Ticks are not only capable of causing damage to their host through their physical attachment but also through their ability to act as a vector for various viral, bacterial and protozoal diseases both abroad and in the UK. Sauer et al (2000) discuss how when feeding, in order to concentrate their blood meal, ticks go through periods of sucking followed by periods of excretion which lengthen as time progresses. It is this excretion back into the host that allows for the transmission of infectious pathogens (Sauer et al, 2000). Additionally as feeding time lengthens the likelihood of transmission occurring is increased (Schoeman and Leisewitz, 2006; Health Protection Agency, 2012a).
Ticks are endemic throughout the UK but in greater densities in certain areas, possibly due to greater quantities of woodland/scrubland in such areas which provide an ideal environment for ticks to reside. In recent years the abundance and distribution of ticks has increased (Scharlemann et al, 2008) and their activity throughout the year prolonged (Smith et al, 2011). This is likely due to changes in climate, change in landscape such as reforestation and increases in the populations of wild hosts such as roe deer (Gilbert, 2010; Beugnet et al, 2011). Within the UK, Ixodes ricinus the ‘sheep tick’ is the most abundant and widely distributed species of tick (Pietzsch, 2005; Smith et al, 2011). Other species that have been identified within the UK, although to a lesser degree, are Dermacentor reticulatus and Rhipicephalus sanguineus (Hoyle et al, 2001; Jameson et al, 2010). In contrast to most tick species R. sanguineus has adapted to survive in more urban environments, such as kennels and attics, potentially increasing the risk of contact with humans and their companion animals (Cousquer, 2006; Little et al, 2007).
Transmitted by I. ricinus, borreliosis/Lyme disease, is a tick-borne disease (TBD) that can affect animals and humans, with the potential for spread between animals and humans via a tick vector. It is the most common vector-borne disease affecting humans in England and Wales and in recent years incidence in humans has increased dramatically from 340 reportend cases in 2002 to 905 reported cases in 2012 (Health Protection Agency, 2012a). Although data are not available, a similar increase is likely to have occurred in animals. This increase may not only be due to increased populations of ticks and their prolonged activity throughout the year, but also to a rise in the popularity of outdoor activities which brings the public (and their pets) in contact with ticks (Szell et al, 2006).
There are also many TBDs throughout the world that had previously not been a risk to pets in the UK. The introduction of Pet Travel Scheme (PETS) in 2000, which allows the movement of dogs, cats and ferrets in and out of the UK without the need for quarantine, has changed this. Additionally, changes made to the scheme in January of this year may lead to a further increased risk from exotic TBDs (Morgan and Smith, 2012). The scheme previously required pets to be treated with an acaricidal product 24–48 hours prior to entering the UK to ensure all ticks were killed before entry. However, as of January 2012, acaricidal treatment is no longer compulsory therefore increasing the risk of exotic ticks and the diseases they carry being brought into the UK. There have also never been any requirements to ensure owners are protecting their pets before or during travel to prevent them from contracting potentially fatal tickborne-borne diseases while abroad.
Babesiosis and ehrlichiosis are examples of exotic TBDs which have been seen in the UK since the introduction of PETS (Shaw et al, 2003; Hillman and Shaw, 2010; DEFRA, 2011). Additionally Holm et al (2006) discuss a case of babesiosis in an untravelled British dog suggesting the disease began to establish itself in the UK as far back as 6 years ago. Babesiosis is transmitted by D. recticulates and R. sanguineus, and Ehrlichiosis is transmitted by R. sanguineus. Hillman and Shaw (2010) state that D. recticulates is already established in south western areas of England and Wales. R.sanguineus is not currently considered to be endemic to the UK although it has been identified numerously from animals in quarantine kennels and those entering via PETS (Jameson et al, 2010), therefore relaxation of PETS requirements could lead to the establishment of this vector within the UK. Once tick vectors are present in the UK there is the potential for exotic TBDs brought in via travelling pets to become endemic to the UK.
Therefore at a time of increased tick populations, increased occurrence of TBDs in the UK and increased risk of exotic TBDs, client knowledge of ticks and how to protect their pets and themselves is essential. The aim of the study was to investigate the level of knowledge of clients and staff within veterinary practice regarding tick control and related issues. A comparison was made between clients and staff in areas of high risk for the zoonotic TBD borreliosis and clients and staff in areas of low risk. Membership of the PETS was also investigated to see if this had an impact on the level of knowledge of clients.
