Presented by: Maxine Shaw Gray, RN LYME DISEASE Presented by: Maxine Shaw Gray, RN

History of Lyme Disease Lyme disease was first recognized in the United States in 1975, after a mysterious outbreak of arthritis in children near Lyme, Connecticut. It wasn't until 1982 that the spirochaete (bacterium) that causes Lyme was identified.

Lyme Disease in the USA

Lyme Disease in Virginia Most reported infections in Virginia 2013. Number of confirmed reported cases Chlamydia 33561 Influenza 27564 Gonorrhea 6992 Lyme Disease 1307 MRSA 1247 HIV 1151 Salmonella 1048

Lyme Disease in Fairfax County Of the 1307 cases reported in Virginia in 2013 537 cases were reported in Northern Virginia = 41% 260 cases were reported in Fairfax County = 20% When we compare the rate of infections per 100,000 of the population in the reported area. Fairfax County has a rate of 23 There are 23 counties in Virginia with higher rates than Fairfax County including Loudoun County whose rate is 49.9 and Floyd County in southwest Virginia with the highest rate of 344.4

Lyme Disease Transmission The Lyme disease bacterium, Borrelia burgdorferi, is spread through the bite of infected ticks. There are many different types of ticks; most do not cause Lyme disease. The blacklegged tick (or deer tick), Ixodes scapularis) spreads the disease in the northeastern, mid-Atlantic, and north-central United States, and the western blacklegged tick (Ixodes pacificus) spreads the disease on the Pacific Coast.

Transmission (continued) The lifecycle of blacklegged ticks (Ixodes scapularis and Ixodes pacificus) generally lasts two years. During this time, they go through four life stages: egg, six-legged larva, eight-legged nymph, adult. After the eggs hatch, the ticks must have a blood meal at every stage to survive.

Lifecycle of Blacklegged Ticks

Transmission (continued) Most humans are infected through the bites of immature infected ticks called nymphs. Nymphs are tiny (less than 2 mm) and difficult to see; they feed during the spring and summer months. Adult ticks can also transmit Lyme disease bacteria, but they are much larger and may be more likely to be discovered and removed before they have had time to transmit the bacteria. Adult Ixodes ticks are most active during the cooler months of the year.

Transmission (continued) After feeding, ticks drop off the host and live in grasses, ground covers, leaves, wood piles and rock walls. Ticks can live for about 2 years without eating! When they need the next meal they attach themselves to the next host who comes by and are carried to another location where they drop off again after feeding. Most ticks die before finding the next host

Transmission (continued)

Tick after a blood meal

How Do Ticks Become Infected? Ixodes scapularis ticks become infected with the bacteria that causes Lyme disease by feeding on a host who already has the disease. If the tick only feeds on non infected hosts it can’t transmit the disease

Transmission (continued) Ticks can attach to any part of the human body but are often found in hard-to-see areas such as the groin, armpits, and scalp. In most cases, the tick must be attached for 36-48 hours or more before the Lyme disease bacterium can be transmitted.

Removing Ticks From The Skin The best way to remove an attached tick is:  Grasp the tick close to the skin with tweezers and pull straight away from the skin.

Transmission (continued) Lyme disease is not known to be transmitted from person-to-person. Dogs and cats infected with Lyme disease do not spread the disease directly to their owners. However, pets can bring infected ticks into your home or yard. There is no credible evidence that Lyme disease can be transmitted through air, food, water, or from the bites of mosquitoes, flies, fleas, or lice.

Transmission (continued) Although no cases of Lyme disease have been linked to blood transfusion, scientists have found that the Lyme disease bacteria can live in blood that is stored for donation. Individuals being treated for Lyme disease with an antibiotic should not donate blood. Individuals who have completed antibiotic treatment for Lyme disease may be considered as potential blood donors.

Signs and Symptoms of Lyme Disease Early localized stage (3-30 days post-tick bite) Red, expanding rash called erythema migrans (EM) Fatigue, chills, fever, headache, muscle and joint aches, and swollen lymph nodes Some people may get these general symptoms in addition to an EM rash, but in others, these general symptoms may be the only evidence of infection.

Signs & Symptoms (continued) Erythema migrans (EM) or "bull's-eye" rash

Signs & Symptoms (continued) Early disseminated stage (days to weeks post-tick bite) Untreated, the infection may spread from the site of the bite to other parts of the body, producing an array of specific symptoms that may come and go, including: • Additional EM lesions in other areas of the body • Facial or Bell's palsy (loss of muscle tone on one or both sides of the face) • Severe headaches and neck stiffness due to meningitis (inflammation of the spinal cord) • Pain and swelling in the large joints (such as knees) • Shooting pains that may interfere with sleep • Heart palpitations and dizziness due to changes in heartbeat Many of these symptoms will resolve over a period of weeks to months, even without treatment. However, lack of treatment can result in additional complications.

