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Tokat İlinde Yaşayan İnsanlardaki Kene Tutunma Bölgelerinin Değerlendirilmesi

Yıl 2017, Cilt: 74 Sayı: 2, 121 - 128, 01.06.2017

Öz

Amaç: Bu çalışmada, Türkiye’de Kırım Kongo Kanamalı Ateşi KKKA açısından endemik olan bir bölgede kene enfestastonu olan kişilerin demografik özelliklerinin ve kenelerin tutunma bölgelerinin değerlendirilmesi amaçlanmıştır.Yöntem: 2009 yılında Tokat ilinde 5,089 kişi kene enfestasyonu şikayeti ile hastanelere başvurmuştur. Kene tutunması olan her hasta için sağlık personelleri tarafından doldurulan hastaların isim, yaş, cinsiyet, meslek, tarih, yaşadığı alan, seyahat bilgisi ve ek notları içeren standart formlar incelenmiştir. Kene tutunma bölgeleri karın, kollar, koltuk altı, sırt, göğüs, baş ve boyun, kalça, bacaklar ve perine olmak üzere 9 gruba, hastaların yaşları da 0-9, 10-19, 20-39, 40-64 ve ≥65 olmak üzere 5 gruba ayrılarak incelenmiştir. Bulgular: Başvuran kişilerin büyük bir kısmında n=1,051, %23,3 kenelerin bacaklara tutunduğu tespit edilmiştir. 20-39 yaş grubundaki kişiler n=1.228, %27,24 kene tutunması oranının en yüksek olduğu grup olarak belirlenmiştir. Hastalardan 2.825 %62,67 ’inin erkek, 1.683 %37,33 ’ının kadın olduğu tespit edilmiştir. Ayrıca, 2.740 %60.78 hastanın kırsal alanlarda, 1.768 %39,22 hastanın kentsel alanlarda yaşadığı belirlenmiştir. İnsanlar üzerinden toplanan kenelerin tür teşhisleri yapıldığında, örneklerin Argas 1 tür , Dermacentor 2 tür , Haemaphysalis 3 tür ve 1 alttür , Hyalomma 4 tür , Ixodes 5 tür ve Rhipicephalus 4 tür cinsleri içerisinde toplam 20 taksona ait olduğu belirlenmiştir. Sonuç: Bu çalışmayla birlikte, KKKA endemik Tokat bölgesinde kene enfestasyonu olan hastaların demografik özellikleri ve kenelerin tutunma bölgeleri ilk kez değerlendirilmiştir. Ayrıca, Türkiye’de insanların Argas vespertilionis ve Ixodes gibbosus türü keneler tarafından enfeste edildikleri ilk kez tespit edilmiştir

