Recommendations for the Use of Lyme Disease Vaccine

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                                                 E. Anne Peterson, M.D., M.P.H., Acting Health Commissioner   Elizabeth Barrett, D.M.D., M.S.P.H., Editor
                                                 Robert B. Stroube, M.D., M.P.H., State Epidemiologist        Vickie L. O’Dell, Layout Editor

          June 1999                                                                                                                    Volume 99, Number 6

                 Recommendations for the Use of Lyme Disease Vaccine
           Recommendations of the Advisory Committee on Immunization Practices (ACIP)

          Summary                                          public with guidance regarding the risk for            The following is adapted from the MMWR
                                                           acquiring Lyme disease and the role of vac-         article with the above title (1999;48[No. RR-
             This report provides recommendations for      cination as an adjunct to preventing Lyme           7]:1-17). If you would like to receive a copy
          use of a newly developed recombinant outer-      disease. The Advisory Committee on Immu-            of the entire MMWR article, you may call
          surface protein A Lyme disease vaccine           nization Practices recommends that deci-            the Office of Epidemiology at 804/786-6261
          (LYMErix,TM SmithKline Beecham Pharma-           sions regarding vaccine use be made on the          or visit the Centers for Disease Control and
          ceuticals) for persons aged 15-70 years in       basis of assessment of individual risk, tak-        Prevention (CDC) web site at http://
          the United States. The purpose of these rec-     ing into account both geographic risk and a
          ommendations is to provide health-care           person’s activities and behaviors relating to
7654321   providers, public health authorities, and the    tick exposure.
            National Lyme disease risk map with four categories of risk

                                                                                                                               Areas of predicted Lyme
                                                                                                                               disease transmission

