Lyme Disease (Borrelia burgdorferi) - NJ.gov
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Lyme Disease
(Borrelia burgdorferi)
DISEASE REPORTABLE WITHIN 24 HOURS OF DIAGNOSIS
Per NJAC 8:57, health care providers and administrators shall report by mail or by electronic reporting
within 24 hours of diagnosis, confirmed cases of Lyme disease to the health officer of the jurisdiction
where the ill or infected person lives, or if unknown, wherein the diagnosis is made. A directory of
local health departments in New Jersey is available at http://localhealth.nj.gov.
If the health officer is unavailable, the health care provider or administrator shall make the report to
the Department by telephone to 609-826-5964 between 8:00 A.M. and 5:00 P.M. on non-holiday
weekdays or to 609-392-2020 during all other days and hours.
January 20211 THE DISEASE AND ITS EPIDEMIOLOGY
A. Etiologic Agent
In the United States, Lyme disease (LD) is caused by the corkscrew-shaped bacterium (spirochete)
Borrelia burgdorferi. Borrelia mayonii is an additional bacterial species recently found to cause LD
in people who live in the upper Midwestern United States. Worldwide, LD is caused by three main
species of bacteria: B. burgdorferi, B. afzelii, and B. garinii.
B. Clinical Description
Untreated LD can produce a wide range of symptoms, depending on the stage of infection.
Approximately 70-80% of persons will develop an erythema migrans (EM) rash, which can assist in
diagnosis (https://www.cdc.gov/lyme/signs_symptoms/rashes.html), but depending on the
location of the tick bite, it may be undetected. A small bump or redness at the site of a tick bite
that occurs immediately and resembles a mosquito bite is common. This irritation generally goes
away in 1-2 days and is not a sign of LD. Early signs and symptoms can last for several weeks in
untreated patients. Within weeks to months following infection, patients may develop neurological
or cardiac abnormalities. Weeks to years following infection (mean 6 months), patients may
develop intermittent episodes of swelling and pain in large joints, leading to chronic arthritis, or
rarely chronic neurological manifestations. Late-stage symptoms can persist for several years but
tend to resolve spontaneously.
Early Signs and Symptoms (3 to 30 days after tick bite)
• Flu-like symptoms: fever, chills, headache, fatigue, muscle and joint aches, stiff neck, and
swollen lymph nodes (lymphadenopathy)
• Erythema migrans (EM) rash:
o Begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days)
o Expands gradually over several days reaching up to 12 inches or more (30 cm) across
o May feel warm to the touch but is rarely itchy or painful
o Sometimes clears as it enlarges, resulting in a target or “bull’s-eye” appearance
o May appear on any area of the body
Later Signs and Symptoms (days to months after tick bite)
• Severe headaches and neck stiffness
• Additional EM rashes on other areas of the body (secondary lesions indicate that the
infection has spread into the blood, resemble the primary lesion but tend to be smaller)
• Arthritis with severe joint pain and swelling, particularly the knees and other large joints.
• Facial palsy (loss of muscle tone or droop on one or both sides of the face)
• Intermittent pain in tendons, muscles, joints, and bones
• Heart palpitations or an irregular heartbeat (Lyme carditis)
January 2021New Jersey Department of Health
• Episodes of dizziness or shortness of breath
• Inflammation of the brain and spinal cord (meningitis, encephalitis)
• Nerve pain
• Shooting pains, numbness, or tingling in the hands or feet
• Problems with short-term memory
Treatment
Patients treated with appropriate antibiotics in the early stages of LD usually recover rapidly and
completely. CDC recommends the 2006 guidelines for treatment developed by the Infectious
Diseases Society of America (https://www.cdc.gov/lyme/treatment/index.html).
C. Reservoirs
The primary vector for LD in New Jersey is the blacklegged or deer tick, Ixodes scapularis.
