IDEP Training May 5, 2005

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IDEP TrainingMay 5, 2005

• West Virginia Lyme Disease
• Past and Present

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Lyme Disease in North America

• 1977-Lyme disease was named
• 1982-CDC began surveillance of Lyme
  disease
• -Causative spirochete Borrelia
  borgdorferi identified in deer tick
• 1984-B. borgdorferi proven to cause
  disease
• 1991-Became a nationally notifiable disease
• 2002-Caused more than 23,000 infections
  in the United States.

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Lyme disease in North America
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West Virginia Lyme Disease
N147
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Lyme Disease in West Virginia

• Lyme disease cases usually occur between April
  and November, with the peak in June or July.

N147
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West Virginia Lyme Disease by County
N147
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2
4
6
2
1
1
1
1
No Cases
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Clinical symptoms of Lyme Disease

• Erythema Migran (usually 3 to 32 days after tick
  bite)

• First manifestation in 90 of patients is the
  erythema migran, a red macule or papule that
  expands slowly in an annular manner, often with
  central clearing.

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Late Manifestations (when alternate explanation
is not found)

• Clinical symptoms of Lyme disease

• Musculoskeletal system Recurrent, brief attacks
  (weeks or months) of objective joint swelling in
  one or a few joints, sometimes followed by
  chronic arthritis in one or few joints.
• Nervous system Lymphocytic meningitis, cranial
  neuritis, particularly facial palsy,
  radiculoneurapathy, or, rarely,
  encephalomyelitis.
• Cardiovascular system Acute onset of high-grade
  (2 or 3) atrioventricular conduction defects
  that resolve in days to weeks and are sometimes
  associated with myocarditis

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Lyme Disease in West Virginia
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Laboratory criteria for diagnosis

• Isolation of B. burgdorferi from a clinical
  specimen or
• Demonstration of diagnostic immunoglobulin M
  (IgM) or immunoglobulin G (IgG) antibodies to B.
  burgdorferi in serum or cerebrospinal fluid
  (CSF). Requires two-test approach using a
  sensitive enzyme immunoassay (EIA) or
  immunofluorescence antibody (IFA) followed by
  Western Blot confirmation.

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Treatment for Lyme diseasse

• The recommended treatment for Lyme disease is
• Early disease
• Doxycylcline (age 8 years)
• Amoxicillin
• Late manifestations
• Intravenous ceftriaxone or penicillin G

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Case Classification

• Confirmed
• A case with physician diagnosed EM measuring at
  least 5cm
• A case with at least one late manifestation that
  is laboratory confirmed.

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Clarification of Case definition

• A case with at least one late manifestation that
  is laboratory confirmed.
• Objective signs must be present because
• Antibodies persist for months to years
• Biologic false positives

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Case Review

• 45 year old female
• History of camping in Jefferson County, WV last
  month.
• Now has a large, red annular lesion measuring
  almost 5 inches in diameter located on her right
  lower abdomen. She saw a physician who diagnosed
  erythema migrans and ordered a Lyme disease
  test. The patient also complains of sleep
  disturbance, muscle aches, and fatigue.
• Lyme disease test is negative.
• Is this a case? Of what?

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WVEDSS case entry
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Case classification

• This is a confirmed case of Lyme disease.
• Your next step would be to document where the
  patient spent time during the month prior to
  onset of illness. Complete the Lyme disease
  WVEDSS form and forward to IDEP. Educate.

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Case Review

• 45 year old female
• History of camping in Jefferson County, WV last
  year. Recalls removing a tick from the nape of
  her neck at that time.
• Now has difficulty sleeping, daytime drowsiness,
  exhaustion, diffuse aches and pains. On physical
  exam, she has no objective findings. Her
  physician diagnoses chronic fatigue syndrome, and
  works her up by ordering a battery of tests. Her
  neurological exam is normal. She has no history
  of arthritis. Her sedimentation rate is normal.
  Her Lyme disease test is positive.
• Is this a case? Of what?

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WVEDSS case entry
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Case Classification

• This is not a case. There are no objective late
  manifestations.
• Consider doing some physician education about
  diagnosis/treatment of Lyme disease along with
  some patient education about Lyme disease
  diagnosis and prevention.

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Case Review

• 45 year old female
• History of camping in Jefferson County, WV 3
  months ago.
• Presented to a physician with the chief complaint
  of weakness on the right side of her face. She
  also complained of weakness, fatigue and aches.
  Her physician diagnosed Bells palsy, and ordered
  a Lyme disease test which came back positive.
• On treatment with amoxicillin, her facial
  weakness has partially resolved.
• Is this a case? Of what?

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WVEDSS case entry
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still case review

• You need to know what lab test was performed.
  You call the lab and determine that the patient
  had a positive IgM and a positive IgG with a
  confirmatory Western blot that was also positive.

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WVEDSS case entry
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Case classification

• Yes. This is a case of Lyme disease.
• Complete the Lyme disease WVEDSS form and forward
  to IDEP. Educate.

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Proper paperwork (WVEDSS)
If marked yes confirmed case
If any of these
Six are checked
Yes
Then check the lab
Results below
This with one of the six is Confirmed case
With proper testing --- is Confirmed Case
Positive only if EIA or IFA was done With
confirmatory Western Blot
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Surveillance Objectives

• To understand the demographic characteristics of
  persons with Lyme disease
• To identify Lyme endemic areas and the tick
  species involved in transmission.
• To identify risk factors for infection with Lyme
  disease.

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Lyme Disease

• Any questions?