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					     Lyme Disease

David J. Henzler, D.V.M., Ph.D.
         Epidemiologist

       IDEP Winter Training
        Coonskin Park, WV
        February 21, 2008
                   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
          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)
     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
      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.
Chronic Lyme Arthritis
       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.
Lyme disease Bell’s Palsy
      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.
         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.

  – Beyond one month IgM is not acceptable
    evidence
           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.
            Confirmed Case
A. a case of EM with a known exposure

B. a case of EM with laboratory evidence of
   infection and without a known exposure

C. a case with at least one late manifestation
   that has laboratory evidence of infection
Case Classification: Confirmed
Case Classification: Confirmed
One Late Manifestation and Lab
             Probable Case
   Any other case of physician-diagnosed
    Lyme disease that has laboratory evidence
    of infection
Case Classification: Probable
    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)
… 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
                   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.
Thank You … Questions?




                 Somewhere WV 2007

				
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