Materials and methods
To ascertain client and staff knowledge of ticks a questionnaire (or quiz) was produced: ‘The TickTest’. The questionnaire consisted of closed, multiple choice questions offering respondents the choice of the right answer along with a number of wrong answers in order to test their knowledge of various topics regarding ticks, their control and the diseases they can cause. A list of questions asked can be seen in Table 1. ‘Don’t know’ was used as an option where appropriate to minimize the guessing of answers which could have impacted on the results. There were 19 questions to test the respondents’ knowledge totalling 40 marks if all correct answers were given. The questionnaires also included additional questions regarding methods of prevention/control used and also awareness of TBDs. Membership of PETs was also ascertained. Questionnaires were produced using SNAP 9 Professional (a software program for designing questionnaires and collating responses). The questionnaire was self administered within a veterinary practice, with the idea that client could complete the questionnaire while waiting for their appointment.
Ten practices participated in the study which took place prior to changes to the PETs in 2012. Five high-risk (located in Somerset/Dorset/Hampshire), and five low-risk (located in Staffordshire/Shropshire) practices participated. Zoonotic high and low-risk areas were established by looking at the prevalence of borreliosis in humans, as detailed by the Health Protection Agency (2012b). A stratified random sampling method was implemented to ensure equal numbers were sampled from each area (Table 2). Practices were sent ten staff questionnaires and 30 client questions; it was requested that staff questionnaires be completed by all staff who had contact with clients and that client questionnaires be given out at random to clients entering the practice. All responses were given anonymously.
| Total | High-risk area |
Low-risk area |
|
|---|---|---|---|
| Client questionnaire | 300 |
150
|
150
|
| Staff questionnaire | 100 |
50
|
50
|
Once returned, questionnaires were scored to give respondents a knowledge score (out of 40), with a mark being received for each correct answer of the knowledge questions. One-way ANOVAs (analysis of variance) were used to compare the knowledge scores and establish if differences were significant. The following comparisons were made:
Microsoft Excel was used to tabulate and illustrate findings. The responses to individual questions were looked at separately to gain a greater insight into certain aspects of awareness and prevention/control methods.
Results
Response rate
Of the 300 client questionnaires sent out 77 were returned, a response rate of 25.7%. Of the 100 staff questionnaires sent out 27 were returned, a response rate of 27%. Table 2 shows how responses were distributed between high and low-risk areas.
Comparison of knowledge scores
The study showed that staff knowledge was significantly (p<.001) higher than client knowledge of ticks by 34.9%. Client knowledge was found to be significantly (p<0.001) higher in zoonotic high-risk areas than in zoonotic low-risk areas by 51.2%. Staff knowledge was also found to be significantly (p=0.006) higher in zoonotic high-risk areas than in zoonotic low-risk areas by 39.5% (Figure 1).
| Total responses | High-risk area | Low-risk area | |
|---|---|---|---|
| Client questionnaire | 77 | 49 | 28 |
| Staff questionnaire | 27 | 7 | 20 |
From the responses received, 6.5% of clients were members of PETS. No significant difference (p=0.797) was found between the knowledge of those clients who were members of PETS and those who were not (Figure 2).
Prevention/control methods
The proportion of staff and clients who knew the correct treatment protocol (for acaricides available at the time of sampling) to protect animals from ticks was determined; overall, clients and staff in high-risk areas were more aware of the correct treatment protocols (Figure 3).
Staff in high-risk areas advised clients to check their pets for ticks more often than in low-risk areas and clients in high-risk areas checked their pets more often than clients in low-risk areas (Figure 4). Figure 4 also illustrates that how often clients are advised to check their pets differs from how often they actually do so.
Awareness of TBDs
Overall, staff had better awareness of TBDs than clients (Figure 5). A difference can also be seen between high and low-risk areas.
Discussion
Staff knowledge was significantly (p<0.001) higher than that of clients. This was expected due to the specific training that the majority of veterinary staff have undertaken and their access to additional information through academic publications. However, the author of this investigation felt that the knowledge assessed was relevant for both clients and staff, and therefore if staff were aware of any particular issues, then this knowledge should have been passed on to clients and no difference in knowledge should be seen. Therefore results indicate that one or more of the following is occurring:
Client and staff knowledge was significantly (p<0.001 and p=0.006 respectively) higher in zoonotic high-risk areas than that of clients and staff in zoonotic low-risk areas. Veterinary surgeon/nurse training is standardized throughout the UK, therefore the difference in staff knowledge seen must be influenced by other factors linked to the location of the practice. Increased staff knowledge in a topic area is likely to lead to increased client knowledge in that area. However, there was a greater increase in client knowledge (51.2%) than staff knowledge (39.5%) when comparing low and high-risk areas suggesting additional factors are involved in the increase in client knowledge. Such additional factors could be the provision of government awareness schemes in high-risk areas.
