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More than ticking boxes: Training Lyme disease education ambassadors to meet outreach and surveillance challenges in Québec, Canada

['Karl Forest-Bérard', 'Direction Des Risques Biologiques Et De La Santé Au Travail', 'Institut National De Santé Publique Du Québec', 'Inspq', 'Montréal', 'Québec', 'Marion Ripoche', 'Alejandra Irace-Cima', 'École De Santé Publique De L Université De Montréal', 'Espum']

Date: 2021-10

The ongoing emergence of LD throughout Canada warrants more efforts to monitor its northward progression. As part of an attempt to explore alternatives to the current LD awareness and surveillance methods, we evaluated the feasibility and implementation of an adapted ToT-inspired approach. We found it to be a feasible and complementary approach to provincial PH efforts in raising awareness about LD risk and prevention. It also has the potential to contribute to provincial LD surveillance efforts. Fig 5 illustrates how results of activities organized in a ToT-inspired project are amplified, growing increasingly from one level (PH institution) to the next (ambassadors and trainees).

Two of the eighteen ambassadors originally recruited and trained failed to carry out outreach and sampling activities, citing professional obligations as the main barrier. There was also considerable variability in the amount of activities ambassadors carried out individually, ranging from none to eight activities per ambassador. Lack of human resources, financial constraints and lack of time were cited as their main barriers. This is understandable since ambassadors worked voluntarily, adding outreach and sampling activities to their regular professional duties. Including financial incentives could help overcome the barrier to ambassador participation while still keeping the ToT-inspired approach a relatively inexpensive option, at least compared to the classic LD surveillance model currently in place. Involving ambassadors more closely and getting them to train new staff themselves could also help preserve mobilization. Shortening the sampling protocol (covering shorter distances but including multiple visits per site or rotating samplers), organising trainings earlier in the year when workers are more available, sharing documents beforehand to cover some ground and limiting the time spent answering questions during workshops could also contribute to alleviate time investment and encourage participation.

Partnering with a private non-profit organisation such as NCC proved to be a winning combination. The quality and reach of its network coupled with the interest and field experience of the ambassadors were facilitating factors in implementing the ToT-inspired approach. The project also highlighted outdoor workers’ eagerness and ability to participate in outreach and tick sampling activities. This concurs with results obtained from a province-wide 2017 online survey of outdoor park administrators, which highlighted workers’ strong interest in receiving information about LD preventive measures and tick sampling (INSPQ 2017, unpublished data). As shown by ambassadors’ enthusiasm, the project clearly addressed a need in terms of prevention and training, not only for vulnerable outdoor workers, but also for the general population frequenting their organisations. Such interest translates into a certain responsiveness to local concerns, which in turn could lead to higher data resolution at a regional scale. In addition, accessing NCC’s private properties allowed us to survey areas never before sampled by PH authorities, which has interesting advantages to complement the surveillance datasets.

The ToT-inspired approach proved to have multiplicative effects on outreach efforts, allowing knowledge to be passed from a single PH professional to nearly 2 000 individuals throughout the south of the province, considered LD high-risk areas. This number is probably underestimated as it excludes the individuals reached through open activities such as information stands, newsletters, public interviews, etc. In addition, these results do not take into consideration repercussions the network might have in the future, as ambassadors can keep disseminating the preventive information, either by sharing it with their colleagues and clientele in the coming years, or by training new trainers themselves.

Strengths and limitations of the ToT approach

Workers from publicly-accessible outdoor spaces are at particularly high risk of exposure to B. burgdorferi-infected I. scapularis ticks given their recurring exposure to tick habitat [43, 44]. A reform of the occupational health and safety regime in Quebec is currently underway [45] but at the moment many of these workers do not benefit from some of the prevention mechanisms provided under the Act respecting occupational health and safety (Loi sur la santé et la sécurité au travail), since many of them work in a sector where only half of the prescribed prevention mechanisms are applied [46]. The ToT-inspired approach allowed us to reach workers that would not have been otherwise targeted in their workplaces in the immediate future by PH authorities based on the current provincial occupational health plan. While we do not have hard data at the moment to prove knowledge-retention, we believe these individuals benefitted from some level of added protection with the prevention information they received through ambassadors. Furthermore, training publicly-accessible outdoor park staff, who constitute a key interface with the public, has the potential to improve access of the general public to information about LD risks and prevention in a real-world setting (i.e., visiting a natural park) where this information is highly relevant.

This project also succeeded in demonstrating that tick samplings can be carried out independently by newly-trained ambassadors, who together collected 11 I. scapularis specimens in 28 outings. This type of sampling could complement tick data collected by the integrated LD surveillance program in Québec in two ways. Mainly organized during summer months when adult ticks are infrequently encountered, provincial surveillance samplings mostly result in the collection of larvae and nymphs. However, PH authorities are interested in identifying the presence of all three stages of I. scapularis at a given location over the course of one year as indicators of an established tick population, which is of relevance when defining LD endemic areas [28, 47]. In this regard, the timing of the current provincial program is not optimal, and ambassador-led samplings provide an opportunity to enhance surveillance datasets. Furthermore, while their analysis and integration might be more complex, ambassador tick data also prove to be useful in providing intensive tick monitoring of a small area where human activity overlaps with tick biology. Indeed, sites sampled by PH authorities as part of the integrated surveillance program are typically visited only once or twice per year, in areas not necessarily frequented by people. Therefore, repetitive monitoring (sites visited multiple times per year) made available by local ambassadors already on-site allows not only to characterize multiple life stages, but also generates data that is more representative (actual exposure portrait). Active surveillance samplings are known to be inefficient and dependent on numerous variables–both biotic and abiotic [48, 49]. Collecting ticks from a given location on multiple dates could contribute to moderate the potential effects these variables might have on tick detection, while also validating tick data longitudinally.

