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\begin{document}

\title{Equine veterinarian knowledge and perceptions of ticks and tick-borne
diseases in the United States}



\author[1]{Erika Machtinger}%
\author[1]{Danielle Smarsh}%
\author[1]{Laura Kenny}%
\author[1]{Karen Poh}%
\author[1]{Erin Orr-Gissinger}%
\author[1]{Brittani Kirkland}%
\author[1]{Haley Springer}%
\affil[1]{The Pennsylvania State University }%


\vspace{-1em}



  
  \date{June 07, 2024}


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\selectlanguage{english}
\begin{abstract}
Ticks pose a significant threat to horses, as they can cause harm and
transmit diseases. This study aimed to assess the experiences,
knowledge, and practices of equine veterinarians regarding ticks and
tick-borne diseases (TBDs) in the United States. A survey was conducted,
covering topics such as tick biology, identification, prevention, and
veterinary education. The results revealed variations in veterinarians'
knowledge on ticks and TBDs, highlighting the need for improved tick
control options, enhanced education, and comprehensive resources for
tick and TBD prevention. The study emphasizes the importance of accurate
tick identification for effective diagnosis and treatment of TBDs in
horses. The limitations of the study include potential response bias and
a limited sample size. To address these issues, collaborations between
academia, industry, and the human medicine community are recommended to
strengthen veterinarian training and education on ticks and TBDs. This
research provides valuable insights for developing continuing education
programs that focus on tick-borne illness prevention in horses.%
\end{abstract}%



\sloppy


\textbf{Equine veterinarian knowledge and perceptions of ticks and
tick-borne diseases in the United States}

Erika T. Machtinger\textsuperscript{1}, Danielle N.
Smarsh\textsuperscript{2}, Laura B. Kenny\textsuperscript{4}, Karen C.
Poh\textsuperscript{1,5} Erin L. Orr-Gissinger \textsuperscript{2},
Brittani G. Kirkland\textsuperscript{4}, Hayley R.
Springer\textsuperscript{6}

\emph{\textsuperscript{1}Department of Entomology, The Pennsylvania
State University, 4 Chemical Ecology Laboratory, University Park, PA
16802 etm10@psu.edu}

\emph{\textsuperscript{2} Department of Animal Science, The Pennsylvania
State University, 160 Curtin Rd, University Park, PA 16802
dxs1172@psu.edu}

\emph{\textsuperscript{4}Penn State Extension, The Pennsylvania State
University, 1015 College Rd Suite H, Collegeville, PA 19426
lbk8@psu.edu}

\emph{\textsuperscript{5}Department of Entomology, The Pennsylvania
State University, 4 Chemical Ecology Laboratory, University Park, PA
16802.} Current address: \emph{Animal Disease Research Unit, USDA-ARS,
Pullman, WA 99164 karen.poh@usda.gov}

\textsuperscript{6} Department of Veterinary and Biomedical Sciences,
The Pennsylvania State University, 114 Central Milk Testing Laboratory,
University Park, PA 16802 hrs131@psu.edu

\textbf{Keywords:} Ticks, tick-borne disease, equine health, equine
TBDs, veterinary education

\textbf{Summary}

Background. Ticks can harm horses and transmit diseases, making them a
growing concern for owners and veterinarians. Veterinarians play a
crucial role in providing advice on tick prevention and control. Yet, no
research has examined their perspectives on equine ticks and tick-borne
disease (TBD).

Objectives. The objective was to assess the experiences, knowledge, and
practices of equine veterinarians related to fundamental aspects of tick
biology and identification, tick bite prevention, and TBD in the United
States.

Study Design . This project surveyed equine veterinarians in the United
States (U.S.) about their knowledge of ticks and TBD affecting horses
using nonprobability convenience sampling. The survey questions were
grouped into six categories: respondent demographics, knowledge of ticks
and TBDs, tick control option availability, tick and TBD frequency on
horses, and veterinary education and information availability.

Methods. Data were analyzed using descriptive statistics, chi-square
analysis, and t-tests. The sample was divided into Northeast and U.S.
veterinarians, and a significance level of P\textless{}0.05 was set. The
study aimed to inform continuing education development for veterinarians
by assessing their knowledge, practices, and perceptions of ticks and
TBDs.