                                                                                                                                        High risk

                                                                                                                                        Moderate risk

                                                                                                                                        Low risk
654321                                                                                                                                  Minimal or no risk
Lyme Disease Vaccine                                cidence of adverse events more than 30 days       49% (95% confidence interval [CI] = 15%-
                                                    after receiving a dose, and no episodes of        69%) and after three doses was 76% (95%
                                                    immediate hypersensitivity among vaccine          CI = 58%-86%). (In this study, “definite”
Description                                         recipients were noted.                            Lyme disease was defined as the presence of
   LYMErix is made from lipidated recom-                                                              erythema migrans or objective neurologic,
                                                    Safety in Patients with Previously                musculoskeletal, or cardiovascular manifes-
binant outer-surface protein A (rOspA) of
Borrelia burgdorferi. The rOspA protein is          Diagnosed Lyme Disease                            tations of Lyme disease, plus laboratory con-
expressed in Escherichia coli and purified.             The safety of three different dosage          firmation of infection by culture, polymerase
Each 0.5-mL dose of LYMErix contains 30             strengths of rOspA vaccine with adjuvant          chain reaction [PCR] positivity, or Western
mg of purified rOspA lipidated protein              was evaluated in 30 adults with previous          immunoblot [WB] seroconversion.) Efficacy
adsorbed onto aluminum hydroxide adjuvant.          Lyme disease in an uncontrolled safety and        in protecting against asymptomatic infection
The rOpsA vaccine elicits antibodies that kill      immunogenicity trial. Doses were adminis-         (no recognized symptoms, but with WB
Lyme disease spirochetes within the tick gut        tered at 0, 1, and 2 months. Follow-up of         seroconversions recorded in year 1 or year
while the tick is feeding.                          subjects was conducted 1 month after the          2) was 83% (95% CI = 32%-97%) in year 1
                                                    third dose. No serious adverse events were        and 100% (95% CI = 26%-100%) in year 2.
Route of Administration,
                                                    recorded during the study period.                 Immunogenicity
Vaccination Schedule, and Dosage                        In the randomized controlled Phase III
    LYMErix is administered by intramuscu-          trial, the incidence of adverse events among          A subset of adult subjects enrolled in the
lar injection, 0.5 mL (30 mg), into the del-        vaccinees who were seropositive at baseline       Phase III clinical trial was studied for the
toid muscle. Three doses are required for op-       was similar to the incidence among those who      development of OspA antibodies at months
timal protection. The first dose is followed        were seronegative. Among vaccinees, 20%           2, 12, 13, and 20. At month 2, one month
by a second dose 1 month later and a third          of persons who self-reported a history of Lyme    after the second injection, the geometric mean
dose administered 12 months after the first         disease experienced early (within 30 days of      antibody titer (GMT) of IgG anti-OspA an-
dose. Vaccine administration should be timed        vaccination) musculoskeletal symptoms             tibodies was 1,227 enzyme-linked
so that the second dose of the vaccine (year        compared with 13% of persons with no his-         immunosorbent assay (ELISA) units/mL.
1) and the third dose (year 2) are adminis-         tory of Lyme disease (p<0.001). By compari-       Ten months later, the GMT had declined to
tered several weeks before the beginning of         son, a history of self-reported Lyme disease      116 ELISA units/mL. At month 13, one
the B. burgdorferi transmission season,             did not affect the incidence of early muscu-      month after the third injection, a marked an-
which usually begins in April. The safety and       loskeletal symptoms in the placebo group          amnestic response resulted in a GMT of
immunogenicity of alternate dosing sched-           (13% vs 11%, p=0.24). In both the vaccine         6,006 ELISA units/mL. At month 20, the
ules are currently being evaluated.                 and placebo groups, there was an increased        mean response had decreased to 1,991 ELISA
                                                    incidence of late (>30 days post-vaccination)     units/mL. An analysis of antibody titers and
Vaccine Performance                                 musculoskeletal symptoms in subjects with         the risk for developing Lyme disease con-
                                                    a history of Lyme disease compared with           cluded that a titer greater than 1,200 ELISA
Safety                                              persons without a history of Lyme disease.        units/mL correlated with protection.
                                                    No statistically significant difference existed
    A total of 10,936 subjects aged 15-70 years                                                       Effect of Vaccination on the
                                                    in the incidence of late musculoskeletal ad-
living in Lyme disease-endemic areas were           verse events between vaccine and placebo re-
                                                                                                      Serologic Diagnosis of Lyme Disease
recruited at 31 sites and randomized to re-         cipients with a self-reported previous history        Care providers and laboratorians should
ceive three doses of vaccine or placebo (Phase      of Lyme disease (33% vs 35%, p=0.51).             be advised that vaccine-induced anti-rOspA
III clinical trial). The subjects were then fol-                                                      antibodies routinely cause false-positive
lowed for 20 months. Soreness at the injec-         Possible Immunopathogenicity of
                                                                                                      ELISA results for Lyme disease. Experienced
tion site was the most frequently reported          rOspA Vaccine                                     laboratory workers, through careful interpre-
adverse event, which was reported without                                                             tation of the results of WB, can usually dis-
                                                       In chronic Lyme arthritis patients, the lev-
solicitation by 24.1% of vaccine recipients                                                           criminate be-
                                                    els of antibody to OspA have been found to
and 7.6% of placebo recipients (p < 0.001).                                                           tween        B.
                                                    correlate directly with the severity and dura-
Redness and swelling at the injection site                                                            burgdorferi
                                                    tion of the arthritis. The Phase III trial did
were reported by less than 2% of either group                                                         infection and
                                                    not detect differences in the incidence of neu-
but were reported more frequently among                                                               previous
                                                    rologic or rheumatologic disorders between
vaccine recipients than among those who re-                                                           rOspA immu-
                                                    vaccine recipients and their placebo controls
ceived placebo (p < 0.001). Myalgia, influ-                                                           nization, be-
                                                    during the 20 months after the initial dose.
enza-like illness, fever, and chills were more                                                        cause anti-
                                                    However, because the association between
common among vaccine recipients than pla-                                                             OspA anti-
                                                    immune reactivity to OspA and treatment-
cebo recipients (p < 0.001), but none of these                                                        bodies do not
                                                    resistant Lyme arthritis is poorly understood,
was reported by more than 3.2% of subjects.                                                           develop after
                                                    the vaccine should not be administered to
Reports of arthritis were not significantly                                                           natural infec-
                                                    persons with a history of treatment-resistant
different between vaccine and placebo recipi-                                                         tion.
                                                    Lyme arthritis.
ents, but vaccine recipients were significantly
(p < 0.05) more likely to report arthralgia or      Efficacy
myalgia within 30 days after each dose. No
statistically significant differences existed be-      The vaccine efficacy in protecting against
tween vaccine and placebo groups in the in-         “definite” Lyme disease after two doses was