Ticks become infected as larvae or nymphs when they feed on infected animals, especially the
white-footed mouse, and they remain infected for life. Nymphal ticks pose the greatest threat of
transmitting infectious organisms to animals and humans because they are small in size (< 2mm)
and may go undetected. Nymphs are most abundant between May and July, and they are typically
found in wooded areas, brush, and grassy areas near woodland edges. Toward the end of summer
through fall, the nymphs mature to the adult stage. Although adult ticks remain capable of
transmitting B. burgdorferi to humans, they are larger in size and easier to detect. As such, adult
ticks are often removed before they can transmit LD. Deer are an important source of food for
adult ticks, but do not transmit B. burgdorferi.
D. Modes of Transmission
LD is acquired from the bite of an infected tick. In most cases, the tick must be attached for 36 to
48 hours or more before the LD bacteria can be transmitted. 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. As a
result, cases of diagnosed LD frequently have no known history of a tick bite.
LD acquired during pregnancy may lead to infection of the placenta and possible stillbirth;
however, no negative effects on the fetus have been found when the mother receives appropriate
antibiotic treatment. There are no reports of LD transmission from breast milk. LD could potentially
be transmitted through blood transfusion, although there are no documented reports.
Dogs and cats can get LD, but there is no evidence that they spread the disease directly to their
owners. However, pets can bring infected ticks into the home or yard.
E. Incubation Period
EM rashes typically develop 7 to 10 days after exposure (range: 3 to 30 days). However, early signs
of illness may be unapparent, and the patient may present with later manifestations, which could
be several months later.
January 2021 3Communicable Disease Service Manual
F. Period of Communicability or Infectious Period
LD is not generally communicable from person to person, although there is a potential risk of
transmission through blood transfusion and some case reports of LD in pregnancy.
G. Epidemiology
Reports of LD have increased dramatically in the United States since 1975 when the disease was
first recognized in Lyme, Connecticut. Each year, approximately 30,000 cases of LD are reported to
CDC, but annual incidence is estimated at around 300,000 cases. While cases have been reported
from nearly every state, LD cases are concentrated in the Northeast and upper Midwest. In 2018,
95% of confirmed and probable LD cases were reported from 16 states: Connecticut, Delaware,
Iowa, Maine, Maryland, Minnesota, New Hampshire, New Jersey, New York, Ohio, Pennsylvania,
Rhode Island, Vermont, Virginia, West Virginia, and Wisconsin. In 2018, New Jersey had an
incidence of 44.9 confirmed and probable cases per 100,000 population.
Reports of LD in New Jersey have remained relatively constant since 2015. An average of 4,574
confirmed and probable cases were reported each year between 2015-2018 in New Jersey. In 2018,
New Jersey had the second highest reported LD cases in the United States with 4,000 confirmed
and probable LD cases.
In New Jersey, the highest risk for acquiring LD occurs in wooded rural or suburban environments.
However, all parts of the state are considered endemic for LD, and human cases have been
reported from all counties in New Jersey. Hunterdon, Warren, and Sussex counties had the highest
LD incidence per 100,000 population in 2018. Most cases occur between May and October.
2 CASE DEFINITION
The NJDOH Infectious & Zoonotic Disease Program follows the most current Lyme disease case
definition as published on the CDC National Notifiable Disease Surveillance System (NNDSS)
website.
Lyme Disease Case Definition: https://wwwn.cdc.gov/nndss/conditions/lyme-disease/
Case definitions enable public health to classify and count cases consistently across reporting
jurisdictions and should not be used by healthcare providers to determine how to meet an
individual patient’s health needs.
A. Clinical Description
For purposes of surveillance, EM is defined as a skin lesion that typically begins as a red macule or
papule and expands over a period of days to weeks to form a large round lesion, often with partial
central clearing. A single primary lesion must reach greater than or equal to 5 cm in size across its
4 January 2021New Jersey Department of Health
largest diameter. Secondary lesions also may occur. For most patients, the expanding EM lesion is
accompanied by other acute symptoms, particularly fatigue, fever, headache, mildly stiff neck,
arthralgia, or myalgia. These symptoms are typically intermittent. The diagnosis of EM must be
made by a physician.
For purposes of surveillance, late manifestations include any of the following when an alternate
explanation is not found:
• Musculoskeletal system. Recurrent, brief attacks (weeks or months) of objective joint
swelling in one or a few joints, sometimes followed by chronic arthritis in one or a few
joints.
o Manifestations not considered as criteria for diagnosis include chronic progressive
arthritis NOT preceded by brief attacks and chronic symmetrical polyarthritis.
