IMPORTANCE Tick-borne diseases (TBD), including spotted fever group rickettsiosis (SFGR), ehrlichiosis, and, increasingly, Lyme disease, represent a substantial public health concern throughout much of the southeastern United States. Yet, there is uncertainty about the epidemiology of these diseases because of pitfalls in existing diagnostic test methods. OBJECTIVETo examine patterns of diagnostic testing and incidence of TBD in a large, academic health care system. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included diagnostic test resultsfor TBD at UNC Health, a large academic health care system with inpatient and outpatient facilities, from January 1, 2017, to November 30, 2020. Participants included all individuals seeking routine care at UNC Health facilities who had testing for SFGR, ehrlichiosis, or Lyme disease performed during the study period. MAIN OUTCOMES AND MEASURESRates of test positivity, testing completeness, and incidence of TBD. RESULTS During the 4-year study period, 11 367 individuals (6633 [58.4%] female; 10 793 [95%] non-Hispanic individuals and 8850 [77.9%] White individuals; median [IQR] age, 53 [37-66] years) were tested for TBD. Among the 20 528 diagnostic tests performed, 47 laboratory-confirmed, incident cases of SFGR, 27 cases of ehrlichiosis, and 76 cases of Lyme were confirmed, representing incidence rates of 4.7%, 7.1%, and 0.7%, respectively. However, 3984 of SFGR tests (79.3%) and 3606 of Ehrlichia tests (74.3%) lacked a paired convalescent sample. Of 20 528 tests, there were 11 977 tests (58.3%) for Lyme disease from 10 208 individuals, 5448 tests (26.5%) for SFGR from 4520 individuals, and 3103 tests (15.1%) for ehrlichiosis from 2507 individuals. Most striking, testing for ehrlichiosis was performed in only 55% of patients in whom SFGR was ordered, suggesting that ehrlichiosis remains underrecognized. An estimated 187 incident cases of SFGR and 309 of ehrlichiosis were potentially unidentified because of incomplete testing. CONCLUSIONS AND RELEVANCEIn this cross-sectional study, most of the patients suspected of having TBD did not have testing performed in accordance with established guidelines, which substantially limits understanding of TBD epidemiology. Furthermore, the data revealed a large discrepancy between the local burden of disease and the testing performed. These findings underscore the need to pursue more robust, active surveillance strategies to estimate the burden of TBD and distribution of causative pathogens.

Importance: Tick–borne diseases (TBD) including Spotted Fever Group Rickettsiosis (SFGR), ehrlichiosis, and increasingly Lyme disease represent a substantial public health concern throughout much of the Southeastern United States. Yet, there is uncertainty about the epidemiology of these diseases due to pitfalls in existing diagnostic test methodologies. Objective: To examine patterns of diagnostic testing and incidence of TBD in a large, academic healthcare system. Design: Cross–sectional study of diagnostic test results from UNC Health for the period January 1st, 2017 to November 30th, 2020. Setting: Large, academic healthcare system in central North Carolina including inpatient and outpatient facilities. Participants: All Individuals seeking routine care at UNC Health facilities who had testing for SFGR, ehrlichiosis or Lyme disease performed during the study period Measurements: Rates of test positivity, testing completeness, and incidence of TBD Results: Among the 20,528 diagnostic tests performed, we identified 47 laboratory–confirmed, incident cases of SFGR, 27 of ehrlichiosis, and 76 of Lyme, representing incidence rates of 4.7%, 7.1%, and 0.7% respectively. However, 79.3% of SFGR tests and 74.3% Ehrlichia tests lacked a paired convalescent sample. The total number of tests for Lyme disease was more than SFGR and ehrlichiosis combined, despite the relatively low incidence of disease in region. Most striking, testing for ehrlichiosis was performed in only half of patients in whom SFGR was ordered, suggesting that this disease remains underrecognized. Overall, we estimate that there were 187 incident cases of SFGR and 309 of ehrlichiosis that were not identified due to incomplete testing; a number that would drastically increase – and in the case of ehrlichiosis, nearly double – the total number of cases reported. Conclusions and Relevance: A majority of patients suspected of having TBD did not have testing performed in accordance with established guidelines, substantially limiting our understanding of TBD epidemiology. Furthermore, there appears to be a large discrepancy between the local burden of disease and the testing that is performed. These findings underscore the need to pursue more robust, active surveillance strategies to estimate the burden of TBDs and distribution of causative pathogens.

Background: Working while ill, or presenteeism, has been documented at substantial levels among healthcare personnel (HCP) along with its consequences for both patient and HCP safety. Limited literature has been published on HCP presenteeism during the COVID-19 pandemic, and specific motivations for this behavior are not well described. Understanding both individual and systemic factors that contribute to presenteeism is key to reducing respiratory illness transmission in the healthcare setting. We characterized the frequency of and motivations for presenteeism in the workforce of a large academic medical center during the COVID-19 pandemic. Method: We deployed a voluntary, anonymous electronic survey to HCP at University of North Carolina (UNC) Medical Center in December 2021, which was approved by the UNC Institutional Review Board. We received 591 responses recruited through employee newsletters. Respondents recounted their frequency of presenteeism since March 2020, defined as coming to work feeling feverish plus cough and/or sore throat. In total, 24.6% reported presenteeism at least once, with 8.1% reporting twice and 5.3% 3 or more times. Asking more generally about any symptoms while working, the following were most common: headache (26%), sinus congestion (20%), sore throat (13%), cough (13%), and muscle aches (9.3%). Results: Motivations for presenteeism fell broadly into 4 categories: (1) perception of low risk for COVID-19 infection, (2) concerns about workplace culture and operations, (3) issues with sick leave, and (4) concerns about employment record and status. Among HCP reporting at least 1 instance, the most common motivations for presenteeism included feeling low risk for COVID-19 infection due to mild symptoms (59.9%), being vaccinated (50.6%), avoiding increasing colleagues’ workload (48.3%), avoiding employment record impact (39.6%), and saving sick days for other purposes (37.9%). Asked to identify a primary motivation, 40.3% reported feeling low risk for COVID-19 infection due to mild symptoms or vaccination, 21.2% reported a workplace culture issue (ie, increasing colleague workload, perception of weakness, responsibility for patients), 20.6% reported sick leave availability and use (including difficulty finding coverage) and 17.8% reported employment record ramifications including termination. Conclusions: This survey coincided with 2the onset of the SARS-CoV-2 ο (omicron) variant locally, and as such, risk perceptions and motivations for presenteeism may have changed. Responses were self-reported and generalizability is limited. Still, these results highlight the importance of risk messaging and demonstrate the many factors to be considered as potential presenteeism motivators. Mitigating these drivers is particularly critical during high-risk times such as pandemics or seasonal peaks of respiratory illness.Funding: NoneDisclosures: None