Conflict of Interest Declaration
The ILCOR Scientific Advisory Committee process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable
CoSTR Citation
Charlton NP, Carlson JN, Borra V, Singletary EM, and Zideman DA on behalf of the International Liaison Committee on Resuscitation (ILCOR) First Aid and Pediatric Life Support Task Forces, 2021 February 17, 2021 Available from: http://ilcor.org
Collaborators: Goolsby CA, Cassan P, Berry D, Bendall J, Bradley R, Chang W-T, Djärv T, Douma M, Epstein JL, Meyran D, Nemeth M, Orkin A
Methodological Preamble (and if relevant, Link to Published Systematic Review)
The continuous evidence evaluation process for the production of the Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of the use of tick removal techniques. In preliminary literature searches, a well conducted systematic review was identified. {Huygelen 2017 177} This adolopment process incorporates this systematic review and a subsequent review of pertinent literature. Bias assessment, data abstraction and an evidence to decision table were completed by Nathan Charlton and Jestin Carlson of the First Aid Task Force, with significant input from Vere Borra. These data were taken into account when formulating the Treatment Recommendations.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Individuals in the first aid setting with a tick attached to the skin.
Intervention: Any tick removal method, including heat, chemical, commercial tick removal apparatus, or tweezers/forceps
Comparators: Any other method of tick removal
Outcomes: Transmission of disease (critical), removal of (parts of) the tick (critical), damaged or broken off mouth parts (important)
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion.
Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded.
NOTE FOR RISK OF BIAS:
Three RCTs {Bowles 1992 901; Duscher 2012 1505; Zenner 2006 526} and five observational studies {Akin Belli 2016 393; De Boer 1993 748; Needham 1985 997; Sahin 2020 405; Stewart 1998 137} were identified that pertained to the specified outcomes. Bias was assessed per study rather than for a specific outcome. Evidence from these studies was of low to very low certainty and downgraded for risk of bias, indirectness and imprecision. An insufficient number of studies were found to evaluate for publication bias.
Consensus on Science
Three RCTs {Bowles 1992 901; Duscher 2012 1505; Zenner 2006 526} and five observational studies {Akin Belli 2016 393; De Boer 1993 748; Needham 1985 997; Sahin 2020 405; Stewart 1998 137} were identified that pertained to the specified outcomes. Multiple modalities for tick removal were found for each outcome contributing to heterogeneity in the results and in most instances prevented data pooling or metanalysis. For clarity, sections are organized by outcome and then method of tick removal.
Removal of the Tick
For the critical outcome of removal of the tick, three observational studies {Akin Belli 2016 393; De Boer 1993 748; Needham 1985 997} were identified with low to very low certainty evidence.
Chemical or Heat Treatment Compared to Mechanical Removal
When comparing chemical or heat treatment with mechanical removal of ticks, two observational studies {Needham 1985 997; De Boer 1993 748} with very low certainty evidence (downgraded for risk of bias, indirectness and imprecision) were identified. These studies were conducted on animals (pigs and sheep) with researchers applying chemicals or heat to determine if these modalities removed ticks and then providing mechanical removal. Pooled results demonstrated that application of gasoline, nail polish, methylated spirts, petroleum jelly, 70% isopropyl alcohol or a hot kitchen match did not result in detachment of the tick from the animal (0/220). All ticks attached had to be subsequently removed mechanically (220/220).
Freezing Compared with Mechanical Removal
When comparing freezing of a tick with removal using mechanical devices we identified one observational study {Akin Belli 2016 393} with low certainty evidence (downgraded for risk of bias, indirectness and imprecision). In this study dermatologists attempted tick removal with a commercial freezing device (Tickner, Laboratory Tickner AG, Zug Switzerland) or three different mechanical devices [two commercial devices (Trix Ticklasso ®, Innotech, Fridhem, Sweden and Zeckenkarte, SfeCard ApS, Skanderborg, Denmark) and one tweezers]. Freezing removed 0/40 ticks, whereas a card slit and traction device removed 8/40 ticks, a lasso and traction device removed 19/40 ticks and pulling with tweezers by grasping near the mouthparts removed 40/40 ticks, the differences of which were all statistically significant (p<0.001).
