Archive for the ‘Testing’ Category

Burrascano Webinar on Borreliosis Testing (Lyme & TBRF)

https://www.lymedisease.org/burrascano-webinar-borreliosis/

Burrascano webinar on borreliosis testing (Lyme and TBRF)

The name “borreliosis” can refer to two distinct but similar infections: Lyme disease and tick-borne relapsing fever (TBRF).

Both diseases result from different subspecies of Borrelia. They exhibit many of the same symptoms and both are spreading geographically.

According to world-renowned Lyme disease specialist Dr. Joseph Burrascano, these diseases present significant challenges to patients and healthcare practitioners alike.

Dr. Burrascano recently presented a webinar with IGeneX, Inc., about testing for both infections. Dr. Jyotsna Shah, president and laboratory director of IGeneX, joined him in the question and answer period.

Better Diagnostic Teesting: Antibodies & Beyond

https://www.lookingatlyme.ca/2021/10/40-better-diagnostic-testing-antibodies-and-beyond-with-dr-armin-schwarzbach/  Webinar Here

40. Better diagnostic testing: antibodies and beyond with Dr. Armin Schwarzbach

Detecting Lyme disease and related infections.

Episode 40 with Dr. Armin Scharwzbach from Armin Labs in Augsburg Germany.

In this episode of Looking at Lyme, we go to Augsburg, Germany to learn about diagnostic testing with Dr. Armin Schwarzbach, MD, PhD.

Dr. Schwarzbach is a specialist in laboratory medicine and infectious diseases, having worked in the field for over 20 years. He recalls one of his patients who was diagnosed with Multiple Sclerosis and tested positive for a test that was then called a lymphocyte transformation test for Borrelia burgdorferi even though she subsequently tested negative for antibodies to the bacteria. The patient had not responded to previous treatment for her MS (with steroids) but recovered after being treated for Lyme disease.

“[The Western Blot] is a screening test for transmission of Borrelia burgdorferi but not an activity test…I never have seen such cases where there are no antibodies, but cellular immune reactions.”

Dr. Armin Schwarzbach

Testing options

After recognizing that routine antibody tests for Lyme disease were unreliable, Dr. Schwarzbach decided to explore other methods of cellular analytics for patients with tick-borne illnesses based on cellular immune reactions. Although these tests are now performed in some other labs in Germany, Dr. Schwarzbach points out that many countries, including Canada, are not currently offering these types of tests. Canadian patients currently have to arrange to have their blood samples shipped to Germany to access the tests done at his laboratory.

“When I travelled around and people contacted me [I found that] nobody is doing the test in Canada, (or in many other countries).”

Dr. Armin Schwarzbach

B cells and T cells

Dr. Schwarzbach describes the difference between direct and indirect testing. Direct testing, including cultures and PCR (polymerase chain reaction) tests, look for direct evidence of a pathogen. Indirect testing, including antibody and t-cell tests, look at the body’s immune response to a pathogen. He differentiates between B cells, or antibodies in the form of proteins, and T-cells which are living cells called lymphocytes. Dr. Schwarzbach points out that in the US, the Centre for Disease Control (CDC) actually prefers a T-cell test for tuberculosis, but does not yet accept this test for Lyme disease.

 “B cells are the antibodies and the T cells are the lymphocytes. Antibodies are proteins, lymphocytes are living cells…in the whole diagnostic world I think (T cells) are underrepresented.”

Dr. Armin Schwarzbach

Antibody anomalies with Lyme disease

Dr. Schwarzbach also explains one of the other anomalies seen in Lyme disease patients. With other infections, IgM antibodies are normally produced early in the infectious process and IgG antibodies in the long term. In Lyme disease, they are observing the persistence of IgM antibodies but not IgG antibodies. He collaborated with professor Dr. Leona Gilbert, who was leading research on multiple tick borne diseases as well as persister forms and intracellular forms of Borrelia burgdorferi, sometimes called round bodies, cysts, or L-forms. Dr. Leona Gilbert discussed her research with Sarah in Season One of Looking at Lyme.