Additionally, arthralgia, myalgia, or fibromyalgia syndromes alone are not criteria for
musculoskeletal involvement.
• Nervous system. Any of the following signs that cannot be explained by another etiology:
lymphocytic meningitis; cranial neuritis, particularly facial palsy (may be bilateral);
radiculoneuropathy; or, rarely, encephalomyelitis.
o Headache, fatigue, paresthesia, or mildly stiff neck alone, are not criteria for
neurologic involvement.
• Cardiovascular system. Acute onset of high-grade (2nd-degree or 3rd-degree)
atrioventricular conduction defects that resolve in days to weeks and are sometimes
associated with myocarditis.
o Palpitations, bradycardia, bundle branch block, or myocarditis alone are not criteria
for cardiovascular involvement.
B. Laboratory Criteria
For the purposes of surveillance, laboratory evidence includes:
• A positive culture for B. burgdorferi, OR
• A positive two-tier test1. (defined as a positive or equivocal enzyme immunoassay (EIA) or
immunofluorescent assay (IFA) followed by a positive Immunoglobulin M 1 (IgM) or
Immunoglobulin G 2 (IgG) western immunoblot (WB) for Lyme disease) OR
• A positive single-tier IgG2 WB test for Lyme disease
1
Refer to section on Laboratory Testing
January 2021 5Communicable Disease Service Manual
1
IgM WB is considered positive when at least two of the following three bands are present: 24
kilodalton (kDa) outer surface protein C (OspC)*, 39 kDa basic membrane protein A (BmpA), and 41
kDa (Fla). Disregard IgM results for specimens collected >30 days after symptom onset.
2
IgG WB is considered positive when at least five of the following 10 bands are present: 18 kDa, 24
kDa (OspC)*, 28 kDa, 30 kDa, 39 kDa (BmpA), 41 kDa flagellin (Fla), 45 kDa, 58 kDa (not GroEL), 66
kDa, and 93 kDa.
*Depending upon the assay, OspC could be indicated by a band of 21, 22, 23, 24 or 25 kDA.
Exposure
Exposure is defined as having been (≤ 30 days before onset of EM) in wooded, brushy, or grassy
areas (i.e., potential tick habitats) of LD vectors. NJ is considered a high-incidence state for LD and
exposure should be assumed for all reported cases. A list of high and low-incidence states is
available at https://www.cdc.gov/lyme/stats/tables.html. A history of tick bite is not required.
C. Case Classification
CONFIRMED
• A case of EM with exposure in a high incidence state (e.g., New Jersey), OR
• A case of EM with laboratory evidence of infection and a known exposure in a low incidence
state, OR
• A case with at least one late manifestation that has laboratory evidence of infection
PROBABLE
• Any other case of physician-diagnosed LD that has laboratory evidence of infection
POSSIBLE
• A case of EM where there is no known exposure (as defined above) and no laboratory
evidence of infection, OR
• A case with evidence of infection but no clinical information available (e.g., a laboratory
report)
NOT A CASE
• A case not meeting laboratory criteria AND without a healthcare provider reported EM rash
• A case that meets laboratory criteria AND has information provided by a healthcare
provider indicating that the patient does NOT meet EM rash or late state manifestation
clinical criteria AND there is no diagnosis of LD
6 January 2021New Jersey Department of Health
• A healthcare provider states that laboratory testing was performed as a follow-up to a prior
case that has an illness onset greater than 1 calendar year ago with no new onset of LD
symptoms and no new physician diagnosis (enter as NOT A CASE, reason: CASE DIAGNOSED
IN A PRIOR YEAR
NOTES:
• Lyme disease reports should also be classified as NOT A CASE if:
• a healthcare provider specifically states it is not Lyme disease
• the only “symptom” is "tick bite" or "insect bite", or
• the case has labs for a positive two-tier IgM/WB but has no symptoms/no onset date
and no physician diagnosis of LD. If an onset date is provided and is within 30 days
from specimen collection, but there are no symptoms reported, check to see if there
was a physician diagnosis made; this would make the case “probable”.
