ABSTRACT
As of 2013, Pennsylvania (PA) has the highest Lyme disease case count (number of cases) in the United States (US). Lyme disease has become a disease of significant public health concern. There were 4,981 confirmed cases in PA in 2013, yet this number may be ten times higher due to underreporting. Lyme disease impacts all ages, genders, races, and ethnicities. However, the highest rates in PA are among whites, males, and those between the ages of 5 to 14 and above 55. Risk for Lyme disease is dependent upon the number of ticks infected with B. burgdorferi, the density of ticks in the environment, and the extent of contact between a person and ticks.
In order to reduce the Lyme disease incidence rate in PA, it is recommended that the Pennsylvania Department of Health (PA DOH) implement a Lyme Disease Prevention Program (Program). An effective Program will have two components: a pilot program delivered through the Chester County Health Department in Chester County, PA, and a statewide program. The pilot will utilize advisory committees on county-, district-, and state-levels to involve stakeholders and to inform future Program activities and will implement prevention education for the general public and health care professionals. The statewide program will implement education for the public and health care professionals. This paper outlines the goals, objectives, activities, and budget for the Program.
TABLE OF CONTENTS
1.0 Introduction 1
1.1 Problem statement 1
1.2 Lyme Disease burden 1
1.2.1 U.S. Lyme Disease Burden 1
1.2.2 PA Lyme Disease Burden 2
2.0 Background 3
2.1 Lyme Disease 3
2.1.1 Signs and Symptoms 4
2.1.2 Treatment 5
2.1.3 Risk Factors 5
2.1.3.1 Location 6
2.1.3.2 Hosts 9
2.1.3.3 Season 10
2.1.3.4 Activities 13
2.1.3.5 Age, Gender, Race, and Ethnicity 14
3.0 Program Description 18
3.1 Logic Model 21
3.2 Annual Budget 22
3.3 Budget Justification 26
4.0 Pa’s public health network and Lyme Activities 30
5.0 Objectives – Annual activities 32
5.1 Objective 1 32
5.1.1 Objective 1 Title: Increase Collaboration with Stakeholders. 32
5.1.2 Objective 1: Annual Activities 35
5.1.2.1 Form a State-Level Advisory Committee 35
5.1.2.2 Form a County-Level Advisory Committee 36
5.1.2.3 Form a District-Level Advisory Committee 36
5.1.2.4 Develop a Report Format 37
5.1.2.5 Hold Meetings for the State-Level Advisory Committee 37
5.1.2.6 Hold Meetings for the County-Level Advisory Committees 37
5.1.2.7 Hold Meetings for the District-Level Advisory Committees 37
5.1.2.8 Collect Reports from both District-Level and County-Level Meetings 38
5.2 Objective 2 38
5.2.1 Objective 2 Title: Increase Awareness through Lyme Disease Prevention Education for the General Public 38
5.2.2 Objective 2: Annual Activities 39
5.2.2.1 Create Educational Materials for the General Public 39
5.2.2.2 Send a Notification to all Relevant Stakeholders 40
5.2.2.3 Implement Prevention Education for the Public 41
5.2.2.4 Create, Release, and Disperse a Press Release Template 44
5.2.2.5 Determine Relevant Areas for Signs 44
5.2.2.6 Encourage Sign Posting 45
5.3 Objective 3: 45
5.3.1 Objective 3 Title: Increase Awareness through Lyme Disease Prevention Education for Health Care Professionals 45
5.3.2 Objective 3: Annual Activities 46
5.3.2.1 Release a Health Alert 46
5.3.2.2 Email all Healthcare Professionals 47
5.3.2.3 Make Patient Education Materials Available for Health Care Professionals 47
5.3.2.4 Create Education Materials for Health Care Professionals 48
5.3.2.5 Implement Prevention Education for Health Care Professionals 48
Appendix A : POTENTIAL STAKEHOLDERS 51
Appendix B : EDUCATIONAL MATERIALS RESOURCES 53
bibliography 56
List of tables
Table 1: PA counties with the highest Lyme disease case counts in 2013. 8
List of figures
Figure 1: Sizes of blacklegged ticks at different lifecycle stages, as compared to a U.S. dime. 4
Figure 2: 5-year average incidence rate (new cases per 100,000) for Lyme disease in Pennsylvania by county, 2009-2013. 7
Figure 3: Lifecycle of the blacklegged ticks. 12
Figure 4: Mean annual Lyme disease case count (confirmed cases only) by age and sex in the United States, 2001-2010. 15
Figure 5: Lyme disease incidence rate (number of cases per 100,000) by age in Pennsylvania, 2000-2011. 16
Acronyms
The following is a list of several acronyms used throughout this document.