Testing for multiple infections

This research led to the creation of a test panel called the TickPlex, which includes various co-infections and opportunistic infections. Dr. Schwarzbach notes that a patient can test positive for multiple infections even if they test negative for Lyme disease. He explains that co-infections (also called tick-borne or vector-borne infections) are caused by pathogens found in vectors such as ticks, whereas opportunistic infections are already in our bodies and are normally kept under control by our immune system. When our immune system is not functioning properly, these opportunistic infections can re-activate, creating further health issues for patients with tick-borne infections such as Lyme disease.

“The TickPlex was developed because…we saw together with professor Gilbert that there are persister forms…we said why should we not test for these persister form antibodies…and that was a breakthrough because we found around 98% now with a persister form of antibodies.”

Dr. Armin Schwarzbach

The three “I’s” of infection

Dr. Schwarzbach explains that one of the biggest roadblocks to better testing is that many authorities don’t accept the concept of chronic infection. He hopes this will improve with the increased use of other testing modalities such as the TickPlex test. He discusses diagnostics for infections using the three “I’s”;  IgA, IgG and IgM antibodies, immune dysfunction tests, and inflammatory markers. Another test for Borrelia burgdorferi and SARS-CoV-2 is the I-spot, which can test both for past and current infection, and biopsy or tissue testing.  Dr. Schwarzbach points out that all of these tests are helpful not only for initial diagnosis, but also for monitoring patient progress and treatment effectiveness. He also notes that test results need to be considered in conjunction with what is happening clinically with patients, and with what patients are experiencing.

“What I see in this model with the three ‘I’s’ with SARS CoV-2, we diagnose it with antibodies, IgG, IgA…the second ‘I’ is the immune dysfunction…and the (third) ‘I’…is inflammation, the inflammatory markers…(we can) help therapists and to give additional information about infection, inflammation and immune dysfunction.”

Dr. Armin Schwarzbach

The COVID connection

What do Lyme disease, COVID and HIV infections have in common? They all can all cause reactivation of dormant infections in our bodies such as Epstein-Barr, Herpes Simplex, Coxsackie and Cytomegaloviruses as well as imbalances in yeast, mold and gut bacteria. In fact, in a recent study, 66.7% of long COVID patients were found to have reactivation of Epstein-Barr Virus. Dr. Schwarzbach points out that these patients may have other opportunistic infections which require diagnostic testing. He even developed a checklist to help clinicians determine which opportunistic infections may be active in their patients.

“I accept chronic infections… but the majority of doctors don’t accept this. They say yes you can have a current or recent infection… but it cannot get chronic. This is the struggle we have politically… I’m fighting for the acceptance of chronic infection, and this we can do by these wonderful blood tests.”

Dr. Armin Schwarzbach

New directions in testing

Looking to the future, Dr. Schwarzbach hopes to develop tests for biofilms, parasitic infections, gut viruses and bacteria, as well as yeast and mold. Thank you Dr. Schwarzbach for filling us in on the latest testing for infections that can be associated with Lyme disease! Remember to keep an eye out for ticks even as the weather gets cooler, and stay safe in the outdoors!

Resources

“(With the TickPlex test) we found also that all of these patients had multiple infections, so called co-infections from tick bites or re-activated infections, we name opportunistic infections; viruses and so on…so (Dr. Gilbert) designed a panel for that.”

For more:

Re-Cap of LDA/Columbia Lyme Conference

https://www.lymedisease.org/lda-columbia-lyme-conference/

LYME SCI: My re-cap of recent LDA/Columbia Lyme conference

On October 2, I attended the 21st annual scientific conference put on by the Lyme Disease Association and Columbia University’s Vagelos College of Physicians & Surgeons. The virtual event was entitled Lyme & Other Tick-Borne Diseases: Research for a Cure. 