D. Criteria for Distinguishing a New Case
Individuals can be re-infected with LD. In addition, some healthcare providers order serial LD tests,
including in the absence of a new onset of symptoms or suspected new exposure to LD. As a result,
individuals may have multiple LD cases in CDRSS. Some individuals have persistent symptoms after
LD treatment, sometimes non-specific, and it can often be unclear whether the symptoms are the
result of an old or new infection. As a result, it is important to note the dates of physician diagnosis
of LD, as well as the year of original infection.
Effective January 1, 2021, new cases should be created once in a calendar year.
Manual receipt of laboratory test results or physician reports
• If laboratory reports are received manually or if a physician reports a case of Lyme disease,
the LHD should check if there is an existing case in CDRSS for the current calendar year, and
if so, add the new report to the existing case. If the case status isn’t CONFIRMED or
PROBABLE, the new report should be investigated and classified accordingly.
Electronic Laboratory Reports
Electronic laboratory reports will append to existing cases created in the same calendar year as the
date of specimen collection.
Cases diagnosed in prior year (greater than one calendar yeast prior to current calendar year):
If a report meets case definition, but the illness onset is in a prior calendar year greater than one-
year prior to the current year, classify the case accordingly and enter the prior year’s illness onset
date. Do NOT merge current reports with prior year cases.
NOT A CASE: CASE DIAGNOSED IN PRIOR YEAR
January 2021 7Communicable Disease Service Manual
Examples of when to classify cases as NOT A CASE: CASE DIAGNOSED IN PRIOR YEAR include:
• Healthcare provider states “not an acute infection of Lyme,” “old infection,” or “chronic
illness.”
• Healthcare provider reports year of diagnosis in a prior calendar year, no new onset of
symptoms, no new diagnosis, AND it is not in the previous calendar year
These scenarios occur frequently because some healthcare providers choose to order tests
annually (or more often) on patients with prior infection, despite the person having no new
symptoms. Most often, these reports have a single positive IgG Western Blot. If testing was
performed as follow-up to a prior case, try to get the date of the original infection (may only
provide year particularly for old cases), and enter the illness onset date (use January 1 and the
year if only year is known).
Note: if there is a new acute onset of symptoms or a new physician diagnosis based on current
presentation, even if the individual had a prior case of LD, the new case should be classified
according to the case classification criteria.
Cases Diagnosed in previous calendar year:
Merging LD cases should only be done if the patient’s illness onset occurred in the previous
calendar year to the current report’s specimen collection year.
• Example 1: There is a CONFIRMED case for 2020 with an illness onset of October 15, 2020.
• New laboratory tests are received in February 2021 and create a new case in 2021.
• After investigation it is determined that testing was follow-up to the 2020 case and
not a new diagnosis. Since illness onset was in the previous calendar year prior to
the year of the current report’s specimen collection, it should be MERGED with the
2020 case.
• Example 2: There is a case for 2017 with an illness onset of April 1, 2017.
• New laboratory tests are received in February 2021 and create a new case in 2021.
i. If after investigation it is determined that testing was follow-up to the 2017
case, there are no symptoms and no new diagnosis, since illness onset was
greater than one calendar year before the year of the current report’s
specimen collection, it should not be merged. The case should be classified
as NOT A CASE with the reason CASE DIAGNOSED IN A PRIOR YEAR and the
illness onset date, if known should be entered.
ii. If after investigation it is determined that testing was follow-up to the 2017
case, but there are confirmatory late stage symptoms, since illness onset was
greater than one calendar year before the year of the current report’s
specimen collection, it should not be merged. The case should be classified
8 January 2021New Jersey Department of Health
as CONFIRMED2 with the reason CASE DIAGNOSED IN A PRIOR YEAR and the
illness onset date, if known should be entered.
2020 NEW JERSEY LYME DISEASE SURVEILLANCE ALGORITHM
NOTE: THIS IS NOT A DIAGNOSTIC TOOL
3 LABORATORY TESTING
Several forms of laboratory testing for LD are available, some of which have not been adequately
validated. Most recommended tests are blood tests that measure IgM and IgG antibodies made in
response to the infection. During the first few weeks of infection, such as when a patient has an EM
rash, serologic tests are expected to be negative. Several weeks after infection, currently available
ELISA, EIA and IFA tests and two-tier testing have very good sensitivity.
