Lyme Disease Disease

Emergence of a Borreliosis

PandemicPatricia Bolivar PhD. Candidate at

Walden University 2015

Public Health Microbiologist

MSc, CLS, SM (ASCP)

11

Definition of Lyme Disease (LD)Definition of Lyme Disease (LD)Lyme disease is a multisystem inflammatory disorder caused Lyme disease is a multisystem inflammatory disorder caused by a spiral shaped bacteria (spirochete), transmitted to human by a spiral shaped bacteria (spirochete), transmitted to human by a tick bite:by a tick bite:

Borrelia burgdorferi found in the U.S.

Borrelia afzelii found in Europe.

Two different species of ticks: Ixodes scapularis

and Ixodes pacificus, transmit the bacteria to humans via bites.

Ali et al, 2014

22

IntroductionIntroductionIt was first described by Steere et al It was first described by Steere et al in 1975-77 in the towns of Lyme, by in 1975-77 in the towns of Lyme, by the Connecticut river, in a group of the Connecticut river, in a group of children with epidemic arthritis.children with epidemic arthritis.

Isolated in culture by Burgdorfer in Isolated in culture by Burgdorfer in 1982. 1982.

Multiple cases have been reported in Multiple cases have been reported in the United States and many the United States and many countries in Europe, Africa, Asia and countries in Europe, Africa, Asia and Australia. A few cases have been Australia. A few cases have been reported in Latin America: Brazil and reported in Latin America: Brazil and Colombia.Colombia.

Horowitz (2013)33

Transmission and Life Cycle The Lyme disease tick life cycle is approximately 2-3 The Lyme disease tick life cycle is approximately 2-3

years.years. Humans are rarely hosts to tick larvae and most tick Humans are rarely hosts to tick larvae and most tick

bites are from nymphal ticks in their second year of life.bites are from nymphal ticks in their second year of life. In the first year of a tick’s life they are laid as eggs by

adult ticks in the Spring before hatching as larvae in the Summer.

44

Tick Life Cycle in LD Tick Life Cycle in LD These larvae feed on birds,

mice, and other small animals which tend to be close to the ground during the fall. The animals that these larvae feed on may provide a host reservoir of Borrelia which causes the tick larvae themselves to become infected; described as zoonosis.

Larvae usually hatch from a batch of around 2000 eggs and begin searching for food after just a few days.

Tick larvae have six legs and are just about visible with the naked eye. These larvae climb up nearby vegetation and clamp onto the skin of any passing animal.

Two or three days of feeding will see the larvae swell by about ten to twenty times their initial weight.

These engorged larvae will then drop off back into the dense vegetation to digest their blood meal and to move into the next stage inactive during the Winter of their first year

55

Tick Life Cycle in LDTick Life Cycle in LD In the Spring and Summer of the In the Spring and Summer of the

second year of a tick’s life the second year of a tick’s life the larvae change into nymphs. The larvae change into nymphs. The six-legged tick larvae molts to an six-legged tick larvae molts to an eight-legged nymph that is eight-legged nymph that is around 1.5-2mm in size.around 1.5-2mm in size.

The nymphs require around four The nymphs require around four to five days of feeding on a to five days of feeding on a squirrel or mouse and continue squirrel or mouse and continue to feed from late Spring to early to feed from late Spring to early Summer.Summer.

In feeding on one or more In feeding on one or more animals those ticks that were animals those ticks that were infected as larvae will likely infected as larvae will likely transmit the Borrelia bacteria to transmit the Borrelia bacteria to other host animals and humans .other host animals and humans .

66

Tick Life Cycle in LDTick Life Cycle in LD

In the Fall of this same year the In the Fall of this same year the nymphs, providing they have nymphs, providing they have successfully fed, will turn into successfully fed, will turn into adult ticks around 4mm in length adult ticks around 4mm in length or larger as feeding continues.or larger as feeding continues.