Damaged Mouth Parts
For the important outcome of damaged or broken off mouth parts, 3 RCTs {Bowles 1992 901; Duscher 2012 1505; Zenner 2006 526} and 5 observational studies {Akin Belli 2016 393; De Boer 1993 748; Needham 1985 997; Sahin 2020 405; Stewart 1998 137} were identified with low to very low certainty evidence.
Comparing Manual Removal with Tweezers
A single observational study {Sahin 2020 405} with very low certainty evidence (downgraded for risk of bias, indirectness and imprecision) compared manual removal with removal using tweezers. In this study, lay persons removed the tick by hand (n=21) and health care professionals removed ticks with tweezers (n=26). A lower risk of damaging the tick mouthparts upon removal was associated with use of tweezers (4/22) compared with manual removal (11/21; RR 0.35, 95% CI, 0.13-0.92).
Comparing Different Traction Methods
One randomized study {Duscher 2012 1505} and two observational studies {Needham 1985 997; De Boer 1993 748} were identified with very low certainty evidence (downgraded for risk of bias, indirectness and imprecision) that compared different traction methods when removing ticks with a mechanical removal device (TickPic Fact Solution GmbH, Germany; Trix Ticklasso ®, Innotech, Fridhem, Sweden; Tick Twister® O’Tom ® H3D, Lavancia, France; pen-tweezers, WDT, Germany or Adson forceps, Sagalain Intl, Parkistan). In one randomized study {Duscher 2012 1505} veterinarians (n=22) and lay providers (n=4) removed 596 ticks from various pets (e.g., dogs, cats) by either twisting or pulling methods. In this study, twisting methods were superior to pulling methods, resulting in lower number of ticks with damaged mouthparts on removal (37/337 with twisting compared with 60/190 with pulling; RR 0.35, 95% CI, 0.24-0.50).
A second observational study {De Boer 1993 748} conducted by researchers on pigs and sheep compared pulling the tick straight out using blunt forceps with rotation with use of an opposing jaw device (Tick Solution, Instruments of Sweden, Inc, Stamford, CT, USA). In this study, there were a greater number of mouthparts of ticks that remained in the skin when pulling straight out with blunt forceps (59/80) compared with rotation with the opposing jaw device (14/69; RR 3.63, 95% CI, 2.24-5.91).
A third observational study {Needham 1985 997} compared pulling and twisting methods by researchers for removal of 22 ticks on sheep. A greater number of ticks with damaged mouthpart upon removal was associated with pulling straight up using a quick motion of forceps (7/7) compared with twisting clockwise with forceps (0/5; RR 11.25, 95% CI, 0.79-160.81). Pulling straight up with forceps using steady pressure was also associated with more tick mouthpart breakage (5/5) compared with twisting clockwise with forceps (0/5) (RR 11.00, 95% CI, 0.77-158.01). Pulling with forceps parallel to the skin was associated with more tick mouthpart breakage on removal (5/5) compared with twisting clockwise with forceps (0/5) (RR 11.00, 95% CI, 0.77-158.01). In this study, all ticks were grabbed by the forceps as close to the skin as possible. The type of forceps was not described.
Comparing Pulling with Tweezers with Pulling with Commercial Traction Devices
When comparing tweezers/forceps with types of commercial pulling devices, one randomized study {Duscher 2012 1505} and two observational studies {Akin Belli 2016 393; Stewart 1998 137} were identified. In one randomized trial {Duscher 2012 1505} with very low certainty evidence (downgraded for risk of bias, indirectness and imprecision), 596 ticks were removed from various pets (e.g., dogs, cats) by veterinarians (n=22) and lay providers (n=4). There was a greater number of ticks with damaged mouthparts upon removal when pulling with an Adson forceps (Sagalain Intl, Parkistan) (36/90) compared with pulling with a commercial slit and traction device (TickPic, Fact Solution GmbH, Germany) (24/100; RR 1.67 1.08-2.56).