Results. The results indicate that while equine veterinarians are aware
of the importance of TBDs in equine health, knowledge on ticks and TBDs
vary significantly.

Main Limitations. Limitations for the current study include potential
response bias and a limited sample from many states.

Conclusions. There is a need for increased tick control and prevention
options, as well as more animal-specific resources for tick and TBD
prevention. Veterinarians and horse owners require greater education and
comprehensive information to prevent tick-borne illnesses in horses.
Collaborations between academia, industry, and the human medicine
community are suggested to build capacity for training veterinarians.

\textbf{Clinical Relevance}

\begin{itemize}
\tightlist
\item
  Equine veterinarians had limited knowledge on ticks and TBDs, with
  less than half of them correctly identifying tick species and their
  associated diseases.
\item
  The lack of knowledge and confidence in identifying tick species may
  impact equine health as accurate identification is crucial for
  diagnosing and treating TBDs.
\item
  Inadequate training of veterinarians on ticks poses a challenge in
  educating horse owners about tick-borne pathogens.
\end{itemize}

\textbf{Introduction}

Human and animal tick encounters are increasing across the United States
(Eisen and Eisen 2018, Divers et al. 2018), driven by the encroachment
of endemic tick species into new regions and the introduction of
non-native tick species (Sonenshine 2018). Ticks are common
ectoparasites of horses (Duell et al. 2013, Sundstrom et al. 2021). Tick
bites can cause systemic reactions, irritation, and dermal trauma to
horses (Chang et al. 2000). Some species of Ixodid hard ticks can
transmit pathogens to horses that cause diseases such as Lyme
borreliosis, anaplasmosis, and equine piroplasmosis (Chang et al. 2000,
Butler et al. 2005, Pusterla and Madigan 2013, Onyiche et al. 2019).
These diseases, and other tick-associated conditions like gotch ear and
tick paralysis, are of rising concern to horse owners and equine
veterinarians in many areas of the United States (Butler et al. 2005,
Divers et al. 2018).

Horse industry surveys have shown that veterinarians are an important
source of information on equine health and care (Hockenhull et al. 2013,
Lofgren et al. 2016, Hartmann et al. 2017, Carroll et al., 2018).
Veterinarians were the third most important source of welfare
information for horse owners in Pennsylvania (author ETM, unpublished
data). Because equine practitioners are regularly consulted on health
topics, veterinarians are likely an important pathway to deliver
information on tick bite prevention and tick-borne diseases (TBDs) to
horse owners and caretakers and must be prepared to discuss optimal
strategies for tick prevention and control for their animals.

Equine veterinarians should know about ticks and TBDs to serve their
clientele best. However, there has been no research on veterinarian
perspectives focused on ticks and TBDs that affect horses. This survey
aimed to assess the experiences, knowledge, and practices of equine
veterinarians related to fundamental aspects of tick biology and
identification, tick bite prevention, and tick-borne disease in the
United States. This survey's results can inform continuing education
development for veterinarians and augment horse owner and caretaker
knowledge.

\textbf{Materials and Methods}

\emph{Survey Design}

This project was part of a more extensive survey designed to question
two general cohorts -- equine veterinarians and equine
caretakers/owners. Nonprobability convenience sampling was used to
access information from as many producers as possible.~ A survey
questionnaire was created using Qualtrics (Provo, UT), and the questions
were reviewed and approved by the Pennsylvania State University
Institutional Review Board (IRB, STUDY00016457). The survey was then
pilot tested on a sample audience to check for continuity of questions
and any potential errors. The survey was distributed via email (Penn
State Extension equine list) and social media (Facebook) to
veterinarians across the United States and was accessible from
April-July 2021. Several online equine and agriculture publications also
promoted the survey.

The survey questions aimed at veterinarians were grouped into six
categories: respondent demographics, knowledge of ticks and TBDs,
availability of tick control options, frequency of ticks and TBDs on
horses, and availability of veterinary education and information on
equine ticks and TBDs. The target population for this study included
anyone at least 18 years of age who was a veterinarian that evaluated
horses in their practice.

