Shortly after her first child was born, Colleen Safford left Manhattan for a 10-acre spread north of the urban jungle to create a new life for her growing family - a life immersed in the outdoors.
But along with the woods and grassy fields came a drawback of country life in the Northeast: the black-legged tick, which can carry the Lyme disease bacteria.
"I wanted grass stains for my kids instead of cement scrapes," said Safford, who owns a dog boarding business on her property in Chatham, about two hours north of New York City. "I wanted them to have an intense outdoor experience, and Lyme disease came with it. But it's worth it."
There were 30,158 cases of confirmed and probable Lyme cases reported in 2010, according to the federal Centers for Disease Control and Prevention, with 94 percent of those cases being reported from 12 states in the Northeast and upper Midwest.
The disease may be spreading, according to a study released in February in the American Journal of Tropical Medicine and Hygiene. It showed a clear risk across much of the Northeast, from Maine to northern Virginia; a high-risk region in the upper Midwest, including parts of Wisconsin, Minnesota and Illinois; and "emerging risk" regions including the Illinois-Indiana border, southwestern Michigan and eastern North Dakota.
The mild winter this year could increase the number of Lyme cases. Adult ticks have been active earlier than usual and people have been getting outside sooner than they typically do, increasing the exposure season, said Paul Curtis, a natural resources professor and tick expert at Cornell University.
Nobody suggests staying indoors this summer. But nature enthusiasts, hikers, gardeners and people who work outside in high-risk areas need to guard against ticks.
"If you're engaged in outdoor activities and you do regular tick checks, you'll be able to find them," said Phillip Baker, executive director of the American Lyme Disease Foundation. "Once they take a meal, they get bigger. If they're still there the next day and it's still less than 48 hours, you can pick them off. That gives you a bit of a safety measure."
Only an infected tick attached to your body for about 36 to 48 hours can make you sick, he said.
Lyme disease causes flu-like symptoms including fever, chills and achy joints, and often a distinctive bull's-eye rash. Most people recover quickly when treated early with antibiotics, but untreated infections can cause more serious conditions like Bell's palsy, arthritis and neurological problems.
Besides tick checks, the American Lyme Disease Foundation recommends wearing light-colored, tightly woven clothing to make it easier to see crawling ticks; avoiding sitting directly on the ground or on stone walls; walking in the middle of established trails rather than at the edges; tucking pants into socks, and shirts into pants; and wearing covered shoes.
For sun lovers and others who don't want to cover up, there are spray repellents that Baker said work "pretty well."
There also is clothing made with the insect repellent permethrin bonded to the fibers.
Other ways to help prevent Lyme disease, according to the CDC, include bathing after being outside, to help spot ticks or wash of ones that haven't attached yet; checking outdoor gear and pets for ticks; and running clothing through a hot dryer for an hour to kill any ticks.
In New York's Columbia County, where Safford lives, Lyme is a part of everyday life.
"People talk about it like you would talk about a common cold up here," Safford says.
"You just need to be aware that it's in your environment and err on the side of caution in terms of your checking, but not allow it to hinder or affect your lifestyle."
Her two older children - Sayer, 5, and Orla, 3 - attend a school where they spend most of the day outside tending to gardens and animals, and the family of five often hikes on weekends. Only Sayer has been treated for Lyme, twice when he was 4.
Boys ages 5 to 10 have the highest number of reported Lyme disease cases, according to federal figures.
Safford says she uses natural repellents against Lyme and checks her children's bodies nightly at bath time, removing any ticks that are found. Ticks are especially fond of bodily creases such as armpits, the back of the knee, the groin and the nape of the neck.
"We just say, 'tick check,' and they lift up their arms and I look through their scalp and hair," Safford says. And she and her husband scan each other. "It's very romantic," she joked.