Pat Smith, President of the Lyme Disease Association, welcomed the audience and reviewed the huge body of research the LDA has funded. A recent highlight: a paper showing that changes in the eye may serve as a biomarker for Lyme disease.

She also discussed how the CDC’s criteria for listing states as low-incidence leads to underreporting of Lyme disease. (This topic was also featured in the Summer 2021 issue of The Lyme Times.)

I especially enjoyed Pat’s introduction of Dr. Brian Fallon, of Columbia University, which included pictures and stories of their many collaborations since 1995.

The conference was divided into four sessions and was moderated by Dr. Fallon and Monica Embers, PhD, of Tulane University.

Session 1

The first speaker was John Aucott, MD, of Johns Hopkins University. He spoke on Long Haulers: Lessons from Lyme Disease, ME/CFS, and COVID-19.

Summary: The COVID-19 pandemic has drawn attention to the varied outcomes that may follow acute infectious diseases. COVID long haulers present another example of a patient group that fails to recover their normal health after the initial phase of infection has passed. Long haulers in COVID 19 and Lyme disease share many clinical features including extreme fatigue, cognitive difficulties and chronic pain. The current COVID-19 pandemic may present insights and research discoveries that help understand the underlying mechanisms involved in such persisting symptoms. Understanding the cause of these chronic symptoms is the first step to future treatments and recovery.

Dr. Aucott is currently collaborating with several of the following researchers to investigate the proposed mechanisms of chronic Lyme including: persistent infection, immune dysregulation due to by-products of past infection, auto-inflammation, auto-immunity, and neural network alteration. (I will be writing more about these mechanisms in my next article.)

Next up was Dr. Fallon’s talk: Depression, Suicidal Behaviors, and Lyme: Results from a Nationwide Study in Denmark.

Summary: This presentation reviewed the results of  Dr. Fallon’s recent U.S.- Denmark collaboration to determine whether in fact mental disorders and suicidal behaviors are increased after the diagnosis of Lyme disease. Although cases reports, small series, and office-based practice chart reviews have been published suggesting an association, these studies all had methodological limitations which left these questions unanswered.

Using a nationwide sample of people living in Denmark between 1994 and 2016 (n=6,945,837) and data from the Danish registries of hospital-based diagnoses, they investigated whether the rates of mental disorders, affective disorders, suicide attempts, and suicide were each higher after a hospital diagnosis of Lyme borreliosis compared to the rest of the Danish population without a registered diagnosis of Lyme borreliosis. They examined whether temporal proximity to the diagnosis and number of episodes increased the rates of these adverse mental health outcomes.

The researchers found that individuals with Lyme disease had a 28% higher rate of mental disorders, 42% higher rate of mood disorders and 75% higher rate of death by suicide when compared to the non-Lyme controls.

The third speaker of the morning was Ed Breitschwerdt, DVM, of North Carolina State University. He spoke on: Bartonella Bacteremia and Neuropsychiatric Illnesses.

Summary: In the past two decades, over 40 Bartonella species have been discovered, many of which have been implicated in association with a spectrum of disease in animals and human patients. The extent to which, or the mechanisms by which Bartonella infection contributes to neuropsychiatric illnesses has not been systematically studied. However, microbiological detection of the DNA of several species of Bartonella in blood supports a potential role for these bacteria in neuropsychiatric diseases such as Pediatric Acute Onset Neuropsychiatric Syndrome (PANS) and schizophrenia.

In 2021, Dr. Breitschwerdt and his lab published the initial results of a pilot study showing that out of 17 patients with schizophrenia, 12 tested positive for Bartonella in their blood. They now have funding to proceed with a larger study that will include diagnosis and treatment for Bartonella.

Q and A

At the end of Session 1, Dr. Embers moderated the questions and answers  session. I found it enlightening to have these high-level researchers and clinicians answering questions from the audience, including other scientists.

I asked a question about co-infections: “It appears both Lyme and Bartonella patients are prone to psychiatric illness. Has anyone looked at or compared the number of patients who have both? Do we know if these [Fallon study] Lyme patients have Bartonella, or do we know how many of the Bartonella patients [Breitschwerdt study] have Lyme?”