\emph{Data Analysis}

Because not all respondents completed every question, the N for each
question is presented with the data. For demographic data of
veterinarians, the data are presented as frequencies. Likert scale
question scores were either reported as the average \selectlanguage{ngerman}± SD or the median
(IQR) if the data were normally or not normally distributed,
respectively. For concepts such as the overall concern and perceived
risk of ticks, the average score across more than one question was
calculated. For example, the overall concern with ticks was averaged
from the rating of the veterinarian's concern for Lyme disease,
anaplasmosis, piroplasmosis, tick paralysis, and skin conditions in
patients. For the knowledge section of the survey, a point was given for
each correct answer. The knowledge score was then calculated by summing
up the number of correct answers (with a highest possible score of 10).
Chi-square analysis was conducted to determine differences in the
frequency of various yes/no questions regarding tick control and
frequency of tick presence in veterinarian practices.

Due to the sample size, respondents were grouped into Northeast
veterinarians versus veterinarians from all other US regions. For some
questions, respondents were divided by the region of the United States
from which they were based. Regions were previously defined by the
``Tick Bite Data Tracker'' from the Centers for Disease Control and
Prevention (CDC), National Center for Emerging and Zoonotic Infectious
Diseases, Division of Vector-Borne Diseases: Northeast, Southeast,
Midwest, South Central, and West (Figure 1). T-tests and Mann-Whitney U
tests were conducted to compare the average score for questions between
Northeast and US respondents when the data were normally and not
normally distributed, respectively. A paired t-test was conducted to
determine the difference in the available frequency of education and the
desired frequency of education. The significance level was set to
P\textless{}0.05.

\textbf{Results}

\emph{Demographics}

A total of 76 equine veterinarians from across the United States began
the survey (Figure 2). A majority (52.6\%; 39/74) of respondents
graduated from veterinary school from 2006-2020. The highest percentage
of veterinarians taking the survey were from the Northeast (40.8\%;
31/76), followed by the West (26.3\%; 20/76). The number of horses cared
for in an average year was reported as follows: 20.0\% (15/75) of
veterinarians cared for 1-100 horses; 29.3\% (22/75) cared for 101-200
horses; 13.3\% (10/75) cared for 201-300 horses; 8.0\% (6/75) cared for
301-400 horses; and 29.3\% (22/75 for more than 400 horses (Figure 3).

\emph{Knowledge of Ticks and TBDs}

Only 38.7\% (24/62) of veterinarians responded correctly that nymphs and
adults were the most likely life stages of blacklegged (\emph{Ixodes
scapularis} )\emph{,} lone star (\emph{Amblyomma americanum} ), and
American dog ticks (\emph{Dermacentor variabilis} ) to be found on
horses compared to the other possible answers. Over 20\% (13/62) of
respondents thought only adult ticks were the most likely life stage and
6.5\% (4/62) thought only nymphs. Over 11 and 17\% (7/62 and 11/62,
respectively) of veterinarians thought larvae or larvae and adults were
the most common, respectively (Figure 4).

Veterinarians are the point of contact to diagnose and treat diseases
and conditions exhibited by horses, including tick-associated
conditions. However, while 75.0\% (45/60) of veterinarians could
identify a blacklegged tick adult correctly, only 51.8\% (29/56) of
veterinarians correctly identified that blacklegged ticks were
associated with Lyme disease (Table 1). Gulf coast ticks
(\emph{Amblyomma maculatum} ) and American dog ticks were correctly
identified by 56.9\% (33/58) and 53.3\% (32/60) of respondents,
respectively. However, only 11.3\% (7/54) and 29.0\% (18/57) of
respondents correctly associated these two species with tick paralysis,
respectively. Over 32\% (20/55) of respondents incorrectly thought that
lone star ticks were also associated with tick paralysis in horses. On
the other hand, a similar percentage of respondents correctly associated
Gulf Coast ticks (33.9\%, 19/54) and American dog ticks (26.8\%, 15/57)
with piroplasmosis. However, veterinarians were more likely to associate
Gulf Coast ticks with no diseases or conditions (47.9\%, 23/54) over the
other species. Lone star ticks were correctly identified by 64.5\%
(40/62) of respondents. Interestingly, only 12.7\% (7/55) of all
veterinarians were very confident that they could correctly identify a
tick to species and 45.5\% (25/55) were not confident at all. More
respondents were confident in correctly correlating ticks with
region-specific tick-associated conditions (26.3\%; 15/57), but most
were only somewhat confident (36.8\%, 21/57) or not confident at all
(36.8\%; 21/57).