During early Spring of the ticks’ During early Spring of the ticks’ late second or third year of life, late second or third year of life, ticks will start to feed on larger ticks will start to feed on larger mammals, including deer, mammals, including deer, sheep, and humans. sheep, and humans.

The ticks will mate on their The ticks will mate on their animal hosts to create eggs for animal hosts to create eggs for the next generation of Lyme the next generation of Lyme disease ticks.disease ticks.

77

Early Localized Disease Early Localized Disease

Phase 1: Skin inflammationPhase 1: Skin inflammation

Bull's-eye red, “erythema migrans“ flat rash develops in 65% of tick infected bites.

The rash appears days to weeks after the bite and spreads outward.

Some people don't notice or remember being bitten by a tick either because the tick was too small or a rash never appeared.

Someone with newly acquired Lyme disease may suffer from fatigue, headache, joint and muscle stiffness, and swollen glands.

California Lyme Disease Association (2015) 88

Early disseminated diseaseEarly disseminated diseasePhase 2: Early disseminated disease

If untreated, skin redness associated with early localized Lyme disease resolves in about one month. The second stage occurs weeks or months after the appearance of the red rash. During this time, bacteria affect other parts of the body including the heart, joints, and nervous system.

California Lyme Disease Association California Lyme Disease Association (2015)(2015)

99

Late diseaseLate diseasePhase 3: Late diseaseCan inflame the heart and lead to heart rhythm disorders and even heart failure. Nervous system problems associated with late disease may include facial paralysis (Bell's palsy), meningitis, confusion, and abnormal function of the nerves outside of the spinal cord (peripheral neuropathy). Joint inflammation can occur -- typically in just one to a few joints (often the knees) -- resulting in pain, stiffness, and swelling. Arthritis associated with Lyme disease can become chronic and may mimic other forms of inflammatory arthritis.

California Lyme Disease Association (2015)California Lyme Disease Association (2015) 1010

Chronic Lyme Disease (CLD)Chronic Lyme Disease (CLD)CLD is a condition that describes a plethora of persistent symptoms lasting more than six months which develops when Lyme disease diagnosis is missed or as results of inadequate length of antibiotic treatment.

The symptoms range from fatigue, headache, back pain, myalgia, arthralgia, nausea, abdominal pain, and night sweats, to cardiac (arrhythmia) and neurological involvement; cognitive dysfunction, peripheral neuropathy and encephalomyelitis.

Fatigue, musculoskeletal pain and neurocognitive complaints place those individuals diagnosed with the disease with a substantial clinical burden.

Borgersmans, Goderis, Vandevoorde, & Devroey (2014).1111

CLD PreventionCLD Prevention

Antibiotic therapy in the early stage of the disease, within 30 days of exposure, is recommended to hasten symptoms resolution and to prevent development of CLD.However, approximately 10 to 20 percent of patients treated with the recommended dose and duration of antibiotic therapy report persistent symptoms described as “Post-treatment Lyme Disease Syndrome”Failure of standard antibiotic therapy for Lyme disease may be due to the complex genetic makeup of the causative organism such as 3 times more plasmids than any other organism.

Adrion, Aucott, Lemke, & Weiner (2015)1212

Stealth PathologyStealth Pathology

Refers to mechanisms used by Borrelia burgdorferi to evade immune response which include: immunosuppression genetic, phase and antigenic variationphysical seclusion secretion of factor to engage in auto resurrection becoming a dormant organism suggesting the need for prolonged use of antibiotics.

Stricker (2007)1313

DiagnosisDiagnosis Sometimes the diagnosis is not as clear-cut. Person has visited an area known to have ticks that harbor

the bacteria. Physical exam and order tests to exclude other potential

problems with the heart, joints, and nervous system. ELISA: possibility of a false positive diagnosis because

Lyme disease antibodies may be present in the body for years after the illness has resolved.

Western Blot assay: more reliable test to confirm the diagnosis of Lyme disease.