In this very small sample membership of PETS was not found to have a significant effect on client knowledge. This may be due to the fact that PETS was put in place in order to protect the UK from exotic diseases, not to protect pets (ESCCAP, 2012; Morgan and Smith, 2012). It is therefore not a criterion of PETS that owners are aware of the risks of exotic TBDs and how to protect their pets from them while abroad. It has been shown that exotic diseases have occurred in the UK since the introduction of PETS and most have been brought in via PETS (DEFRA, 2011). This information therefore highlights the importance of educating clients about the diseases they are exposing their pets to while abroad and the suitable protective methods.
Overall, higher proportions of staff knew the correct treatment protocols for products in order to provide protection against ticks (Figure 3). This was to be expected with staff working in veterinary practice being more exposed to such information. Greater proportions of clients and staff in zoonotic high-risk areas were aware of the correct treatment protocols than those in zoonotic low-risk areas. This may be because in high-risk areas:
A difference was seen in how often staff advised clients to check their pets for ticks and how often clients actually did so (Figure 4). Regular inspections are important as some pathogens are not transmitted for a number of hours/days after attachment (Schoeman and Leisewitz, 2006; Health Protection Agency, 2012a). To improve compliance this information needs to be relayed to clients so they understand the potential implications of delayed identification and removal.
The disease that most respondents were aware of was borreliosis (Figure 5); this was to be expected as it is the most common zoonotic TBD present in the UK (Health Protection Agency 2012b). There was an increased awareness (both staff and clients) of borreliosis in the zoonotic high-risk areas, which was again expected as it is consistent with the increase in prevalence of this disease in these areas (Health Protection Agency, 2012b). There was increased awareness, especially in staff, of babesiosis and ehrlichiosis. The impact of PETS has resulted in the occurrence of these diseases in the UK (DEFRA, 2011). This has subsequently been reported in the media and academic journals, thus raising awareness of these TBDs.
Limitations and recommendations for further research
The questionnaire was self administered within a veterinary practice, with the idea that clients could complete the questionnaire while waiting for their appointment. The disadvantage of this is that clients may have discussed answers with other people or had access to additional information in the form of leaflets or displays available to them. This may have impacted on the results gained but it was felt that to suggest clients complete the questionnaire under ‘exam conditions’ would be impractical.
Results found from this survey cannot be representative of the entire pet owning population. The survey was biased towards pet owners who visited a veterinary practice and therefore had more chance of being subjected to forms of education as well as being conscientious pet owners who were potentially more likely to seek to educate themselves. This could mean that the knowledge level of pet owners in general is in fact lower than has been found in this investigation. Therefore, a repeat survey where questionnaires were distributed away from veterinary practice (in pet shops, local shops etc) could allow more representative results to be found. Further work into the knowledge of pet shop staff, another common and trusted reference point for many owners, may also be of interest.
Of the respondents sampled only five were members of PETS, therefore results gained should be viewed cautiously. Additional research into the knowledge of PETS members is necessary to confirm this result. Regardless of this educating owners of travelling pets is still of high importance to ensure they have the knowledge to protect their pets from potentially fatal exotic TBDs.
Conclusion
This research has shown that client knowledge of ticks and related issues is better in zoonotic high-risk areas than in zoonotic low-risk areas. This is a promising finding as it shows that, in areas of increased risk, pet owners are more aware of such risks and how to provide protection for their pets. However, the risks posed by ticks are not confined to populations of high-risk areas. Tick populations are growing and expanding and people travel within the UK as well as abroad with their pets exposing them to a variety of environments. Also, with the introduction of PETS and the recent elimination of mandatory ectoparasite treatment on return to the UK, the risk of exposure to exotic diseases both abroad and within the UK has increased. This research also found that respondents who were members of PETS had no better knowledge of ticks and related issues than non members and this may have been instrumental in the occurrence of exotic TBDs in pets who had travelled outside of the UK.
Therefore the importance of client education (both PETS members and non members) regarding ticks and TBDs has never been more important. Clients need to be made aware of ticks, the potential for TBDs (in the UK and abroad) and how to protect their pets from such diseases not only to protect their pets as individuals but to protect the UK as a whole.