Kaynakça

  • 1. Williamson PC, Billingsley PM, Teltow GJ, Seals JP, Turnbough MA, Atkinson SF. Borrelia, Ehrlichia and Rickettsia spp. in ticks removed from persons, Texas, USA. Emerg Infect Dis, 2010; 16: 441-6
  • 2. Tekin S, Bursali A, Mutluay N, Keskin A, Dundar E. Crimean-Congo hemorrhagic fever virus in various ixodid tick species from a highly endemic area. Vet Parasitol, 2012; 186: 546-52.
  • 3. Oteo JA, Portillo A. Tick-borne rickettsioses in Europe. Ticks Tick Borne Dis, 2012; 3: 271-8.
  • 4. Gargili A, Kar S, Yılmazer N, Cerit C, Sonmez G, Sahin F, Alp H, Vatansever Z. Evaluation of ticks biting humans in Thrace Province, Turkey. Kafkas Univ Vet Fak Derg, 2010; 16: 141-6.
  • 5. Bursali A, Tekin S, Keskin A, Ekici M, Dundar E. Species diversity of ixodid ticks feeding on humans in Amasya, Turkey: seasonal abundance and presence of Crimean-Congo hemorrhagic fever virus. J Med Entomol, 2011; 48: 85-93.
  • 6. Bakirci S, Aysul N, Eren H, Unlu AH, Karagenc T. Diversity of ticks biting humans in Aydın province of Turkey. Ankara Univ Vet Fak Derg, 2014; 61: 93-8.
  • 7. Whitehouse CA. Crimean-Congo hemorrhagic fever. Antiviral Res, 2004; 64: 145-60.
  • 8. Yilmaz GR, Buzgan T, Irmak H, Safran A, Uzun R, Cevik MA, Torunoglu MA. The epidemiology of Crimean-Congo hemorrhagic fever in Turkey, 2002– 2007. Int J Infect Dis, 2009; 13: 380-6.
  • 9. World Health Organization (WHO) 2015. CrimeanCongo haemorrhagic fever, Available from http:// www.who.int/mediacentre/factsheets/fs208/en.
  • 10. Tonbak S, Aktas M, Altay K, Azkur AK, Kalkan A, Bolat Y, Dumanli N, Ozdarendeli A. CrimeanCongo hemorrhagic fever virus: genetic analysis and tick survey in Turkey. J Clin Microbiol, 2006; 44: 4120-4
  • 11. Hoogstraal H. The Epidemiology of Tick-Borne Crimean-Congo Hemorrhagic Fever in Asia, Europe, and Africa. J Med Entomol, 1979; 15: 307-417.
  • 12. Piesman J. Transmission of Lyme disease spirochetes (Borrelia burgdorferi). Exp Appl Acarol, 1989; 7: 71-80
  • 13. Otranto D, Dantas-Torres F, Giannelli A, Latrofa MS, Cascio A, Cazzin S, Ravagnan S, Montarsi F, Zanzani SA, Manfredi MT, Capelli G. Ticks infesting humans in Italy and associated pathogens. Parasit Vectors, 2014; 7: 328
  • 14. des Vignes F, Piesman J, Heffernan R, Schulze TL, Stafford KC 3rd, Fish D. Effect of tick removal on transmission of Borrelia burgdorferi and Ehrlichia phagocytophila by Ixodes scapularis nymphs. J Infect Dis, 2001; 183: 773-8
  • 15. Ebel GD, Kramer LD. Duration of tick attachment required for transmission of Powassan virus by deer ticks. Am J Trop Med Hyg, 2004; 71(3): 268-71
  • 16. Lane RS. Competence of ticks as vectors of microbial agents with an emphasis on Borrelia burgdorferi. In: Sonenshine, D.E., Mather, T.N., (Eds.), Ecological dynamics of tick-borne zoonoses. New York: Oxford University Press, 1994; 45-67
  • 17. Slaff M, Newton NH. Location of tick (Acari: Ixodidae) attachment sites on humans in North Carolina. J Med Entomol, 1993; 30: 485-8.
  • 18. Felz MW, Durden LA. Attachment sites of four tick species (Acari: Ixodidae) parasitizing humans in Georgia and South Carolina. J Med Entomol, 1999; 36: 361-4
  • 19. Gunduz A, Turkmen S, Turedi S, Nuhoglu I, Topbas M. Tick attachment sites. Wilderness Environ Med, 2008; 19: 4-6
  • 20. Erol S, Yenisolak A, Toros GY, Albayrak A. Evaluation of the tick bites in a Crimean-Congo haemorrhagic fever (CCHF) endemic area in Turkey. Turk J Med Sci, 2011; 41: 131-6
  • 21. Filippova NA. Ixodid ticks (Ixodinae). Fauna USSR New Ser. 4 (4), Moscow, Leningrad: Nauka Publishing House, 1977
  • 22. Filippova NA. Ixodid ticks of subfamily Amblyomminae. Fauna of Russia and neighbouring countries. St. Petersburg: Nauka Publishing House, 1997
  • 23. Estrada-Peña A, Bouattour A, Camicas JL, Walker AR. Ticks of veterinary and medical importance: the mediterranean basin. A guide of identification of species. Zaragoza: University of Zaragoza Press, 2004
  • 24. Apanaskevich DA, Horak IG. The Genus Hyalomma Koch, 1844: V. re-evaluation of the taxonomic rank of taxa comprising the H. (Euhyalomma) marginatum Koch complex of species (Acari: Ixodidae) with redescription of all parasitic stages and notes on biology. Int J Acarol, 2008; 34: 13-42
  • 25. Hoogstraal H, Aeschlimann A. Tick–host specificity. Bull Societe Entomol Suisse, 1982; 55: 5-32
  • 26. Dantas-Torres F, Chomel BB, Otranto D. Ticks and tick-borne diseases: a One Health perspective. Trends Parasitol, 2012; 28: 437-46
  • 27. Vatansever Z, Uzun R, Estrada-Pena A, Ergonul O. Crimean-Congo hemorrhagic fever in Turkey. In: Ergonul, O., Whitehouse, C.A., (Eds.,), CrimeanCongo Hemorrhagic Fever: A Global Perspective. Netherlands: Springer, 2007: 59-74
  • 28. Gunes T, Poyraz O, Vatansever Z. CrimeanCongo hemorrhagic fever virus in ticks collected from humans, livestock, and picnic sites in the hyperendemic region of Turkey. Vector Borne Zoonotic Dis, 2011; 11(10): 1411-6.
  • 29. Duygu F, Kaya T, Baysan P. Re-evaluation of 400 Crimean-Congo hemorrhagic fever cases in an endemic area: is ribavirin treatment suitable?. Vector Borne Zoonotic Dis, 2012; 12: 812-6
  • 30. Bursali A, Tekin S, Orhan M, Keskin A, Ozkan M. Ixodid ticks (Acari: Ixodidae) infesting humans in Tokat province of Turkey: species diversity and seasonal activity. J Vector Ecol, 2010; 35: 180-6
  • 31. Keskin A. Systematic investigation of hard ticks (Acari: Ixodidae) parasitizing humans in Tokat region and determination of rickettsiae in these ticks. PhD dissertation. Tokat: Gaziosmanpasa University Institute of Science, 2014
  • 32. Bursali A, Keskin A, Tekin S. A review of the ticks (Acari: Ixodida) of Turkey: species diversity, hosts and geographical distribution. Exp Appl Acarol, 2012; 57: 91–104
  • 33. Sumer A. Kene Isırığı Nedeniyle Kaş Devlet Hastanesi Acil Servisine Başvuran Hastaların Değerlendirilmesi. Kafkas Univ Vet Fak Derg, 2010; 16: 49-53
  • 34. Over L, Inceboz T, Yapar N, Bakirci S, Gunay T, Akisu C. Dokuz Eylül Üniversitesi Hastanesi’ne Kene Tutması Yakınması ile Başvuran Olguların Araştırılması. Turkiye Parazitol Derg, 2012; 36: 75-81
  • 35. Falco RC, Fish D, Piesman J. Duration of tick bites in a Lyme disease-endemic area. Am J Epidemiol, 1996; 143: 187-92
  • 36. Robertson JN, Gray JS, Stewart P. Tick bite and Lyme borreliosis risk at a recreational site in England. Eur J Epidemiol, 2000; 16: 647-52
  • 37. Parola P, Raoult D. Ticks and tick-borne bacterial diseases in humans: an emerging infectious threat. Clin Infect Dis, 2001; 32: 897-928
  • 38. Kar S, Dervis E, Akın A, Ergonul O, Gargili A. Preferences of different tick species for human hosts in Turkey. Exp Appl Acarol, 2013; 61: 349-55
  • 39. Stafford KC 3rd. Tick Management Handbook: An Integrated Guide for Homeowners, Pest Control Operators, and Public Health Officials for the Prevention of Tick-Associated Disease. Connecticut: The Connecticut Agricultural Experimental Station, 2007
  • 40. Piesman J, Eisen L. Prevention of Tick-Borne Diseases. Annu Rev Entomol, 2008; 53: 323-43.