  2                                                                                                                                       June 1999
Assessing the Risk for Lyme                        favorable for deer and the
                                                   ticks’ rodent hosts. Outdoor        Remembering Our Past - Looking to Our Future
Disease                                            activities such as recreation,         APIC - Virginia’s 25th Annual Educational
    The decision to administer Lyme disease        property maintenance, and oc-                          Conference
vaccine should be made on the basis of an          cupational pursuits that are
assessment of individual risk, which depends       carried out in tick habitat can      Date: September 29 - October 1, 1999
on a person’s likelihood of being bitten by        be risky activities.                 Location: Fort Magruder Inn, Williamsburg, VA
tick vectors infected with B. burgdorferi. This                                         Contact: Mary Ann Robinson RN, CIC
likelihood is primarily determined by the fol-
                                                   Recommendations                              Eastern State Hospital
lowing:                                            and                                          Williamsburg, VA 23187-8791
• density of vector ticks in the environ-          Contraindications for                        Phone: 757-253-5599
    ment, which varies by place and
                                                   Use of Lyme Disease
• prevalence of B. burgdorferi infection           Vaccine                                               result in frequent or prolonged
    in vector ticks; and                                                                                 exposure to tick-infested habitat.
                                                       Lyme disease vaccine does not protect all     Lyme disease vaccination may be consid-
• extent of person-tick contact, which is          recipients against infection with B.                  ered for persons aged 15-70 years who
    related to the type, frequency, and            burgdorferi and offers no protection against
    duration of a person’s activities in a                                                               are exposed to tick-infested habitat but
                                                   other tickborne diseases. Vaccinated persons
    tick-infested environment.                                                                           whose exposure is neither frequent nor
                                                   should continue to practice personal protec-
    Assessing risk should include consider-                                                              prolonged. The benefit of vaccination
                                                   tive measures against ticks and should seek
ation of the geographic distribution of Lyme                                                             beyond that provided by basic personal
                                                   early diagnosis and treatment of suspected
disease. The areas of highest Lyme disease         tickborne infections. Because Lyme disease            protection and early diagnosis and
risk in the United States are concentrated         is not transmitted person-to-person, use of           treatment of infection is uncertain.
within some northeastern and north-central         the vaccine will not reduce risk among un-        Lyme disease vaccination is not recom-
states (see Map). The risk for Lyme disease        vaccinated persons. Decisions regarding the           mended for persons who have minimal
differs not only between regions and states        use of vaccine should be based on individual          or no exposure to tick-infested habitat.
and counties within states, but even within        assessment of the risk for exposure to infected   • Persons Who Reside, Work, or
counties and townships. Detailed informa-          ticks and on careful consideration of the rela-       Recreate in Areas of Low or No Risk
tion regarding the distribution of Lyme dis-       tive risks and benefits of vaccination com-       Lyme disease vaccination is not recom-
ease risk within specific areas is best obtained   pared with other protective measures, includ-         mended for persons who reside, work,
from state and local public health authori-        ing early diagnosis and treatment of Lyme             or recreate in areas of low or no risk.
ties.                                              disease.                                          • Travelers to Areas of High or
    Activities that place persons at high risk         The following recommendations are made            Moderate Risk
are those that involve frequent or prolonged       regarding use of Lyme disease vaccine:            Because of the limited time of exposure,
exposure to the habitat of infected ticks at       • Persons Who Reside, Work, or                        travelers to Lyme disease-endemic
times of the year when the nymphal stages              Recreate in Areas of High or                      areas within the United States are
of these ticks are actively seeking hosts,             Moderate Risk                                     generally expected to be at lower risk
which in most endemic areas is April-July.         Lyme disease vaccination should be
Typical habitat of Ixodes ticks are wooded,                                                              for Lyme disease than those who
                                                       considered for persons aged 15-70                 permanently reside in endemic areas.
brushy, or overgrown grassy areas that are
                                                       years who engage in activities that               Vaccination should be considered for
                                                                                                         travelers to areas of high risk if
 Tick Vectors of Lyme Disease
 Tick ectors     Lyme                                                                                    frequent or prolonged exposure to tick
     Ixodes scapularis, the black-legged or deer tick, is the vector in the eastern United               habitat is anticipated.
 States; I. pacificus, the western black-legged tick is the vector in the western United                 Travelers can obtain some protection from
 States. I. scapularis is also a vector for human granulocytic ehrlichiosis and babesio-             two doses of vaccine but will not achieve
 sis. In their nymphal stage, these ticks feed predominantly in the late spring and early            optimal protection until the full series of three
 summer. The majority of Lyme disease cases result from bites by infected nymphs. In                 doses has been administered. All travelers to
 highly enzootic areas of the United States, approximately 15%-30% of questing I.                    high- or moderate-risk areas during Lyme
 scapularis nymphs and up to 14% of I. pacificus nymphs are infected with B. burgdorferi.            disease transmission season should practice
 However, in the southern United States, the prevalence of infection in I. scapularis                personal protection measures and seek
 ticks is generally 0%-3%. This low prevalence may be due in part to the feeding habits              prompt diagnosis and treatment if signs or
 of southern I. scapularis larvae and numphs that prefer skinks and lizards, instead of              symptoms of Lyme disease develop. Lyme
 the B. burgdorferi reservoir rodents. The risk for acquiring Lyme disease in the United             disease is endemic in some temperate areas
 States varies with the distribution, density, and prevalence of infection in vector ticks.
                                                                                                     of Europe and Asia; however, considerable
     During the past several decades, the distribution of I. scapularis has spread slowly
                                                                                                     heterogeneity of expression exists in the Eur-
 in the northeastern and upper north-central regions of the United States. Although
 deer are not competent reservoirs of B. burgdorferi, they are the principal mainte-
                                                                                                     asian strains of B. burgdorferi that infect
 nance hosts for adult black-legged ticks, and the presence of deer appears to be a                  humans, and whether the rOspA vaccine li-
 prerequisite for the establishment of I. scapularis in any area. The explosive repopulation         censed for use in the United States would
 in the eastern United States by white-tailed deer during recent decades has been linked             protect against infection with Eurasian
 to the spread of I. scapularis ticks and of Lyme disease in this region. The future limits          strains is uncertain.
 of this spread are not known.                                                                                                  (continued on page 5)

