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BACKGROUND Babesia microti has gained a foothold in Canada as tick vectors become established in broader geographic areas. B. microti infection is associated with mild or no symptoms in healthy individuals but is transfusion-transmissible and can be fatal in immunocompromised individuals. This is the first estimate of clinically significant transfusion-transmitted babesiosis (TTB) risk in Canada. STUDY DESIGN AND METHODS The proportion of B. microti-antibody (AB)/nucleic acid amplification test (NAT)-positive whole blood donations was estimated at 5.5% of the proportion of the general population with reported Lyme Disease (also tick-borne) based on US data. Monte Carlo simulation estimated the number and proportion of infectious red cell units for three scenarios: base, localized incidence (risk in Manitoba only), and donor study informed (prevalence from donor data). The model simulated 1,029,800 donations repeated 100,000 times for each. RESULTS In the base scenario 0.5 (0.01, 1.75), B. microti-NAT-positive donations would be expected per year, with 0.08 (0, 0.38) recipients suffering clinically significant TTB (1 every 12.5 years). In the localized incidence scenario, there were 0.21(0, 0.7) B. microti-NAT-positive donations, with 0.04 (0, 0.14) recipient infections (about 1 every 25 years). In the donor study informed scenario, there were 4.6 (0.3, 15.8) B. microti-NAT-positive donations expected, and 0.81 (0.05, 3.14) clinically significant TTB cases per year. DISCUSSION The likelihood of clinically relevant TTB is low. Testing would have very little utility in Canada at this time. Ongoing pathogen surveillance in tick vectors is important as B. microti prevalence appears to be slowly increasing in Canada.

Range expansion of the vector tick species

Background Lyme disease is emerging in Canada due to expansion of the range of the tick vector Ixodes scapularis from the United States. National surveillance for human Lyme disease cases began in Canada in 2009. Reported numbers of cases increased from 144 cases in 2009 to 2025 in 2017. It has been claimed that few (

Lyme disease is an emerging public health threat in Canada. In this context, rapid detection of new risk areas is essential for timely application of prevention and control measures. In Canada, information on Lyme disease risk is collected through three surveillance activities: active tick surveillance, passive tick surveillance, and reported human cases. However, each method has shortcomings that limit its ability to rapidly and reliably identify new risk areas. We investigated the relationships between risk signals provided by human cases, passive and active tick surveillance to assess the performance of tick surveillance for early detection of emerging risk areas. We used regression models to investigate the relationships between the reported human cases, Ixodes scapularis (Say; Acari: Ixodidae) ticks collected on humans through passive surveillance and the density of nymphs collected by active surveillance from 2009 to 2014 in the province of Quebec. We then developed new risk indicators and validated their ability to discriminate risk levels used by provincial public health authorities. While there was a significant positive relationship between the risk signals provided all three surveillance methods, the strongest association was between passive tick surveillance and reported human cases. Passive tick submissions were a reasonable indicator of the abundance of ticks in the environment (sensitivity and specificity [Se and Sp] < 0.70), but were a much better indicator of municipalities with more than three human cases reported over 5 yr (Se = 0.88; Sp = 0.90). These results suggest that passive tick surveillance provides a timely and reliable signal of emerging risk areas for Lyme disease in Canada.

Climate warming and other environmental changes have contributed to the expansion of the range of several tick species into higher latitudes in North America. As temperatures increase in Canada, the environment becomes more suitable for ticks and the season suitable for tick activity lengthens, so tick-borne diseases are likely to become more common in Canada. In addition to Lyme disease, four other tick-borne diseases (TBDs) have started to emerge and are likely to increase: Anaplasmosis; Babesiosis; Powassan virus; and Borrelia miyamotoi disease. Increased temperature increases the survival and activity period of ticks, increases the range of both reservoir and tick hosts (e.g. mice and deer) and increases the duration of the season when people may be exposed to ticks. Other ticks and TBDs may spread into Canada as the climate changes. The public health strategies to mitigate the impact of all TBDs include surveillance to detect current and emerging TBDs, and public health actions to prevent infections by modifying environmental and social-behavioral risk factors through increasing public awareness. Clinical care strategies include patient education, early detection, laboratory testing, and treatment.

