Interdisciplinary Approach to Reducing the Burden of Lyme Disease in Rural. Wisconsin

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1 Interdisciplinary Approach to Reducing the Burden of Lyme Disease in Rural Wisconsin Can you check my back? This phrase was spoken very often around my household as I was growing up. There was no telling when, upon inspection, someone may find an unwelcome visitor along for the ride after a day working outdoors. This visitor is commonly called a deer tick in our neck of the woods, and they are very common in rural parts of Wisconsin, especially the West Central region. I grew up on a beef farm in Trempealeau County, which is located in the epicenter of the deer tick s statewide range. Therefore, removing deer ticks became common practice to me, and I thought nothing of it. One day though, I noticed an odd looking rash developing around a site where I had removed a deer tick one week prior. In the following days I soon came to realize that the deer tick had left me a present before it was removed, namely Lyme disease. I underwent subsequent treatment and cleared the infection, but not before I vowed to do everything in my power to avoid contracting this potentially lethal affliction again. Lyme disease was first recognized in the United States at Lyme, Connecticut in This infection is caused by a gram negative, motile, spirochete bacterium known as Borrelia burgdorferi. This bacterium is transmitted via the bite of a tiny parasite known as Ixodes scapularis (commonly called a deer tick). This parasite gets its common name due to its habit of using white tailed deer (among other animals) for sustenance. As a result, Ixodes scapularis is present in most areas where white tailed deer are present 3. Figure 1 below gives an accurate representation of the size and phenotypical characteristics of this parasite.

2 Figure 1. Northern Tick Identification Card Distributed by GHS Historically, deer have been localized in more rural areas of Wisconsin, but we are beginning to see more and more deer in cities now. This means that deer ticks are becoming a concern for citydwelling inhabitants of our state as well. Currently however, deer ticks are a much bigger concern for farmers, hunters, hikers, and outdoorsman who spend a majority of their time in the field. This is especially seen in West Central Wisconsin where outdoor opportunities abound and many people participate in the aforementioned activities. Within this region, Trempealeau and La Crosse counties have the highest prevalence of deer ticks. As a result, these two counties also have the highest prevalence of Lyme disease as well. This sentiment is reflected in the maps located in Figures 2 through 4 below.

3 Figure Forecasted Lyme Disease Prevalence Lyme Disease Prevalence Map Image.jpg Figure 3. Prevalence of Ixodes scapularis (deer ticks) in Wisconsin (2012) ticks/files/2012/05/map of tick presence.jpg

4 Figure 4. Incidence of Lyme disease in Wisconsin (2011) content/uploads/2011/09/lyme Disease in Wisconsin Mean annual Lyme disease incidence per persons by county of residence jpg Lyme disease symptoms usually appear anywhere from 3 to 30 days after an infected deer tick bites a human. It often, but not always, begins with roughly circular reddish rash at or around the site of the tick bite. This rash usually expands in size over days to weeks and may have a bull s eye appearance. The technical term for this rash is erythema migrans (EM rash) and this is the hallmark sign of Lyme disease. When the EM rash develops, other symptoms such as fever, headache, fatigue, stiff neck, muscle or joint pain, and swelling may be present and can last for several weeks. If this disease is left untreated, severe infection can develop. This would be evidenced by complications such as meningitis, facial palsy, heart abnormalities, or arthritis occurring a few weeks to months after initial onset of symptoms. In some cases people get infected, don t realize it, and their body is able to overcome the acute phase infection on its own. However, these people are at high risk for reactivation of latent infection as their body may not have cleared the bacterium completely. Other times people get infected and get treatment right away, but the bacterium hides out in an area of the body with poor antibiotic

5 penetration, resulting in persistent or recurrent symptoms. This is referred to as post treatment Lyme disease syndrome (PTLDS) 3. For patients who recognize the signs and symptoms of Lyme disease, it is very important to seek medical attention immediately. The prognosis for this infection is much better if it is caught in the early stages. Better outcomes are associated with early antibiotic administration and almost all patients recover after antibiotic treatment. For treatment recommendations, I sought the advice of Dr. Todd J Kowalski, an infectious disease specialist at Gundersen Lutheran Health System (GHS) located in La Crosse, WI. As the premier health institution serving Trempealeau and La Crosse counties, GHS sees many cases of Lyme disease every year. Dr. Kowalski has helped construct GHS s antibiotic management guidelines for treatment of tick borne illness in conjunction with hospital pharmacy staff, which are outlined in Table 1 below. Table 1. Gundersen Lutheran Health System Tick Borne Illness Recommendations Lyme Disease Once a Lyme titer is positive by EIA or Western Blot, it may stay positive for years and doesn t bear repeating Do not check Lyme titer if erythema migrans is present; initiate therapy doxycycline for 10 days Deer tick attachment < 36º no treatment; > 36º observe for development of erythema migrans OR give doxycycline 200 mg orally once Lyme Disease early (single EM rash) doxycycline for 10 days Lyme Disease early disseminated stage (multiple EM rashes, facial palsy, carditis, neuritis) doxycycline for 21 days Lyme Disease late stage (arthritis, especially knee, neurologic conditions) doxycycline 100 mg orally twice a day for 28 days consider ID consult