BCHS / Bureau of Community Health SystemsCT DPH / Connecticut Department of Public Health
DHSS / Delaware Department of Health and Social Services
DCNR / Pennsylvania Department of Conservation and Natural Resources
DOH / Pennsylvania Department of Health
HAN / Health Alert Network
ITM / Integrate Tick Management
MA DPH / Massachusetts Department of Public Health
ME DHHS / Maine Department of Health and Human Services
MDH / Minnesota Department of Health
NH DHHS / New Hampshire Department of Health and Human Services
NY DOH / New York State Department of Health
PA HAN / Pennsylvania Health Alert Network
US BOC / United States Bureau of the Census
VDH / Virginia Department of Health
VT DOH / Vermont Department of Health
WI DHS / Wisconsin Department of Health Services
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1.0 Introduction
1.1 Problem statement
As of 2013, Pennsylvania has the highest Lyme disease case count in the United States. Although Lyme disease impacts all ages, genders, races, and ethnicities, the highest rates are among whites, males, and those between the ages of 5 to 14 and above 55. Risk for Lyme is dependent upon the number of ticks infected with B. burgdorferi, the density of ticks in the environment, and the extent of contact between a person and ticks.
1.2 Lyme Disease burden
1.2.1 U.S. Lyme Disease Burden
In the US in 2013, there were 27,203 confirmed and 9,104 probable cases of Lyme disease, which is a total of 36, 307 confirmed and probable cases. The incidence rate during that same year was 8.6 cases per 100,000 population (Centers for Disease Control and Prevention, 2014a). These statistics reveal an increase from 2012, with 30,831 confirmed and probable cases and an incidence rate of 7.0 cases per 100,000 population (Centers for Disease Control and Prevention, 2013a). Because of underreporting, the CDC estimates that the true number of Lyme disease cases diagnosed per year is 300,000, which is around ten times higher than the actual case count reported each year. The chief of epidemiology and surveillance for the CDC’s Lyme disease program commented on this underreporting: “This new preliminary estimate confirms that Lyme disease is a tremendous public health problem in the US, and clearly highlights the urgent need for prevention” (Centers for Disease Control and Prevention, 2013b).
1.2.2 PA Lyme Disease Burden
In 2013, Pennsylvania had the highest number of confirmed Lyme disease cases and the highest sum of confirmed and probable Lyme disease cases in the US. There were specifically 4,981 confirmed and 777 probable cases in PA, a sum of 5,758 cases. PA also had the eighth highest incidence rate, with a rate of 39 cases per 100,000 population (Centers for Disease Control and Prevention, 2014a). These statistics highlight a need for greater disease prevention measures in PA. This need is even more augmented when underreporting is taken into consideration, as the number of Lyme disease cases could be up to ten times greater.
2.0 Background
2.1 Lyme Disease
Lyme disease is caused by Borrelia burgdorferi (B. burgdorferi), a corkscrew-shaped bacterium, also known as a spirochete (Centers for Disease Control and Prevention, 2013c; Stafford, 2007). This bacterium is spread through the bite of infected ticks. Infected ticks are limited to blacklegged ticks (Ixodes scapularis), commonly known as the deer tick, which spread Lyme in the northeastern, mid-Atlantic, and north-central US, and the western blacklegged tick (Ixodes pacificus), which spreads Lyme on the Pacific Coast (Centers for Disease Control and Prevention, 2013c).
Ticks have four lifecycle stages, but only the last three must have a blood-meal to survive: egg, six-legged larva, eight-legged nymph, and adult. Thus, humans are bitten by larva, nymph, and adult ticks (Centers for Disease Control and Prevention, 2014b). Because both the larvae and nymphs feed on hosts that can act as reservoirs for B. burgdorferi, more adult ticks than nymphs are infected (Stafford, 2007). Humans can be infected by the bite of adult ticks, but they are large and more likely to be removed before bacterial transmission. Instead, humans are most often infected by the bite of nymphs, which are difficult to see at a size of less than 2mm, similar to the size of a poppy seed (Figure 1). A tick must normally be attached for 36-48 hours to transmit the bacterium (Centers for Disease Control and Prevention, 2013c).
(Centers for Disease Control and Prevention, 2013c)
Figure 1: Sizes of blacklegged ticks at different lifecycle stages, as compared to a U.S. dime.
2.1.1 Signs and Symptoms
The signs and symptoms of Lyme disease present themselves in three stages. Without treatment, Lyme disease could progress from the early localized stage, to the early disseminated stage, to the late disseminated stage. The early localized stage is characterized by erythema migrans (EM), which is a red, expanding rash commonly known as the “bull’s-eye” rash. It is also characterized by “fatigue, chills, fever, headache, muscle and joint aches, and swollen lymph nodes” (Centers for Disease Control and Prevention, 2013d). The early disseminated stage is characterized by EM lesions in other areas of the body, Bell’s palsy, meningitis, pain and swelling in large joints, shooting pains, heart palpitations, and dizziness. Without treatment symptoms may resolve within a few weeks to months or may create further difficulties. The late disseminated stage is characterized by arthritis, joint pain, swelling, and, in rare cases, chronic neurological problems. Even with treatment, Lyme patients may experience symptoms.