ObjectiveThis study aims to describe incidence over time, geographic and seasonal distribution, demographic and clinical characteristics of Lyme disease cases in Canada.IntroductionLyme disease (LD), a multisystem infection that is manifested by progressive stages (1), is emerging in central and eastern provinces of Canada due to northward expansion of the geographic range of Ixodes scapularis, the main vector in these regions (2). In 2004, approximately 40 human cases of LD were reported in Canada. In 2009, LD disease became nationally notifiable, with provincial and territorial health departments reporting clinician-diagnosed cases to the Public Health Agency of Canada (PHAC). This study summarizes seven years (2009-2015) of national surveillance data for LD in Canada.MethodsNational Lyme disease surveillance data is collected through two surveillance systems, the Canadian National Disease Surveillance System (CNDSS) and the Lyme disease enhanced surveillance system (LDES). The CNDSS collects only demographic data (age and sex), and information on episode date and case classification. The LDES system captures additional data, including: possible geographic location of infection (for both locally acquired and travel-related cases); clinical manifestations; and results of laboratory testing. Nine provinces out of ten participate to LDES that means they provide a part of or all the data elements of this surveillance system. The 2009 national Lyme disease case definition (3) that distinguishes confirmed and probable cases (Table 1) is used to classify and report cases diagnosed by clinicians.This study describes the incidence over time, seasonal and geographic distribution, demographic and clinical characteristics of reported LD cases. Logistic regression was used to explore variations among age groups, sex and year of reporting clinical manifestations to better understand potential demographic risk factors for the occurrence of LD. Different models were used with as outcomes absence or presence of: erythema migrans (early Lyme disease), neurologic and cardiac symptoms and multiple erythema, migrans (early disseminated Lyme disease); and arthritis (late disseminated Lyme disease). The most parsimonious multivariate models were sought by backward elimination of nonsignificant variables until all factors in the model were significant (P

In eastern North America, including Canada, Lyme disease is caused by Borrelia burgdorferi sensu stricto and transmitted to humans by the blacklegged tick, Ixodes scapularis. The last decade has seen a growing incidence of Lyme disease in Canada, following the northward range expansion of I. scapularis tick populations from endemic areas in eastern United States. This may be attributable to movement of the many hosts that they parasitize, including songbirds, deer and small mammals. In this study, we wanted to test the effect of spatial, temporal and ecological variables, on blacklegged tick density and infection rates, near the northern limit of their distribution in Ontario and Quebec, Canada. We found an effect of both proportion of forested areas and distance to roads, on density of I. scapularis ticks and prevalence of infection by B. burgdorferi. We also found an effect of both sampling year and ordinal sampling data on prevalence of infection by B. burgdorferi. In six adjacent sites showing evidence of reproducing I. scapularis populations, we found that forest composition and structure influenced density of I. scapularis ticks. Our results suggest that blacklegged tick density and infection rate in Canada may be influenced by a variety of factors.

SUMMARYWidespread access to the internet is offering new possibilities for data collection in surveillance. We explore, in this study, the possibility of using an electronic tool to monitor occurrence of the tick vector of Lyme disease, Ixodes scapularis. The study aimed to compare the capacity for ticks to be identified in web-based submissions of digital images/photographs, to the traditional specimen-based identification method used by the provincial public health laboratory in Quebec, Canada. Forty-one veterinary clinics participated in the study by submitting digital images of ticks collected from pets via a website for image-based identification by an entomologist. The tick specimens were then sent to the provincial public health laboratory to be identified by the ‘gold standard’ method using a microscope. Of the images submitted online, 74·3% (284/382) were considered of high-enough quality to allow identification. The laboratory identified 382 tick specimens from seven different species, with I. scapularis representing 76% of the total submissions. Of the 284 ticks suitable for image-based species identification, 276 (97·2%) were correctly identified (Kappa statistic of 0·92, Z = 15·46, P < 0·001). This study demonstrates that image-based tick identification may be an accurate and useful method of detecting ticks for surveillance when images are of suitable quality.

