Archive for the ‘research’ Category

Ecologically Diverse Texas Needs County-Level Data For Tick-borne Diseases

https://www.lymedisease.org/maxwell-texas-tick-borne-diseases/

Ecologically diverse Texas needs county-level data for tick-borne diseases

Aug. 2, 2021

By Sarah Maxwell, PhD

Welcome to the complex world of tick-borne disease surveillance. But honestly, it should not be so difficult. Why does the public health system fail to inform schools, camps, parents, physicians, pediatricians, psychiatrists, and others about county-level risks of tick-borne disease? Why are prevention and diagnosis so difficult?

The answers are rooted in the lack of available, dis-aggregated, and comprehensive data. But they are also complicated  by the use of “Lyme” as a catch-all phrase encompassing a variety of tick-borne diseases, when Lyme may be less endemic in some areas than other tick-borne diseases.

From a health policy perspective, the importance of county-level data to prevention, diagnosis, and treatment cannot be overstated.  For almost all other diseases, sustainable and reliable county data are the foundations to building healthy communities. So why not tick-borne diseases?

Focusing on Texas

In a recent article, Drs. Connie McNeely, Kip Thomas, and Chris Brooks and I employed promising new approaches to tick-borne disease surveillance in Texas with the goal of linking differing forms of tick-borne disease surveillance data into a comprehensive picture. The Centers for Disease Control (CDC) supports the “One Health Model,” which considers people, animals, and the environment as interconnected in assessing and addressing zoonotic disease.

In our article in the journal Healthcare titled “Tick-Borne Surveillance Patterns in Perceived Non-Endemic Geographic Areas: Human Tick Encounters and Disease Outcomes,” we compared canine serological reports of Lyme, ehrlichiosis, and anaplasmosis; patient self-reported diagnoses and tick-bite recall; official reports of Lyme disease from the CDC; and ecosystem habitat suitability through multi-layer thematic mapping.

As noted in our study: “The overall purpose was to determine if clinically diagnosed and CDC-positive Lyme disease human reports are geographically similar in disaggregated form via county, bordering county, and ecosystem to canine and official CDC counts. Comparisons between patient self-reported disease and official counts of disease are not widely used methods of surveillance, but are important epidemiological tools when disease can be linked to an event, such as a tick bite.”

Texas is a large state and often perceived to be non-endemic for tick-borne diseases. However, at the county level, the picture is quite different. Numerous counties in Texas are endemic to tick-borne diseases. So why the dilemma?

Importance of county-level data

The need for such comprehensive and new surveillance techniques is imperative. Here is why: The CDC publishes county-level Lyme disease data for anyone to view. However, the CDC limits all other tick-borne diseases to state-level surveillance only. The public and researchers do not have access to these data.[1]

CDC’s Lyme disease spreadsheet, on the other hand, is updated annually and published on the CDC website. Therefore, public health officials should, in theory, have the data they need to design prevention campaigns and assess human disease risk. Nationally, however, those data are known to undercount the real presence of Lyme disease, as numerous scholars have demonstrated.

Additionally, some of the cases within the CDC dataset may not be locally acquired. Hypothetically, an individual may travel to the Northeast, return ill, and be listed in the CDC database as a case in Contra Costa, California. Researchers who study Lyme disease prevalence must dig, and dig hard, state by state to double check those cases that may not be locally acquired.[2]

In our paper in Healthcare, we did just that. However, our focus was Texas, so the digging was concentrated to one state, where we were able to remove non-locally-acquired cases.

Even if Lyme disease data were perfect, however, researchers and some public health officials are faced with a constant obstacle: Lyme disease is not the only tick-borne disease. Ticks can carry many different pathogens. Yet, the CDC does not publish county-level data for tick-borne diseases other than Lyme. Given many patients with Lyme disease report having multiple co-infections, knowing the disease risk is imperative for physician knowledge and adoption of prevention behaviors among local community residents.

“Lyme” is often a catch-all phrase

At the same time, “Lyme” is often used as a blanket term and adopted by national and state organizations to cover a host of possible other infections such as Babesia or ehrlichiosis. The catch-all phrase “Lyme” could potentially detract from the wide range and prevalence of other tick-borne diseases in the United States.