Even with the recommended 2-4 weeks of treatment, 10-20% of patients have symptoms lasting months to years, especially for those diagnosed later (Centers for Disease Control and Prevention, 2011; Centers for Disease Control and Prevention, 2013d; Centers for Disease Control and Prevention, 2014c). This is called post-treatment Lyme disease syndrome. Its symptoms include “muscle and joint pains, cognitive defects, sleep disturbance, or fatigue” (Centers for Disease Control and Prevention, 2013d). According to the CDC, patients "almost always get better with time," even if it takes months (Centers for Disease Control and Prevention, 2011).
In about 1% of Lyme disease cases, patients may also experience Lyme carditis, which is mild, moderate, or severe "heart block." In these cases, Lyme bacteria enter the heart tissue (Centers for Disease Control and Prevention, 2014d).
2.1.2 Treatment
Treatment for early localized stage of Lyme disease consists of antibiotic treatment for approximately 14 days. The range is 14 to 21 days. Both adults and children are treated with amoxicillin, doxycycline, or cefuroxime axetil, and dosage amounts vary both by antibiotic type and by whether a person is an adult or child (United States Department of Health and Human Services, 2014).
2.1.3 Risk Factors
Risk for contracting Lyme disease depends largely on the prevalence of B. burgdorferi infection in ticks, the density of ticks in the environment, and the extent of contact between a person and ticks. The density of ticks in the environment “varies by place and season,” and the extent of contact depends on the “type, frequency, and duration of a person’s activities in a tick infested environment” (Pennsylvania Department of Health, 2013c). Ultimately, a greater amount of exposure to an area with a high number of infected ticks increases risk.
2.1.3.1 Location
Lyme disease risk varies by region, state, and county. In the US, risk is highest in the northeastern, mid-Atlantic, and north-central states (Centers for Disease Control and Prevention, 2013c). In Pennsylvania specifically, Lyme disease risk varies by county. Figure 2 shows the 5-year average incidence rates in PA counties from 2009 to 2013. The counties with the highest incidence rates have white stars overlaid on top, with over 100 new cases per 100,000 population each year. These counties were Butler, Clarion, Armstrong, Jefferson, Elk, Cameron, Clearfield, Fulton, Montour, Wyoming, Wayne, and Chester, in no particular order. Table 1 reveals the case counts for ten counties with the highest Lyme disease case counts in PA in 2013. Chester County, which also appears in Figure 2 with a star, had the highest case count of all other PA counties.
Within counties, the greatest risk for tick bites and Lyme disease occurs in suburban residential areas and rural homes when both are adjacent to wooded areas. Tick hosts thrive in these areas (Connecticut Department of Public Health, 2008). The Virginia Department of Health similarly notes that areas with expanding suburban development have a higher prevalence of Lyme disease (Virginia Department of Health).
(Pennsylvania Department of Health, 2013b)
Figure 2: 5-year average incidence rate (new cases per 100,000) for Lyme disease in Pennsylvania by county, 2009-2013.[1]
Table 1: PA counties with the highest Lyme disease case counts in 2013.
1. Chester / 489
2. Bucks / 337
3. Butler / 332
4. Clearfield / 308
5. Montgomery / 301
6. Jefferson / 236
7. Armstrong / 232
8. York / 219
9. Indiana / 208
10. Westmoreland / 159
(Pennsylvania Department of Health, 2013a)
Data on the incidence rates per county is available on the PA DOH website by clicking on Diseases and Conditions on the tabs along the left hand of the webpage and scrolling down until Lyme disease is reached. This opens up a page on the Lyme Disease Task Force. The bottom of the page contains a link to information on Lyme disease, which opens up a Lyme Disease Fact Sheet. At the very bottom of the Fact Sheet, the last link will take the reader to county- and region-level Lyme disease data. The second-to-last link will take the reader to helpful maps and graphs, which illustrate the data from the last link.
2.1.3.2 Hosts
Within locations, the risk of contracting Lyme disease may be impacted by the presence of tick hosts. Deer are key hosts for blacklegged ticks. The size of the deer population often determines the number and distribution of the blacklegged tick population. Thus, where deer populations are overabundant, tick populations are often overabundant. Areas with adequate food and shelter for the deer, such as a “mosaic of light fragmented woodland and woodland edges, clearings and abundant shrubs, berries, grass, and forbs, and a lack of predators” attract deer (Stafford, 2007). The residential landscape often encourages their presence (Stafford, 2007). Thus, these locations may have a greater number of deer and ticks and greater rates of Lyme disease.