Canadians face an emerging threat of Lyme disease due to the northward expansion of the tick vector,Ixodes scapularis. We evaluated the degree ofI.scapularispopulation establishment andBorrelia burgdorferioccurrence in the city of Ottawa, Ontario, Canada from 2017–2019 using active surveillance at 28 sites. We used a field indicator tool developed by Clow et al. to determine the risk ofI.scapularisestablishment for each tick cohort at each site using the results of drag sampling. Based on results obtained with the field indicator tool, we assigned each site an ecological classification describing the pattern of tick colonization over two successive cohorts (cohort 1 was comprised of ticks collected in fall 2017 and spring 2018, and cohort 2 was collected in fall 2018 and spring 2019). Total annual site-specificI.scapularisdensity ranged from 0 to 16.3 ticks per person-hour. Sites with the highest density were located within the Greenbelt zone, in the suburban/rural areas in the western portion of the city of Ottawa, and along the Ottawa River; the lowest densities occurred at sites in the suburban/urban core.B.burgdorferiinfection rates exhibited a similar spatial distribution pattern. Of the 23 sites for which data for two tick cohorts were available, 11 sites were classified as “high-stable”, 4 were classified as “emerging”, 2 were classified as “low-stable”, and 6 were classified as “non-zero”.B.burgdorferi-infected ticks were found at all high-stable sites, and at one emerging site. These findings suggest that high-stable sites pose a risk of Lyme disease exposure to the community as they have reproducing tick populations with consistent levels ofB.burgdorferiinfection. Continued surveillance forI.scapularis,B.burgdorferi, and range expansion of other tick species and emerging tick-borne pathogens is important to identify areas posing a high risk for human exposure to tick-borne pathogens in the face of ongoing climate change and urban expansion.

Lyme disease, the most commonly reported vector-borne disease in North America, is caused by the spirochete Borrelia burgdorferi sensu stricto, which is transmitted by Ixodes scapularis in eastern Canada and Ixodes pacificus in western Canada. Recently, the northward range expansion of I. scapularis ticks, in south-eastern Canada, has resulted in a dramatic increase in the incidence of human Lyme disease. Detecting emerging areas of Lyme disease risk allows public health to target disease prevention efforts. We analysed passive tick surveillance data from Ontario and Manitoba to i) assess the relationship between the total numbers of I. scapularis submissions in passive surveillance from humans, and the number of human Lyme disease cases, and ii) develop province-specific acarological indicators of risk that can be used to generate surveillance-based risk maps. We also assessed associations between numbers of nymphal I. scapularis tick submissions only and Lyme disease case incidence. Using General Estimating Equation regression, the relationship between I. scapularis submissions (total numbers and numbers of nymphs only) in each census sub-division (CSD) and the number of reported Lyme disease cases was positively correlated and highly significant in the two provinces (P ≤ 0.001). The numbers of I. scapularis submissions over five years discriminated CSDs with ≥ 3 Lyme disease cases from those with < 3 cases with high accuracy when using total numbers of tick submission (Receiver Operating Characteristics area under the curve [AUC] = 0.89) and moderate accuracy (AUC = 0.78) when using nymphal tick submissions only. In Ontario the optimal cut-off point was a total 12 tick submissions from a CSD over five years (Sensitivity = 0.82, Specificity = 0.84), while in Manitoba the cut-off point was five ticks (Sensitivity = 0.71, Specificity = 0.79) suggesting regional variability of the risk of acquiring Lyme disease from an I. scapularis bite. The performances of the acarological indicators developed in this study for Ontario and Manitoba support the ability of passive tick surveillance to provide an early signal of the existence Lyme disease risk areas in regions where ticks and the pathogens they transmit are expanding their range.