The fact that ambassadors were indeed able to collect ticks in their environment also demonstrates two things related to prevention and education: (A) that the workers recruited for our project are indeed at risk of tick bites in their occupational environment and that they do benefitted from having received educational material of bite prevention; and (B) that the sampling protocol taught is feasible, understandable and effective, but also that they understood when, where and how to find ticks, which speaks volumes in terms of education and awareness.

On a larger scale, the ToT-inspired approach could allow the establishment of a flexible network of community samplers that could provide regular collections from early spring through late fall, thus covering the entire I. scapularis life cycle. This would allow a thorough characterisation of tick population in endemic areas, helpful both locally (public outdoor parks) and provincially (PH authorities) [9].

Ambassador-led samplings provide a variety of other advantages compared to standard surveillance, the main ones being their inexpensiveness and their potential to cover large areas. They also allow access to never-before sampled sites. On the other hand, the overall small number of samplings in this study limits results interpretation. Low tick numbers are likely explained by ambassadors’ lack of time rather than by a lack of understanding of the sampling protocol since most participants reported feeling confident in leading samplings in the project final evaluation (86,4% weighted average, shown in supplement information). It may also indicate a need for stronger post-training follow-ups.

The overall yield of ticks collected by ambassadors can appear low and insignificant (n = 11 in 28 samplings). However, taken in context with LD’s actual epidemiology in Québec, and based on the regional risk-assessment criterions currently in place in the province, every collected tick has the potential to change the LD risk level of the given municipality where it was detected. In the case of this specific project, most ticks collected by ambassadors came from locations were PH authorities had already recorded a I. scapularis presence signal in the past. However, one of the collected ticks came from an area where such signal had not yet been documented, thus changing the risk area for that municipality from 2019 to 2020 (along with other data from the provincial active surveillance program). This change appeared on the yearly provincial risk-assessment map and could translate into different PH interventions and recommendations for this area.

In past studies, having an unstructured methodology for tick recovery proved to be a disadvantage for data interpretation [50]. The ambassador-approach using a standardized protocol close to that used by PH authorities overcame that issue. The fact that so many tick samplings were negative (completed protocol without detecting ticks) raises some questions about adherence to the procedure, especially in areas where human cases of LD are known to occur. Lack of experience may have contributed to these results, but even skilled samplers do not detect ticks at each drag. It is also known that sampling the same area twice within hours can give very different results for various reasons (predatorial dynamics, increased tick alertness after first drag, weather variability, etc.) [51]. As null samplings don’t necessarily indicate a tick-free environment, and as most sites were sampled only once during the summer, negative sampling results have to be interpreted cautiously, especially near endemic areas. Ideally, samplings could be repeated in the same areas or multiple samplings could be conducted per sites. Perhaps some ambassadors could have benefited from additional practice time during workshops and this could be considered in future ToT initiatives (e.g., classroom role-play, having participants teaching segments to others, etc.). A rating of the ambassador-led outreach and sampling activities could also have provided some insight on ambassadors’ integration and mastering of the content, and this should also be integrated in eventual reboots. In spite of the fact that one of the objectives of this project was to collect ticks actively by flannel-dragging, a high number of “passive” ticks–fortuitously encountered on clothes or skin, outside of sampling activities–was also reported during the course of the project (14 encounters, totalling 25 ticks, in three PHUs: Mauricie-Centre-du-Québec, Montérégie, Outaouais). These specimens were not analysed at this stage, but can provide some interesting insight on ambassadors’ exposure and behaviour. Indeed, passive ticks represent a good indicator of how much ambassadors and similar workers are exposed to ticks in their daily activities, and how aware they now are of their exposure, having a trained eye for otherwise easily missed arthropods. This points out that, beyond surveillance purposes, ambassador-led tick samplings can be highly valuable in terms of prevention, as witnessing the tick presence first-hand strongly consolidates risk awareness on a local scale. Furthermore, this leads us to believe that passive surveillance could be more effective in collecting ticks in the environment, especially when people are well-informed.

Taking into account that passive tick surveillance is already one of the components of the provincial surveillance program, consideration could be given to exploit this in the future to complement tick datasets, embracing a community or citizen science (CS) approach. CS-based projects, which involve citizens in scientific projects as contributing members at different levels, are praised for their scientific output, data quality and wider societal impact where both professional and citizen scientists benefit from the collaborative effort [52]. Growing in popularity worldwide, the usefulness of CS has already been demonstrated in recent papers, successfully being used in numerous fields of research, from monitoring water quality [53] to biodiversity and invasive alien species [54, 55]. In terms of vector-borne disease, CS has been used to monitor the geographic range expansion of invasive mosquito species (ex. Aedes albopictus) in Europe and the US [56–58] or predicting West Nile Virus transmission in North American bird communities [59]. It has also been adopted to look at different aspects of tick-borne diseases in Canada, Finland, the Netherlands and Massachusetts in the recent past [20, 60–66]. On a similar note, and as our work suggests, CS-based tick data could offer significant insights at a scale that is difficult to achieve by a single research group, improving detection resolution. Over time, such data could guide PH interventions and policies at a more local scale.

[END]

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