In our study, we attempted to improve surveillance of tick-borne diseases, including Lyme, using data drawn from a specialized survey—the Texans and Ticks Survey (TTS)—developed to collect state-, county-, and zip-code-level self-reported patient information.

TTS included the geographic location of tick bite encounters. All survey respondents reported a Lyme disease diagnosis by a medical professional. Survey respondents were asked if they had received a diagnosis, and if so, how they had been diagnosed. They could select: (1) Clinically (the doctor thinks you have Lyme disease based on your history and symptoms); (2) Western Blot, where some bands were positive; (3) Western Blot, where five or more bands were positive (“CDC-positive”); (4) IGeneX or other specialty lab; or (5) I do not know/Not sure.

Respondent tick bite encounters of those who self-reported a Lyme diagnosis were mapped at the county level. Since counties with higher populations would naturally experience more tick bites (all else held constant), by-county raw case frequencies were corrected with respect to the county’s population density, and standardized as the number of cases per 100,000 individuals.

Comparing maps

We overlaid survey respondents’ tick bite encounter locations on maps with official CDC human Lyme disease cases and canine cases of Lyme, ehrlichiosis, and anaplasmosis. Examples are below:

Overall, we found that the survey respondents only reported tick bites in areas known to be suitable to ticks and tick-borne disease transmission as shown via canine serological and official CDC human reports. These findings held true for all official human Lyme cases, as well as canine Lyme, ehrlichiosis, and anaplasmosis (not pictured).

Importantly, clinically diagnosed patients match known and official cases of Lyme and other tick-borne diseases in Texas. Without access to CDC cases of other county-level tick-borne disease, self-reported tick bite encounters, associated diseases, and a one-health approach to assess overlap with human and canine cases, proved to be a promising exploratory study that warrants further attention at the national level. We suggest that self-reported clinically diagnosed patient reports and serological canine reports can serve as proxies for assessing human disease risk.

These findings were not a result of simple population density, and also followed the same hot-spot clusters as human and canine cases. Additionally, they occurred in ecosystems suitable for ticks. If these respondents were randomly lying about their tick bite locations, chances of all the respondents making up tick-bite encounters only in suitable or endemic counties would be almost impossible.

Diverse ecosystems

Back to our data dilemma: Why is providing only state level data insufficient? In states such as Texas, ecosystems are diverse and not all are suitable tick habitats. If the perception is that Texas is not endemic, we miss numerous counties where individuals have reported tick bites and a subsequent clinical Lyme diagnosis. Our study demonstrates that county-level data allow for more fine-tuned decision-making and risk assessment.

Take Potter County, Texas, as one example. The  drier northwestern area of the state, known as the Texas Panhandle, has an ecoregion suitable for tick habitat that extends into a drier, less tick-suitable ecosystem. The ecoregion that covers most of the panhandle is not as suitable for tick populations, However, the extension from the Rolling Plains into just a few counties does offer suitable tick habitat. We find overlap in Potter County with canine reports of tick-borne disease and CDC cases.

Did you know that in 2020, 1 in 20 dogs tested for ehrlichiosis in Potter County Texas was positive? However, only 1 in 1,000 canines in Potter County tested positive for Lyme disease. Should physicians test humans for ehrlichiosis in addition to Lyme disease in a few counties in the Texas Panhandle if the patient presents with tick-borne illness symptoms? I don’t have the answer to that. But I do know county-level data are desperately needed in tick-borne disease surveillance if public health officials hope to prevent disease.

Indeed, most diseases, for example West Nile, are incorporated into interactive, useful, county-level maps on the CDC webpage. Perhaps it is time to rethink the public health commitment to tick-borne disease surveillance so that both the general public and health officials can make informed and equitable decisions.

There are no sustainable, easy-to-access local tick-borne disease data that allow for communities to improve health outcomes for those who may be affected, including vulnerable populations who are the least likely to receive a diagnosis and care, especially in areas that are perceived to be “non-endemic.”

Click here to read the journal article.

Dr. Sarah Maxwell is an assistant provost and associate professor at the University of Texas at Dallas. Her research and grants focus on tick-borne disease surveillance and patient experiences with Lyme disease. She and her co-authors are founding members of ICI-Vector, created to Integrate, Communicate, and Inform others about tick-borne disease. She also serves on the scientific board of the Texas Lyme Alliance.