\emph{Availability of Tick Control Options}

Overall, 58.6\% of veterinarians responding felt insufficient tick
control options were available. Fewer veterinarians in the Northeast
felt that there were enough control measures compared to the other
combined regions (9.5\% vs. 32.4\%, respectively; P=0.03). Most
veterinarians (79.7\%; 47/59) across all regions have recommended tick
control to clients, but fewer veterinarians (61.4\%; 35/57) were
interested in a new passive method of tick control. Respondents
considered tick research important (mean = 4.33 out of 5, with 1 being
not important and 5 being very important). These opinions on new methods
and tick research did not differ between the Northeast and the other
combined regions.

When veterinarians were asked to respond to topics that they wished they
knew more about ticks and tick control for horses, the most common
responses were related to preventing bites. Choosing the best repellents
or products for tick bite prevention was the most common response
(73.3\% of responses, 44/60), followed by tick prevention on the farm
and (61.7\% of responses, 37/60), and products or options available for
tick prevention on the farm (61.7\% of responses, 37/60) (Figure 5).
Only 25.0\% of respondents (15/60) wished to know more about finding
ticks/conducting tick checks.

\emph{Veterinary Education and Information on Equine Ticks and TBDs}

While 73.7\% (42/57) of veterinarians responded that clients have asked
them for information regarding ticks, only 28.6\% (16/56) said they had
any coursework on ticks in vet school (Table 2). Furthermore, 68.4\%
(39/57) of veterinarians were concerned about ticks on horses in their
care, but 59.3\% (35/59) of veterinarians did not feel that enough
information was provided to vets on TBDs and tick bite prevention (and
an additional 15.3\% (9/59) of respondents did not know if enough
information was provided). Similarly, over 53\% (31/58) of responding
veterinarians thought there was not enough information available for
horse owners and caretakers on tick bite prevention and TBDs in horses.
These responses were not different by U.S. region.

When asked about the frequency of education that veterinarians receive
on TBDs for horses, the average from all respondents was between every
year and every 2-3 years, with 34\% (20/59) of veterinarians receiving
continuing education yearly, 42\% (25/59) receiving continuing education
every 2-3 years, and almost 24\% (14/59) receiving continuing education
infrequently (more than every 3 years) or never receiving continuing
education on this topic. Regionally, the education frequency was higher
in other regions of the United States compared to the Northeast
(P=0.025). In contrast, over 52\% (31/59) of veterinarians indicated
that they would prefer to receive yearly education. The desired
education frequency did not differ between the Northeast and the other
regions of the United States. There was a significant difference between
the current frequency at which continuing education is offered and the
desired frequency of education, with more veterinarians preferring a
higher frequency of education (P=0.009)\emph{.}

When searching for information regarding ticks, tick prevention, and
tick control, over 39\% (30/76) of all respondents received information
from veterinary organizations and groups, followed by information from
continuing education offerings (29.0\%, 22/76; Table 3). There were
similar responses when veterinarians were asked about references for
TBDs, specifically. Veterinarians most often found information on TBDs
from veterinary organizations or groups (30.3\%, 23/76). Alternatively,
27.6\% (21/76) of veterinarians referred to colleagues and the same
percentage received information about TBDs from continuing education
offerings. University Extension-led education on ticks, tick prevention,
and tick control and TBDs were used by 19.7\% and 18.4\% of
veterinarians, respectively.