Epidemiology Bulletin                                                                                                                                   3
          A Primer on Lyme Disease and Considerations for Using the Vaccine in Virginia
                            Suzanne R. Jenkins, VMD, MPH, Director, Zoonotic Disease Control

Introduction                                develop chronic axonal polyneuropathy        dium (i.e., modified Barbour-Stoenner-
    The availability and widespread         or encephalopathy with subtle cognitive      Kelly medium) and protracted observa-
marketing of the first human vaccine        disorders, sleep disturbance, fatigue        tion of cultures. Polymerase chain
for the prevention of Lyme disease          and personality changes. An ill-defined      reaction (PCR) has been used to
(LYMErix, SmithKline Beecham) is            post-Lyme disease syndrome has been          amplify genomic DNA of B. burgdorferi
raising questions for both public and       described for some persons following         in skin, blood, cerebrospinal fluid, and
private health care providers about the     treatment for the disease. Lyme              synovial fluid, but PCR has not been
most appropriate use for such a             disease is rarely, if ever, fatal.           standardized for routine diagnosis of
vaccine. Lyme disease is caused by          Diagnosis                                    Lyme disease.
Borrelia burgdorferi, a tick-borne              Patients who present with EM             Treatment
spirochete. In this country, more than      should be treated without serologic              Early and uncomplicated infection,
90% of the reported cases occur in the      testing. Serologic testing may be useful     including infection presenting with
Northeast, Mid-Atlantic area (which         for persons with endemic exposure,           isolated cranial nerve palsy, almost
does not include Virginia) and upper        signs of disseminated disease, and no        always responds to treatment with
Midwest, with the highest incidence in      EM. Negative test results help rule out      orally administered antibiotics.
persons who live, work or recreate in       Lyme disease for persons with symp-          Parenteral antibiotics are recom-
grassy or wooded areas. The tick            toms compatible with disseminated or         mended for treating meningitis, later
vector in these areas is Ixodes             late-stage infection. The proportion of      stage neurologic Lyme disease and
scapularis, the deer tick. Transmission     false positive results increases as the      complicated arthritis. Late, complicated
of the spirochete from the tick requires    likelihood of exposure decreases so          Lyme disease may respond slowly or
attachment of the tick for at least 36 to   serologic testing is not recommended         incompletely, and more than one
48 hours.                                   for persons who do not have endemic          treatment course may be required to
Disease                                     exposure.                                    eliminate active infection. Refractory
    Lyme disease most often presents            When serologic testing is indicated,     Lyme disease arthritis is associated
with a characteristic rash, erythema        the Centers for Disease Control and          with the HLA-DR4 haplotype and may
migrans (EM), that occurs at the site of    Prevention (CDC) recommends testing          require anti-inflammatory agents and
the bite and expands to >5cm with           initially with a sensitive test, either an   surgical synovectomy for relief. The
central clearing, or annular clearing if    enzyme-linked immunosorbent assay            minority of patients reporting persistent
there is local reaction to the bite. The    (ELISA) or an indirect fluorescent           or recurrent symptoms following
rash may be accompanied by nonspe-          antibody test, followed by testing with      appropriate antibiotic therapy (chronic
cific symptoms such as fever, malaise,      the more specific Western immunoblot         Lyme disease, Post-Lyme disease
fatigue, headache, myalgia and              (WB) test to corroborate equivocal or        syndrome) may have symptoms due to
arthralgia. The incubation period can       positive results obtained with the first     some other cause.
range from a few days to a month, but       test. Although antibiotic treatment in       Considerations for Vaccine Use
is usually between one and two weeks.       early-localized disease can blunt or             The risk of acquiring Lyme disease
EM is recognized in 85% or more of          abrogate the antibody response,              should be assessed based on density
the patients. A small percentage of         patients with early disseminated or          of vector ticks, prevalence of infected
infected individuals have no recogniz-      late-stage disease usually have strong       ticks (which requires infected rodent
able illness.                               serologic reactivity and demonstrate         reservoirs), reported rates of human
    Signs of early disseminated infec-      expanded WB immunoglobulin G (IgG)           cases, and extent of contact that an
tion usually occur days to weeks after      banding patterns to diagnostic B.            individual has with the vector ticks. In
the appearance of a single EM lesion        burgdorferi antigens.                        Virginia, I. scapularis is most prevalent
and may include multiple EM lesions,            Antibodies often persist for months      on the Eastern Shore. There are also
neurologic manifestations (lymphocytic      or years after successfully treated or       higher populations on the Peninsula
meningitis; cranial neuropathy, espe-       untreated infection. Thus, seroreactivity    and possibly in the Potomac River
cially facial nerve palsy; and              alone cannot be used as a marker of          basin. As you move west through the
radiculoneuritis), musculoskeletal          active disease. Neither positive             Piedmont Plateau and into the moun-