Objectives To summarize the first four years of national surveillance for Lyme disease in Canada from 2009 to 2012 and to conduct a preliminary comparison of presenting clinical manifestations in Canada and the United States. Methods The numbers and incidence of reported cases by province, month, year, age and sex were calculated. Logistic regression was used to examine trends over time. Acquisition locations were mapped and presenting clinical manifestations reported for jurisdictions where data was available. Variations by province, year, age and sex as well as presenting clinical symptoms were explored by logistic regression. An initial comparative analysis was made of presenting symptoms in Canada and the United States. Results The numbers of reported cases rose significantly from 144 in 2009 to 338 in 2012 (coefficient = 0.34, standard error = 0.07, P

Background Lyme disease (LD) is an infectious disease that is emerging in eastern and central Canada associated with the spread of the tick vector Ixodes scapularis. National surveillance shows that children are an at-risk age group. Objectives To study the epidemiology of LD in Canadian children using the Canadian Paediatric Surveillance Program (CPSP) to better understand exposure history, clinical manifestations, diagnosis and treatment of paediatric LD cases in Canada. Methods A structured questionnaire was completed by paediatricians for each LD case reported as part of the Canadian Paediatric Surveillance Program from 2014 to 2017. Results There were 95 cases that met inclusion criteria as confirmed or probable cases. The median age was 7 years; 38 % were 5–9 years and 35 % were 10−15 years of age. Most cases were acquired in known Canadian endemic locations; 5 were acquired during travel to the US. Most cases were reported from Nova Scotia and Ontario (46 % and 38 % respectively). The most common clinical presentation was arthritis (59 % of all cases), which is a manifestation of the late disseminated stage of LD. Late disseminated disease presented through the year, whereas early LD (Erythema migrans) and early disseminated LD presented during the summer and fall. Antibiotic choice and duration of therapy generally followed accepted guidelines. Conclusion This study of the clinical spectrum of LD in Canadian children underlines the need for preventive measures to protect children in Canada from emerging LD, and the need for health care provider awareness.

Lyme borreliosis is rapidly emerging in Canada, and climate change is likely a key driver of the northern spread of the disease in North America. We used field and modeling approaches to predict the risk of occurrence of Borrelia burgdorferi, the bacteria causing Lyme disease in North America. We combined climatic and landscape variables to model the current and future (2050) potential distribution of the black-legged tick and the white-footed mouse at the northeastern range limit of Lyme disease and estimated a risk index for B. burgdorferi from these distributions. The risk index was mostly constrained by the distribution of the white-footed mouse, driven by winter climatic conditions. The next factor contributing to the risk index was the distribution of the black-legged tick, estimated from the temperature. Landscape variables such as forest habitat and connectivity contributed little to the risk index. We predict a further northern expansion of B. burgdorferi of approximately 250–500 km by 2050 – a rate of 3.5–11 km per year – and identify areas of rapid rise in the risk of occurrence of B. burgdorferi. Our results will improve understanding of the spread of Lyme disease and inform management strategies at the most northern limit of its distribution.

Background: The risk of contracting Lyme disease (LD) can vary spatially because of spatial heterogeneity in risk factors such as social-behavior and exposure to ecological risk factors. Integrating these risk factors to inform decision-making should therefore increase the effectiveness of mitigation interventions. Objectives: The objective of this study was to develop an integrated social-behavioral and ecological risk-mapping approach to identify priority areas for LD interventions. Methods: The study was conducted in the Montérégie region of Southern Quebec, Canada, where LD is a newly endemic disease. Spatial variation in LD knowledge, risk perceptions, and behaviors in the population were measured using web survey data collected in 2012. These data were used as a proxy for the social-behavioral component of risk. Tick vector population densities were measured in the environment during field surveillance from 2007 to 2012 to provide an index of the ecological component of risk. Social-behavioral and ecological components of risk were combined with human population density to create integrated risk maps. Map predictions were validated by testing the association between high-risk areas and the current spatial distribution of human LD cases. Results: Social-behavioral and ecological components of LD risk had markedly different distributions within the study region, suggesting that both factors should be considered for locally adapted interventions. The occurrence of human LD cases in a municipality was positively associated with tick density (p

