Short repo r t Prevention o{ Lyme borreliosis Need qf interdisciplina,y competence and the role qf the llepartment qf Hea,lth in the Struggle againstLyme borreliosis W.O. Pavan SuMM ARY Lyme borreliosis is the most frequent vector-borne disease in North America and Europe. Currently the most important way to tace it is prevention with the diffusion of correct information. The principal goals of prevention are to avoid tick bites and to stop the progression of the disease. These results are obtained by a correct behavior and, in case of a tick bite, by proper procedures that can reduce the risk of infection. Patients need to be instructed about the correct tick removal method and about the possible signs and symptoms of the disease. The use of prophylactic antimicrobials following a tick bite is not recommended. Due to the problems of scarce sensitivity, specificity and standardization, serological tests should not be used as screening method. Lyme borrelios is (LB) is the most frequent vector- borne disease in North America ancl Europe. However, certain confusion stili exists, partly clue to the scarce circulation of correct information (1, 2, 3, 4). In Italy (5) there is scarce perception of this pathology and the tendency to submit information to the mass-media by "apparent experts" has often furnished incorrect ancl also risky information. Due to the impossibility to eliminate the vector or the reservoirs (6, 7) , ancl because no vaccination is avail- able in Europe , currently the most important way to face LB is prevention (8, 9). This implicates the neces- sity for faultless information that is actively clistributecl among physicians as well as laymen. What bas hap- penecl in Italy ancl in o ther countries, however, shows that there is a lack of such information, with the result that people toclay are familiar with rickettsial cliseases or have hearcl about the so-callecl "killer tick" but clon 't know the real facts about the problems associatecl w ith LB. Nevertheless we are in an advantageous situation for at least two reasons : 1) LB has not yet reachec! cliffu- sion equal to that in the USA or in some European coun- tries close to us; 2) we can utilize the experience from the USA ancl are therefore able to avoicl the same mis- takes that have been macle there. The activity of spreading correct information is one of the assignments of the Departmerit of Health, but eve1y physician should provicle competent advice . Sci- entifically well-founcled information must not be con- fusec! with contraclictory information ancl alarming anc! unserious news needs to be avoided (10, 11 , 12). Prevention is an effective methoc!, when performed Acta Dermatoven APA Vol 11, 2002, No 1 ----- --- ----- -----29 Prevention of Lyme borreliosis correctly. The principal goals of prevention are to avoid tick bites and to stop the progression of the disease. The avoidance oftick bites is best obtainecl by suit- able clothing and a correct behavior, during outcloor activities, and with a correct and frequent rnaintenance of gardens and parks. In case of a tick bite, it is again a proper procedure that can reduce the risk of infection ancl consequent rnanifestation of LB (13). In LB endernic areas, the infection rate of ticks with Borrelia burgdot/eri is up to 5-20%. Thus it has to be suspected, as a rnatter of principle, that a tick that is attached to a person in such areas could be infected. It has been shown that the risk of infection increases after 36-48 hours frorn the beginning of the bloocl rneal of the tick. Accordingly, a prornpt rernoval of the tick no- tably reduces the risk of a transrnission of spirochetes. Ali the traditional rernoval rnethods , i.e. application of various agents on the tick such as alcohol, gasoline, oil, nail-polish, heat etc. to facilitate its detachrnent, have to be avoidecl. These rnethods induce regurgitation in the