Horowitz (2013) 1414

CoinfectionsCoinfections Ticks(or other biting insect) carrying Borrelia infections will often carry micro Ticks(or other biting insect) carrying Borrelia infections will often carry micro

organisms that complicate the illness.organisms that complicate the illness. Tick borne coinfections exacerbate Lyme disease symptoms and cause a low-

grade infection that can increase the duration and severity of Lyme disease. Co-infections along with Lyme are not all the same in each person. Some Lyme Co-infections along with Lyme are not all the same in each person. Some Lyme

infected people may not have any co-infections at all and then others may have infected people may not have any co-infections at all and then others may have many.many.

New organisms are being discovered in ticks all the time, such as New organisms are being discovered in ticks all the time, such as toxoplasmosis, giardia, roundworms, tapeworms, , amoebas, clostridia, the toxoplasmosis, giardia, roundworms, tapeworms, , amoebas, clostridia, the herpes virus family, parvovirus B 19, chronic strep infections, leptospirosis, herpes virus family, parvovirus B 19, chronic strep infections, leptospirosis, molds and fungi, Chlamydia pneumoniae, Human Herpes Virus #6…molds and fungi, Chlamydia pneumoniae, Human Herpes Virus #6…

California Lyme Disease Association (2015)California Lyme Disease Association (2015)

(CDC, 2015).1515

Tick transmitted CoinfectionsTick transmitted CoinfectionsBabesia: Protozoan parasite that infect the blood and cause a parasitic, hemolytic disease known as babesiosis. Symptoms: fever and chills then fatigue, headache, drenching sweats, muscle aches, chest pain, hip pain and shortness of breath as the disease progresses . Babesia can be transmitted from mother to unborn child or through a contaminated blood transfusion. Currently, most blood banks do not screen donated blood for Babesia.Treatment: Atovaquone along with Azithromycin or Atovaquone along with Azithromycin or Clindamycin along with Quinine. Clindamycin along with Quinine.

(CDC, 2015).

1616

Coinfections continuationCoinfections continuationBartonella: Bartonella: Bacteria that live primarily inside the lining of the blood vessels that can infect humans, mammals and a wide range of wild animals. It can be transmitted by fleas, ticks, animals, even spiders causing bartonellosis. Symptoms are fever, fatigue, lost of peripheral vision, bouts of muscle and joint, numbness of the hands, headaches, memory loss, and hallucinations. In California, 92% of the In California, 92% of the I. pacificus ticksI. pacificus ticks that that have been collected, had five different species of the Bartonella have been collected, had five different species of the Bartonella bacteria. bacteria. Treatment: Doxycycline, ErythromycinDoxycycline, Erythromycin

Azithromycin for children under the age of eighteen.Azithromycin for children under the age of eighteen.

CiprofloxacinCiprofloxacin

LevofloxacinLevofloxacin

(CLDA, 2015). 1717

CoinfectionsCoinfectionsEhrlichia: Ehrlichia: The lone star tick (Amblyomma americanum) is the primary vector of both of both Ehrlichia chaffeensisEhrlichia chaffeensis and and Ehrlichia Ehrlichia ewingiiewingii in the United States. in the United States.Typical symptoms: fever, headache, fatigue, and muscle Typical symptoms: fever, headache, fatigue, and muscle aches occur within 1-2 weeks following a tick bite. aches occur within 1-2 weeks following a tick bite. Diagnosis based on symptoms, clinical presentation, and Diagnosis based on symptoms, clinical presentation, and later confirmed with laboratory tests. Treatment for adults later confirmed with laboratory tests. Treatment for adults and children of all ages is doxycyclineand children of all ages is doxycycline Blood Transfusion and Organ Transplant Risks Blood Transfusion and Organ Transplant Risks associated with some associated with some EhrlichiaEhrlichia species that have shown species that have shown survive for more than a week in refrigerated bloodsurvive for more than a week in refrigerated blood

CDC (2015). 1818

Coinfections continuationCoinfections continuationAnaplasmaAnaplasma

Organisms that parasitize erythrocytes, thrombocytes and leukocytes causing of human granulocytic anaplasmosis (HGA). The infection can be mild causing anemia, low white blood cell count, low platelet count, and elevated liver enzymes or severe causing respiratory insufficiency, kidney failure, and eventually death.

