Training Ambassadors in the Prevention and Surveillance of Lyme Disease in Québec
The Institut national de santé publique du Québec (INSPQ) conducted a training project with the Nature Conservancy of Canada (NCC) from January to December 2019 in the regions where Lyme disease (LD) is a growing public health issue. The objective was to train Lyme disease prevention ambassadors through a cascade training approach (training trainers).
Once trained, the members of this new regional network had to lead activities to raise LD awareness among their colleagues and clients and independently carry out tick sampling activities in their respective communities. In total, 18 ambassadors were trained and 28 awareness-raising activities were organized, directly reaching at least 1,860 people in seven different public health units. During this period, 28 sampling activities were completed, and 36 ticks were collected (through active and passive surveillance). The participants’ evaluation of the project was very positive. The project very clearly fulfilled a need of outdoor workers and the general population, indicating that this type of initiative—combining cascade training and community science—offers promising aspects from which public health authorities could benefit to meet LD prevention and surveillance needs in Quebec.
Lyme disease (LD) is currently the main vector-borne disease transmitted by ticks in Europe and North America and a significant emerging zoonosis in Canada . Its principal vector in the northeastern United States, the blacklegged tick (Ixodes scapularis, I. scapularis), is progressively colonizing new regions in a northward direction, notably due to climate change. This has a direct impact on the number of cases of the disease reported annually, which increased from 144 reported cases in Canada in 2009 to 2,025 in 2017, and from 66 cases reported and contracted in Quebec in 2014 to 338 in 2019 (as at January 8, 2020) [2,3]. This trend is not likely to slow down; some models from 2012 estimated that 80% of the population of Eastern Canada could be living in an endemic area by 2020 [4, 5].
To address this emerging problem, public health (PH) authorities in Quebec have implemented an integrated LD surveillance program. This program is based on a compilation of the human case surveillance data (LD has been a notifiable disease since 2003) and acarological surveillance data (ticks reported through active and passive methods). It helps guide PH interventions and support healthcare professionals in a clinical context . However, deploying this surveillance program requires significant resources. This is particularly true for active surveillance, which requires conducting tick sampling in different municipalities across the province. With that in mind, it is advisable to find alternative approaches to optimize this program.
Furthermore, some populations in Quebec are particularly vulnerable to LD. These populations include certain workers, especially those working in the forestry, agriculture, construction, and public works (e.g., road works, maintenance of municipal land and publicly accessible parks) sectors as well as at summer camps [10, 12]. The main risk factors that can lead to workers contracting LD relate to the following:
- The work setting (e.g., rural environment and outdoor work, especially in wooded areas in the southern part of the province, which increase the likelihood of exposure to ticks)
- The nature of the professional duties (physical jobs that involve carrying out manual tasks in contact with vegetation, e.g., technical workers responsible for maintenance or forestry work, day camp activities, challenge courses, outreach)
- Employment status and sociodemographic profile (e.g., seasonal positions causing workers to be absent from awareness training, immigrant and/or allophone workers who are not fluent in the language in which the preventative measures are communicated, etc.)
- Work organization (no individual prevention due to lack of awareness and underestimation of this occupational disease, etc.) 
A large amount of information on LD is available from various sources, especially on the Internet. Yet, despite the comprehensiveness and quality of the information available on Quebec and Canadian government websites on preventing this disease and PH-supported efforts toward this purpose, there are vulnerable populations in Quebec who are not reached by awareness-raising campaigns. It would be worthwhile to find solutions to improve the dissemination of relevant information to these populations (residents, workers) in a consistent and standardized way.
To address these surveillance and prevention issues, an innovative cascade training project was launched. The aim of the project was to train employees and managers of different publicly accessible nature parks so that they can be LD educators referred to as “prevention ambassadors.”
The main objective of this project was to develop a bilingual training program for managers of Canadian parks using a cascade training method (i.e., training trainers). It targeted employees and managers of various publicly accessible nature parks (and any nature conservancy organization with outdoor workers) so that they could become prevention ambassadors in different regions of the province where there is a risk of contracting LD.
The specific goals of the training were to:
1) equip each ambassador to inform and raise the awareness of various vulnerable populations on LD contraction (colleagues, managers, volunteers, and park visitors); and 2) teach these ambassadors to independently conduct I. scapularis tick sampling in the environment in a way that is safe and follows a standardized protocol.