Lyme Disease Surveillance in Nrth Carlina 2008-2014 Carl Williams DVM Megan Sanza MPH Cmmunicable Disease Branch Divisin f Nrth Carlina Public Health
Lyme Disease Surveillance in Nrth Carlina 2008-2014 Wake AHEC requires all speakers t disclse any relevant financial cnflicts f interest. Carl Williams and Megan Sanza have n relevant financial cnflicts f interest t disclse.
Objectives 1. Review Lyme disease (LD) basics (brief) 2. Present surveillance findings, 2008-2014 3. Lk at data cmpleteness, accuracy, and reprting prcesses 4. Suggestins fr imprving Lyme Disease reprting
Overview Tick-brne illness caused by Brrelia burgdrferi Symptms may vary significantly Early manifestatin 3-30 days fllwing tick bite Fatigue, chills, fever, HA, muscle and jint aches Erythema migrans (EM) rash Disseminatin/late manifestatin if nt treated early May affect heart, jints, nervus system Cases caught early enugh can be treated successfully with antibitics; hwever 10-20% f patients experience symptms that persist after antibitics (PTLDS)
Pst-treatment Lyme Disease Syndrme (PTLDS) In 10-20% f treated patients, symptms can linger mnths t years after treatment with antibitics Symptms may include muscle and jint pains, cgnitive difficulties, sleep disturbances r fatigue The cause fr these symptms is unknwn Sme evidence t suggest caused by autimmune respnse (infectin cleared, but persn s immune system still respnding) Studies shw cntinuing antibitic therapy is nt helpful http://www.cdc.gv/lyme/signs_symptms/index.html
LD Case Definitin Fr mst N.C. cunties, case definitin is met by having bth clinical and lab requirements met. N.C. cunties designated as endemic n lnger need lab requirements met if EM rash is present (Haywd, Wilkes, Guilfrd, Alleghany, Wake) Physician diagnsis f disease is acceptable if clinical criteria is nt met (will still need lab criteria met). If yu feel yu need assistance understanding LD case investigatin, surveillance requirements r labratry testing please cntact Jdi Reber at (919) 715-5416.
Lyme Disease in Nrth Carlina 2013 Incidence Rate per 100,000 = 0.4 (CDC) Fairly lw incidence, but significant public interest Treatment fr each case is nt always timely 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Pennsylvania 32.1 34.6 26.1 32.1 30.7 39.3 26 37.2 32.5 39 Maryland 16 22.1 22.2 45.8 31 25.7 20.1 16.1 18.9 13.5 Virginia 2.9 3.6 4.7 12.4 11.4 8.9 11.4 9.3 9.8 11.2 West Virginia 2.1 3.4 1.5 4.6 6.6 7.9 6.9 5.8 4.4 6.3 Gergia 0.1 0.1 0.1 0.1 0.4 0.4 0.1 0.3 0.3 0.1 Suth Carlina 0.5 0.4 0.5 0.7 0.3 0.5 0.4 0.5 0.7 0.7 Nrth Carlina 1.4 0.6 0.4 0.6 0.2 0.2 0.2 0.2 0.3 0.4 Tennessee 0.3 0.1 0.2 0.5 0.1 0.2 0.1 0.1 0 0.2 U.S. Incidence 6.7 7.9 8.2 9.1 9.4 9.8 7.3 7.8 7 8.6
Surveillance Data Ntes Very brad range f clinical manifestatins Large investigatin effrt with lw yield f reprting (fr 2014, 866 cases investigated in NC EDSS with nly 172 reprted.20%) EM rash indicative f early disease EM bserved by HCP is mst reliable indicatr f true Lyme disease Surce f illness identificatin dates vary Symptm nset, labratry testing, date f diagnsis by HCP, date f reprt t public health Data presented fr cnfirmed and prbable cases where applicable, but nly cnfirmed presumed t have true disease
Cases by Age and Gender Bys 10-14 years have the mst cases reprted in Nrth Carlina This is similar t CDC s 2013 natinal findings f bys 5-9 years Prbable cases mst cmmn amng females, but mre age variatin
Case Reprting Since 2008 Prbable case definitin first intrduced in 2008 After 2009, fewer cases classified as Suspect New case definitin
Surce f Initial Reprt t Public Health Lyme disease identified thrugh a variety f surces in Nrth Carlina ELR feeds are by far the mst cmmn surce - limited case infrmatin
Cases by Illness Identificatin Date Categry Cnfirmed cases have a larger prprtin symptm nset illness ID dates; mre cmplete infrmatin
Cases Reprted by Year Steady increase amng prbable cases since 2008 Cnfirmed case numbers fairly cnsistent 2008-2014, with slight increases ver the last 3 years