(Krakowetz, Dibernardo, Lindsay, & Chilton (2014) and CLDA (2015).

RickettsiaRickettsiaAre bacteria that live mainly within Are bacteria that live mainly within host cells like in the case of host cells like in the case of Rocky Mountain Spotty Fever Rocky Mountain Spotty Fever (RMSF), typhus, and Q fever. (RMSF), typhus, and Q fever.

RMSF are transmitted by several RMSF are transmitted by several species of ticks: species of ticks: The lone star tick (The lone star tick (Amblyomma Amblyomma americanumamericanum).).The wood tick (The wood tick (Dermatocenter Dermatocenter andersoniandersoni).).The dog tick (The dog tick (Dermatocenter Dermatocenter variabilisvariabilis))

Horowitz, R. (2013) 1919

StatisticsStatistics Lyme disease is and Emerging Infectious Disease (EID). LD is the most-prevalent arthropod-borne disease in North

America and one of the fastest growing infectious diseases. The incidence has approximately doubled between 1991

and 2012 from 3.74 to 7.01 reported cases per 100,000 people.

LD annual incidence has steadily increased more than 25-fold since 1982 when national surveillance began in the United States.

Cases reported to the Centers for Disease Control and Prevention in 2013 yielded a national incidence of 8.6 per 100,000 people (CDC, 2013).

Extrapolations estimate annual cases to be from 240,000 to 400,000 cases.

Adrion, Aucott, Lemke, & Weiner (2015) 2020

LD in Southern CaliforniaLD in Southern California The lack of early diagnosis, awareness, and prevention

measures pose a great danger. Statistical figures indicate that from 1,561 LD total

reported cases in a period of ten years from 1992 to 2001 there were 200 cases (13%) from Southern California mainly from San Diego, Los Angeles, and San Bernardino County.

A total of 120 cases of LD with onset in 2013 were reported to the California Department of Public Health of which 17 confirmed cases where from Los Angeles County (CDPH, 2014).

Hui (2008)2121

Antibiotic TreatmentAntibiotic TreatmentCan antibiotics cure Lyme disease?

Different stages treated with different antibiotics:

Early stages when bull’s bull's-eye: the rash typically resolves in about 1 or 2 weeks with antibiotic treatment such as oral amoxicillin (Amoxil), cefuroxime axetil (Ceftin), and doxycycline (Vibramycin).

Later stages: Intravenous medications such as ceftriaxone (Rocephin) may be necessary to treat Lyme disease.

Additional antibiotics used for the treatment of LD include: Augmentin, Additional antibiotics used for the treatment of LD include: Augmentin, Amoxicillin, Azithromycin, Biaxin, Penicillin, Rifampin, Flagyl, Plaquenil, Amoxicillin, Azithromycin, Biaxin, Penicillin, Rifampin, Flagyl, Plaquenil, Imipenem, and Colloidal silver.Imipenem, and Colloidal silver.

Vojdani et al (2007)Vojdani et al (2007)2222

Complementary and Alternative TreatmentComplementary and Alternative TreatmentCAMCAM

Nutritional Supplements:Nutritional Supplements:

Omega 3- Fatty Acids, Omega 3- Fatty Acids,

Coenzyme Q10,Coenzyme Q10,

Grapeseed Extract, Magnesium,Grapeseed Extract, Magnesium,

L-Carnitine, Vitamin C and D, L-Carnitine, Vitamin C and D,

αα Lipoic acid, Dimethylglycine, Lipoic acid, Dimethylglycine, Methylcobalamine, Methylcobalamine,

Mushroom Extracts, Mushroom Extracts,

Beta-glucan, Hydrolytic enzymes, Beta-glucan, Hydrolytic enzymes, Probiotics, Royal Jelly, Probiotics, Royal Jelly,

Thymic peptides, Pycnogenol, Thymic peptides, Pycnogenol,

N-Acetylcysteine and Glutathione , N-Acetylcysteine and Glutathione ,

CAM treatment of LD includes the CAM treatment of LD includes the combination of different combination of different antibiotics, herbal remedies, and antibiotics, herbal remedies, and nutritional supplements.nutritional supplements.