Lyme disease is emerging in Canada due to geographic range expansion of the tick vector Ixodes scapularis Say. Recent areas of emergence include parts of the southeastern Canadian Prairie region. We developed a map of potential risk areas for future I. scapularis establishment in the Canadian Prairie Provinces. Six I. scapularis risk algorithms were developed using different formulations of three indices for environmental suitability: temperature using annual cumulative degree-days 0 °C (DD 0 °C; obtained from Moderate Resolution Imaging Spectroradiometer satellite data as an index of conditions that allow I. scapularis to complete its life cycle), habitat as a combined geolayer of forest cover and agricultural land use, and rainfall. The relative performance of these risk algorithms was assessed using receiver-operating characteristic (ROC) area under the curve (AUC) analysis with data on presence-absence of I. scapularis obtained from recent field surveillance in the Prairie Provinces accumulated from a number of sources. The ROC AUC values for the risk algorithms were significantly different (P 0.01). The algorithm with six categories of DD 0 °C, habitat as a simple dichotomous variable of presence or absence of forest, and normalized rainfall had the highest AUC of 0.74, representing "fair to good" performance of the risk algorithm. This algorithm had good (80%) sensitivity in predicting positive I. scapularis surveillance sites, but low (50%) specificity as expected in this region where not all environmentally suitable habitats are expected to be occupied. Further prospective studies are needed to validate and perhaps improve the risk algorithm.

Lyme disease (LD) is emerging in Canada. A key preventive strategy is promoting the adoption by the general public of personal preventive behaviors regarding tick bites. The aim of this study was to measure the changes in public awareness toward ticks and LD before and after the launch of a national communication campaign in Canada using data from two surveys conducted in March and December 2014. The results show a significant increase in awareness of LD after compared to before the campaign, but also suggest that the importance of this increase is not equal amongst Canadian regions. Moreover, respondents whose level of awareness increased most significantly were those who lived in regions with low entomologic risk. The findings underline the importance of risk communications for emerging diseases and reinforce the need to understand the specific characteristics of the targeted populations before the implementation of communication campaigns to increase their efficacy.

Lyme disease (LD) risk is increasing in Canada. In 2014, the government of Canada launched a national communication campaign to raise awareness and promote the adoption of individual preventive behaviours toward ticks and LD. The objectives of this study were to evaluate and compare the adoption of LD preventive behaviours and the exposure to tick bites of Canadians in the five main targeted regions (British Columbia, Prairie provinces, Ontario, Quebec and the Atlantic provinces). A national survey was conducted in December 2014 (n=2876) to collect data on LD awareness, behaviours and risk factors. Overall, the proportion of respondents reporting tick exposure was high (20%). The results suggest that even though LD awareness was found to be high (with only 12% of the respondents reporting that they never heard about LD), less than half of the Canadians who heard about it have adopted specific preventive behaviours toward tick bites, such as regular tick checks (reported by 52%), protective clothing (50%), using tick repellent (41%) or shower or bath (41%) after visiting a wooded area in a LD risk area. Moreover, significant differences were found between regions, gender, age groups and dog ownership status, regarding preventive behaviours and factors of exposure. A high level of knowledge of Lyme disease, living in the Prairie region, as well as having found a tick on oneself or a relative, were found to be associated with the adoption of preventive behaviours. This study underlines the importance to take into account specific regional characteristics of risk and to maintain public health communication efforts through time in order to increase the adoption of preventive behaviours of Canadians.