\emph{Frequency of Ticks and TBDs of Horses}

Veterinarians were asked to rank concern regarding specific TBD
conditions on a Likert scale, with 1 being the most concerning and 6
being the least concerning. Veterinarians were primarily concerned with
Lyme disease and anaplasmosis (mean = 2.0 for each, respectively). There
were no differences among regions for either tick-borne disease. There
was less concern for piroplasmosis (mean = 4.0) and tick-associated skin
conditions (mean = 3.0). There was a trend towards a higher concern of
piroplasmosis in the northeastern states, but it was not statistically
significant. There was less concern for tick-borne skin conditions in
the Northeast than in other regions of the United States (P=0.016).
Overall, most equine veterinarians removed three or more ticks from
horses per year (81.7\%, 49/60; Table 4) and only 5\% (3/60) of
veterinarians never removed a tick, although the ``0 tick'' response was
exclusively from the Midwest region. Nearly 70\% (15/22) of
veterinarians removed six or more ticks in the Northeast region. This
was significantly more than the combined responses of the remaining
regions (Mann-Whitney U; P=0.030), where most veterinarians reported
removing less than five ticks per year. However, the frequency of body
checks for ticks did not differ between the Northeast and the combined
responses from the remaining regions. Seventy-five percent (42/56) of
responding veterinarians removed ticks from horses, and 51.8\% (29/56)
of veterinarians responded that clients had brought in ticks that had
been removed from a horse. Interestingly, neither response differed
among U.S. regions.

Equine veterinarians were asked to click on locations on an image
representing an equine body that best represented where ticks were most
frequently removed (Figure 6). Responses from the Northeast and Midwest
were grouped and responses from the Southeast and South-Central were
grouped; this was done to combine regions where tick species presence
and abundance would be similar. Veterinarians in the Northeast and
Midwest most frequently removed ticks from under the jaw, the hind legs,
and by the elbow/between the front legs (Figure 6A). In the Southeast
and South-Central regions (Figure 6B), ticks were commonly collected
from the ears, between and on the front legs, on the flank, between the
hind legs, and on the horse's sides. In the West region, veterinarians
removed ticks scattered on the ears, crest, under the jaw, limbs, flank,
belly, and between the back legs (Figure 6C).

The frequency of diagnosis of any TBD (anaplasmosis and Lyme disease) in
horses was higher in the Northeast than in other regions of the country
(P=0.001). However, there were no differences in the confidence of
veterinarians to accurately diagnose TBDs based on disease signs, tick
identification, and knowing which tick transmits diseases in the
Northeast versus other regions of the United States. Over 28\% (16/57)
of veterinarians responded that they had diagnosed a horse with
tick-borne paralysis, and over 25\% (15/59) for piroplasmosis.
Cumulatively, most veterinarians have found a tick on a horse being
treated for a tick-borne disease (75\%; 42/56). Finding a tick was more
frequent in the Northeast (90.5\% of respondents) compared to other
regions (65.7\% of respondents) (P=0.038). Fewer veterinarians reported
clients removed ticks and brought them to the provider (51.8\%; 29/56)
and this did not differ among regions. However, most veterinarians
across all regions (73.7\%; 42/57) responded that clients ask them for
tick information, and even more veterinarians recommend tick control
(79.7\%; 47/59). Overall, veterinarians reported that clients were
willing to spend an average of \$141.53 a year on tick control for their
horses, and this did not differ among regions.

\textbf{Discussion}

Horses are susceptible to multiple TBDs transmitted by Ixodid hard ticks
in the U.S. As the distribution of ticks of medical and veterinary
concern shifts, it will become increasingly important for veterinarians
to have a working knowledge of ticks and TBDs of their region. This
survey aimed to assess equine veterinarians' current knowledge and
perceptions regarding ticks and TBDs. The results indicate that while
equine veterinarians are aware of the importance of TBDs in equine
health, knowledge of ticks and TBDs vary significantly as was found with
small mammal veterinarians (Crist et al. 2022).