Dr. Breitschwerdt said it is important to track this and that the work coming out of his lab as well as Embers’ work is helping to elucidate. Embers added:

Borrelia may be comparable to AIDS, in its ability to suppress the immune system and these co-infections definitely warrant further study.”

Session 2

The first speaker of session two was Brandon L. Jutrus, PhD, of Virginia Tech. The title of his talk: Not just another brick in the wall.

Summary: The unusual peptidoglycan of Borrelia burgdorferi. The peptidoglycan sacculus is a mesh-like bag that protects bacterial cells from bursting. Virtually all bacteria have similar peptidoglycan structure. Borrelia burgdorferi—the Lyme disease agent— produces peptidoglycan with extremely unusual chemical features. Further, during growth, peptidoglycan is shed and is capable of causing arthritis. He discussed how the Jutras lab is exploiting the unusual properties of B. burgdorferi peptidoglycan to understand and diagnose Lyme disease.

Dr. Jutrus presented some unpublished data that may lead to an early diagnostic test and targeted treatment for Lyme.

The next speaker was Catherine A. Brissette, PhD, of the University of North Dakota School of Medicine and Health Sciences. The title of her talk: Borrelia colonization of the dura mater induces inflammation in the CNS.

Summary: “Lyme disease, which is caused by infection with Borrelia burgdorferi, can lead to inflammatory pathologies affecting the joints, heart, and nervous systems including the central nervous system (CNS). Laboratory mice have been used to define the kinetics of B. burgdorferi infection and host immune responses in other tissues, but similar studies are lacking for the CNS of these animals. Previously, we reported the ability of B. burgdorferi to colonize the dura mater of mice during late disseminated infection. We now show acute and persistent extravascular B. burgdorferi colonization of the dura mater after both needle inoculation and tick transmission, accompanied by increases in expression of inflammatory cytokines. These increases in inflammatory gene expression are similar to what is observed with B. burgdorferi stimulation of human astrocytes, microglia, brain endothelial cells, and choroid plexus epithelial cells in vitro. In addition, we observe a robust interferon response in the dura mater. Dura colonization is associated with perivascular leukocyte infiltration and meningitis, demonstrating for the first time that B. burgdorferi-infected mice can develop meningitis. We also observe an increase in interferon-stimulated genes in both the cortex and hippocampus of infected mice, despite a lack of detectable bacteria in the brain parenchyma. Combined with the increases in inflammatory gene expression and down-regulation of genes involved in maintenance of blood-brain and blood-CSF barriers in both mice and human cell culture models, these results could provide insights into the mechanism of B. burgdorferi dissemination into the CNS and the damage associated with this pathogen.”

The last speaker of Session 2 was Adrian Baranchuk, MD, FACC, FRCPC, FCCS, FSIAC, of Queen’s University in Ontario, Canada. The title of his talk: All you need to know about Lyme carditis…and more.

Summary: Lyme disease (LD) is a tick-borne bacterial infection caused by Borrelia burgdorferi. It is the most reported vector-born disease in North America, and its incidence has risen dramatically in recent years. In up to 10% of cases, bacterial dissemination of LD may lead to cardiac tissue inflammation and early disseminated Lyme carditis. The most common clinical presentation of Lyme carditis is high-degree atrioventricular block (AVB) which can progress rapidly over minutes, hours, or days. Most AVB in Lyme carditis resolves with appropriate antibiotic treatment without the need for a permanent pacemaker.

Dr. Baranchuk, encourages medical providers to do an ECG on all patients with cardiac symptoms and to consider Lyme carditis when heart block is observed.

Another Q & A

At the end of Session 2, there was another question and answer time, moderated by Dr. Fallon. Let me just say the work coming out of the labs of Dr. Jutrus and Dr. Brissette is groundbreaking. I will definitely be writing more about what I learned from this session.