CDC currently recommends a two-step process when testing blood for evidence of antibodies
against the LD bacteria. Both steps can be done using the same blood sample. If the first step is
2
May result in multiple confirmed/probable cases for an individual in a single prior calendar year, but this will not impact
historical statistics or reports.
January 2021 9Communicable Disease Service Manual
negative, no further testing is recommended. If the first step is positive or indeterminate
(sometimes called "equivocal"), the second step should be performed. The overall result is positive
only when the first test is positive (or equivocal) and the second test is positive (or for some tests
equivocal).
Traditionally, the CDC recommended two-tier test uses an enzyme immunoassay (EIA) or indirect
immunofluorescence assay (IFA), followed by a western immunoblot assay. On July 29, 2019, the
FDA cleared several LD serologic assays with new indications for use, allowing for an EIA rather
than western immunoblot assay as the second test in a LD testing algorithm.
Traditional Two-Tier Testing
The first step uses an EIA or rarely, an IFA. Enzyme-linked immunoassay (EIA or ELISA) or IFA
determines if a person has developed antibodies to LD. These tests are sometimes called LD
screens and can be reported as positive results or as titers. These tests normally measure the
amount of IgM and IgG together, although testing can be ordered for IgM or IgG independently. All
tests should be interpreted using the reference range provided by the ordering laboratory. These
tests are designed to be very “sensitive,” meaning that almost everyone with LD, and some people
who do not have LD, will test positive. If the ELISA or IFA is negative, it is highly unlikely that the
person has LD, and no further testing is recommended. If this first step is negative, no further
testing of the specimen is recommended. If the first step is positive or indeterminate (sometimes
called "equivocal"), the second step should be performed.
The second step uses a test called an immunoblot test, commonly, a “Western blot” test. If the
patient has had symptoms for less than or equal to 30 days, an IgM Western Blot should be
performed. If the patient has had symptoms for more than 30 days, the IgG Western Blot should be
performed. The IgM should not be used if the patient has been ill for more than 30 days. Results
are considered positive only if the EIA/IFA and the immunoblot are both positive.
The immunoblot is a laboratory test that looks for antibodies against specific B. burgdorferi
antigens. A Western Blot (WB) is a type of immunoblot that requires interpretation of bands.
Immunoblot tests for LD testing can detect two different classes of antibodies: IgM and IgG. IgM
antibodies are made earlier, so testing for them can be helpful for identifying patients during the
first few weeks of infection. The downside of testing for IgM antibodies is that they are more likely
to give false positive results. Tests for IgG antibodies are more reliable but can take 4-6 weeks for
the body to produce large enough quantities for the test to detect them. Used appropriately, this
test is designed to be “specific,” meaning that it will usually be positive only if a person has been
truly infected. If the WB is negative, it suggests that the first test was a false positive.
CDC does not recommend a WB without first performing an ELISA or IFA. Doing so increases the
potential for false positive results. Such results may lead to patients being treated for LD when they
do not have it and not getting appropriate treatment for the true cause of their illness.
Modified Two-Tier Testing
In July 2019, FDA cleared four previously cleared tests with new indications to aid in the diagnosis
of LD. These four tests have been cleared so that two EIA tests are run concurrently or sequentially,
10 January 2021New Jersey Department of Health
rather than the traditional two-step process in which a Western Blot must be run after the initial
EIA test.
The FDA reviewed data from clinical studies of the ZEUS ELISA Borrelia VlsE1/pepC10 IgG/IgM Test
System, ZEUS ELISA Borrelia burgdorferi IgG/IgM Test System, ZEUS ELISA Borrelia burgdorferi IgM
Test System, and the ZEUS ELISA Borrelia burgdorferi IgG Test System that showed this alternative
approach, referred to as a modified two-tier test, is as accurate as current methods for detecting
antibodies for assessing exposure to Borrelia burgdorferi.