Herbal Remedies:Herbal Remedies:

Samento, Cumada, Burbur, Samento, Cumada, Burbur, Allicin, Dragon’s blood, Devil’s Allicin, Dragon’s blood, Devil’s claw, Echinacea, Citriodiol (lemon claw, Echinacea, Citriodiol (lemon eucalyptus extract), Astragallus, eucalyptus extract), Astragallus, Nettle, Ginkgo biloba, Nettle, Ginkgo biloba, Curcumin,Boswellia, Parsley Curcumin,Boswellia, Parsley extract, Red Chili pepper extract, Red Chili pepper (capsaicin) and Quercetin. (capsaicin) and Quercetin.

Vojdani et al (2007)Vojdani et al (2007)2323

CAM Treatment Prevention of CAM Treatment Prevention of CLD ProcessesCLD Processes

2424

Holistic ApproachHolistic Approach

ApitherapyApitherapyIntegral ApproachIntegral Approach

An integral approach requires more than just treating with medicines and supplements. It also includes getting regular physical exercise, eating right, tending to psychological/spiritual needs through a regular practice of meditation, prayer, affirmations, network of support including close loved ones, social systems, nurse practitioner, doctor, as well as the money you must generate, and/or the insurance forms, in order to access all of the above.  

Lyme Disease Research Database (2015). Lyme Disease Research Database (2015). 2525

VaccinationVaccination

Currently, there is no vaccine available to prevent Lyme disease. The LYMErixTM Lyme disease vaccine was withdrawn from the market in 2002. More vaccine research is needed. Prevention is the best weapon against Lyme disease.

California Lyme Disease Association (2015)California Lyme Disease Association (2015) 2626

PreventionPrevention The best way to avoid Lyme disease is to prevent it! Wear shirts with long sleeves and pants to protect the

skin. Apply bug repellant containing DEET or lemon eucalyptus

oil to exposed areas. Examine clothing, kids, and pets for ticks after excursions

to areas known to harbor ticks. If a tick bites, use tweezers to remove it from the skin.

Place the tick in a closed container and provide it to health professionals for identification.

Remove clothes and bathe -- washing the entire body and scalp -- to help prevent tick bites and the transmission of Lyme disease.

California Lyme Disease Association (2015)California Lyme Disease Association (2015) 2727

My Dissertation Research StudyMy Dissertation Research StudyTitle:Title:“Health Promoting Behaviors of Young Adults with Chronic Lyme Disease” fulfill Public Health – Epidemiology PhD degree dissertation requirements at Walden University.

Study Design:

Qualitative hermeneutical phenomenological research design based on participants answers to interview questions.Purpose of the study:Examine the impact that CLD has on the health promoting behaviors of ethnically diverse, insured, young adults from similar educational and socio-economic backgrounds based on their lived experiences.

2828

Study CharacteristicsStudy CharacteristicsGeographical focus: Restricted to Los Angeles County, because there is a general lack of awareness of Lyme Disease and Chronic Lyme Disease on the West Coast of the United States.

Participants: Young adult’s ages 18-40 from diverse racial/ethnical background, various levels of education as well as socio-economic status, who may or may not have health care coverage. Recruited from social media groups (Facebook Chronic Lyme Disease page and the California Lyme Disease Association).

Expected results: Give healthcare providers and the public a deeper insight into the impact CLD has on the personal and professional lives of affected clients and its impact on their decision-making processes.