manifestations (migratory joint and         serologic test results nor a history of      tains, the I. scapularis densities fall off.
muscle pains with or without joint          previous Lyme disease ensures that a         These ticks may be found sporadically
swelling), or rarely, cardiac manifesta-    person has protective immunity.              in these areas, but are not well estab-
tions (transient atrioventricular blocks    Repeated infection with B. burgdorferi       lished. West of the Blue Ridge Moun-
of varying degrees).                        has been reported.                           tains the American Dog Tick, Derma-
    Untreated infection may progress to         B. burgdorferi can be cultured from      centor variabilis, predominates. The
late disseminated disease weeks to          80% or more of biopsy specimens              Lone Star Tick, Amblyomma
months after infection. The most            taken from early EM lesions. However,        americanum, the one with the white
common clinical picture is intermittent     the diagnostic usefulness of this            spot on its back, is more likely than the
arthritis of one or more joints, particu-   procedure is limited because of the          deer tick to be found on humans in
larly the knee. Less commonly, patients     need for a special bacteriologic me-         Virginia.
  4                                                                                                                         June 1999
    Studies conducted in the early               is a “low risk” state for Lyme disease.           Lastly, as with any new vaccine, a
1990s by Dr. Daniel Sonenshine of Old                In Virginia, an annual average of 1.3      number of issues still need to be
Dominion University detected infected            Lyme disease cases per 100,000                 settled. There are the questions about
populations of I. scapularis and rodents         population were reported during 1993-          use in children and the elderly, what the
on the Eastern Shore and near                    1997 versus a national average of 5.5          optimal dosing and scheduling should
Williamsburg. However the rates of               per 100,000. Some states have rates            be, the need for and spacing of booster
infection on the Peninsula were lower            as high as 15 to 40 per 100,000. As            doses, the potential for rare or late-
than those on the Eastern Shore, which           indicated, some areas in Virginia pose         developing adverse effects, and the
were well below those found in known             a higher risk than others, so it is            cost effectiveness of the vaccine.
highly endemic areas such as Long                important to know what is being seen in        Efficacy is reported to be about 50%
Island, New York and New England. In             your community. The extent of contact          after two doses and 76% after three
addition, the military has found the tick        with ticks should be evaluated by              doses.
vector for Lyme disease to be estab-             determining whether or not the person
lished at the following sites:                        engages in activities that result in
                                                                                                   It is unlikely that very many Virgin-
Fort A.P. Hill, Fort Belvoir,                                frequent or prolonged expo-
                                                                                                ians are at risk for acquiring Lyme
Fort Eustis, and                                             sure to tick-infested habitats.
                                                                                                disease given the restricted areas in
Quantico. Although ticks                                        There are additional
                                                                                                which the tick is commonly found, the
and rodents have not                                       considerations when deciding
                                                                                                low rates of infection in ticks and
been sampled in most                                       whether to use the Lyme
                                                                                                rodents, and the availability of a
other areas, the locations                                  disease vaccine. Individuals at
                                                                                                treatment when symptoms are recog-
that were studied were                                       risk for tick exposures still
                                                                                                nized. When considering whether to
selected because ecologi-                                     need to be stringent in their
                                                                                                recommend the vaccine, the low risk
cally they were the most                                       personal protection mea-
                                                                                                for disease must be weighed against
likely to have infected ticks                                   sures. Rocky Mountain
                                                                                                what is known about the efficacy of the
and rodents. We concur                                          Spotted Fever and
                                                                                                vaccine and what is unknown about its
with the CDC that Virginia                                       ehrlichiosis are both very
                                                                                                long-term effects.
                                                                 real risks in Virginia.