Session 3

The first speaker for session three was Dr. Monica Embers, on the topic of Combined Antimicrobial Therapy for Eradication of B. burgdorferi.

Summary: Given the potential for standard antibiotic treatment regimens for Lyme disease to fail to eradicate persisters, we aim to discover a drug combination that can eliminate B. burgdorferi infection. The goals of this project are to: (1) using a library of FDA-approved drugs, identify the optimal antimicrobial combinations that could kill B. burgdorferi in vitro; and (2) test them in animal models of Lyme disease for cure of infection. The most effective combinations of drugs that kill the bacteria have been identified with in vitro studies. These were then evaluated in B. burgdorferi-infected mice, using long-term infection to allow for regrowth of persisters. Finally, the most effective regimens are being assessed in nonhuman primates. Importantly, we have refined the selection of drugs to those that can be administered orally.

Next, Kim Lewis, PhD, of Northeastern University, spoke about Developing therapies for Lyme disease.

Summary: Symptoms of Post-Treatment Lyme Disease Syndrome (PTLDS) are experienced by approximately 10% of patients after antibiotic therapy for an acute B. burgdorferi infection. The underlying causes of PTLDS symptoms have remained unclear. We reasoned that the gut microbiome may play an important role in PTLDS given the overlapping symptoms associated with a dysbiotic microbiome, including mood, cognition, and autoimmune disorders. Using sequencing data from stool of a cohort of PTLDS patients, we identified a gut microbiome signature characterized primarily by high relative abundance of Blautia species and reduction in levels of the symbiotic Bacteroides genus. These findings suggest that Lyme disease should be treated with selective antibiotics that will not harm the microbiome. We find that hygromycin A selectively kills B. burgdorferi and cures the acute disease in a mouse model without affecting the microbiome.

The last speaker for session three was Kenneth B. Liegner, MD, discussing Disulfiram in the Treatment of Lyme disease: Promise & Perils.

Summary: Some four years have elapsed since disulfiram was first knowingly applied in the treatment of persons with Lyme disease. Dr. Liegner reviewed several trial cases of patients with Lyme disease who responded positively to disulfiram. He cautioned that the drug comes with a strong warning against alcohol use/proximity, and cross-reactions to certain other medications.

Learn more about disulfiram and why is it sparking excitement in Lyme community.

Q and A

The Q&A segment at the end of session 3 was moderated by Dr. Fallon. It was really fantastic to have Dr. Liegner who has been treating Lyme patients for the past 30 years, be able to interact with these researchers who are both currently working hard to finding a cure for Lyme disease. Dr. Fallon made a point of stating the use of disulfiram is experimental and not currently approved for Lyme disease.

Session 4

Session four began with Marna Erricson, PhD, of the University of Minnesota. She spoke on Bartonella henselae Detected in Malignant Melanoma

Summary: Bartonella bacilliformis (B. bacilliformis), Bartonella henselae (B. henselae), and Bartonella quintana (B. quintana) are bacteria known to cause verruga peruana or bacillary angiomatosis, vascular endothelial growth factor (VEGF)‐dependent cutaneous lesions in humans. Given the bacteria’s association with the dermal niche and clinical suspicion of occult infection by a dermatologist, we determined if patients with melanoma had evidence of Bartonella spp. infection. Within a one‐month period, eight patients previously diagnosed with melanoma volunteered to be tested for evidence of Bartonella spp. exposure/infection. Subsequently, confocal immunohistochemistry and PCR for Bartonella spp. were used to study melanoma tissues from two patients. Blood from seven of the eight patients was either seroreactive, PCR positive, or positive by both modalities for Bartonella spp. exposure. Subsequently, Bartonella organisms that co‐localized with VEGFC immunoreactivity were visualized using multi‐immunostaining confocal microscopy of thick skin sections from two patients. Using a co‐culture model, B. henselae was observed to enter melanoma cell cytoplasm and resulted in increased vascular endothelial growth factor C (VEGFC) and interleukin 8 (IL‐8) production. Additionally, the two tissues also were found to have BRAF mutations, an oncogene expressed in up to 70% of melanomas. Findings from this small number of patients support the need for future investigations to determine the extent to which Bartonella spp. are a component of the melanoma pathobiome. Being at the frontier of understanding the role of the microbiome in cancer, we will discuss some new papers on this topic and future research plans.

