Researchers surveying over 70,000 U.S. adults and caregivers found that while awareness of Lyme disease is nearly universal, daily habits lag behind, revealing that the greatest risk often starts just steps from home.
Study: Risk factors for Lyme disease in the general population - a survey of adults and caregivers in 28 states. Image Credit: Bukhta Yurii / Shutterstock
In a recent study published in the Open Forum Infectious Diseases, a group of researchers estimated, across multiple U.S. regions, how often adults and children engage in outdoor activities associated with LD risk, what prevention measures they report using, and how awareness and perceptions align with reported exposures.
Background
Nearly 476,000 people in the U.S. are diagnosed and treated for LD each year, a reminder that a single backyard walk can matter when Ixodes ticks are present. Risk is not only where infected ticks occur, but also where people actually spend time.
Yards, dog walks, trails, cabins, and outdoor jobs shape exposure in suburban and rural communities alike. Awareness is high, yet behaviors vary, and prevention routines (repellent use, tick checks) are inconsistently applied during routine outdoor time.
As documented range expansions and climate-suitability modeling alter tick habitats and human movement, clearer population-level data on behaviors and prevention gaps are needed to guide action.
About the study
Researchers conducted an online cross-sectional survey (October–December 2024) of adults (≥18 years) and caregivers of children (1–17 years) across 26 jurisdictions with high or neighboring LD incidence, plus selected counties in California/Oregon (CA/OR).
High-incidence areas included states in the Northeast, mid-Atlantic, and upper Midwest; neighboring states bordered these high-incidence jurisdictions; CA/OR counties were chosen based on reported case counts and panel availability.
Participants completed a structured online questionnaire that captured demographics; outdoor recreation and occupation in forests, wooded areas, or tall grass; time spent in a yard; personal prevention (e.g., repellents, tick checks); tick encounters; prior LD diagnoses; and knowledge and risk perceptions.
Samples combined a probability panel (KnowledgePanel) and multiple opt-in panels; state-level targets were set for adults and caregivers. Caregiver data were not collected for CA/OR due to panel size constraints.
Data were weighted by age, gender, race/ethnicity, urbanicity, income, education, and language dominance; additional calibration aligned opt-in respondents to behavioral attributes of the probability sample.
Analyses summarized frequencies with 95% CI and medians with interquartile range (IQR), accounting for the complex survey design using Statistical Package for the Social Sciences (SPSS) and R (survey package). Ethical review determined that the study was exempt from Institutional Review Board (IRB) review.
Reporting followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Results were evaluated by region and by respondent type (adults, caregivers).
Study results
A total of 44,330 adults and 28,380 caregivers completed the survey, yielding analytic samples of 25,677 adults in high-incidence states, 18,392 adults in neighboring states, 261 adults in CA/OR, 15,725 caregivers in high-incidence states, and 12,655 caregivers in neighboring states.
Most surveys (≈99%) were completed in English, with the remainder in Spanish. Adult samples were approximately balanced by gender and predominantly White and non-Hispanic; CA/OR adults skewed older. Caregivers were more often women and more likely to report a household dog or cat that goes outdoors.
Outdoor exposure was common. Among adults, 73% in high-incidence and 70% in neighboring states (and 79% in CA/OR) reported recreational time outdoors in forests, wooded areas, or tall grass during April 1–November 30. Among caregivers, 84% (high-incidence) and 83% (neighboring) reported their child spent recreational time outdoors.
Spending time in a yard each week was reported by 88–92% of adults and 96–98% of children, with a typical duration of 1–4 hours per week. Hiking/walking/running was the most frequent activity (adults 68–76%; children 79%). About 32–35% of adults and 51% of older teens (≥14 years) reported some time spent outdoors.
Activities typically occurred near home or in the neighborhood (e.g., dog walking and local walks/runs), whereas camping and overnight stays in cabins or cottages were more often elsewhere in-state. This pattern suggests substantial exposure potential in peridomestic settings where people spend routine time.
Tick encounters and LD awareness reflected this backdrop. In the past six months, 16% of adults (high-incidence) and 15% (neighboring) reported finding a tick on themselves (CA/OR 11%); 16% of caregivers reported a tick on their child. Nearly everyone had heard of LD (~88–93% awareness).
Lifetime healthcare provider-diagnosed LD was reported by 5.8% of adults in high-incidence states (neighboring 1.8%, CA/OR 3.3%) and 6.0% of children in high-incidence states (5.4% neighboring).
Despite high awareness and frequent outdoor and yard time, personal prevention was inconsistent. Among adults in high-incidence states, 40% “always/almost always” used repellents or performed tick checks after forest/wooded/tall-grass activities (neighboring 35%, CA/OR 34%). After yard time, routine prevention dropped to 23% (high-incidence), 17% (neighboring), and 21% (CA/OR).
Caregiver reports for children were similar (40–42% after recreational activities), again lower after yard time. Risk perception skewed low, though about a quarter viewed LD as a somewhat/very serious or common community problem. If available, intent to receive an LD vaccine reached 43% among adults in high-incidence states, 37% in CA/OR, and 47% for their children (neighboring adults 32%, children 40%).
Collectively, these findings show a very high prevalence of everyday exposures (yards, dog walks, neighborhood exercise) alongside modest perceived risk and sub-optimal prevention routines, especially for yard time, where many exposures can occur.
Conclusions
In regions where LD is established or emerging, people routinely spend time in yards and nearby green spaces, and these everyday settings likely contribute substantially to risk. While awareness is high, consistent prevention remains uncommon, particularly after yard activities, and perceived personal risk is often low.
For families, pet owners, outdoor workers, and communities managing changing tick ecologies, the practical takeaway is clear: pair routine outdoor time with routine prevention (repellent use, tick checks, and, where appropriate, general guidance such as clothing choices or landscape maintenance, though these were not studied variables in this survey).
While widely recommended, epidemiologic evidence on the effectiveness of personal protective measures is limited, underscoring the need for layered approaches. Public-health campaigns, employer guidance, and clinician counseling can close behavior gaps, and future vaccines, if licensed, could add another protective layer.
The study was jointly funded by Valneva and Pfizer, which are co-developing a Lyme disease vaccine; several authors are Pfizer employees.
Journal reference:
- Gould, L. H., Shafquat, M., Duench, S., Tan, Y., Gilvad, A., Katzenberger, B., Moïsi, J., & Stark, J. H. (2025). Risk factors for Lyme disease in the general population, a survey of adults and caregivers in 28 states. Open Forum Infectious Diseases. DOI: 10.1093/ofid/ofaf658. https://academic.oup.com/ofid/advance-article/doi/10.1093/ofid/ofaf658/8294334