An emerging public health concern in the New River Valley is the increase in reported cases of Lyme disease. According to the Centers for Disease Control and Prevention (CDC), “Lyme disease is the most commonly reported vectorborne illness in the United States,” although it is concentrated primarily in only thirteen states. The New River Valley reported a record number of cases in 2012, and is considered endemic to Lyme disease per the Virginia Department of Health (VDH) (Jones, S, 2010). There is no clear explanation, but some theories attribute the increased prevalence to environmental factors.
There are many implications for health care providers and public health clinicians. Potential Health Effects If diagnosed in the early stage, Lyme disease can be cured with antibiotic therapy; however it can lead to serious health problems if not treated adequately (Nichols & Windemuth, 2013). The first stage of Lyme disease is a localized infection occurring 7-14 days after infection (Nichols & Windemuth, 2013). Symptoms may include a characteristic “bulls-eye” rash, called erythema migrans, as well as flu-like symptoms including fever, headache, fatigue, and myalgia (Nichols & Windemuth, 2013).
The second stage, early disseminated disease, may occur weeks or months after the initial infection (Nichols & Windemuth, 2013). The symptoms may include muscle and joint pain, and cardiac or neurologic problemsNichols & Windemuth, 2013). The third stage may occur months or years later, and is characterized by chronic symptoms affecting the skin, nervous system, joints, and heart (Nichols & Windemuth, 2013). Risk Assessment Lyme disease was first identified as a hazard in the 1970’s, when it was found to be the “cause of a cluster of pediatric arthritis cases in Lyme, Connecticut (Nichols & Windemuth, 2013).
According to the American Lyme Disease Foundation (ALDF), residents of areas endemic to Lyme disease, such as the New River Valley, are at risk of exposure. Also, engaging in frequent outdoor activities, and neglecting to wear tick-repellent increases the risk for exposure to Lyme disease (ALDF, 2011). The dose response is believed to be that the tick must be attached for 36-48 hours before transmitting Lyme disease (CDC, 2013). Therefore, someone who has experienced a tick bite in the New River Valley, by a deer tick that appears to have been attached for greater than 36 hours would be at high risk for Lyme disease. Community Action.
With the surge in Lyme disease, there has been an increase in public concern and community activism. Across the state of Virginia, several communities have held forums or town hall meetings to address Lyme disease (Remley, 2010). Southwest Virginia Lyme, is the local chapter of National Capital Lyme, a not for profit organization dedicated to increasing community awareness and support for victims of Lyme disease. The organization also works with government officials and health leaders at the national, state, and local levels to promote awareness and discover new strategies to overcome this and other tick-borne diseases (NatCapLyme.
org, 2013). Legislative Activity According to a search at Congress. gov, there are currently two bills in the U. S. House of Representatives and one bill in the U. S. Senate related to Lyme disease: H. R. 611, Lyme and Tick-Borne Diseases Prevention, Education and Research Act of 2013, H. R. 610, To Provide for the establishment of Tick-Borne Diseases Advisory Committee, and S. 719, Lyme and Tick-Borne Diseases Prevention, Education and Research Act of 2013. All three bills call for a federal advisory committee on Lyme and tick-borne diseases.
These bills have been presented, and are currently pending. In Virginia, the Lyme Disease Testing Information Disclosure Act of 2013 went into effect on July 1, 2013. The law requires healthcare providers to notify those tested for Lyme disease that the testing may provide false negative results in the early stages of the disease. The Medical Society of Virginia opposed the legislation, citing interference with the physician-patient relationship; however, supporters of the legislation claim that the risk of false negative results leads to misdiagnosis, and patients not receiving appropriate treatment (Simpson, 2013).
Industry Response The CDC has responded to the increase in Lyme disease with a program of research and education aimed at prevention and control (CDC, 2013). Specific actions include maintaining and analyzing national surveillance data, conducting epidemiologic investigations, offering diagnostic and reference laboratory services, and developing and testing strategies for control and prevention of Lyme disease (CDC, 2013). The CDC also provides education for the public and health care providers (CDC, 2013).
The role of the VDH is tracking and education (VDH, 2011). The VDH monitors the number of annual cases in Virgina, as well as the geographic distribution (VDH, 2011). They also provide education to the public and health care providers (VDH, 2011). Both agencies’ websites offer extensive information on transmission, symptoms, diagnosis, and treatment. They also provide resources for healthcare providers including current guidelines for diagnosis and treatment, as well as reporting and surveillance guidelines.
