1. West Virginia Lyme Disease Past and Present
IDEP Training May 5, 2005
West Virginia Lyme Disease
Past and Present

2. 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.
Named when arthritis was observed in a cluster of children in and around Lyme, Conn.
Identified in midgut of adult deer tick
Spirochetes were cultured from blood of patients with EM, from the rash itself, and from CSF from a patient with meningoencephilitis with prior history of EM.
Council of State and Territorial Epidemiologists designated it as a nationally notifiable disease.

3. Lyme disease in North America
The explosive repopulation of white-tailed deer in Eastern US has been linked to the spread of Lyme disease.

4. West Virginia Lyme Disease

5. Lyme Disease in West Virginia
Lyme disease cases usually occur between April and November, with the peak in June or July.
N=147

6. West Virginia Lyme Disease by County
Berkeley has had the most cases at 51 (35%)
Jefferson was second with 32 (22%)
Morgan had 9 cases (6%).
Ohio had 7 (5%)
Harrison had 6 (4%)
Hampshire and Kanawha both had 5 (3%)
Marion had 4 (3%)
Brooke, Doddridge, Monongalia, and Wetzel all had 2 (1%).
Other counties that only had one case include: Barbour, Braxton, Calhoun, Gilmer, Grant, Hardy, Logan, Marshall, McDowell, Mercer, Mineral, Monroe, Nicholas, Preston, Putnam, Raleigh, Randolph, Upshur, Webster, Wetzel, and Wyoming (< 1%).

7. WEST VIRGINIA LYME DISEASE
2000 THRU 2004
HANCOCK
BROOKE
OHIO
MARSHALL
WETZEL
TYLER
PLEASANTS
WOOD
JACK-
SON
RITCHIE
WIRT
ROANE
CAL-
HOUN
MONONGALIA
MARION
TAYLOR 2
DODD-
RIDGE
LEWIS
GILMER
PRESTON
BARBOUR
TUCKER
UP-
SHUR
RANDOLPH
HARRISON
MORGAN
BERKELEY
JEFFERSON
MINERAL
HAMPSHIRE
GRANT
HARDY
PENDLETON
BRAXTON
WEBSTER
POCAHONTAS
NICHOLAS
GREENBRIER
FAYETTE
CLAY
PUTNAM
KANAWHA
BOONE
MASON
CABELL
WAYNE
LINCOLN
MINGO
LOGAN
McDOWELL
WYOMING
RALEIGH
MERCER
SUM-
MERS
MONROE 1 32 5 51 7 9
More than 10 cases
5 – 9 Cases
1 to 4 Cases 2 4 6 2 1 1 1 1
No Cases

8. 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.
This Zoonotic disease is characterized by a distinctive skin lesion, systemic symptoms and nuerologic, rheumatologic and cardiac involvement that occur in varying combinations over a period of months to years
"bull's-eye" rash > 5 cm
typically 7 to 14 days after tick exposure (range 3 to 30 days)
early disseminated disease may see multiple smaller EM
Mean of 7 to 14 days.

9. Late Manifestations : (when alternate explanation is not found)
Clinical symptoms of Lyme disease
Late Manifestations : (when alternate explanation is not found)
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
Facial Palsy may be bilateral
Muscle aches and joint pain
Swollen lymph nodes
Malaise, headache, fever, stiff neck
Chronic arthritis, heart and nervous system complications
Malaise, headache, fever, stiff neck
Muscle aches and joint pain
Swollen lymph nodes
Chronic arthritis, heart and nervous system complications

10. Lyme Disease in West Virginia
Two of the cases from 2001 were not reported until 2004

11. 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.
PCR has not been standardized for routine diagnosis of Lyme disease.

12. 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
Cefuroxime axetil or erythromycin can be used for patients with allergies to penicillin or who cannot take tetracycline.

13. 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.

14. 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
Patients with acute Lyme disease almost always have objective signs of infection (EM, facial palsy, arthritis)—Nonspecific signs may accompany these, but are almost never the only evidence of Lyme disease
Antibodies persist following successfully treated or untreated infection.
Syphillis and other known causes of biologic false-reactive serologic test results should be excluded when laboratory confirmation has been based on serologic testing alone.

15. 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?

16. WVEDSS case entry:

17. 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.

18. 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?
The patient is begun on tetracycline for chronic Lyme disease and feels better after about three weeks of therapy. When she goes back to the doctor, he recommends that she remain on medication indefinitely because he has seen many cases of chronic Lyme disease that relapse when medication is withdrawn.

19. WVEDSS case entry:

20. 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.

21. 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 Bell’s 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?

22. WVEDSS case entry:

23. …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.

24. WVEDSS case entry

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

26. 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

27. 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.

28. Lyme Disease
Any questions?