Summary 1. Over the past two decades, Ixodes scapularis, the primary tick vector of the Lyme disease pathogen Borrelia burgdorferi in North America has expanded its range northward from the USA to colonize new regions in southern Canada. We have previously projected range increases for I. scapularis based on temperature suitability, but to what extent this is matched by actual tick range expansion is unknown. 2. Since 1990, I. scapularis ticks have been collected across Canada offering a unique opportunity to track the range expansion of an arthropod vector. We used these data to model time-to-establishment for tick populations across Canada to identify factors influencing the rate of spread. 3. Our results point to both long-distance dispersal of ticks by migratory birds and local dispersal by resident hosts as important potential mechanisms underlying patterns of tick range expansion. 4. Temperature (accumulated degree days > 0 � C) was the most important determinant of environmental suitability for tick population establishment, suggesting that climate warming may facilitate range expansion. 5. Model projections suggest that I. scapularis range will expand c. 46 km year )1 in the coming decade, with climate warming expected to increase the rate of spread. This expansion is likely to result in a substantial increase in human Lyme disease risk, with the proportion of the human population of eastern Canada inhabiting areas with established tick populations increasing from 18% in 2010 to over 80% by 2020. 6. This first empirical model of I. scapularis invasion supports theoretical range projections based on climate suitability and provides a unique data-driven estimate of the speed of northward range expansion for I. scapularis at the continental scale. 7. Synthesis and applications .B y trackingI. scapularis invasion in Canada over the past two decades, we show that I. scapularis is rapidly expanding its range and is likely to colonize the most densely populated areas of southern Canada in the coming decade. These projections suggest that prompt action is necessary to prepare the Canadian public for a likely epidemic of Lyme disease, with emphasis on focusing surveillance activities to confirm the locations of emerging Lyme disease risk.

Lyme disease (LD) is emerging in Canada because of the northward expansion of the geographic range of the tick vector Ixodes scapularis (Say). Early detection of emerging areas of LD risk is critical to public health responses, but the methods to do so on a local scale are lacking. Passive tick surveillance has operated in Canada since 1990 but this method lacks specificity for identifying areas where tick populations are established because of dispersion of ticks from established LD risk areas by migratory birds. Using data from 70 field sites in Quebec visited previously, we developed a logistic regression model for estimating the risk of I. scapularis population establishment based on the number of ticks submitted in passive surveillance and a model-derived environmental suitability index. Sensitivity-specificity plots were used to select an optimal threshold value of the linear predictor from the model as the signal for tick population establishment. This value was used to produce an "Alert Map" identifying areas where the passive surveillance data suggested ticks were establishing in Quebec. Alert Map predictions were validated by field surveillance at 76 sites: the prevalence of established I. scapularis populations was significantly greater in areas predicted as high-risk by the Alert map (29 out of 48) than in areas predicted as moderate-risk (4 out of 30) (P < 0.001). This study suggests that Alert Maps created using this approach can provide a usefully rapid and accurate tool for early identification of emerging areas of LD risk at a geographic scale appropriate for local disease control and prevention activities.

This study summarize the first 4 years (2009-2012) of national surveillance for Lyme Disease (LD) in Canada. LD surveillance data for 2009-2012 are analyzed to describe the early patterns (age, seasonality and presenting manifestations) of LD emergence in Canada and to compare against those reported in the US. The study shows that: i) LD incidence is increasing in central and eastern Canada due to northwards expansion of the tick vector Ixodes scapularis ; and ii) there is a lower proportion of cases presenting with early LD in Canada compared with the US suggesting lower awareness of early LD in Canada.