The final speaker of the day was, Richard Maggi, PhD, North Carolina State University. His topic: Simultaneous detection and absolute quantification of Babesia, Bartonella and Borrelia by droplet digital PCR.

Summary: This presentation describes the development, optimization, and validation of a ddPCR assay for the simultaneous detection of Babesia, Bartonella, and Borrelia spp. DNA from several sample matrices, including clinical blood samples from animals and patients, vectors (ticks, fleas, sandflies), as well as samples from human and animal cell lines and tissues from animal models (infected with Bartonella and/or B. burgdorferi). The multiplex ddPCR assay (BBB ddPCR), developed based upon a recently published a Bartonella ddPCR assay using the QX200 system from Bio-Rad, is able to detect 31 Bartonella spp. (including 8 previously uncharacterized species), 8 Borrelia spp, and 24 Babesia spp. (including 8 previously uncharacterized species). The assay is also able to detect 2 Theilaria spp. (T. equi and T. cervi) and well as C. felis from naturally infected wildlife species. The BBB ddPCR assay, based on the QX One ddPCR system from Bio-Rad, showed to be able to perform the simultaneous detection and absolute quantification of multiple vector-borne pathogens (such as Babesia, Bartonella and Borrelia) from clinical samples.

Q & A

The Q&A at the end was moderated by Dr. Embers. The research presented by these two was highly technical, but I can say their work will provide better diagnostics that will lend to each of the previous researcher work.

LymeSci is written by Lonnie Marcum, a Licensed Physical Therapist and mother of a daughter with Lyme. She serves on a subcommittee of the federal Tick-Borne Disease Working Group. Follow her on Twitter: @LonnieRhea  Email her at: lmarcum@lymedisease.org.

Bartonella for Clinicians

http://

Bartonella for Clinicians

Introducing IGeneX Bartonella ImmunoBlots
Jul 15, 2021

For more:

COVID Impacts on Lyme Disease Reporting

https://wwwnc.cdc.gov/eid/article/27/10/21-0903_article

Research Letter

Effects of COVID-19 Pandemic on Reported Lyme Disease, United States, 2020

David W. McCormickComments to Author , Kiersten J. Kugeler, Grace E. Marx, Praveena Jayanthi, Stephanie Dietz, Paul Mead, and Alison F. Hinckley
Author affiliations: Centers for Disease Control and Prevention, Fort Collins, Colorado, USA. (D.W. McCormick, K.J. Kugeler, G.E. Marx, P. Mead, A.F. Hinckley); ICF International Inc., Atlanta, Georgia, USA (P. Jayanthi); Centers for Disease Control and Prevention, Atlanta (P. Jayanthi, S. Dietz)

Cite This Article

Abstract

Surveys indicate US residents spent more time outdoors in 2020 than in 2019, but fewer tick bite–related emergency department visits and Lyme disease laboratory tests were reported. Despite ongoing exposure, Lyme disease case reporting for 2020 might be artificially reduced due to coronavirus disease–associated changes in healthcare-seeking behavior.

The coronavirus disease (COVID-19) pandemic has altered how humans interact with their environment and the healthcare system (1,2), and strained resources have limited the ability of state and local health departments to respond to reports of notifiable diseases (3). The Centers for Disease Control and Prevention (CDC) typically is notified of 30,000–40,000 Lyme disease cases annually (4), but the COVID-19 pandemic likely will affect the case counts. Most Lyme disease cases are acquired in spring and early summer (5); in 2020, these seasons coincided with the initial spread of COVID-19 and widespread stay-at-home orders. We explored 4 data sources to assess how the COVID-19 pandemic might have influenced tick bite risk and associated healthcare-seeking practices and affected reported Lyme disease cases for 2020.