Tick attachment sites in humans living in the Tokat province of Turkey

Yıl 2017, Cilt: 74 Sayı: 2, 121 - 128, 01.06.2017

Öz

Objective: The aim of this study was to evaluate the attachment sites of ticks and the demographic properties of patient infested by ticks in Tokat province, a Crimean-Congo hemorrhagic fever CCHF endemic region in Turkey.Methods: In 2009, 5,089 patients with tick bites admitted to hospitals of Tokat province. A standard questionnaire, including the name, age, gender, profession, date, living area, and travel history of patients, was filled by health personals for each patient with a tick bite. Attachment sites of ticks were divided into 9 groups: abdomen, arms, axilla, back, chest, head and neck, hip, legs, and perineum, while the age-group of patients were as follows: 0-9, 10-19, 20-39, 40-64 and ≥65. Results: The majority of the patients applied n=1,051, 23.3% were found ticks on the legs of them. 20-39 year age group tick-infested were the highest proportion n=1228, 27.24% , while 2,825 62.67% of patients were male, and 1,683 37.33% were female. In addition, it was determined that 2,740 60.78% of patients were living in rural, while 1,768 39.22% were living in urban areas. A total of 20 tick taxa were identified, comprising 6 genera: Argas 1 species , Dermacentor 2 species , Haemaphysalis 3 species and 2 tür , Haemaphysalis 3 tür ve 1 alttür , Hyalomma 4 tür , Ixodes 5 tür ve Rhipicephalus 4 tür cinsleri içerisinde toplam 20 taksona ait olduğu belirlenmiştir. Sonuç: Bu çalışmayla birlikte, KKKA endemik Tokat bölgesinde kene enfestasyonu olan hastaların demografik özellikleri ve kenelerin tutunma bölgeleri ilk kez değerlendirilmiştir. Ayrıca, Türkiye’de insanların Argas vespertilionis ve Ixodes gibbosus türü keneler tarafından enfeste edildikleri ilk kez tespit edilmiştir