tick with consequent increase of the risk. The cor- rect rnethod to rernove the tick isto puli it out with fine tweezers, which have to be set on to the skin as close as possible, and then applying an antibiotic locally (14, 15, 16). After that the patient should daily and carefully observe, at least for 30-40 days, the tick bite site for the developrnent of a skin lesion suspicious of LB, the pathognornonic erytherna rnigrans. The patient should also pay attention to extracutaneous rnanifestations of LB, as well as to rnanifestations of other infections. Pa- l> Jl 1;, ,,, R. J1' ,"\. r ;---. 1/ c . l .. i .t:' .l.'J. . . .. ...1 .:. , . t . .J .J. .• .1 i~J tients need to be instructed about possible signs and syrnptorns and the tirne interval frorn the tick bite to disease, which rnay last severa! rnonths. This observa- tion is crucial in order to be able to initiate an appropri- ate treatrnent as early as possible. Weighing both the risk and the consequences of developing LB, including late rnanifestations, for per- sons bitten ancl the costs and adverse effects of pro- phylactic antirnicrobials, a routine prescription of anti- biotics following a tick bite is not recommencled (17, 18, 19). During the observation, if it is necessary to use antibiotics for other reasons, they rnust be effective also on LB. The closage and tirne for the treatrnent rnust last three weeks. The purpose is to avoicl a "decapitated LB", as happened in the past with the syphilis . Given the problerns with sensitivity, specificity and standardization, serological tests should not be used as screening rnethod because, with rnany false results , they are useless in this setting (20, 21 , 22, 23). We rnust rernember that up to 15% of healthy people result posi- tive because of a prececlent exposure or due to cross- reactions, so that a serological reactivity alone is not synonyrnous with disease (24, 25, 26, 27, 28, 29); more- over, antibodies to Borrelia hurgdorferi are not detect- able within the early weeks after an infectious tick bite, which means that a negative serological ti ter after a bite does not exclude the infection. Finally, the diagnosis of LB is rnainly clinical, while laboratory is a valid help but not sufficient to make the diagnosis (30, 31, 32, 33, 34, 35, 36, 37, 38). l. CDC. Wharton M, Chorba TL, Vogt RL, Morse DL, Buehler JW. Lyme disease: case definition for puhlic health surveillance. MMWR 1990; 39 (RR-13): 19-21. 2. Siga! LH. Lyme disease: primum non nocere. J Infect Dis 1995; 171: 423-24. 3. Siga! LH. The Lyme disease controversy. Social and financial costs of misdiagnosis and mismanage- ment. Arch Intern Med 1996; 156: 1493-1500. 4. Siga! LH. Overdiagnosis and overtreatment ofLyme disease leads to inappropriate Health Service use. Ciin Exp Rheumatol 1999; 17: 41. 5. Trevisan G, Pavan WO, Rorai E. Malattia di Lyme segnalazione di un caso a Cavarzere (Venezia). G Ital Dermatol Venereol 1991; 126: 435-37. 6. Jaenson TGT, Fish D, Ginsberg HS, Gray JS, Mather TN, Piesman J. Methods for control of tick vectors ofLyme Borreliosis. Scand J Infect Dis 1991; Snppl. 77: 151-57. 7. Olsen B, Jaenson TGT, Noppa L, Bunikis J, Bergstrom S. A Lyme borreliosis cycle in seabirds and Ixodes uriae ticks. Nature 1993; 362: 340-42. 8. Schutzer SE, Brown T, Holland BK. Reduction of Lyme disease exposure by recognition and avoid- ance of high-risk areas. Lancet 1997; 349: 1668. 9. McCaulley ME. The costs of Lyme disease. Arch Intern Med 1997; 157: 817. 10. Aronowitz RA. Lyme disease: the social construction of a new disease and its social consequences. Milbank Q 1991; 69: 79-112. 11. Lyme borreliosis. WHO Bulletin OMS 1994; 72, 4: 677-78. 