Cases Reprted by Mnth Mst cases reprted during summer mnths, May-September Clear seasnality similar t natinal data, mre ntable amng cnfirmed cases June/July illness identificatin
Cases by Cunty Endemic cunty = 2 r mre cnfirmed cases with n knwn travel during 32 days prir t nset 5 cunties: Alleghany, Guilfrd, Haywd, Wake, Wilkes
Reprted Symptms EM rash mst cmmn, fllwed by musculskeletal Cnsistent with natinal CDC findings thrugh 2013
Cases by Prvider Diagnsis Prbable case definitin added in 2008, requires prvider diagnsis (100% f cases beginning in 2012) 80% f cnfirmed cases have a prvider diagnsis
Cases by Onset and Year Mst cases are acute nset cases; mre apparent 2008-2011 2012 is an exceptin with almst 80% f late manifestatins
Cases by Onset and Mnth Seasnality is smewhat apparent when lking at cases by nset categry; acute increases during summer mnths All Jan cases are late manifestatin alng with mst Sep-Dec
Data Reprting and Data Quality Mst cases are initially reprted thrugh ELR feeds; patient infrmatin ften sparse Prvider cmmunicatin is encuraged but always fruitful; patient interviews fr LD are less cmmn than ther diseases Use 2008-2014 data t lk mre clsely at data flw and entry fr LD events in NC EDSS Analyze missing key fields and variatin in hw data have been entered Underlying gal t imprve efficiency f data entry and cmpleteness and quality f data
Data Cmpleteness: Demgraphics Cnfirmed case data mre cmplete than prbable, as might be expected Race is mst cmmn missing demgraphic Number Missing (%) - PROBABLE Number Missing (%) - CONFIRMED AGE 2 (12) 0 GENDER 1 (2) 1 (.5) RACE 19 (3) 2 (1)
Why Cases Were Tested fr Lyme Disease Reasn Selected fr Testing Number Tested (%) N reasn selected 30 (17%) Symptmatic f disease 128 (74%) Symptmatic f disease; Tick bite withut symptms f disease 9 (5%) Tick bite withut symptms f disease 19 (3) Other* 8 (5%) *Of these 8, 5 had ntes that indicated LD symptms were present.
Imprvements t Data Cllectin Surce f illness Identificatin date: Best is illness nset date; if unknwn, use lab testing date Avid using Date f Reprt t Public Heath Is patient symptmatic fr disease? If Lyme disease testing is fr a general screen then the answer is n. EM rash must have a size t cunt and be diagnsed by the physician. EM rash must be greater than 5cm Illness greater than 30 days shuld have a psitive IgG Western Blt lab r it may nt be cunted. Must answer the Did Patient Survive questin in clinical package.
Imprvement t Data Cllectin If a nn-endemic cunty has a new case f lcally acquired LD (EM rash + Labs), DPH wuld like t cnfirm labs by having IgG Western Blt run if nt already dne. Free labratry testing can be perfrmed at CDC fr these cases. Lcality can perfrm testing and send t CDC via NC SLPH. (Lcality must decide if they will perfrm venipuncture at n charge) Results can take sme time and are nly used fr surveillance purpses A negative result will nt change case classificatin frm riginal lab results
Physician and Public Outreach DPH prvides a yearly mems t prvider t discuss LD and the ther tick and msquit illness present in N.C. Please distribute these t the prviders in yur cmmunity. These mems are available n ur websites at: http://epi.publichealth.nc.gv/cd/arb/prviders.html and http://epi.publichealth.nc.gv/cd/ticks/lhds.html DPH has tickbrne bklets available fr prvider use Tickbrne psters are als available that shuld be widely utilized in physicians ffices, parks, utdr trails, etc. (Please see Jdi at the handuts bth)
Summary Surveillance numbers apprpriately reflect revised case definitin after 2008 Cnfirmed cases static since 2008 Late manifestatin diagnses have increased since 2008; highest in 2012 Nrth Carlina case distributin mimics expected seasnality f LD Similar demgraphic and symptm distributin 2008-2014 t natinal findings 2001-2010 Challenges with regard t diagnsis and expsure infrmatin
Resurces NC EDSS http://www.cdc.gv/lyme/index.html http://epi.publichealth.nc.gv/cd/ticks/lhds.html