Footnotes

[1] Researchers may apply for these data from the CDC, but if granted access, are prohibited from publishing data at the county-level.

[2] My understanding is that not all states differentiate locally-acquired cases.

Category:

research, Ticks

Longitudinal Analysis Shows Durable & Broad Immune Memory After SARS-CoV-2 Infection With Persisting Antibody Responses and Memory B & T Cells

https://www.cell.com/cell-reports-medicine/fulltext/S2666-3791(21)00203-2?s=03#secsectitle0020

Longitudinal analysis shows durable and broad immune memory after SARS-CoV-2 infection with persisting antibody responses and memory B and T cells

Open AccessPublished: July 14, 2021DOI:https://doi.org/10.1016/j.xcrm.2021.100354

Highlights

  • Most recovered COVID-19 patients mount broad, durable immunity after infection
  • Neutralizing antibodies show a bi-phasic decay with half-lives >200 days
  • Spike IgG+ memory B cells increase and persist post-infection
  • Durable polyfunctional CD4 and CD8 T cells recognize distinct viral epitope regions

Summary

Ending the COVID-19 pandemic will require long-lived immunity to SARS-CoV-2. Here, we evaluate 254 COVID-19 patients longitudinally up to 8 months and find durable broad-based immune responses. SARS-CoV-2 spike binding and neutralizing antibodies exhibit a bi-phasic decay with an extended half-life of >200 days suggesting the generation of longer-lived plasma cells. SARS-CoV-2 infection also boosts antibody titers to SARS-CoV-1 and common betacoronaviruses. In addition, spike-specific IgG+ memory B cells persist, which bodes well for a rapid antibody response upon virus re-exposure or vaccination. Virus-specific CD4+ and CD8+ T cells are polyfunctional and maintained with an estimated half-life of 200 days. Interestingly, CD4+ T cell responses equally target several SARS-CoV-2 proteins, whereas the CD8+ T cell responses preferentially target the nucleoprotein, highlighting the potential importance of including the nucleoprotein in future vaccines.
Taken together, these results suggest that broad and effective immunity may persist long-term in recovered COVID-19 patients.

____________________

**Comment**

Please watch numerous doctors state how the COVID response is out of step with medicine and science. 

Previously, Dr. Beda M Stadler, former director of the Institute for Immunology at the University of Bern, a biologist and professor emeritus is on record stating:

  • Firstly, it was wrong to claim that this virus was novel.
  • Secondly, It was even more wrong to claim that the population would not already have some immunity against this virus.
  • Thirdly, it was the crowning of stupidity to claim that someone could have Covid-19 without any symptoms at all or even to pass the disease along without showing any symptoms whatsoever.

Dr. Rodger Hodkinson, a medical specialist in pathology which includes virology, chairman of the Royal College of Physicians and Surgeons Committee in Ottawa, and CEO of a large private medical laboratory in Edmonton, Alberta and chairman of a medical biotechnical company stated:

“This is the greatest hoax ever perpetrated on an unsuspecting public.

There is absolutely nothing that can be done to contain this virus other than protecting older more vulnerable people.  It should be thought of as nothing more than a bad flu season. This is not Ebola, it’s not SARS.  It’s politics playing medicine and that’s a very dangerous game.

I’m absolutely outraged that this has reached this level.  It should all stop tomorrow.”

And many, many more have been outspoken of the COVID fiasco.

For more:

Category:

research, vaccines, Viruses

What is Borrelia miyamotoi?

https://danielcameronmd.com/what-is-borrelia-miyamotoi/

WHAT IS BORRELIA MIYAMOTOI?

What is Borrelia miyamotoi

What is Borrelia miyamotoi? This tick-borne illness, transmitted by deer ticks, is believed to be underrecognized and a growing concern, as studies indicate a B. miyamotoi infection may be as common as anaplasmosis and babesiosis. Researchers randomly tested 250 individuals living in Manitoba, Canada and found that 10% were seropositive for B. miyamotoi. [1]

By 

Borrelia miyamotoi (B. miyamotoi) was first reported in the United States in 2013 but has become increasingly more common.  The tick-borne illness can be transmitted by the same tick that carries Borrelia burgdorferi, the Lyme disease pathogen. In their article, Della-Giustina and colleagues² address the question, “What is Borrelia miyamotoi?” and concerns surrounding this growing threat.

