Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Management of Tick-Borne Illness in the United States

Wilderness Environ Med. 2021 Dec;32(4):474-494. doi: 10.1016/j.wem.2021.09.001. Epub 2021 Oct 9.


The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the prevention and management of tick-borne illness (TBI). Recommendations are graded based on quality of supporting evidence according to criteria put forth by the American College of Chest Physicians. The guidelines include a brief review of the clinical presentation, epidemiology, prevention, and management of TBI in the United States, with a primary focus on interventions that are appropriate for resource-limited settings. Strong recommendations are provided for the use of DEET, picaridin, and permethrin; tick checks; washing and drying clothing at high temperatures; mechanical tick removal within 36 h of attachment; single-dose doxycycline for high-risk Lyme disease exposures versus "watchful waiting;" evacuation from backcountry settings for symptomatic tick exposures; and TBI education programs. Weak recommendations are provided for the use of light-colored clothing; insect repellents other than DEET, picaridin, and permethrin; and showering after exposure to tick habitat. Weak recommendations are also provided against passive methods of tick removal, including the use of systemic and local treatments. There was insufficient evidence to support the use of long-sleeved clothing and the avoidance of tick habitat such as long grasses and leaf litter. Although there was sound evidence supporting Lyme disease vaccination, a grade was not offered as the vaccine is not currently available for use in the United States.

Keywords: DEET; Lyme disease; prophylaxis; rickettsia; spirochetes.

Publication types

  • Review

MeSH terms

  • Animals
  • Humans
  • Insect Repellents*
  • Lyme Disease* / drug therapy
  • Lyme Disease* / epidemiology
  • Lyme Disease* / prevention & control
  • Societies, Medical
  • Tick Bites*
  • Ticks*
  • United States


  • Insect Repellents