Lyme disease is the most common vector-borne disease in the United States. The Centers for Disease Control and Prevention reported more than 36,000 confirmed or probable Lyme disease cases in 2013 and has estimated that the total number of people diagnosed with Lyme disease annually is roughly 10 times higher than the number of cases reported. People who are at the highest risk for tick bites are those who work or spend their leisure time outdoors. Outdoor workers in endemic areas are at increased risk of contracting Lyme disease and other tick-borne diseases through contact with ticks during their work. Coordination of federal efforts to prevent Lyme and other tick-borne infections is needed, as is additional funding for research on Lyme disease prevention and vaccine development. Employers need to provide appropriate personal protective equipment and health education materials so that outdoor workers will be aware of tick-borne risks as well as prevention measures.
Lyme disease is now recognized as the most common vector-borne disease in the United States and Europe. Lyme disease cases reported to the Centers for Disease Control and Prevention (CDC) through national surveillance are concentrated most heavily in the Northeast and upper Midwest, with 96% of reported cases occurring in 13 states. The CDC reported more than 36,000 confirmed or probable Lyme disease cases in 2013 and has estimated that the total number of people diagnosed with Lyme disease annually is roughly 10 times higher than the number of cases reported.[1] In their study, Hinkley et al. estimated that approximately 240,000 to 440,000 cases of Lyme disease occur each year.[2] Outdoor workers in endemic areas are at increased risk of contracting Lyme disease or other tick-borne diseases through contact with ticks during their work.
Lyme disease is a common but frequently misunderstood illness that, if not diagnosed early and treated properly, can cause serious health problems. Lyme disease is caused by the bacterium Borrelia burgdorferi, which belongs to the spirochete class, and is transmitted to humans through bites from infected ticks. Early signs of infection may include a rash and flu-like symptoms, such as fever, muscle aches, headaches, and fatigue. Although Lyme disease can be treated with antibiotics if diagnosed early, the disease often goes undetected because it mimics other illnesses or may be misdiagnosed. Untreated, Lyme disease can lead to severe heart, neurological, and joint problems because the bacteria can affect many different organs and organ systems. Although Lyme disease accounts for 90% of all vector-borne disease in the United States, the ticks that spread the illness also transmit other diseases, such as anaplasmosis and babesiosis, and carry other strains of Borrelia burgdorferi. Other tick species, such as the aggressive lone star tick, spread ehrlichiosis, Rocky Mountain spotted fever, and southern tick-associated rash illness (STARI). Multiple diseases in one patient and persistence of symptomatology in many patients make diagnosis and treatment more difficult.
According to the estimates of Adrion et al., total direct medical costs attributable to Lyme disease and posttreatment symptoms could range between $712 million and $1.3 billion each year, with each individual diagnosed with the illness incurring increased health care expenses averaging nearly $3,000 annually.[3] People who are at the highest risk for tick bites, including children, are those who work or spend their leisure time outdoors. Occupations that have been identified as involving an increased risk of exposure to infected ticks include construction, landscaping, forestry, brush clearing, land surveying, farming, railroad work, oil field work, utility line work, and park/wildlife management.[4]
Evidence-Based Strategies to Address the Problem
One of the objectives of Healthy People 2010 was to reduce the incidence of Lyme disease. Without an available vaccine, however, this goal is difficult to attain.[5–7]
In the absence of a safe and effective human vaccine, reducing exposure to ticks is the best defense against Lyme disease, Rocky Mountain spotted fever, and other tick-borne diseases. Entomology-based approaches to preventing tick-borne diseases include the development and use of insect repellent, prompt tick removal, application of pesticides, and reduction of tick habitats.
Legislation to create a national tick-borne disease advisory committee has been proposed as a means of enhancing federal efforts related to Lyme disease and other tick-borne diseases, including prevention, education, treatment, and research activities.[8]
Early clinical trials are under way for at least one new candidate vaccine,[9] and other promising approaches to vaccine development are being studied.[10]
Action Steps
APHA recommends that:
- A federal tick-borne disease advisory committee be established to coordinate research and prevention efforts aimed at tick-borne diseases. The committee’s purpose should be to advise the secretary and assistant secretary for health regarding the manner in which they and other officials can ensure interagency coordination and communication and minimize overlap regarding efforts to address tick-borne diseases, identify opportunities to coordinate efforts with other federal agencies and private organizations addressing such diseases, ensure interagency coordination and communication with constituency groups, ensure that a broad spectrum of scientific viewpoints are considered in public health policy decisions and that information disseminated to the public and physicians is based on the best available science and is appropriately balanced, and advise relevant federal agencies on priorities related to Lyme disease and other tick-borne diseases.
