during 1987-1988 examined the incidence of E. chaffeensis infection among hospitalized patients with fever and determined an incidence of 5.3 cases per 100,000 total population per year. Passive surveillance data for these infections are also sparse, and are collected from relatively few regions of the United States where Ehrlichia species are endemic.
As of 1999, cases of ehrlichiosis must be reported to the state health department in at least 20 states (Alabama, Arkansas, Arizona, California, Connecticut, Delaware, Florida, Georgia, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, New Jersey, New Hampshire, New York, North Carolina, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, and Utah) (Figure 5).
- Figure 5: States where Ehrlichiosis is a notifiable disease
Data from statewide laboratory-based surveillance initiated by New York in 1994 and by Connecticut in 1995 revealed annual reporting rates of ehrlichiosis of 0.4 and 1.8 cases per 100,000 persons, respectively. Foci of disease have been identified in defined geographical regions with reported annual rates as high as 16 cases per 100,000 persons for HGE and 31 cases per 100,000 persons for HME infection.
Worldwide
Ehrlichial pathogens are distributed globally, primarily in temperate regions. Patients with serologic evidence of infection with E. chaffeensis or, more likely, with a species antigenically related to E. chaffeensis have been identified in several other countries, including Argentina, Belgium, Israel, Italy, Mali, Mexico, Portugal, and Thailand. Similarly, human infections with E. phagocytophila have been confirmed in Belgium, Denmark, Hungary, Slovenia, and Sweden, and persons with antibodies reactive to granulocytic ehrlichiae have been identified in Germany, Israel, Italy, Norway, Switzerland, and the United Kingdom.