2929

Health Belief ModelHealth Belief Model The HBM will be used as the framework for the study to

explain and predict health behaviors of CLD by focusing on the attitudes and beliefs of the individuals afflicted with the disease.

Social psychologists Hochbaum, Rosenstock, and Kegels in the 1950s popularized the HBM while working in the U.S. Public Health Services to better understand the widespread failure of people to participate in programs to diagnose or prevent disease.

The dimensions of the Health Belief Model constructs are six: perceived susceptibility, severity, benefits, barriers, cues to action, and self- efficacy

Schiavo (2007); Crosby, DiClemente & Salazar (2006) and Hayden (2014)

3030

Health Belief ModelHealth Belief Model

3131

Significance of the StudySignificance of the Study Uniquely address the need for a deeper understanding of the impact of

CLD on the health promoting behavior of ethnically diverse, young adults in a community. (L.A. County)

Results from this study may positively impact individuals, the community, and society by shedding light on the nature and scope of this disease from the perspective of those infected.

Probe into the perceived effectiveness of conventional and non-conventional treatment modalities, which may lay the foundation for re-examining the care planning process.

Increase awareness of the scope and nature of CLD, in a community with limited but growing infection rates.

Motivate providers and the public to work collaboratively to retard the spread of this disease and safeguard the health and safety of society.

Serve as a positive catalyst for societal change by altering health promoting behaviors of the public.

Lay the foundation for future qualitative inquiry in the nature and scope of CLD in the U.S. and abroad. 3232

3333

ReferencesReferences Adrion, E., Aucott, J., Lemke, K.W., & Weiner, J.P. (2015). Health Care

Cost, Utilization Patterns of Care Following Lyme Disease. PLoS ONE, 10(2).

Ali, A., Vitulano, L., Lee, R., Weiss, T., & Colson, E. (2014). Experiences of patients identifying with chronic Lyme disease in the health care system: a qualitative study. BioMedical Central Family Practice, 15(79).

Borgersmans, L., Goderis, G., Vandevoorde, J., & Devroey, D. (2014). Relevance of Chronic Lyme Disease to Family Medicine as a Complex Multidimensional Chronic Disease Construct: A Systematic Review. International Journey of Family Medicine, 2014, 1-10.

California Lyme Disease Association (2015). Lyme disease in California 2008. Retrieved from http://lymedisease.org/california/california_map.html

Centers for Disease Control and Prevention (2015). Zoonotic disease. Retrieved from http://www.cdc.gov/onehealth/zoonotic-diseases.html

3434

References continuationReferences continuation Hui, L. (2008). Lyme and Other Tick-Borne Diseases are Under-recognized in

California. Retrieved from http://www.lymedisease.org/california.pdf Horowitz, R. (2013). Why Can’t I Get Better? Solving the Mystery of Lyme &

Chronic Disease. New York: St Martin’s Press. Lyme Disease Research Database (2015). A Holistic Approach to Treating Lyme.

Retrieved from http://www.lyme-disease-research-database.com/lyme_disease_blog_files/http://www.lyme-disease-research-database.com/lyme_disease_blog_files/holistic-treatment-lyme.htmlholistic-treatment-lyme.html

Krakowetz, C., Dibernardo, A., Lindsay, L.R., & Chilton, N.B. (2014). Two Anaplasma phagocytophilum strains in Ixodes scapularis ticks, Journal of Emerging Infectious Diseases, 20(12).

Stricker, R.B. (2007). Counterpoint: Long-term antibiotic therapy improves persistent symptoms associated with Lyme disease. Clinical Infectious Diseases 45,149-57.

Vojdani, A., Hebroni, F., Raphael, Y., Erde, J., and Raxien, B. (2007). Novel Diagnosis of Lyme Disease: Potential for CAM Intervention. eCAM, 6 (3) 283-295.

3535

THE ENDTHE END

Questions?Questions?

3636