In an observational study {Akin Belli 2016 393} with low certainty evidence (downgraded for risk of bias and imprecision) dermatologists removed 160 ticks from participants using a commercial freezing device (Tickner, Laboratory Tickner AG, Zug, Switzerland) or three different mechanical tick removal devices (two commercial devices and one tweezers). Freezing removed no ticks. Pulling with a card slit and traction device (Zeckenkarte, SafeCard ApS, Skanderborg, Denmark) resulted less intact tick removal (3/40) than pulling with tweezers (33/40; RR 0.09, 95% CI, 0.03-0.27). Pulling with a lasso device (Trix Ticklasso®, Innotech, Fridhem, Sweden) also resulted in less intact tick removal (19/40) than pulling with tweezers (33/40; RR 0.58, 95% CI, 0.40-0.83).
In a second observational study {Stewart 1998 137} with very low certainty evidence (downgraded for risk of bias, indirectness and imprecision) three untrained volunteers removed 342 ticks from rabbits using three different mechanical removal devices. Fewer damaged mouthparts were associated with pulling with a slit and traction device (Ticked Off™, Ticked Off, Inc, Dover, NH, USA) (9/104) compared with use of medium tipped tweezers (Fisher Scientific, Waltham, MA, USA) (20/79; RR 0.34, 95% CI, 0.16-0.71). When comparing pulling with a second slit and traction device (Protick Remedy™, SCS Ltd. Lake Ariel, PA, USA) with use of tweezers, there was no difference in the number of damaged mouthparts (13/82 vs 20/79; RR 0.63, 0.33-1.17). When comparing pulling with an opposing jaw and traction device (Tick Nipper™ Joslyn Designs, Mahopac, NY USA) to pulling with tweezers there was no difference reported in the number of ticks with damaged mouthparts (10/77 with use of device compared with 20/79 using tweezers; RR 0.51, 95% CI, 0.26-1.02).
Comparing Types of Commercial Rotation Devices
When comparing types of commercial rotation devices, two randomized trials {Duscher 2012 1505; Zenner 2006 526} were identified with very low certainty evidence (downgraded for risk of bias, indirectness and imprecision). In one randomized trial {Duscher 2012 1505}, veterinarians (22) and lay providers (4) removed 596 ticks from various pets (e.g., dogs, cats) with commercial tick removal devices or tweezers. In this study more ticks with damaged mouth parts were reported when rotating with a lasso device (Trix Ticklasso®, Innotech, Fridhem, Sweden) (20/108) compared with rotating with a slit and rotation device (Tick Twister® O’Tom ® H3D, Lavancia, France) (7/108; RR 2.86, 95% CI, 1.26-6.48). There was also a higher number of damaged tick mouthparts upon removal when rotating with a lasso device (Trix Ticklasso ®, Innotech, Fridhem, Sweden) (20/108) compared with rotating with an opposing jaw device (pen-tweezers, WDT, Germany) (10/121; RR 2.24; 95% CI, 1.10-4.57). Finally, there was a similar risk of damaged tick mouthparts when rotating with the slit and rotation device (Tick Twister® O’Tom ® H3D, Lavancia, France) 7/108) compared with rotation with the opposing jaw device (pen-tweezers, WDT, Germany) (10/121; RR 0.78; 95% CI, 0.31-1.99).
In a second randomized trial {Zenner 2006 526} pet owners and veterinarians (unknown numbers) compared commercial devices and tweezers for 236 tick removals on pets. When comparing rotation devices used by pet owners, there was a statistically significant decrease in ticks with damaged mouthparts upon removal when using a slit and rotation device (Tick Twister® O’Tom ® H3D, Lavancia, France) compared with either rotation with an opposing jaw rotation device (Buster Tick forceps, Kruuse UK Ltd, Langeskov, Denmark) or Adson forceps (p<0.01, raw data not available). The same comparison was not performed by the veterinarians.