The pathway for Lyme disease case reporting begins with environmental risk and culminates with case notification to CDC (Appendix Figure). Environmental risk is relatively stable in high-incidence areas and driven by ecologic factors unaffected by COVID-19 (6). The pandemic might have altered the frequency of outdoor activities and probability of encountering ticks, healthcare-seeking and provider services patterns, and case investigation and reporting. The data sources we used measure changes in time spent outdoors, information-seeking patterns for tick removal, emergency department (ED) visits for tick bites, and laboratory testing for Lyme disease. This analysis was considered nonhuman subjects research by CDC.

To assess potential behavior shifts that might have increased risk for tick encounters, we analyzed data from Porter Novelli’s PN View 360+ consumer survey (7). Among 4,013 participants who responded to the survey distributed during July 31–August 9, 2020, approximately half (49.9%) reported that they had spent a lot more time or slightly more time outdoors by that point in 2020 compared with prior years. Only 20.9% of respondents reported spending less time outdoors in 2020.

Comparison of visits to the Centers for Disease Control and Prevention (CDC) website on tick removal, 2018–2020, and to the ED for tick-bite related chief complaints, 2017–2020, United States. A) Website visits per month for https://www.cdc.gov/ticks/removing_a_tick.html. B) ED visits by month in which the chief health complaint was tick bite. Comparison of 2020 to the average of the previous 4 years is shown. ED, emergency department.Figure. Comparison of visits to the Centers for Disease Control and Prevention (CDC) website on tick removal, 2018–2020, and to the ED for tick-bite related chief complaints, 2017–2020, United States. A)…

To indirectly assess frequency of tick encounters in 2020 compared with prior years, we evaluated total monthly visits during 2018–2020 to a CDC website describing tick removal (8). Visits to this website typically increase during late spring and summer and again in October, when most bites from blacklegged ticks (Ixodes scapularis and Ixodes pacificus) occur (5). We observed 818,167 website visits during 2020, ≈25% more than in 2019 (681,021) and 2018 (630,839) (Figure).

To assess patterns related to healthcare-seeking for tick encounters, we identified ED visits for tick bites by using the National Syndromic Surveillance Program (NSSP) BioSense platform (9). ED visits for tick bites decreased in 2020 from 2019 in both total number and rate per 100,000 ED visits (Figure). The largest relative decreases were observed in May. During 2017–2019, the average number of ED visits for tick bites during the month of May was 12,693, an average rate of 145/100,000 ED visits. During May 2020, only 5,845 ED visits for tick bites occurred, a rate of 89/100,000 ED visits.

We quantified cumulative counts and percent positivity of serologic tests for Lyme disease performed by an independent clinical laboratory. Lyme disease testing volume decreased from 2019 to 2020; 25.0% fewer tests were performed, and test positivity decreased slightly to <1% (Table).

During the first wave of the COVID-19 pandemic in 2020, the US population spent more time outdoors and visited a CDC website describing safe tick removal more frequently than during prior years. However, fewer persons sought care for tick bites, and substantially fewer laboratory tests for Lyme disease were ordered. These findings suggest that the risk of acquiring Lyme disease was similar or potentially higher in 2020 compared with risk during prior years, but fewer persons sought care, and fewer positive laboratory reports were referred for case investigation. Consequently, we anticipate that, once ultimately finalized, the official number of confirmed and probable Lyme disease cases in 2020 will be substantially lower than that for prior years.

One limitation of our study is that data sources we examined represent national trends and are indirect surrogates for Lyme disease risk and reporting, which vary geographically. Visits to a website describing tick removal might not correspond with finding an attached tick. Available data on laboratory testing represents 1 independent clinical laboratory; other commercial or academic laboratories might not have experienced a similar decrease in testing. Data sources associated with telehealth utilization and prescription claims could provide additional insights into the diagnosis and treatment for Lyme disease in 2020.