6 Table 1. Gundersen Lutheran Health System Tick Borne Illness Recommendations (Continued) Anaplasmosis Doxycycline 100 mg orally twice daily for 10 days Babesiosis Atovaquone 750 mg orally twice daily PLUS azithromycin 500 mg on day 1, then 250 mg daily on days 2 7 In addition to the above recommendations, Dr. Kowalski conducted a retrospective cohort study and follow up survey of patients diagnosed as having early localized and early disseminated Lyme disease at GHS. This study had 607 patients who were treated with primarily doxycycline for either 10 days, days, or 16 days. The 2 year treatment failure free survival rates of patients treated with antibiotics were 99.0%, 98.9%, and 99.2%, respectively. Based on this study, we can see that patients treated for 10 days with antibiotic therapy for early Lyme disease have long term outcomes similar to those of patients treated with longer courses 2. This is very important because it shows that we can eliminate the infection while shortening duration of therapy to prevent antimicrobial resistance. We can further optimize medication therapy for Lyme disease by ensuring the proper route of administration is used, and unnecessary IV line placement is avoided. For early localized Lyme disease oral antibiotics usually suffice. UpToDate recommends treatment in concordance with GHS guidelines, with the additional option of using amoxicillin or cefuroxime for 14 to 21 days. However, in keeping with the principles of antimicrobial stewardship, we would choose the option with the shortest duration as discussed previously. For early disseminated Lyme disease, UpToDate recommends oral or IV formulations, with IV formulations being reserved for more serious manifestations such as meningitis

7 and advanced heart block. For late stage Lyme disease, UpToDate recommends 28 days of oral antibiotics, with IV formulations being reserved only for those patients whose arthritis does not improve with oral treatment 1. Our approach to optimizing recognition and treatment of Lyme disease must be multidisciplinary in fashion. Physicians and nurses should be encouraged to seek additional education regarding the signs and symptoms of this infection, so that it can be recognized upon physical examination of their patients during regular checkup visits. This will allow us to catch the infection earlier, which as discussed previously, is important in obtaining the best therapeutic outcomes and avoiding lasting damage due to Lyme disease. Physicians should also be made aware of the fact that shorter durations of therapy are just as effective and help prevent antimicrobial resistance so that it can be reflected in their prescribing practices. When warm weather hits in the early spring and summer, people start spending more time outdoors. This means that we see a dramatic increase in the number of patients presenting with tickborne illnesses during these months. Luckily, there are several non pharmacologic and over the counter (OTC) methods that can be utilized to help decrease the incidence of tick bites. The following strategies could be especially useful for farmers, rural workers, outdoorsmen, hunters, and hikers 4 : 1. Application of insect repellant, such as DEET (for skin) or permethrin (for clothing). For hunters, there is a new line of camouflage clothing (Gamehide Elimitick) containing permethrin bonded to the fabric fibers, which acts to keep ticks away as well as eliminate human odor when you are in the woods. 2. Wearing long sleeves, pants, and socks 3. Tucking pants into socks

8 4. Performing regular tick checks after having been outdoors. Common bite areas include around the belt or bra line, back of the knees, groin area, underarms, ears, and the hair line of the neck. 5. Lastly, remove ticks carefully and immediately, making sure to remove the head. Without a doubt, Lyme disease is a significant health concern in rural Wisconsin. Several institutions are raising awareness of this affliction within the state by distributing educational material to the general public, such as the tick identification card made by GHS in Figure 1. These are important tools in the fight against tick borne illness, but they are only part of the puzzle. Efforts should also be made to optimize medication therapy to ensure better therapeutic outcomes as well as decrease antimicrobial resistance. Education of the multidisciplinary healthcare team is important in the early recognition and appropriate treatment of Lyme disease. Lastly, non pharmacologic and over the counter methods for preventing tick bites are essential in decreasing human exposure to these parasites that are vectors for deadly disease.

9 References: 1. Hu, Linden. Lyme Disease Treatment (Beyond the Basics). UpToDate website. disease treatment beyond the basics. Updated December 2, Accessed April 18, Kowalski TJ, Tata S, Berth W, Mathiason MA, Agger WA. Antibiotic treatment duration and longterm outcomes of patients with early lyme disease from a lyme disease hyperendemic area. Clin Infect Dis. 2010;50(4): Lyme Disease. Wisconsin Department of Health Services website. https://www.dhs.wisconsin.gov/tickborne/lyme/index.htm. Updated February 22, Accessed April 18, Tickborne Illnesses. Gundersen Health System Infectious Disease website. disease/ticks. Updated January 5, Accessed April 18, 2016.

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