Results
During 2012–2021, 251 cases were identified in 11 states. A median of 24 cases were reported from these states per year (range = 15 [2020] to 41 [2014]). No significant change in the number of cases was observed during this period (p = 0.21). The median age of infected persons was 39 years (range = 2–92 years); 60% were male (Table 1). No infected persons were reported to be pregnant. Race and ethnicity data were available for 190 (76%) persons; among these, 93% were non-Hispanic White persons.
Reported case counts varied by state, with four states accounting for >75% of all cases (California [33%], Washington [18%], Colorado [14%], and Oregon [12%]). Other states with reported cases included Arizona (9%), Texas (5%), Idaho (4%), Utah (3%), Montana (1%), Nevada (1%), and New Mexico (<1%). Among the 12 states with mandated reporting, no cases were reported in Wyoming. Among 232 (92%) cases with available data on state of residence and exposure, 33 (14%) occurred in out-of-state visitors; among the 210 (84%) cases for which county of the patient’s exposure was available (Figure), 118 (56%) occurred in out-of-county visitors. Epidemiologic links to other cases were documented in 21% of cases; the largest outbreak (11 cases) occurred in Arizona in 2014 (7). Four (2%) cases were attributed to exposures occurring during international travel to Argentina, Canada, Jordan, and Tanzania.
Among 11 reported STRF cases with patient exposures in counties of lower elevations in central Texas, where infections are more likely to be caused by B. turicatae, cave exposures were documented in four. Among 217 cases with patient exposures in other western U.S. states, where infections are more likely to be caused by B. hermsii, a summer peak was observed, with 154 (71%) cases occurring during June–September. Notable exposures documented among 177 patients in these western states included visits to cabins (131, 74%) and camping (15, 8%).
Some clinical data were provided for 207 (82%) patients with reported STRF (Table 2). Fever was documented in 97% of cases; a median of two distinct febrile episodes (range = 1–9)** was reported among febrile patients. Other commonly reported signs and symptoms included headache (63%), myalgias (59%), chills (54%), and nausea or vomiting (45%). Among 211 patients for whom hospitalization data were available, 115 (55%) were hospitalized, including 44% of 36 children aged ≤12 years and 67% of 30 adults aged ≥65 years (Table 1). No deaths were reported.
Laboratory test data were available for 221 (88%) patients; among these, spirochetes were identified by microscopy of peripheral blood smear in 130 (59%). In addition, relapsing fever Borrelia antibodies were detected by serologic testing in 91 (41%) patients, and relapsing fever Borrelia DNA was detected by polymerase chain reaction (PCR) testing in 33 (15%).†† Relapsing fever spirochetes were cultured in four (2%) cases.
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Soft Tick Relapsing Fever — United States, 2012–2021 | MMWR - CDC
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