IDEP Training May 5, 2005

1. IDEP TrainingMay 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 Borreliaborgdorferi 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.

3. Lyme disease in North America

4. West Virginia Lyme Disease N=147

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

6. West Virginia Lyme Disease by County N=147

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

8. Clinical symptoms of Lyme Disease • 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. • ErythemaMigran (usually 3 to 32 days after tick bite)

9. 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

10. Lyme Disease in West Virginia

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.

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

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

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?

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?