To date, FDA has granted clearance only to ZEUS Scientific for use of these specific four assays
when using the modified two-tier testing approach. If these labs are received, same logic should be
followed when classifying cases as with traditional two-tier testing (IgM valid only if it is within 30
days of illness onset).
Note: Electronic laboratory reporting processes in CDRSS can NOT currently identify these new tests.
Tests not acceptable for public health surveillance
LD tests whose accuracy and clinical usefulness have not been adequately established include urine
antigen tests, immunofluorescent staining for cell-wall-deficient forms of B. burgdorferi,
lymphocyte transformation tests, and “reverse western blots.” In general, the CDC does not
recommend these tests. Patients are encouraged to ask their physicians whether their LD test was
performed using validated methods and whether results were interpreted using appropriate
guidelines.
The NJDOH Public Health and Environmental Laboratories (PHEL) does not provide human testing
for the detection of B. burgdorferi.
4 PURPOSE OF SURVEILLANCE AND REPORTING
• To better understand the local epidemiology of infection with B. burgdorferi
• To recognize areas in New Jersey where LD incidence has changed (increased or decreased)
• To focus LD preventive education
5 CASE INVESTIGATION
A. Investigation
Local health departments are asked to investigate LD reports and close cases in CDRSS within 3
months of case creation. Cases that remain open for three months or more and have no
investigation or update notes will be closed by NJDOH. Local health departments can fax the CDS-
14 Lyme Disease Case Investigation form (Attachment A) to the patient’s healthcare provider to
January 2021 11Communicable Disease Service Manual
collect information needed to classify the case. Case report forms should NOT be sent to NJDOH.
Document all information in CDRSS.
A minimum of 3 attempts should be made to obtain information from the patient’s healthcare
provider. After 3 attempts, enter what is known into CDRSS, including attempts to obtain
information (dates and results of the attempts), and classify/close the case according to the case
definition.
It is NOT necessary to interview the patient because the information needed for case classification
MUST be provided by a healthcare provider.
B. Key CDRSS Fields Specific for Lyme Disease
CDRSS Screen Required Information
Signs/Symptoms • Check appropriate boxes for signs and symptoms and indicate their
onset/resolution dates. Onset dates are important to interpret
laboratory test results (IgM WB vs IgG WB).
• If an exact onset date was not provided, but the healthcare provider
indicates if symptom onset was greater than 30 days, write this in the
“Attribute” field next to that sign/symptom
• Add/select reported signs/symptoms even if they are not part of case
definition.
Additional • Note if physician diagnosed the patient with LD and date if available
Requirements
• Note if symptoms developed greater than 30 days prior to specimen
collection. This is important to interpret IgM WB labs.
Case Comments • If requested information was not provided by the patient’s healthcare
provider, list the dates attempts were made to obtain information and
the outcomes. For example, 1/12/21 faxed form to provider; 1/31/21,
spoke with office manager and re-sent form; 2/15/21, re-faxed form
to provider. Provider non-responsive.
• Note any other information that may be related but does not
otherwise have a specific field.
12 January 2021New Jersey Department of Health
CDRSS Screen Required Information
Case • If information was not provided by the healthcare provider, despite at
Classification least 3 attempts, classify case as POSSIBLE and next to Case Status /
Reason for Status, select “UNABLE TO OBTAIN INFO FROM MD”.
• If new testing was performed as follow-up to an existing case greater
than one-calendar year prior to the year of the current report’s
specimen collection date, the case should be classified accordingly
with the reason “CASE DIAGNOSED IN A PRIOR YEAR”.
• If a patient’s onset date was one calendar year prior to the new
laboratory report’s specimen collection date and there is an existing
LD case in the prior year, the cases should be merged.
6 CONTROLLING FURTHER SPREAD
C. Isolation and Quarantine Requirements / Protection of Contacts of a Case
There are no isolation or quarantine restrictions.
D. Managing Special Situations
Removing a Tick
Ticks should be removed as soon as they are found on the skin. Fine-tipped tweezers should be
used to firmly grasp the tick very close to the skin. Using a steady motion, the tick’s body should be
pulled away from the skin. Efforts should be made to not twist or jerk the tick - this can cause the
mouth-parts to break off and remain in the skin. If this happens, the mouth-parts should be
removed with tweezers. If they can’t be removed, it isn’t cause for concern. Once the mouthparts
are removed from the rest of the tick, it can no longer transmit the LD bacteria. After the tick is
removed, the bite area should be cleaned with rubbing alcohol, an iodine scrub, or soap and water.