Notably, while 75\% of veterinarians could identify a blacklegged tick
adult, only half of them correctly identified that blacklegged ticks
were associated with Lyme disease. Less than half of respondents
correctly associated Gulf Coast ticks and American dog ticks with tick
paralysis. Additionally, most veterinarians were not confident in
correctly identifying a tick. This is not surprising considering nearly
three-quarters of respondents stated they did not have a course related
to ticks in veterinary school. Awareness and concern for parasites but
lack of knowledge about the system has been found previously
with\emph{Onchocerca cervicalis} and equine veterinarians in the UK
(Mansell and Behnke 2022). This lack of veterinarian confidence in
identifying tick species may impact equine health as accurate
identification is crucial for diagnosing and treating TBDs.

There is a perceived need for an increase in the number of tick control
options and on-animal tick bite prevention options. While most
veterinarians have recommended tick bite prevention measures to clients,
over 58\% of veterinarians felt that there were not enough tick control
options available. Most respondents wished to know more about tick bite
prevention, products and options for tick prevention, and the best
repellents for tick bite prevention. It was not surprising that the
desire for more control options was higher from respondents from the
northeastern states. Unfortunately, recent studies have demonstrated
that permethrin, a commonly used active ingredient in arthropod
repellent sprays for horses, is ineffective at preventing tick activity
on horses at percentages tolerated by horses (Poh et al. 2023).
Veterinarians also reported that, on average, clients were willing to
spend just over \$140 for tick control. This is similar to the
\textasciitilde{}\$157.00 homeowners reported being willing to spend
(Gould et al. 2008; adjusted to 2023 dollars). There is a need to
develop effective, user-friendly, and economical tick control options,
validate methods and tools currently available for use on or with
horses, and provide information on these tools to veterinary
professionals.

The availability of animal-specific resources regarding ticks and TBDs
is limited, resulting in a greater emphasis for veterinarians to treat
horses rather than prevent tick bites. Despite the concern of more than
two-thirds of veterinarians surveyed about ticks on horses under their
care, a significant majority of over 59\% felt inadequate information
was available to them on TBDs and tick bite prevention. Similarly,
almost the same percentage of respondents believed that horse owners and
caretakers also lacked sufficient information on these topics. These
findings emphasize the need for greater education and training for
veterinarians on ticks and TBDs and accessible and comprehensive
information for horse owners and caretakers to prevent tick-borne
illnesses in horses.

The inadequate training of veterinarians on ticks, particularly in the
northeastern United States, poses a challenge in educating horse owners
about tick-borne pathogens. Ticks are a significant concern for clients
seeking veterinary care for their animals, but a considerable number of
veterinarians reported that they did not receive adequate training on
this topic during their veterinary education. This issue is particularly
concerning in the northeastern United States, where the burden of TBDs
affecting horses is high (USDA 2017, Thompson et al. 2022).
Surprisingly, most veterinarians did not receive training on ticks in
veterinary school. A previous study on \emph{B. burgdorferi} in horses
in Germany suggested that horse owners should be educated by
veterinarians, but this can only happen if veterinarians themselves are
adequately trained (Gall and Pfister 2006).

The importance of providing veterinary professionals with comprehensive
knowledge on ticks and TBDs for effective prevention and treatment calls
for various initiatives, including continuing education and partnerships
within a One Health framework. To effectively prevent and treat TBDs, it
is crucial to enhance the knowledge of veterinary professionals on ticks
and TBDs. One way to achieve this goal is by providing continuing
education to veterinarians. However, there is a need for more
comprehensive approaches to enhance the knowledge and resources of
veterinary professionals in TBDs. A recent study by Crist et al. (2022)
suggested building capacity for training veterinarians through
collaborations between academia, industry, and the human medicine
community. Such partnerships would enable the sharing of knowledge,
resources, and expertise that could strengthen the understanding and
treatment of TBDs in the veterinary community. For example, human
medicine practitioners can share information on the latest diagnostic
tools and treatment approaches, while industry players can contribute
funding and expertise in product development.