(continued from page 3)

• Children Aged < 15 Years                       cination by calling (800) 366-8900, ext.         illness related to Lyme disease, as well
Until the safety and immunogenicity of           5231.                                            as second- or third-degree atrioven-
   rOspA vaccines in children have been          • Persons with Immunodeficiency                  tricular block, were excluded from the
   established, this vaccine is not              Persons with immunodeficiency were               Phase III safety and efficacy trial, and
   recommended for children aged less               excluded from the Phase III safety and        thus, the safety and efficacy of Lyme
   than 15 years. Currently, LYMErix is             efficacy trial, and no data are available     disease vaccine in such persons are
   licensed for use in persons aged 15-70           regarding Lyme disease vaccine use in         unknown.
   years only.                                      this group.                                 • Boosters
• Persons Aged > 70 Years                        • Persons with Musculoskeletal                 Whether protective immunity will last
The safety and efficacy of LYMErix have             Disease                                       longer than 1 year beyond the month-
   not been established for persons aged         Persons with diseases associated with            12 dose is unknown. Data regarding
   greater than 70 years.                           joint swelling (including rheumatoid          antibody levels during a 20-month
• Pregnant Women                                    arthritis) or diffuse musculoskeletal         period after the first injection of
Because the safety of rOspA vaccines                pain were excluded from the Phase III         LYMErix indicate that boosters
   administered during pregnancy has                safety and efficacy trial, and only           beyond the month-12 booster might be
   not been established, vaccination of             limited data are available regarding          necessary. Additional data are needed
   women who are known to be pregnant               Lyme disease vaccine use in such              before recommendations regarding
   is not recommended.                              patients.                                     vaccination with more than three
   No evidence exists that pregnancy in-         • Persons with a Previous History of             doses of rOspA vaccine can be made.
creases the risk for Lyme disease or its se-        Lyme Disease                                • Simultaneous Administration with
verity. Acute Lyme disease during pregnancy      Vaccination should be considered for             Other Vaccines
responds well to antibiotic therapy, and ad-        persons with a history of previous          The safety and efficacy of the simulta-
verse fetal outcomes have not been reported         uncomplicated Lyme disease who are            neous administration of rOspA
in pregnant women receiving standard                at continued high risk.                       vaccine with other vaccines have not
courses of treatment. A vaccine pregnancy        Persons who have treatment-resistant             been established. If LYMErix must be
registry has been established by SmithKline         Lyme arthritis should not be vacci-           administered concurrently with other
Beecham Pharmaceuticals. In the event that          nated because of the association              vaccines, each vaccine should be
a pregnant woman is vaccinated, health-care         between this condition and immune             administered in a separate syringe at a
providers are encouraged to register this vac-      reactivity to OspA.                           separate injection site.
                                                 Persons with chronic joint or neurologic