Where is B. miyamotoi found?

Borrelia miyamotoi (B. miyamotoi) can be found in various ticks including the deer tick. It has been detected in ticks located in the northeastern and northern Midwestern United States, California, Europe, and Asia.

What stage of deer ticks transmit B. miyamotoi?

Borrelia miyamotoi can be transmitted from all stages of a tick including the larval stage. The larval tick can harbor and transmit B. miyamotoi by passing the pathogen from the parent to the offspring, a process called transovarial transmission.

How fast can B. miyamotoi be transmitted?

Quickly, according to the authors.  “B. miyamotoi can be transmitted 10% of the time within the first 24 hours of attachment, increasing steadily to reach 73% for a complete feeding.  Thus, transmission of B. miyamotoi is more rapid than transmission of B. burgdorferi.”²

Symptoms of B. miyamotoi

The symptoms that have been described include fever, malaise, headache, and myalgias.  Some cases present with an elevated liver test, low white count and abnormal liver tests that have been described in Anaplasmosis, another tick-borne illness.  Only 11% of patients presented with an erythema migrans rash, according to findings from a case series.

Making the diagnosis

It can be difficult to diagnose B. miyamotoi.  “No test specific to B. miyamotoi has been approved by the United States Food and Drug Administration as of October 2020,” the authors explain.

“The most specific test currently available in several public health and commercial laboratories is polymerase chain reaction (PCR) testing of blood or cerebrospinal fluid for the B. miyamotoi GlpQ enzyme.”

“Serologic testing of B. miyamotoi IgM and IgG antibodies is possible by a few commercial laboratories.” Unfortunately, it can be hard to interpret these tests, as they may cross-react to other spirochetes.  (The authors did not address the risk of cross reactions.)

“One test using this approach, the TBD serochip, is an array-based assay testing for 8 different tick-borne diseases, including B. miyamotoi. Developed in 2018, it is promising but has not yet become widely available.”

Treatment of B. miyamotoi 

There are no evidence-based trials to determine the best treatment for B. miyamotoi. Doxycycline has been suggested, as Lyme disease patients have improved with doxycycline.  “In vitro analysis has shown the susceptibility of B. miyamotoi to ceftriaxone, azithromycin, and doxycycline, with resistance to amoxicillin,” the authors explain.

Prophylactic treatment

Since B. miyamotoi can be transmitted rapidly, it may be prudent to consider prophylactic antibiotic treatment immediately, even if the tick has not been attached for 24 to 36 hours.

“Understanding this more rapid transmission of infection of B. miyamotoi may be a consideration in determining prophylactic treatment for tick bites with a shorter time of attachment in endemic areas for B. miyamotoi.”

Related Articles:

Could Borrelia miyamotoi infections explain persistent symptoms in Lyme disease patients?

C6 peptide test may indicate Borrelia miyamotoi infection

The best antibiotics to treat Borrelia miyamotoi?

References:
  1. Kadkhoda K, Dumouchel C, Brancato J, Gretchen A, Krause PJ. Human seroprevalence of Borrelia miyamotoi in Manitoba, Canada, in 2011-2014: a cross-sectional study. CMAJ Open. 2017;5(3):E690-E693.
  2. Della-Giustina D, Duke C, Goldflam K. Underrecognized Tickborne Illnesses: Borrelia Miyamotoi and Powassan Virus. Wilderness Environ Med. Jun 2021;32(2):240-246. doi:10.1016/j.wem.2021.01.005

____________________

**Comment**

I’m always extremely skeptical of ALL information given on transmission times as reality has shown a far different picture.  For more on this:  https://madisonarealymesupportgroup.com/2017/04/14/transmission-time-for-lymemsids-infection/   Important to note: minimum transmission time has never been determined and reality shows it can happen within a few hours.  Certain coinfections can happen within minutes.

Since Borrelia miyamotoi is not a reportable illness to the CDC, no one has any clue about prevalence but reports are coming in continually that it’s highly likely to be a much bigger problem than ‘authorities’ believe.

It was recently discovered that:

Category:

Borrelia Miyamotoi (Relapsing Fever Group), research, Testing, Ticks, Transmission, Treatment

IPM Tick Academy in September

Tick IPM Working Group Presenting Second Annual Tick Academy

IPM tick academyThe Tick IPM Working Group is presenting the second annual Tick Academy, September 13-15, 2021 from 10 AM until 2 PM each day.