Kaynakça

  • 1. Williamson PC, Billingsley PM, Teltow GJ, Seals JP, Turnbough MA, Atkinson SF. Borrelia, Ehrlichia and Rickettsia spp. in ticks removed from persons, Texas, USA. Emerg Infect Dis, 2010; 16: 441-6
  • 2. Tekin S, Bursali A, Mutluay N, Keskin A, Dundar E. Crimean-Congo hemorrhagic fever virus in various ixodid tick species from a highly endemic area. Vet Parasitol, 2012; 186: 546-52.
  • 3. Oteo JA, Portillo A. Tick-borne rickettsioses in Europe. Ticks Tick Borne Dis, 2012; 3: 271-8.
  • 4. Gargili A, Kar S, Yılmazer N, Cerit C, Sonmez G, Sahin F, Alp H, Vatansever Z. Evaluation of ticks biting humans in Thrace Province, Turkey. Kafkas Univ Vet Fak Derg, 2010; 16: 141-6.
  • 5. Bursali A, Tekin S, Keskin A, Ekici M, Dundar E. Species diversity of ixodid ticks feeding on humans in Amasya, Turkey: seasonal abundance and presence of Crimean-Congo hemorrhagic fever virus. J Med Entomol, 2011; 48: 85-93.
  • 6. Bakirci S, Aysul N, Eren H, Unlu AH, Karagenc T. Diversity of ticks biting humans in Aydın province of Turkey. Ankara Univ Vet Fak Derg, 2014; 61: 93-8.
  • 7. Whitehouse CA. Crimean-Congo hemorrhagic fever. Antiviral Res, 2004; 64: 145-60.
  • 8. Yilmaz GR, Buzgan T, Irmak H, Safran A, Uzun R, Cevik MA, Torunoglu MA. The epidemiology of Crimean-Congo hemorrhagic fever in Turkey, 2002– 2007. Int J Infect Dis, 2009; 13: 380-6.
  • 9. World Health Organization (WHO) 2015. CrimeanCongo haemorrhagic fever, Available from http:// www.who.int/mediacentre/factsheets/fs208/en.
  • 10. Tonbak S, Aktas M, Altay K, Azkur AK, Kalkan A, Bolat Y, Dumanli N, Ozdarendeli A. CrimeanCongo hemorrhagic fever virus: genetic analysis and tick survey in Turkey. J Clin Microbiol, 2006; 44: 4120-4
  • 11. Hoogstraal H. The Epidemiology of Tick-Borne Crimean-Congo Hemorrhagic Fever in Asia, Europe, and Africa. J Med Entomol, 1979; 15: 307-417.
  • 12. Piesman J. Transmission of Lyme disease spirochetes (Borrelia burgdorferi). Exp Appl Acarol, 1989; 7: 71-80
  • 13. Otranto D, Dantas-Torres F, Giannelli A, Latrofa MS, Cascio A, Cazzin S, Ravagnan S, Montarsi F, Zanzani SA, Manfredi MT, Capelli G. Ticks infesting humans in Italy and associated pathogens. Parasit Vectors, 2014; 7: 328
  • 14. des Vignes F, Piesman J, Heffernan R, Schulze TL, Stafford KC 3rd, Fish D. Effect of tick removal on transmission of Borrelia burgdorferi and Ehrlichia phagocytophila by Ixodes scapularis nymphs. J Infect Dis, 2001; 183: 773-8
  • 15. Ebel GD, Kramer LD. Duration of tick attachment required for transmission of Powassan virus by deer ticks. Am J Trop Med Hyg, 2004; 71(3): 268-71
  • 16. Lane RS. Competence of ticks as vectors of microbial agents with an emphasis on Borrelia burgdorferi. In: Sonenshine, D.E., Mather, T.N., (Eds.), Ecological dynamics of tick-borne zoonoses. New York: Oxford University Press, 1994; 45-67
  • 17. Slaff M, Newton NH. Location of tick (Acari: Ixodidae) attachment sites on humans in North Carolina. J Med Entomol, 1993; 30: 485-8.
  • 18. Felz MW, Durden LA. Attachment sites of four tick species (Acari: Ixodidae) parasitizing humans in Georgia and South Carolina. J Med Entomol, 1999; 36: 361-4
  • 19. Gunduz A, Turkmen S, Turedi S, Nuhoglu I, Topbas M. Tick attachment sites. Wilderness Environ Med, 2008; 19: 4-6
  • 20. Erol S, Yenisolak A, Toros GY, Albayrak A. Evaluation of the tick bites in a Crimean-Congo haemorrhagic fever (CCHF) endemic area in Turkey. Turk J Med Sci, 2011; 41: 131-6
  • 21. Filippova NA. Ixodid ticks (Ixodinae). Fauna USSR New Ser. 4 (4), Moscow, Leningrad: Nauka Publishing House, 1977