The recommendations for prevention are aimed at reducing exposure to ticks by avoiding areas with high grass or woods, and using insect repellents. The CDC also offers landscaping tips aimed at reducing the tick population (CDC, 2011). Currently there is no available vaccine for Lyme disease. The manufacturer of a previous vaccine discontinued production in 2002 (CDC, 2011). However, a new vaccine for Lyme disease has shown promise in two phases of clinical trials at the Stony Brook University School of Medicine and Brookhaven National Laboratory (Fitzgerald, 2013). Applications for Future Practice
In a 2012 letter to healthcare providers, the Virginia State Health Commissioner, Karen Remley, MD states that clinicians should consider the possibility of Lyme disease whenever a patient reports a febrile illness in the warmer months, especially when accompanied by flu-like symptoms or a rash. Laboratory testing can be unreliable in the early stage of illness, since it may take several weeks for the body to produce antibodies (Remley, 2012). Early treatment should be initiated based on history of exposure, symptoms, and physical exam, since delayed treatment could lead to more serious progression of the illness (Remley, 2012).
According the National Institute of Allergy and Infectious Diseases (NIAID), most cases of Lyme disease respond well to 3-4 weeks of antibiotic therapy. Some patients may continue to complain of symptoms after treatment, and may be diagnosed with post-treatment Lyme disease syndrome (PTLDS). The use of prolonged antibiotic therapy for PTLDS is not supported by clinical evidence (NIAID, 2013). In pregnant women, Lyme disease may lead to infection of the placenta, and possibly stillbirth, if untreated (CDC, 2013).
Treatment for pregnant women is the same as other non-pregnant adults, except that different antibiotics may be used (CDC, 2013). Doxyclycine should not be used during pregnancy (CDC, 2013). Lyme disease is not transmitted through breast milk (CDC, 2013). Patient education is another responsibility of the healthcare provider. In addition to informing them of the risk of Lyme disease, a new law requires healthcare providers to inform patients that laboratory testing may not be accurate in the early stages of the disease.
Healthcare providers can also educate patients in methods for reducing their exposure to ticks (Remley, 2012). Healthcare providers in Virginia are also required to report cases of Lyme disease to the local health department (VDH, 2011). The VDH uses this data to identify trends and risk areas across the state. Providers can find information about how to report Lyme disease cases on the VDH website (VDH, 2011). Conclusion As the incidence of Lyme disease increases, healthcare providers and public health clinicians play a vital role in the prevention and control of the disease.
We can improve patient outcomes through early detection and treatment, so we must remain alert to the possibility of Lyme disease. We can also play a role in reducing exposure to ticks in our community, by providing prevention tips to our patients and being a resource for Lyme disease information.
References American Lyme Disease Foundation. ( 2010). Specific information on the prevention and diagnosis. Retrieved from http://www. aldf. com/faq. shtml#Risk. Centers for Disease Control and Prevention. (2011). Lyme Disease. Preventing Tick Bites. Retrieved from http://www. cdc.gov/lyme/prev/index. html. Centers for Disease Control and Prevention. (2013). Lyme Disease Frequently Asked Questions. Retrieved from http://www. cdc. gov/lyme/faq/index. html. Centers for Disease Control and Prevention. (2013). Lyme Disease Data.
Retrieved from http://www. cdc. gov/lyme/stats/index. html. Fitzgerald, K. (2013). Potential Lyme disease vaccine shows promise. Medical News Today. Retrieved from http://medicalnewstoday. com/articles/260474. php. Jones, S. (2010). Virginia sees rise in Lyme disease. The Roanoke Times. Retrieved from http://ww2. roanoke. com/news/roanoke/wb/249149/.
National Capital Lyme Disease Association. (2013). Retrieved from http://www. natcaplyme. org. National Institute of Allergy and Infectious Diseases. (2013). Lyme Disease. Retrieved from http://www. niaid. nih. gov/topics/lymedisease/research/Pages/antibiotic/aspx. Nichols, C. & Windemuth, B. (2013). Lyme disease: from early localized disease to post-lyme disease syndrome. The Journal for Nurse Practitioners. 9(6). 362-367. Remley, K. (2012). Lyme disease clinician letter. Retrieved from http://www. vdh. virginia. gov/clinicians. pdf/Lyme disease Update 2012. pdf. Simpson, E.
(2013). Doctors say state is meddling with Lyme disease bill. The Virginian-Pilot. Retrieved from http://www. hamptonroads. com/2013/03/doctors-say-state-meddling-lyme-disease-bill. United States Legislative Information. (2013). Legislative search results. Retrieved from http://beta. congress. gov/search? q={“congress”%3A”113”%2C”source”%3A”legislation”%2C”search”%3A”lyme”}. Virginia Department of Health. (2011). Lyme disease tracking and prevention in Virginia. Retrieved from http://wwww. vhd. virginia. gov/epidemiology/DEE/Vectorborne/HCPs/Lyme presentation for LHDs_2011a. pptx.