Background: Lyme disease is the most commonly reported vector-borne disease in the temperate world. It is emerging in central and eastern Canada due to spread of the tick vector Ixodes scapularis into and within Canada to form new areas of environmental risk known as Lyme disease-endemic areas. Identifying the geographic location of Lyme disease-endemic areas is important to identify the population at risk, target interventions, and inform the clinical diagnosis of Lyme disease patients. Objective: To provide an up-to-date picture of current and emerging areas of Lyme disease risk in eastern and central Canada by summarizing recent information on Lyme disease-endemic areas, and surveillance for I. scapularis ticks. Methods: Data on locations where I. scapularis have been found in field surveillance studies by a range of federal and provincial organizations were collated and mapped to obtain a fuller picture of the occurrence of I. scapularis in Canada. The geographic locations of ticks submitted in passive tick surveillance were mapped for comparison. Results: The number of confirmed Lyme disease-endemic areas in southern Manitoba, southern and eastern Ontario, southern Quebec, southern New Brunswick and in some locations in Nova Scotia increased from 10 in 2009 to 22 confirmed endemic areas in 2012. The collated field surveillance data indicated that I. scapularis tick populations and Lyme disease risk are more geographically widespread than known Lyme disease-endemic areas and that the pattern of emergence of tick populations varies among provinces. There was a tenfold increase in the numbers of I. scapularis reported for passive surveillance from 2 059 submissions from 1990 to 2003 to 25 738 submissions from 2004 to 2012. Conclusions: The increasing numbers of Lyme disease-endemic areas, the much wider distribution of tick populations identified by field surveillance, as well as the marked increase in numbers of ticks identified through passive surveillance suggest that the geographic scope of environmental risk of acquiring Lyme disease is expanding in central and eastern Canada, although here it still remains mostly limited to the southern parts of five provinces.

Background Lyme disease is emerging in eastern and central Canada due to the spread of the tick vector Ixodes scapularis. Currently, the test to establish Lyme disease-endemic areas requires multiple site visits and multiple sampling methods, and is consequently complex, time-consuming, and resource-expensive. Objective To assess the capacity of drag sampling alone as a screening technique to identify areas of Lyme disease risk. Method We conducted a retrospective analysis of field surveillance data obtained at 100 site visits in 2007 and 2008 in southern Quebec. Outcome Drag sampling used alone had 50% sensitivity but 86% specificity to identify early-established I. scapularis populations. Ticks were found throughout the period May to October. Conclusion One site visit of drag sampling of three person-hours between May and October may be sufficient to identify a Lyme disease risk location. This information can be used by public health professionals to develop public health responses and by medical practitioners to assist in the clinical diagnosis of Lyme disease.

1Department of Paediatrics, Western University, London; 2Centre for Food Environmental and Zoonotic Infectious Diseases, Public Health Agency of Canada, Ottawa, Ontario; 3National Microbiology Laboratory, National Public Health Laboratories, Public Health Agency of Canada, Winnipeg, Manitoba; 4Departments of Paediatrics and Community Health and Epidemiology, Dalhousie University and IWK Health Centre, Halifax, Nova Scotia; 5Centre for Food Environmental and Zoonotic Infectious Diseases; 6Laboratory for Foodborne Zoonoses, National Public Health Laboratories, Public Health Agency of Canada, Saint-Hyacinthe, Quebec Correspondence: Canadian Paediatric Surveillance Program, 2305 St Laurent Boulevard, Ottawa, Ontario K1G 4J8. Telephone 613-526-9397 ext 239, fax 613-526-3332, e-mail cpsp@cps.ca, website www.cpsp.cps.ca Accepted for publication April 8, 2015 A six-year-old boy presented to a walk-in clinic with a four-day history of an isolated, painless, nonpruritic, red rash with gradually expanding borders on his right arm. There was no history of fever, headache, myalgia, joint symptoms, palpitations, fainting or facial weakness. His family had returned two days previously from a three-week camping trip in the Point Pelee area of southern Ontario. During the trip, the patient had worn shorts and T-shirts most of the time, and rarely applied insect repellents. His examination was normal except the exanthem on his arm, which had a ‘bull’s eye’ appearance and measured 5 cm in diameter (Figure 1). He received a three-week course of amoxicillin and the rash was noted to gradually disappear over the period of therapy. Serological laboratory testing for Lyme disease was negative. He improved during follow-up, with resolution of the rash and no occurrence of neurological or musculoskeletal symptoms.