  • 22. Filippova NA. Ixodid ticks of subfamily Amblyomminae. Fauna of Russia and neighbouring countries. St. Petersburg: Nauka Publishing House, 1997
  • 23. Estrada-Peña A, Bouattour A, Camicas JL, Walker AR. Ticks of veterinary and medical importance: the mediterranean basin. A guide of identification of species. Zaragoza: University of Zaragoza Press, 2004
  • 24. Apanaskevich DA, Horak IG. The Genus Hyalomma Koch, 1844: V. re-evaluation of the taxonomic rank of taxa comprising the H. (Euhyalomma) marginatum Koch complex of species (Acari: Ixodidae) with redescription of all parasitic stages and notes on biology. Int J Acarol, 2008; 34: 13-42
  • 25. Hoogstraal H, Aeschlimann A. Tick–host specificity. Bull Societe Entomol Suisse, 1982; 55: 5-32
  • 26. Dantas-Torres F, Chomel BB, Otranto D. Ticks and tick-borne diseases: a One Health perspective. Trends Parasitol, 2012; 28: 437-46
  • 27. Vatansever Z, Uzun R, Estrada-Pena A, Ergonul O. Crimean-Congo hemorrhagic fever in Turkey. In: Ergonul, O., Whitehouse, C.A., (Eds.,), CrimeanCongo Hemorrhagic Fever: A Global Perspective. Netherlands: Springer, 2007: 59-74
  • 28. Gunes T, Poyraz O, Vatansever Z. CrimeanCongo hemorrhagic fever virus in ticks collected from humans, livestock, and picnic sites in the hyperendemic region of Turkey. Vector Borne Zoonotic Dis, 2011; 11(10): 1411-6.
  • 29. Duygu F, Kaya T, Baysan P. Re-evaluation of 400 Crimean-Congo hemorrhagic fever cases in an endemic area: is ribavirin treatment suitable?. Vector Borne Zoonotic Dis, 2012; 12: 812-6
  • 30. Bursali A, Tekin S, Orhan M, Keskin A, Ozkan M. Ixodid ticks (Acari: Ixodidae) infesting humans in Tokat province of Turkey: species diversity and seasonal activity. J Vector Ecol, 2010; 35: 180-6
  • 31. Keskin A. Systematic investigation of hard ticks (Acari: Ixodidae) parasitizing humans in Tokat region and determination of rickettsiae in these ticks. PhD dissertation. Tokat: Gaziosmanpasa University Institute of Science, 2014
  • 32. Bursali A, Keskin A, Tekin S. A review of the ticks (Acari: Ixodida) of Turkey: species diversity, hosts and geographical distribution. Exp Appl Acarol, 2012; 57: 91–104
  • 33. Sumer A. Kene Isırığı Nedeniyle Kaş Devlet Hastanesi Acil Servisine Başvuran Hastaların Değerlendirilmesi. Kafkas Univ Vet Fak Derg, 2010; 16: 49-53
  • 34. Over L, Inceboz T, Yapar N, Bakirci S, Gunay T, Akisu C. Dokuz Eylül Üniversitesi Hastanesi’ne Kene Tutması Yakınması ile Başvuran Olguların Araştırılması. Turkiye Parazitol Derg, 2012; 36: 75-81
  • 35. Falco RC, Fish D, Piesman J. Duration of tick bites in a Lyme disease-endemic area. Am J Epidemiol, 1996; 143: 187-92
  • 36. Robertson JN, Gray JS, Stewart P. Tick bite and Lyme borreliosis risk at a recreational site in England. Eur J Epidemiol, 2000; 16: 647-52
  • 37. Parola P, Raoult D. Ticks and tick-borne bacterial diseases in humans: an emerging infectious threat. Clin Infect Dis, 2001; 32: 897-928
  • 38. Kar S, Dervis E, Akın A, Ergonul O, Gargili A. Preferences of different tick species for human hosts in Turkey. Exp Appl Acarol, 2013; 61: 349-55
  • 39. Stafford KC 3rd. Tick Management Handbook: An Integrated Guide for Homeowners, Pest Control Operators, and Public Health Officials for the Prevention of Tick-Associated Disease. Connecticut: The Connecticut Agricultural Experimental Station, 2007
  • 40. Piesman J, Eisen L. Prevention of Tick-Borne Diseases. Annu Rev Entomol, 2008; 53: 323-43.
Toplam 40 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Bölüm Araştırma Makalesi
Yazarlar