Epidemiology Bulletin                                                                                                                    5
                                       Cases of Selected Notifiable Diseases Reported in Virginia*

                                                     Total Cases Reported, May 1999

                                                                                                         Total Cases Reported Statewide,
                                                                         Regions                               January through May

      Disease                               State    NW         N        SW         C         E        This Year        Last Year      5 Yr Avg
AIDS                                          56         2        8       24        11       11            295             343            450
Campylobacteriosis                            77         9       11       21        19       17            180             193            183
E. coli O157:H7                                9         2        0        1         1        5             18              11               6
Giardiasis                                    31         5       12        7         3        4            127             141            122
Gonorrhea                                    730        18       75      113       237      287           3847            2441           3871
Hepatitis A                                   13         0        6        0         4        3             54             115             77
          B, acute                            11         3        3        3         0        2             40              45             48
          C/NANB, acute                        2         0        2        0         0        0              8               3               8
HIV Infection                                 59         8       12       10        11       18            268             364            411
Lead in Children†                             18         1        1        4         7        5            126             194            233
Legionellosis                                  4         0        1        2         0        1             10               7               7
Lyme Disease                                  12         1        2        0         6        3             15              10               9
Measles                                        0         0        0        0         0        0              3               2               1
Meningococcal Infection                        5         0        2        1         1        1             24              20             28
Mumps                                          1         0        0        0         0        1               8              4              10
Pertussis                                      1         0        0        0         0        1             13               6              10
Rabies in Animals                             72        11       25        7        17       12            207             261            2 13
Rocky Mountain Spotted Fever                   0         0        0        0         0        0              0               0               1
Rubella                                        0         0        0        0         0        0              0               0             <1
Salmonellosis                                 72         5       18       19         8       22            239             301            311
Shigellosis                                    8         1        6        0         0        1             29              54            150
Syphilis, Early§                              22         0        3       10         3        6            16 3            189            395
Tuberculosis                                  21         0       10        0         5        6            10 8            121            136
Localities Reporting Animal Rabies This Month: Accomack 2 raccoons; Alexandria 1 bat; Alleghany 1 raccoon; Amelia 2 raccoons; Arlington 1 raccoon;
Botetourt 1skunk; Charles City 1 raccoon; Chesapeake 1 raccoon; Chesterfield 1 dog, 3 raccoons; Culpeper 1 cat; Dinwiddie 1 dog; Fairfax 4 foxes, 9
raccoons; Frederick 1 raccoon; Gloucester 1 raccoon; Halifax 1 skunk; Hanover 1 bat, 1 fox; Henrico 1 bat; Isle of Wight 1 raccoon; King George 2
raccoons, 1 skunk; Loudoun 1 bat, 2 foxes, 5 raccoons; Mathews 1 raccoon; Middlesex 1 skunk; Northampton 1 raccoon; Page 1 raccoon; Pittsylvania 1
raccoon; Powhatan 1 fox, 1 raccoon; Prince George 1 raccoon; Prince William 1 fox, 1 raccoon; Pulaski 1 raccoon; Richmond City 2 raccoons;
Rockingham 2 raccoons; Russell 1 fox; Scott 1 skunk; Stafford 1 raccoon, 1 skunk; Suffolk 2 raccoons; Wythe 1 raccoon; York 2 raccoons.
Occupational Illnesses: Asbestosis 51; Carpal Tunnel Syndrome 51; Carbon Monoxide Exposure 1; De Quervain’s Syndrome 1; Hearing Loss 36; Lead
Exposure 15; Mercury Exposure 1; Pneumoconiosis 5.
*Data for 1999 are provisional. †Elevated blood lead levels >10µg/dL.
 Includes primary, secondary, and early latent.
Published monthly by the                                                                                                        Bulk Rate
VIRGINIA DEPARTMENT OF HEALTH                                                                                                 U.S. POSTAGE
Office of Epidemiology                                                                                                             PAID
P.O. Box 2448                                                                                                                 Richmond, Va.
Richmond, Virginia 23218                                                                                                      Permit No. 591
Telephone: (804) 786-6261

  6                                                                                                                                      June 1999