While the current study has limitations, including potential response
bias and a limited sample from many states, the results of this survey
highlight the importance of continued education and training for equine
veterinarians on ticks and TBDs, as well as the development of effective
and user-friendly tick control options. It also underscores the need for
accessible and comprehensive information on tick bite prevention and
TBDs for veterinarians, horse owners, and caretakers. Further research
should be conducted to assess the impact of increased education and
training on the knowledge and practices of equine veterinarians, as well
as the development of new tick control options and their effectiveness.
Future research should expand to better compare regional differences.
Given the burden of ticks and TBDs on the equine community, it is
especially vital for veterinarians to be prepared and knowledgeable on
these topics. However, our results demonstrate that both initial and
continued education and training for veterinarians on ticks, TBDs, and
tick control options are required to adequately address, prevent, and
treat TBDs that affect horses.

\textbf{Acknowledgements:} The authors would like to thank Penn State
Extension and the veterinarians who responded to this survey. We would
also like to thank Matthew Spindler for his insight into the survey and
survey results. This work was supported by the USDA National Institute
of Food and Agriculture and Hatch Appropriations under Project PEN04608
and Accession number 1010032.

Mention of trade names or commercial products in this publication is
solely for the purpose of providing specific information and does not
imply recommendation or endorsement by the USDA. The USDA is an equal
opportunity provider and employer.

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\textbf{Table 1.} Equine veterinarian responses to the
question\textbf{``} Match the tick species with the disease/condition
associated with that tick'' given as a percent of total respondents and
n responding in parentheses. Correct answers are in bold.\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\textbf{Disease or condition} & \textbf{Tick Species (N)} & \textbf{Tick
Species (N)} & \textbf{Tick Species (N)} & \textbf{Tick Species
(N)}\tabularnewline
\midrule
\endhead
& \textbf{Blacklegged tick (N=56)} & \textbf{Gulf coast tick (N=54)} &
\textbf{Lone star tick (N=55)} & \textbf{American dog tick
(N=57)}\tabularnewline
No disease(s) or condition(s) & 12.5\% (6) & \textbf{47.9\% (23)} &
\textbf{14.6\% (7)} & 25.0\% (12)\tabularnewline
Tick paralysis & 27.4\% (17) & 11.3\% (7) & 32.3\% (20) & \textbf{29.0\%
(18)}\tabularnewline
Lyme disease & \textbf{51.8\% (29)} & 8.9\% (5) & 17.9\% (10) & 21.4\%
(12)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2.} Questions related to tick bite prevention and
tick-borne disease concerns and education provided to equine
veterinarians during a survey on ticks and tick-borne diseases.\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\textbf{Question} & \textbf{Total Number of Respondents} &
\textbf{Veterinarian response \% (N)} & \textbf{Veterinarian response \%
(N)} & \textbf{Veterinarian response \% (N)}\tabularnewline
\midrule
\endhead
& & \textbf{Yes} & \textbf{No} & \textbf{I don't know}\tabularnewline
Do you think there is enough information on tick and tick bite
prevention for horses available to veterinarians? & 59 & 25.4 (15) &
59.3 (35) & 15.3 (9)\tabularnewline
Did you have coursework during veterinary school related to ticks and
tick-borne diseases? & 56 & 28.6 (16) & 64.3 (36) & 7.1
(4)\tabularnewline
Do you think there is enough information on ticks and tick-borne
diseases in horses provided to horse owners or caretakers? & 58 & 26.0
(15) & 53.4 (31) & 20.6 (12)\tabularnewline
Is tick info easy to understand in lay terms? & 59 & 23.7 (14) & 62.7
(37) & 13.6 (8)\tabularnewline
How concerned are you about horse(s) that you own, ride, or care for
contracting any tick-borne disease? & 57 & 68.4 (39) & 22.8 (13) & 8.8
(5)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3.} Sources of educational materials about ticks and
tick-borne diseases reported by equine veterinarians during a survey on
ticks and tick-borne diseases. The numbers in the table represent the
percentage of respondents (with the number of respondents in
parentheses) who retrieve information on ticks and tick-borne diseases
from each source, out a total of 76 respondents for each question.\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Education Source} & \textbf{Question} &
\textbf{Question}\tabularnewline
\midrule
\endhead
& \textbf{Where do you get information on ticks, tick prevention, and/or
tick control (not tick-borne disease)?} & \textbf{Where do you get
information on tick-borne diseases (not tick information, prevention, or
control methods)?}\tabularnewline
Textbooks & 9.2 (7) & 17.1 (13)\tabularnewline
Veterinary organizations/groups & 39.5 (30) & 30.3 (23)\tabularnewline
University Extension & 19.7 (15) & 18.4 (14)\tabularnewline
Colleagues & 22.4 (17) & 27.6 (21)\tabularnewline
Continuing Education & 29.0 (22) & 27.6 (21)\tabularnewline
Conferences or workshops & 13.2 (10) & 22.4 (17)\tabularnewline
Other & 4.0 (3) & 3.9 (3)\tabularnewline
I don't get information on ticks and tick-borne diseases & 9.2 (7) & 6.6
(5)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4.} Equine veterinarian responses to the
question\textbf{``} How many ticks do you estimate you remove from
horse(s) in your veterinary care annually per horse?'' given as a
percent of responses by CDC region.\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\textbf{Region} & \textbf{Number of Ticks} & \textbf{Number of Ticks} &
\textbf{Number of Ticks} & \textbf{Number of Ticks} & \textbf{Number of
Ticks} & \textbf{Number of Ticks}\tabularnewline
\midrule
\endhead
& \textbf{0 ticks} & \textbf{1-2 ticks} & \textbf{3-5 ticks} &
\textbf{6-10 ticks} & \textbf{11 or more ticks} & \textbf{I don't
know}\tabularnewline
Northeast (N=22) & 4.3\% & 8.7\% & 17.4\% & 34.8\% & 34.8\% &
0.0\%\tabularnewline
Midwest (N =10) & 20.0\% & 0.0\% & 40.0\% & 20.0\% & 20.0\% &
0.0\%\tabularnewline
Southeast (N =8) & 0.0\% & 12.5\% & 50.0\% & 12.5\% & 25.0\% &
0.0\%\tabularnewline
South-Central (N =6) & 0.0\% & 33.3\% & 33.3\% & 16.7\% & 16.7\% &
0.0\%\tabularnewline
West (N =14) & 0.0\% & 21.4\% & 42.9\% & 21.4\% & 7.1\% &
7.1\%\tabularnewline
All Regions (N =60) & 5.0\% & 13.3\% & 31.7\% & 25.0\% & 23.3\% &
1.7\%\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figure 1.} The Centers for Disease Control and Prevention ``Tick
Bite Data Tracker'' defined regions (Northeast, Southeast, Midwest,
South Central, and West) were used to analyze equine veterinarian
responses to survey questions related to ticks and tick-borne
diseases.\textbf{~}

