Lyme Disease Surveillance in Wisconsin Christopher Steward Division of Public Health Wisconsin Department of Health Services 04/10/2014 Protecting and promoting the health and safety of the people of Wisconsin
Overview Lyme disease epidemiology and statistics Laboratory testing and interpretations Treatment and prevention 2
Lyme Disease Borrelia burgdorferi 3
Most frequently reported notifiable diseases in the United States, 2011 Reported Cases 1. Chlamydia 1,412,791 2. Gonorrhea 321,849 3. Salmonellosis 51,887 4. Syphilis 46,042 5. HIV 35,266 6. Lyme disease 33,097 7. Coccidioidomycosis 22,634 8. Pertussis (Whooping Cough) 18,719 9. Strep. pnuemoniae, invasive 17,138 10. Giardiasis 16,747 4
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Most frequently reported notifiable diseases in Wisconsin, 2012 Reported Cases 1. Chlamydia 23,969 2. Pertussis 6,461 3. Gonorrhea 4,741 4. Hepatitis C 2,634 5. Lyme disease 1,960 6. Influenza-associated hospitalization 1,489 7. Campylobacteriosis 1,320 8. Mycobacterial (non-tuberculous) 1,196 9. Salmonellosis 889 10. Cryptosporidiosis 637 6
Reported Lyme Disease Cases (n=28,446) 4000 3600 3200 329 437 470 384 399 370 407 486 607 516 658 653 1103 767 1191 1479 1487 1838 1496 1948 1487 2511 2376 545 636 473 1113 987 1233 2800 2400 2000 1600 1200 800 400 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008* 2009 2010 2011 2012 No. of Cases Year of Illness Onset 70 60 50 Incidence Estimated Cases Probable Cases Confirmed Cases Incidence per 100,000 *Surveillance case definition change to include probable cases Reporting criteria change Rev 01/30/2014 40 30 20 10 0 7
Lyme Disease 3-Year Average Incidence, 1990-2010 1990-1992 1993-1995 1996-1998 1999-2001 2002-2004 2005-2007 2008-2010 8
Rev 05/09/2011 Confirmed Lyme Disease Cases Wisconsin 2012 (n=1,487) 9 Jan Feb Mar April May June July Aug Sept Oct Nov Dec 41 33 57 38 25 15 93 83 108 200 341 453 500 400 300 200 100 0 Month of Illness Onset No. of Confirmed Cases Updated 01/30/2014
Confirmed Lyme Disease Cases Wisconsin 2012 (n=1,487) 10
Early Localized Stage - Erythema Migrans (EM) Rash Ticks must be attached for at least 24-48 hours to transmit the bacteria. The EM rash expands in size over time and often has partial clearing. Usually appears 3-30 days after a tick bite. Skin irritation at the site of a tick bite that can appear within hours of a tick bite is not an EM rash. EM rash ( 5cm) is considered as a confirmed case with or without laboratory testing and should be reported to health departments. 11
Erythema Migrans (EM) Rash Source: CDC.gov 12
Lyme disease: early disseminated stage Occurs days to weeks after tick bite: Multiple EM rashes Arthritis (asymmetrical, larger joints) Bell s palsy (facial paralysis) Nerve damage Meningitis Irregular heart beat Fever and chills Headaches Fatigue Muscle and joint pain Dizziness 13
Lyme disease: late persistent stage Occurs months to years after tick bite: Arthritis (asymmetrical, larger joints) Swelling of brain Swelling of spinal cord Other neurologic abnormalities Cardiovascular abnormalities Fatigue Numbness in hands and feet Cognitive impairment 14
Clinical Manifestations of Confirmed Lyme Disease Cases, United States, 2001-2010 Source: CDC.gov 15
Lyme Disease - Testing Methods Serologic assays are the most common tests to detect antibodies to Borrelia burgdorferi. Diagnostic testing should include 2-step testing on the same sample. 1 st step test: Enzyme immunoassay (EIA) tests Immunofluorescent assays (IFA) 2 nd step test: Western Blot test 16
Source: CDC.gov 17
Testing Limitations A negative result in the EM rash phase or in a PCR test does not exclude the possibility of infection with B. burgdorferi. A positive result is not definitive evidence of current infection with B. burgdorferi. Clinical signs and symptoms are also needed. Other conditions cross-react with the tests. Antibodies can last for years. 18
Lyme Disease - Treatment CDC follows the Infectious Diseases Society of America (IDSA) guidelines. Antibiotics- very effective if treated early. Children 8 years and adults: doxycycline 100 mg 2x day for 14 to 21 days. Children <8 years: amoxicillin 50 mg/kg/day in 3 divided doses for 14 to 21 days. Usually given orally but may be given intravenously in more severe cases. Recurrent symptoms may require an additional course of antibiotics. Long-term intravenous courses (months to years) have not been shown to be beneficial and may cause more complications. 19
Prevention Avoid tick exposures when possible. Use tick repellants. 20-30% DEET. Permethrin on clothes. http://cfpub.epa.gov/oppref/insect/ No vaccine currently available. No lasting immunity. Prophylaxis. 20
Prophylaxis to Prevent Lyme Disease At least 20% tick infectivity all of Wisconsin meets this criteria. Tick had to be attached for at least 24 hours. Tick has been removed within 72 hours of seeking prophylaxis. One single dose of doxycycline (200mg) for adults and children 8 years. 21
Reporting Requirements as of June 2012 Required reporting: Laboratories continue to report all Lyme positive results. Health care providers continue to report all cases of erythema migrans (EM 5cm and diagnosed by a physician or medical personnel). Continue to report date of illness onset and patient demographic information (address, birthdate, gender, race, and ethnicity). Optional reporting: Reporting of Lyme disease cases without EM rash is optional, unless requested by the LHDs (these include non-em confirmed and probable cases). Reporting of signs and symptoms other than EM rash, exposure, and treatment information is now optional, unless requested by the LHDs. 22
Resources http://www.dhs.wisconsin.gov/communica ble/tickborne/index.htm http://www.cdc.gov/ticks/index.html http://www.cdc.gov/lyme/ http://cfpub.epa.gov/oppref/insect/ 23
Additional Questions Feel free to contact DPH: Diep (Zip) Hoang Johnson, Epidemiologist Phone: (608) 267-0249 Email: diep.hoangjohnson@wisconsin.gov Christopher Steward, Research Analyst Phone: (608) 261-8354 Email: christopher.steward@wisconsin.gov 24