Lyme Disease

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Lyme Disease

• David J. Henzler, D.V.M., Ph.D.
• Epidemiologist
• IDEP Winter Training
• Coonskin Park, WV
• February 21, 2008

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Objectives

• Explain case ascertainment for Lyme disease
• this is a new case definition
• information needed for case ascertainment
• how to complete missing information
• clinical
• laboratory
• epidemiological

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Reporting Disease

• Provider to LHD within 1 wk (section is yellow)
  with copies of labs
• Lab to LHD within 1 wk (positive EIA/IFA or
  Western immunoblot)

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Clinical Description (early)

• Erythema migrans (EM). at least a 5 cm skin
  lesion that typically begins as a red macule or
  papule and expands over a period of days to weeks
  to form a large round lesion, often with partial
  central clearing. Secondary lesions also may
  occur. Annular erythematous lesions occurring
  within several hours of a tick bite represent
  hypersensitivity reactions and do not quality as
  EM. For most patients, the expanding EM lesion
  is accompanied by other acute symptoms-
  particularly fatigue, fever, headache
• The DX of EM must be physician made

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Clinical Description (late)

• Musculoskeletal. recurrent, brief attacks (wks or
  months) of objective joint swelling in one or few
  joints, sometimes followed by chronic arthritis
  in one or a few joints. Not considered as
  criteria of DX include chronic progressive
  arthritis not preceded by brief attacks and
  chronic symmetrical polyarthritis. Additionally,
  arthralgia, myalgia or fibromyalgia syndromes
  alone are not criteria.

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Chronic Lyme Arthritis
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Clinical Description (late)

• Nervous System. any of the following, alone or in
  combination lymphocytic meningitis cranial
  neuritis, particularly facial palsy (may be
  bilateral) radiculoneuropathy or rarely
  encephalomyelitis. Encephalomyelitis must be
  demonstration of antibody production against
  Borrelia burgdorferi in the CSF, evidenced by a
  higher titer of antibody in CSF than in serum.
  Headache, fatigue, paresthesia or mildly stiff
  neck alone are not criteria for neurologic
  involvement.

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Lyme disease Bells Palsy
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Clinical Description (late)

• Cardiovascular. Acute onset of high-grade (2nd or
  3rd degree) atrioventicular conduction defects
  that resolve in days to wks and are sometimes
  associated with myocarditis. Palpitations,
  bradycardia, bundle branch block or myocarditis
  alone are not criteria for cardiovascular
  involvement.

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Laboratory Evidence

• Qualified lab assay is positive culture for B.
  burgdorferi, two-tier testing interpreted using
  established criteria or single-tier IgG
  immunoblot seropositivity interpreted using
  established criteria (EIA/IFA or Western
  immunoblot)
• Beyond one month IgM is not acceptable evidence

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Exposure Evidence

• Having been (less than or equal to 30 days before
  onset of EM) in wooded, brushy or grassy areas in
  a county in which Lyme disease is endemic. A
  history of a tick bite is not required. the
  county is endemic for Lyme disease is one in
  which at least two confirmed cases have been
  acquired in the county or in which established
  populations of a known tick vector are infected
  with B. burgdorferi.

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Confirmed Case

• a case of EM with a known exposure
• a case of EM with laboratory evidence of
  infection and without a known exposure
• a case with at least one late manifestation that
  has laboratory evidence of infection

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Case Classification Confirmed
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Case Classification Confirmed One Late
Manifestation and Lab
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Probable Case

• Any other case of physician-diagnosed Lyme
  disease that has laboratory evidence of infection

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Case Classification Probable
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Getting Missing Information

• Contact physicians office or reference laboratory
• ask for clinical information
• obtain copies of laboratory results
• offer testing free at OLS
• Send WVEDDS clinical section to physicians office
  or call and ask them (physician office should
  have both clinical info and labs)

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next after case ascertainment

• If case early (EM) observed with past 30 days
  Identify location of likely exposure (county)
• Enter case in WVEDSS
• Education risk factors, personal preventive
  measures
• Especially important is to educate medical health
  providers on availability of free OLS testing

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References

• http//www.cdc.gov/ncidod/dvbid/lyme/index.htm.
• Centers for Disease Control and Prevention.
  Recommendations for test performance and
  interpretation from the Second National
  Conference on Serological Diagnosis of Lyme
  Disease. MMWR Morb Mort Wkly Rep 1995 44
  (31)590-1.
• Centers for Disease Control and Prevention.
  Notice to readers caution regarding testing for
  Lyme disease. MMWR Morb Mortal Wkly Rep 2005 54
  (05)125-6.
• Hanincova K, Kurtenbach K, Diuk-Wassar M, Brei B,
  Fish D. Epidemic Spread of Lyme Borreliosis,
  Northeastern United States. Emer Infect Dis
  2006 12(4)604-610.

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Thank You Questions?
Somewhere WV 2007