Dispose of a live tick by submersing it in alcohol, placing it in a sealed bag/container, wrapping it
tightly in tape, or flushing it down the toilet. Never crush a tick with fingers.
Petroleum jelly, a hot match, nail polish, or other products should not be used to remove a tick. An
area of redness occurring within several hours of a tick bite represents a hypersensitivity reaction
and does not represent an EM. The date of tick attachment should be documented so if symptoms
develop, this information can be relayed to a healthcare provider.
Tick Testing and Identification:
January 2021 13Communicable Disease Service Manual
Tick testing of individual ticks is not useful because:
• If the test shows that the tick contained disease-causing organisms, that does not
necessarily mean that the person has been infected.
• If someone has been infected, s/he will probably develop symptoms before results of tick
testing are available. Treatment should not be delayed while waiting for tick testing results.
• Negative results can lead to false assurance. For example, the person concerned may have
been unknowingly bitten by a different tick that was infected.
Tick identification (not testing) may be of value when discussing tick bite exposures with a
healthcare provider. County mosquito control agencies or agricultural extension offices may offer
tick identification services. The TickEncounter Resource Center also has tick identification resources
online: http://www.tickencounter.org/tick_identification.
E. Preventive Measures
Preventing ticks in the yard: Prevention of LD involves keeping wildlife (especially deer and rodents)
out of the backyard and making it less attractive to ticks.
• Clear tall grasses and brush around homes and at the edge of lawns.
• Place a 3-ft wide barrier of wood chips or gravel between lawns and wooded areas and
around patios and play equipment. This will restrict tick migration into recreational areas.
• Mow the lawn frequently and keep leaves raked.
• Stack wood neatly and in a dry area (discourages rodents that ticks feed on).
• Keep playground equipment, decks, and patios away from yard edges and trees and place
them in a sunny location, if possible.
• Remove any old furniture, mattresses, or trash from the yard that may give ticks a place to
hide.
• When using acaricides (tick pesticides) around the home, always follow the label
instructions and never use near streams or other bodies of water.
Preventing ticks on pets: Although dogs and cats can get LD, there is no evidence that they spread
the disease directly to their owners. However, pets can bring infected ticks into the home or yard.
For these reasons, it’s important to use a tick preventive product for dogs.
14 January 2021New Jersey Department of Health
Preventing tick bites on people: The best preventive measure is to avoid tick-infested areas. In
areas where contact with ticks may occur, individuals should be advised to do the following:
• Wear long-sleeved shirts and long, light-colored pants tucked into socks or boots.
• Stay on trails when walking or hiking and avoid high grass.
• Use repellent that contains 20 percent or more DEET, picaridin, or IR3535 on exposed skin
for protection that lasts several hours. Always follow product instructions. Parents should
apply this product to their children, avoiding hands, eyes, and mouth.
• Use products that contain permethrin on clothing. Treat clothing and gear, such as boots,
pants, socks and tents with products containing 0.5% permethrin. It remains protective
through several washings.
• Bathe or shower as soon as possible after coming indoors (preferably within 2 hours) to
wash off and more easily find ticks that are crawling on you.
• Conduct a full-body tick check using a hand-held or full-length mirror to view all parts of
your body upon return from tick-infested areas. Parents should check their children for ticks
under the arms, in and around the ears, inside the belly button, behind the knees, between
the legs, around the waist, and especially in their hair.
• Examine gear and pets. Ticks can ride into the home on clothing and pets, then attach to a
person later, so carefully examine pets, coats, and day packs.
• Tumble dry clothes in a dryer on high heat for 10 minutes to kill ticks on dry clothing after
you come indoors.