Comparing Types of Tweezers
A single randomized study {Bowles 1992 901} with very low certainty evidence (downgraded for risk of bias, indirectness and imprecision) was identified that compared types of tweezers on tick removal. In this study 299 ticks were removed by investigators on dogs using three different types of forceps. There was no difference in the number of ticks with damaged mouthparts upon removal between angled forceps (1/73) or economy forceps (2/73; RR 0.50, 95% CI, 0.05-5.40) or between jewelers’ forceps (2/72) and economy forceps (2/73; RR 0.90, 95% CI, 0.15-7.00).
Transmission of Disease
No studies were identified for the critical outcome of transmission of disease.
Treatment Recommendations
We recommend against the use of chemicals, heat or ice in comparison with mechanical methods for the removal of a tick. (strong recommendation, very low certainty evidence)
We suggest either pulling with tweezers or using commercial devices according to the manufacturer’s instructions to remove a tick rather than removal by hand. (weak recommendation, very low certainty evidence)
Justification and Evidence to Decision Framework Highlights
This topic was prioritized by the First Aid Task Force as there has been no prior review of tick removal methods in the first aid setting.
In making this recommendation, the First Aid Task force considered the following:
- Early removal of a tick is likely the most important aspect of preventing infection. The Task Force, therefore, prioritized methods of tick removal that would be safe and effective, while promoting early tick removal.
- While comparative studies are limited, it was noted by the Task Force that the use of chemicals, heat and freezing did not result in any tick detachment. As these methods do not result in tick detachment and in some instances, could potentially result in harm, the Task Force recommended against the use of chemicals, heat or freezing for tick removal.
- The Task Force discussed that tweezers are likely more readily available, have more first aid uses, and are less expensive than commercial tick removal devices, and are therefore likely more feasible for use than a commercial tick removal device. It was noted by the Task Force that because tweezers are commonly available, earlier tick removal is more likely than with use of a commercial tick removal device.
- While studies differentiated adult and nymph ticks, different species of ticks and time of tick attachment/engorgement, the Task Force felt it was impractical for lay providers to differentiate their features or the potential need for different devices for removal of each stage. Therefore, these data were combined in this review.
- Only one study evaluated the different methods of removing a tick with tweezers. While this study presented some data that suggested that rotating with tweezers may result in fewer retained mouthpart than pulling, this data was of very low certainty and the study had very limited numbers. The majority of the studies reviewed used pulling with the tweezer after grasping as close to the skin as possible.
- When described in the studies, the tweezers or forceps that were used typically had a thin jaw, similar to Adson forceps, which would allow for gripping of the tick near the skin without crushing the body of the tick. While the term forceps was often used in the studies, the Task Force discussed that these devices would often be described as tweezers by the general public.
- While some studies evaluated commercial devices compared to other commercial devices, this data was of very low certainty and heterogenous in nature. Based on the data, the Task Force did not feel it was possible to recommend one type of device over another.
- The Task Force discussed that while the included studies evaluated removal of the tick and damage to the tick during removal, no studies evaluated disease transmission. In Task Force discussions it was noted that removal of the tick does not guarantee lack of disease transmission and that persons should be aware of signs of both local and systemic illness following tick bites.
- The Task Force discussed that all techniques of tick removal are subject to user error and could result in retained tick mouthparts in the skin. It was noted that persons should evaluate for retained mouthparts following tick removal.
Knowledge Gaps
- Studies are needed among lay providers to determine the most efficacious methods of tick removal in humans.
- Studies with clinical outcomes of transmission of disease are needed to help determine the best methods of tick removal.
Attachments
Et D-Should-twisting-vs.-pulling-be-used-for-tick-removal
Et D-Should-twisting-vs.-pulling-be-used-for-tick-removal
Et D-Should-pulling-with-a-device-vs.-pulling-with-tweezers-be-used-for-tick-removal
Et D-Should-jewellers-forceps-or-angled-forceps-vs.-economy-forceps-be-used-for-tick-removal
Et D-Should-freezing-chemical-or-heat-removal-vs.-mechanical-removal-be-used-for-tick-removal
Et D-1-Should-tweezers-vs.-manual-removal-be-used-for-tick-removal
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