The Tick Academy is the premier event for educators, students, researchers, pest control professionals, public health professionals, public-space managers, and citizen scientists, who want to learn more about what they can do to stop the spread of ticks and tickborne diseases in their respective communities.

The event will take place virtually and will feature twelve presentations over three, four-hour sessions during which the presenters will share the latest information about:

  • tick management
  • tickborne disease prevention
  • recent discoveries of emerging pathogens
  • public perceptions of risk, diversity, identification of ticks
  • ongoing research on control and vaccine developments

For more details, please view the Tick Academy Announcement Flyer.

To register for this virtual event, click the registration link at the bottom of the flyer or visit tickacademy.brownpapertickets.com.

For more IPM information: IPM Pest Alert-Asian longhorned tick

Category:

Activism, Prevention, research, Ticks, vaccines

Doctors Warn CDC, “It’s Not All COVID” And Anchoring Bias is Causing Doctors To Miss Tick-Borne Infections

https://wwwnc.cdc.gov/eid/article/27/8/21-1107_article

Volume 27, Number 8—August 2021
Research Letter

COVID-19 and the Consequences of Anchoring Bias

Harold W. HorowitzComments to Author , Caren Behar, and Jeffrey Greene
Author affiliations: Weill Cornell Medicine, New York, New York, USA (H.W. Horowitz); New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA (H.W. Horowitz); New York University Langone School of Medicine, New York (C. Behar, J. Greene)

Abstract

Suspicion of coronavirus disease in febrile patients might lead to anchoring bias, causing misdiagnosis of other infections for which epidemiologic risks are present. This bias has potentially severe consequences, illustrated by cases of human granulocytic anaplasmosis and Lyme disease in a pregnant woman and human granulocytic anaplasmosis in another person.

Coronavirus disease (COVID-19) took the United States by force during the first quarter of 2020, affecting the economy, societal norms, and the delivery of medical care (1,2). As fear of COVID-19 has spread, diagnosing COVID-19 in febrile persons has been prioritized, and patients may be presumed to have COVID-19 pending results of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This mindset has had unintended consequences, including delaying of evaluations for other infectious diseases, potentially leading to adverse outcomes. We describe 2 cases that illustrate this point.

In the first case, a 35-year-old man left New York, New York, USA, to go hiking in Maryland during June 5–June 7, 2020. He experienced fever, body aches, and fatigue during June 10–13 that resolved but left him fatigued and weak. He was seen on June 19; laboratory results were unremarkable, but lymphopenia was detected. He tested negative for SARS-CoV-2 on June 19 and June 25 by PCR. On June 25, ELISA for Lyme disease was positive, and reflex to Western blot revealed IgM 41-kD, 39-kD, and 23-kD bands but no IgG bands. Fever up to 38°C recurred on June 22 and lasted until June 29; he also experienced persistent fatigue and myalgia. Further testing on July 6 revealed serologic results for Lyme similar to results from June 25 and Anaplasma phagocytophilum titers of IgM 1:320 and IgG 1:1260. Anaplasma PCR was negative on that date. He was treated with doxycycline for 10 days and recovered.

In the second case, a 31-year-old woman who was 6 months pregnant left New York at the end of May 2020 to rent a house in Ulster County, New York. On June 3, she removed a tick from her neck. On June 9, she experienced severe headaches and the next day had low-grade fever, chills, and body aches. She had no cough, shortness of breath, or sore throat. On June 10, she tested negative for SARS-CoV-2 by PCR. She continued to have extreme fatigue, myalgia, and low-grade fever. She was prescribed oseltamivir by her obstetrician on June 11. On June 14, she felt better. Repeat PCR testing for SARS-CoV-2 on June 15 was negative. She continued to improve until June 23, when she experienced recurrent fever up to 38.9°C, chills, and lethargy. She contacted her obstetrician and was told she had a presumptive diagnosis of COVID-19. On June 30, she saw her internist and underwent laboratory testing for tickborne illnesses; she was treated empirically with amoxicillin because of her risks for Lyme disease. PCR for A. phagocytophilum was positive, as was a second test on July 8. Serologic results for Lyme were positive for 41-kD, 39-kD, and 23-kD bands with no IgG bands. Platelets were 140,000 (previously 336,000), aspartate aminotransferase was 95, and alanine aminotransferase was 81. Several weeks later, studies revealed anaplasma IgM 1:256 and IgG 1:1,280. Lyme disease C6 antibody was positive. After discussion, the patient and her physicians chose not to treat for anaplasmosis because she was clinically improving. The patient has remained well, and the child was born healthy by normal spontaneous vaginal delivery.