12. Nahass RG, Herman DJ, Hirsh EJ. Lyme disease: public education key to appropriate care. Arch Intern Med 1997; 157: 697 . Short repo rt .JO - - ----------------------------- ----Acta Dermatoven APA Vol 11, 2002, No 1 Short repo rt AUTHOR'S ADDRESS Prevention of Lyrne borreliosis 13. HerringtonJEJr, Campbell GL, Bailey RE, Cartter ML, Adams M, Frazier EL, Damrow TA, Gensheimer KF. Predisposing factors for individuals' Lyme disease prevention practices: Connecticut, Maine and Montana. Am J Public Health 1997; 87: 2035-38. 14. Needham GR. Evaluation of five popular methods for tick removal. Pediatrics 1985; 75: 997-1002. 15. Kammholz LP. Variation on tick removal. Pediatrics 1986; 78: 378-79. 16. Schwartz BS, Goldstein MD. Lyme disease in outdoor workers: risk factors, preventive measures and tick removal methods. Am J Epidemiol 1990; 131: 877-85. 17. Agre F, Schwartz R. The value of early treatment of deer tick bites for the prevention of Lyme disease. Am J Dis Child 1993; 147: 945-47. 18. Fix AD, Strickland GT, Grant J. Tick bites and Lyme disease in an endemic setting, problematic use of serologic testing and prophylactic antibiotic therapy. JAMA 1998; 279: 206-10. 19. Barbour AG. Expert advice and patient expectations, laboratory testing and antibiotics for Lyme disease. JAMA 1998; 279: 239-40. 20. Sigal LH. Lyme Disease: testing and treatment. Who should be tested and treated for Lyme disease and how? Rheum Dis Clin North Am 1993; 19: 79-93. 21. Ley C, Le C, Olshen EM, Reingold AL. The use of serologic tests for Lyme disease in a prepaid health plan in California. JAMA 1994; 271: 460-63. 22. Seltzer EG, Shapiro ED. Misdiagnosis of Lyme disease: when not to order serologic tests. Pediatr Infect Dis J 1996; 15: 762-63. 23. Reid CM, Schoen RT, Evans J, Rosenberg JC, Horwitz RI. The consequences of overdiagnosis and overtreatment of Lyme disease: an observational study. Ann Intern Med 1998; 128: 354-62. 24. Steere AC, Taylor E, McHugh GL, Logigian EL. The overdiagnosis of Lyme disease. JAMA 1993; 269: 1812-16. 25. Lutwick LI. Borrelia seropositive with no symptoms of Lyme disease. Lancet 1994; 343: 1442 26. Cooke WD, Bartenhagen NH. Seroreactivity to Borrelia burgdorferi antigens in the absence of Lyme disease. J Rheumatol 1994; 21: 126-31. 27. Cunha BA. Overdiagnosing and overtreating Lyme disease. Emerg Med Ciin North Am 1994; 8: 30-36. 28 .. Sigal LH, Fish D, Magnarelli LA, Nadehnan RB, Wormser GP, Pachner AR, Steere AC, Halperin JJ, Lesser RL, Uowite NT, Shapiro ED. A Symposium: National Clinical Conference on Lyme disease. Am J Med 1995; 98 (suppl. 4A): 1-84. 29. CDC. Recommendations for test performance and interpretation from the Second National Confer- ence on Serologic Diagnosis of Lyme Disease. MMWR 1995; 44, 31: 590-91. 30. Rahn DW, Malawista SE. Lyme disease: recommendations for diagnosis and treatment. Ann Intern Med 1991; 114: 472-81. 31. Dressler F, Whalen JA, Reinhardt BN, Steere AC. \Vestern blotting in the serodiagnosis of Lyme disease. J Infect Dis 1993; 167: 392-400. 32. Dressler F. Serologic testing in the diagnosis of Lyme borreliosis. Acta Derm APA 1994; 1/2: 83-8. 33. Weber K, Pfister HW. Clinical management of Lyme borreliosis. Lancet 1994; 343: 1017-20. 34. Rahn DW. Lyme disease - where's the bug ? N Engl J Med 1994; 330: 282-83. 35. Coyle PK, Luft BJ. Management of Lyme disease. Curr Opin Infect Dis"1995; 8: 444-49. 36. Sigal LH. Lyme disease overdiagnosis: causes and cure. Hosp Pract 1996; 31: 13-28. 37. Nichol G, Dennis DT, Steere AC, Lightfoot R, Wells G, Shea B, Tugwell P. Test-treatment strategies for patients suspected ofhaving Lyme disease: a cost-effectiveness analysis. Ann Intern Med 1998; 128: 37-48. 38. Liegner KB, McCaulley ME, Blaauw AAM, van der Linden S, Tugwell P, Steere AC, Weinstein A. Guidelines for the clinical diagnosis of Lyme disease. Ann Intern Med 1998; 129: 422-23. Walter Os car Pavan MD, Emilia-Romagna Region, Lyme Borreliosis RegionalReferral Centre, Department ofHealth, Corso Baccarini 16, 48018 Faenza, Italy, e-mail: wopavan@libero.it Acta Dermatoven APA Vol 11, 2002, No 1 ------------ - ----- 31