\textbf{Figure 2.} Total equine veterinarian responses by state to
survey questions related to ticks and tick-borne diseases. The color
shows number of respondents in each state, with darker colors
representing higher response rates and lighter colors lower response
rates; white represents 0 respondents.

\textbf{Figure 3} . The number of horses cared for in an average year as
reported by equine veterinarians during a survey on ticks and tick-borne
diseases. N=75

\textbf{Figure 4.} Percent of equine veterinarians responding to ``What
life stage(s) of blacklegged, lone star, or American dog ticks is/are
most likely to be found on horses?'' in a survey of ticks and tick-borne
diseases. The correct answer is in bold. N=62

\textbf{Figure 5.} Topics related to ticks and tick-borne disease that
veterinarians wished they knew more about as determined during a survey
on ticks and tick-borne diseases. Respondents could select as many
options as desired, thus percentage represents the percent of the total
number of respondents that completed the question independently for each
question (N=58).

\textbf{Figure 6.} Locations on the equine body that best represents
where ticks are removed by equine veterinarians from the A) Northeast
and Midwest regions (N=33), B) the Southeast and South-Central regions
(N=14), and C) West region (N=15). Responses from the Northeast and
Midwest and the Southeast and South Central were grouped to combine
regions where similar tick species presences and abundance were
anticipated. The color scale represents the frequency at which
veterinarians found ticks on horses, with blue representing a lower
frequency and red representing a higher frequency.\selectlanguage{english}
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