COVID-19 has had devastating effects on the medical system and led to widespread changes in the practice of medicine. We believe that the imperative to rule out COVID-19 led to diagnostic anchoring bias in these cases. Such biases are among the most common in the heuristic decision-making process (3,4). Of note, in these 2 cases (case 1, human granulocytic anaplasmosis [HGA]; case 2, co-infection with Lyme disease and HGA), COVID-19 was ruled out without considering other diagnoses, even though the patients were visiting areas to which tickborne diseases are endemic. Given the incidence of such diseases in these areas and widespread attempts to educate healthcare providers about these diseases, failure to evaluate for tickborne infections would be difficult to imagine before COVID-19. Although both of these patients have done well, serious consequences to the fetus could have occurred if Lyme disease had gone undiagnosed and untreated (5). Although transmission of A. phagocytophilum during pregnancy has been reported (6) and treatment during pregnancy in a limited number of cases has possibly prevented transmission (7), in this instance the patient cleared the anaplasma without treatment, and the child was born disease-free. Clearance of infection without treatment has been reported in other studies, but we are unaware of cases describing the outcome of pregnancy in untreated women with acute HGA (8).

We appreciate the devastating effects that a missed COVID-19 diagnosis can have on a person, as well as the epidemiologic implications thereof. However, failing to diagnose tickborne illnesses and other infections also can have serious consequences. Healthcare providers must keep an open mind to diagnoses other than COVID-19 in febrile patients and not fall prey to misdiagnosis because of current pressures to evaluate for COVID-19.

Dr. Horowitz is clinical professor of medicine at Weill Cornell Medicine and chief of infectious diseases at New York-Presbyterian Brooklyn Methodist Hospital. He has been involved in clinical practice for the past 38 years, and his research has focused on immune-suppressed patients, tickborne diseases, and, more recently, antimicrobial stewardship and hospital-acquired infections.

References

  1. CDC. COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19)—United States, February 12–March 16, 2020. MMWR Morb Wkly Rep. 2020;69:343–6.
  2. Hollander  JE, Carr  BG. Virtually Perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382:1679–81. DOIExternal LinkPubMedExternal Link
  3. Sapersnik  G, Redelmeier  D, Ruff  CC, et a. Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak. 2016;16:138. DOIExternal LinkPubMedExternal Link
  4. Ogdie  AR, Reilly  JB, Pang  WG, Keddem  S, Barg  FK, Von Feldt  JM, et al. Seen through their eyes: residents’ reflections on the cognitive and contextual components of diagnostic errors in medicine. Acad Med. 2012;87:1361–7. DOIExternal LinkPubMedExternal Link
  5. Waddell  LA, Greig  J, Lindsay  LR, Hinckley  AF, Ogden  NH. A systematic review on the impact of gestational Lyme disease in humans on the fetus and newborn. PLoS One. 2018;13:e0207067. DOIExternal LinkPubMedExternal Link
  6. Horowitz  HW, Kilchevski  E, Haber  S, et al. Brief report: Perinatal transmission of the human granulocytic ehrlichiosis agent. N Engl J Med. 1998;339:375–8. DOIExternal LinkPubMedExternal Link
  7. Dhand  A, Nadelman  RB, Aguero-Rosenfeld  ME, Haddad  F, Stokes  D, Horowitz  HW. Human granulocytic anaplasmosis in pregnancy: case series and review of literature. Clin Infect Dis. 2007;45:589–93. DOIExternal LinkPubMedExternal Link
  8. Bakken  JS, Haller  I, Riddell  D, Walls  JJ, Dumler  JS. The serological response of patients infected with the agent of human granulocytic ehrlichiosis. Clin Infect Dis. 2002;34:22–7. DOIExternal LinkPubMedExternal Link

DOI: 10.3201/eid2708.211107

Original Publication Date: July 01, 2021

Category:

Anaplasmosis, Lyme, research