Adem Keskin Bu kişi benim

Yunus Emre Bulut Bu kişi benim

Aysun Keskin Bu kişi benim

Ahmet Bursalı Bu kişi benim

Yayımlanma Tarihi 1 Haziran 2017
Yayımlandığı Sayı Yıl 2017 Cilt: 74 Sayı: 2

Kaynak Göster

APA Keskin, A., Bulut, Y. E., Keskin, A., Bursalı, A. (2017). Tick attachment sites in humans living in the Tokat province of Turkey. Türk Hijyen Ve Deneysel Biyoloji Dergisi, 74(2), 121-128.
AMA Keskin A, Bulut YE, Keskin A, Bursalı A. Tick attachment sites in humans living in the Tokat province of Turkey. Turk Hij Den Biyol Derg. Haziran 2017;74(2):121-128.
Chicago Keskin, Adem, Yunus Emre Bulut, Aysun Keskin, ve Ahmet Bursalı. “Tick Attachment Sites in Humans Living in the Tokat Province of Turkey”. Türk Hijyen Ve Deneysel Biyoloji Dergisi 74, sy. 2 (Haziran 2017): 121-28.
EndNote Keskin A, Bulut YE, Keskin A, Bursalı A (01 Haziran 2017) Tick attachment sites in humans living in the Tokat province of Turkey. Türk Hijyen ve Deneysel Biyoloji Dergisi 74 2 121–128.
IEEE A. Keskin, Y. E. Bulut, A. Keskin, ve A. Bursalı, “Tick attachment sites in humans living in the Tokat province of Turkey”, Turk Hij Den Biyol Derg, c. 74, sy. 2, ss. 121–128, 2017.
ISNAD Keskin, Adem vd. “Tick Attachment Sites in Humans Living in the Tokat Province of Turkey”. Türk Hijyen ve Deneysel Biyoloji Dergisi 74/2 (Haziran 2017), 121-128.
JAMA Keskin A, Bulut YE, Keskin A, Bursalı A. Tick attachment sites in humans living in the Tokat province of Turkey. Turk Hij Den Biyol Derg. 2017;74:121–128.
MLA Keskin, Adem vd. “Tick Attachment Sites in Humans Living in the Tokat Province of Turkey”. Türk Hijyen Ve Deneysel Biyoloji Dergisi, c. 74, sy. 2, 2017, ss. 121-8.
Vancouver Keskin A, Bulut YE, Keskin A, Bursalı A. Tick attachment sites in humans living in the Tokat province of Turkey. Turk Hij Den Biyol Derg. 2017;74(2):121-8.