1.  Martha’s Vineyard Boards of Health Tick-Borne Illness Initiative MDPH Internship 2012 Hannah Emily Nichols

2. Martha’s Vineyard  Martha’s Vineyard is an island off the coast of MA  Year-round population: 20,000  Summer population: 100,000  Tick-borne illnesses are endemic on the island  High deer population  Mild climate  Vast undeveloped land

3. Tick-Borne Illness Initiative  Mission: To reduce the incidence and medical consequences of tick-borne illnesses through public education and modification of disease transmission vectors  Island-Wide Board of Selectman Resolution  Public Education  Resident population, tourist population, website and videos  Medical Education  Standard of care: Prophylatic vs. symptomatic treatment  Environmental  Outside workers; landscape of the island, deer population www.MVBOH.org

4. MDPH Internship  Assess under-reporting of Lyme disease on Martha’s Vineyard  2010  25 confirmed cases of Lyme disease reported to CDC  Island pharmacies filled enough Doxycycline prescriptions to treat >1200 patients for Lyme disease

5. Confirmed Cases  Patient must have “Bulls Eye” or Erythema migrans rash (<40% of Island cases have the EM rash)  OR have positive lab testing (many cases are diagnosed and treated based on symptoms, without lab testing)  Positive Results are often reported to public health department of patient’s primary residence  Physician offices lack time and financial resources to do the paperwork

6. Incidence Data for TBI: A New Approach  Goal : Retrospectively collect incidence data of Tick- borne illnesses (TBI)  Methods : Total number of Doxycycline prescriptions and total numbers of doses (tablets and pills) were collected from island pharmacies for years 2008-2011.  Number of prescriptions and doses were unavailable for one pharmacy; wholesaler information was used to estimate numbers*

7. TBI Incidence Findings Methodology2008200920102011 CDC Confirmed Cases 472825N/A Doxycycline Doses50914505214909057825 Doxycycline Pills Per Rx 30.830.531.227.5 Doxycycline Prescriptions 1654164715822089 90% Probability of Prescriptions 1489148214241880

8. Payor Database  Using Doxycycline Rxs as a surrogate for Lyme Disease  Physicians and pharmacists interviewed on the island estimated that >90% of Doxycycline prescriptions were used for TBIs  Doxycycline Rxs by month for all 5 Island zipcodes, available 2 weeks after the end of the month  Rx for 14 days  Primary Residence: Martha’s Vineyard, MA, or out-of-state

9. Incidence Data for TBI: An Old Approach  Methods : A Linelist/Spreadsheet approach to Lyme disease was implemented in three private physician offices. Lyme disease patient information was collected from medical records from the Martha’s Vineyard Hospital Emergency Department.

10. Linelist/Spreadsheet  Spreadsheet included the following information:  Patient Name, Permanent Address, DOB, Gender, MV Town  Prophylaxis for Tick Bite Only (Y/N)  Date of Symptom Onset, EM Rash (Y/N), Arthritis (Y/N), Bells Palsy (Y/N), Radiculoneuropathy (Y/N), Lymphocytic Meningitis (Y/N), 2 nd or 3 rd Degree Heart Block (Y/N), Other Lyme Symptoms, Labs Sent (Y/N)

11. Linelist/Spreadsheet Conclusions  The approach identified approximately 100 Lyme disease patients for the month of July  Out-of-state residents were identified  Time constraints and volume of patients were major barriers for physician offices

12. MV Hospital Findings  136 patients were tested for Lyme disease in the Emergency Department in July 2012  60 of the patients tested were treated with Doxycycline or Amoxicillin and identified as probable Lyme patients to the MDPH  Lab Results: 21/60 tested positive for Lyme disease  Symptoms: 11/60 EM Rash, 2/60 Bell’s Palsy  Other symptoms: unexplained weakness, joint pain, fatigue, malaise, fever, tick bite

13. Hospital Findings Cont’d  Residence :  27/60 permanent Martha’s Vineyard residents  18/60 off-island MA residents  45/60 total MA residents  15/60 out-of-state residents  Other Diagnoses: 11/60 patients were treated with either 21 or 28 days of Doxycycline and were not diagnosed with Lyme but the following:  Lyme Disease Risk, Unexplained Weakness, Febrile Illness, Myalgia, Rash

14. Conclusions  Vast discrepancy between reported cases of Lyme and suspected cases of Lyme disease are evident  Linelist/Spreadsheet approach increased the number of cases reported and included out-of-state patients  Payor Database/Prescription approach is a new way to capture estimated real-time incidence data

15. Moving Forward  Widening the definition of “confirmed” Lyme disease case; or promote reporting of “suspected” cases  Apply payor database approach to other diseases in the future; can also capture other trends from the information:  Prophylatic vs. therapeutic treatment