Signs & Symptoms of Lyme Disease Late disseminated stage (months to years post-tick bite) Approximately 60% of patients with untreated infection may begin to have intermittent bouts of arthritis, with severe joint pain and swelling. Large joints are most often affected, particularly the knees. Up to 5% of untreated patients may develop chronic neurological complaints months to years after infection. These include shooting pains, numbness or tingling in the hands or feet, and problems with short-term memory.

Testing for Lyme Disease The "two-tiered" blood test measures antibodies that the human body naturally makes to "fight off" infection. The blood is analyzed first with a test known as ELISA or EIA. If the result is positive or borderline, then a second test, known as a Western Blot, is performed. It will typically take up to several weeks after a person is infected for the test to produce a positive result. This delay is common for all antibody tests. In particular, persons with a pink or reddish "bulls- eye" rash (erythema migrans) may have negative test results early in the illness. However, patients who have been ill and infected for more than a few weeks will test positive 85-100% of the time.

Treatment for Lyme Disease Persons treated with appropriate antibiotics in the early stages of Lyme disease usually recover rapidly and completely. Antibiotics commonly used for oral treatment include doxycycline, amoxicillin, or cefuroxime axetil. Persons with certain neurological or cardiac forms of illness may require intravenous treatment with drugs such as ceftriaxone or penicillin.

Treatment to prevent Lyme disease when the tick I Treatment to prevent Lyme disease when the tick I. scapularis is attached to skin (CDC recommendations) A single dose of 200mgm of doxycycline for adult patients when all of the following circumstances exist: the attached tick can be reliably identified as I. scapularis tick that is estimated to have been attached for ⩾36 h on the basis of the degree of engorgement of the tick with blood or of certainty about the time of exposure to the tick; medication can be started within 72 hours of the time that the tick was removed; Person has no allergy or other contraindication to doxycycline treatment.

Treatment for Lyme Disease for Adults Early Lyme Disease; Doxycycline 100 mg twice per day for 10 -21 days Amoxicillin 500 mg 3 times per day for 14 -21 days Cefuroxime axetil 500 mg twice per day for 14 -21 days Lyme meningitis and other manifestations of early neurologic Lyme disease. Ceftriaxone 2 g once per day intravenously for 14 days -28 days Penicillin G 18–24 million U per day for 10 -28 days Late Lyme Disease (Lyme Arthritis) Same antibiotics as for Early Lyme Disease but given for 28 days

Lingering symptoms after treatment Post-treatment Lyme disease syndrome (PTLDS) 10-20% of patients with Lyme disease have symptoms that last months to years after treatment with antibiotics. These symptoms can include: muscle and joint pains, cognitive defects, sleep disturbance, or fatigue. The cause of these symptoms is not known, but there is no evidence that these symptoms are due to ongoing infection with B. burgdorferi.

Prevention of Tick Exposure When working in the yard cover all exposed skin and hair; Wear long pants, long sleeved shirt (tucked into pants) shoes (no open toed sandals) socks (tuck pants into socks) bandana around neck unless wearing polo shirt cloth hat that fits your head snugly

Prevention (continued)

Hats

Prevention (continued) Use insect repellant spray as directed that contains 20-30% DEET Wear clothing that has been treated with Permethrin (do not apply directly to skin) Take a shower immediately after working outdoors and examine all areas of your skin for ticks. If you find a tick save it and take it to your doctor. Wash your garden clothes after each use and dry on high heat for 60 minutes (CDC recommendations)

Creating a Tick Free Garden Keep grass mowed Remove leaves, brush and weeds from landscape Restrict the use of ground covers in areas frequented by family members Keep rodent populations controlled (snakes eat mice) Move wood piles and bird feeders away from the house Keep pets out of the woods Use plantings that do not attract deer and use deer repellants on your plants or deer fencing Create a 3 foot wide wood chip or gravel barrier between lawn and stone walls

Who eats Ticks! One tick can lay 1000 -1800 eggs. Fortunately for us, birds, ants, rodents, spiders, and many carnivorous insects (such as preying mantis) eat tick eggs, larvae and ticks. So, don’t kill ants, feed birds in the winter be happy to see spiders and love your preying mantis.

THE END

References Centers for Disease Control and Prevention: Lyme Disease http://www.cdc.gov/lyme/ The Clinical Assessment, Treatment, and Prevention of Lyme Disease: Gary P Wormser; et al http://cid.oxfordjournals.org/content/43/9/1089.full Department of Health, Commonwealth of Virginia www.vdh.virginia.gov Department of Health, Connecticut www.ct.gov/dph/cwp/view.asp?a=3136&q=395590