Already an issue in high-incidence states, the pandemic has highlighted the need for alternative Lyme disease surveillance strategies that rely less on human resources. An anticipated and potentially substantial decrease in reported Lyme disease in 2020 likely reflects the effects of the COVID-19 pandemic rather than a true change in Lyme disease incidence. Decreased reporting also could render 2020 inconsistent with long-term trends and changes in the epidemiology of the disease. Although nonpharmaceutical interventions for COVID-19 have mitigated the transmission of respiratory pathogens (10), these results suggest the behavioral and reporting changes seen for Lyme disease might extend to other nonrespiratory diseases.

Dr. McCormick is an Epidemic Intelligence Service Officer in the Bacterial Diseases Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado. His primary research interests are the epidemiology and prevention of bacterial vectorborne diseases.

Acknowledgment

We thank Melanie Spillane for her assistance with collating data from National Syndromic Surveillance Program and Anna Perea for assistance with Porter Novelli’s PN View 360+ consumer survey data.

References

  1. Hartnett  KP, Kite-Powell  A, DeVies  J, Coletta  MA, Boehmer  TK, Adjemian  J, et al.; National Syndromic Surveillance Program Community of Practice. Impact of the COVID-19 pandemic on emergency department visits—United States, January 1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:699704. DOIExternal LinkPubMedExternal LinkGoogle ScholarExternal Link
  2. Czeisler  , Marynak  K, Clarke  KEN, Salah  Z, Shakya  I, Thierry  JM, et al. Delay or avoidance of medical care because of COVID-19–related concerns—United States, June 2020. MMWR Morb Mortal Wkly Rep. 2020;69:12507. DOIExternal LinkPubMedExternal LinkGoogle ScholarExternal Link
  3. Weber  L, Ungar  L, Smith  MR, Recht  H, Barry-Jester  AM. Hollowed out public health system faces more cuts amid virus. Associated Press. 2020 Jul 1 [cited 2021 Apr 20]. https://apnews.com/article/b4c4bb2731da9611e6da5b6f9a52717aExternal Link
  4. Schwartz  AM, Hinckley  AF, Mead  PS, Hook  SA, Kugeler  KJ. Surveillance for Lyme disease—United States, 2008–2015. MMWR Surveill Summ. 2017;66:112. DOIExternal LinkPubMedExternal LinkGoogle ScholarExternal Link
  5. Mead  PS. Epidemiology of Lyme disease. Infect Dis Clin North Am. 2015;29:187210. DOIExternal LinkPubMedExternal LinkGoogle ScholarExternal Link
  6. Burtis  JC, Sullivan  P, Levi  T, Oggenfuss  K, Fahey  TJ, Ostfeld  RS. The impact of temperature and precipitation on blacklegged tick activity and Lyme disease incidence in endemic and emerging regions. Parasit Vectors. 2016;9:606. DOIExternal LinkPubMedExternal LinkGoogle ScholarExternal Link
  7. Porter Novelli. ConsumerStyles & YouthStyles 2021 [cited 2021 Apr 20]. http://styles.porternovelli.com/consumer-youthstylesExternal Link
  8. Centers for Disease Control and Prevention. Tick removal [cited 2021 Apr 20]. https://www.cdc.gov/ticks/removing_a_tick.html
  9. Marx  GE, Spillane  M, Beck  A, Stein  Z, Powell  AK, Hinckley  AF. Emergency department visits for tick bites—United States, January 2017–December 2019. MMWR Morb Mortal Wkly Rep. 2021;70:6126. DOIExternal LinkPubMedExternal LinkGoogle ScholarExternal Link
  10. Olsen  SJ, Azziz-Baumgartner  E, Budd  AP, Brammer  L, Sullivan  S, Pineda  RF, et al. Decreased influenza activity during the COVID-19 pandemic-United States, Australia, Chile, and South Africa, 2020. Am J Transplant. 2020;20:36815. DOIExternal LinkPubMedExternal LinkGoogle ScholarExternal Link