- The CDC develop improved surveillance and reporting of Lyme disease and other tick-borne diseases to accurately determine the incidence of these diseases, to evaluate the feasibility of developing a reporting system for the collection of data on Lyme disease cases that do not meet the CDC surveillance criteria so as to more accurately gauge disease incidence, to evaluate the feasibility of creating a national uniform reporting system including required reporting by laboratories in each state, and to evaluate the feasibility of creating a national monitoring system for tick populations.
- The Occupational Safety and Health Administration (OSHA) require employers to provide health education materials related to Lyme disease and other tick-borne diseases in English, Spanish, and other languages as appropriate so that outdoor workers in endemic tick-borne disease regions will be aware of risks as well as prevention measures[11] Also, OSHA should require that employers provide at-risk workers with appropriate personal protective equipment to protect against Lyme disease and other tick-borne diseases (e.g., long pants, tick repellents) and should adopt an infectious disease standard to protect workers and the public.
- Federal support of prevention activities related to Lyme disease and other tick-borne diseases be increased, including establishment of a comprehensive, up-to-date clearinghouse of peer-reviewed information on Lyme disease and other tick-borne diseases and increases in the provision of public education related to these diseases through expansion of the CDC’s Educational and Community-Based Programs. These efforts should include expansion of public information access points; creation of a physician education program that comprises the full spectrum of scientific research related to the identification of symptoms associated with, and the diagnosis of, Lyme disease and other tick-borne diseases; and, in coordination with the advisory committee described above, the publication of an annual report that evaluates published guidelines and current research available on Lyme disease. The aims of this report would be to educate health professionals on the latest Lyme disease research and treatment options, to help provide an understanding of the mechanisms of tick repellents and develop new chemical and nonchemical strategies for the control of ticks, and to explore the utility of and potential for the development of a safe and effective vaccine against Lyme disease and other tick-borne diseases.
References
1. Centers for Disease Control and Prevention. How many people get Lyme disease? Available at: http://www.cdc.gov/lyme/stats/humanCases.html. Accessed January 5, 2016.
2. Hinckley AF, Connally NP, Meek JI, et al. Lyme disease testing by large commercial laboratories in the United States. Clin Infect Dis. 2014;59:676–681.
3. Adrion ER, Aucott J, Lemke KW, Weiner JP. Health care costs, utilization and patterns of care following Lyme disease. PLoS One. 2015;10:e0116767.
4. Occupational Safety and Health Administration. Safety and health information bulletin: potential for occupational exposure to Lyme disease. Available at: https://www.osha.gov/dts/shib/shib021103.html. Accessed January 5, 2016.
5. Poland GA. Vaccines against Lyme disease: what happened and what lessons can we learn? Clin Infect Dis. 2011;52(suppl 3):253–258.
6. College of Physicians, Philadelphia. The history of vaccines: the history of the Lyme disease vaccine. Available at: http://www.historyofvaccines.org/content/articles/history-lyme-disease-vaccine. Accessed January 5, 2016.
7. King LP. The ongoing 30-year Lyme disease war: case study of a failure to communicate. Available at: http://www.yaleclimatemediaforum.org/2008/11/30-year-lyme-disease-war. Accessed January 5, 2016.
8. US Senate. S.1503: Lyme and Tick-Borne Disease Prevention, Education, and Research Act of 2015. Available at: https://www.congress.gov/bill/114th-congress/senate-bill/1503/text?q=%7B%22search%22%3A%5B%22Lyme+disease+2015%22%5D%7D&resultIndex=1. Accessed January 5, 2016.
9. Comstedt P, Hanner M, Schuler W, Meinke A, Lundberg U. Design and development of a novel vaccine for protection against Lyme borreliosis. PLoS One. 2014;9:1-12.
10. Livey I, O’Rourke M, Traweger A, et al. A new approach to a Lyme disease vaccine. Clin Infect Dis. 2011;52(suppl 3):s266–s270.
11. Garvin AH, Gordon TF, Haigneri C, DuCette JP. Development of a public health assessment tool to prevent Lyme disease. Perspect Health Inf Manag. 2005;2:11.