January 2021 15Communicable Disease Service Manual
Tick Bite Prophylaxis
The Infectious Disease Society of America (IDSA) does not generally recommend antimicrobial
prophylaxis for prevention of LD after a recognized tick bite. However, in areas that are highly
endemic for LD (i.e., New Jersey), a single dose of doxycycline may be offered to adult patients (200
mg) who are not pregnant and to children older than 8 years of age (4 mg/kg up to a maximum
dose of 200 mg) when all of the following circumstances exist:
• Doxycycline is not contraindicated
• The attached tick can be identified as an adult or nymphal I. scapularis tick
• The estimated time of attachment is ≥36 h based on the degree of engorgement of the tick
with blood or likely time of exposure to the tick
• Prophylaxis can be started within 72 h of tick removal
• LD is common in the county or state where the patient lives or has recently traveled, (i.e.,
CT, DE, MA, MD, ME, MN, NH, NJ, NY, PA, RI, VA, VT, WI).
Additional information is available at https://www.cdc.gov/ticks/tickbornediseases/tick-bites-
prevention.html
F. Immunization
A LD vaccine is no longer available. The vaccine manufacturer discontinued production in 2002.
Protection provided by this vaccine diminishes over time. Therefore, persons who received the LD
vaccine before 2002 are probably no longer protected against LD.
Additional Information
NJDOH: http://www.nj.gov/health/cd/topics/lyme.shtml
CDC: https://www.cdc.gov/lyme/
References
Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System (NNDSS), Case
Definitions: https://wwwn.cdc.gov/nndss/conditions/lyme-disease/case-definition/2017/
Centers for Disease Control and Prevention. Lyme Disease: https://www.cdc.gov/lyme/.
Centers for Disease Control and Prevention. Notice to Readers: Cautions Regarding Testing for Lyme Disease.
MMWR. 2005; 54(05):125.
Chin, J., ed. Control of Communicable Diseases Manual, 20th Edition. Washington, DC, American Public Health
Association, 2014.
16 January 2021New Jersey Department of Health
Mandell G, Bennett J, Dolin R, eds. Principles and Practice of Infectious Diseases. 8th ed. New York, NY: Churchill
Livingstone, 2015.
Nadelman, R.B., Nowakowski, J., Durland, F., et al. Prophylaxis with Single-Dose Doxycycline for the Prevention of
Lyme Disease after an Ixodes scapularis Tick Bite. N Engl J Med 345:79-84.
New Jersey State Health Assessment Data. Complete Health Indicator Report of Lyme Disease: https://www-
doh.state.nj.us/doh-shad/indicator/complete_profile/LymeDisease.html
Serious Bacterial Infections Acquired During Treatment of Patients Given a Diagnosis of Chronic Lyme Disease —
United States. MMWR Weekly Report, June 16, 2017, 66(23): 607-609.
January 2021 17Communicable Disease Service Manual Appendix A: NJDOH Lyme Disease Case Investigation Form, CDS-14 18 January 2021
New Jersey Department of Health Appendix B: Frequently Asked Questions Are equivocal antibody labs considered positive or negative? Positive. Should patient interview be utilized for Lyme case information? While local health departments are encouraged to provide education on Lyme disease to case-patients, information needed for case investigation and classification must be provided by a healthcare provider. This is due to the highly specified nature of the symptomology of Lyme, particularly in relation to the characteristic erythema migrans (EM) rash, as well as other specific confirmatory symptoms. Does every acceptable lab have to be investigated, even if the patient is known to suffer from chronic Lyme disease or has several previous Lyme cases? Yes. Due to the fact that a person can be reinfected with Lyme disease several times, every acceptable lab must be investigated to ascertain whether the case is a new infection or an old or chronic infection. Is a positive IgM Western Blot lab alone considered an acceptable lab to base investigation off of? No. In addition to a positive IgM Western Blot, there must also be a positive EIA/IFA lab present. This is considered a two-tier IgM test. After this, investigation can begin. However, if after investigation is completed, and it is found that the specimens were not collected within 30 days or less of symptom onset, then the labs are not considered acceptable. Does the IgG Western Blot lab have to have the specimen drawn within 30 days or less of symptom onset date? No. The IgG Western Blot is considered an acceptable lab regardless of symptom onset date. How long is the window to add further labs onto existing cases? New labs should be added to existing cases within the same calendar year only. January 2021 19
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