July 3, 2000 -- As public concern about Lyme disease continues to mount, doctors and public health officials disagree about diagnosis, treatment, and prevention of the tick-borne illness. But after several warm winters, consensus is sorely needed for the 16,000 new cases expected this year.
Transmitted by ticks from infected deer, Lyme disease is a bacterial infection that's especially prevalent in the northeast and north-central U.S. Many of those bitten develop a red rash that looks like a bulls-eye and flu-like symptoms for up to a week. Often the cause isn't recognized, and the disease can progress and become chronic, causing destruction of joints, heart problems, neurological problems, and other serious complications.
Blood tests are used to screen for the condition, but the results often vary, even when conducted at Lyme disease specialty labs. For this reason, some doctors say that positive results should be considered accurate only if there are clear indications of the disease, like the bulls-eye rash. Other doctors contend that Lyme disease can be present even when the results are negative.
When screening tests are inconclusive, a more precise test called the Western blot test is conducted with the same blood sample, according to early Lyme disease expert Michael Felz, MD, an associate professor of family medicine at the Medical College of Georgia, in Augusta.
Last fall, a new blood test was shown to be a reliable indicator of active disease, correctly identifying 95% of those with Lyme disease. The new test also detects the infection much sooner, according to lead study author Steven Schutzer, MD, an associate professor at the University of Medicine and Dentistry of New Jersey.
Early detection, within 6-12 months, improves patient outcomes significantly. Lyme disease can be treated effectively with antibiotics, "but the longer you wait, the harder it is to treat," says infectious diseases specialist Sam Donta, MD, director of the Lyme Disease Center and professor of medicine at Boston University.
Many patients are successfully treated in just four to eight weeks with the antibiotic doxycycline. "Four to five years after diagnosis, most of those treated [early on] with antibiotics report the same [lack] of symptoms as those who never had Lyme disease," says lead study author Eugene Shapiro, MD, a professor of pediatrics at Yale University School of Medicine.
And yet a few patients may develop "post-Lyme disease syndrome," which resembles another disease known as fibromyalgia, says rheumatologist Nancy Shadick, MD, MPH, director of the Lyme Disease Center at Boston's Brigham and Women's Hospital and assistant professor of medicine at Harvard Medical School. Symptoms include fatigue, joint pain, and poor concentration and memory, but some doctors don't recognize the symptoms of the chronic syndrome.
This issue is at the heart of the debate over long-term antibiotic therapy, frequently prescribed for several years. Proponents say that the bacteria that causes Lyme disease can bore deeply into tissue, evading initial treatment and remaining infectious. Skeptics say that the condition isn't fatal, but adverse effects from long-term antibiotics can be. Over the last several months, physicians in both camps have answered to state medical boards on the issue.
The prevention of Lyme disease is no less controversial. Eighteen months ago, the FDA approved the first vaccine for those at high risk of tick exposure -- those 15-70 years old. Last month, the federal Occupational Safety and Health Administration (OSHA) issued a warning for outdoor workers to ask their doctors about vaccination.
Since the vaccine was launched, there have been numerous reports of severe arthritic reactions.
Many believe that the vaccine's genetic engineering produces arthritis in certain people. Thirty percent of the population is thought to be capable of having a reaction to the vaccine because of their specific genetic makeup.
Citing uneventful human trials with 11,000 participants, drug giant SmithKline Beecham, the maker of the vaccine, denies any association with arthritis. The FDA, which closely monitors adverse events from vaccines in conjunction with the Centers for Disease Control and Prevention (CDC), says the vaccine is not for everybody but sees no red flags for the vaccine, which is known as LYMErix. Officials at both agencies urge those at risk to weigh the risks and benefits with their doctor.
Because the LYMErix vaccine requires three injections over the course of a year and is only 70-80% effective, the CDC advises other preventive measures when working or playing in wooded areas. These measures include wearing long-sleeved shirts, tucking long pants into socks, and spraying clothing with insect repellant containing the pesticide DEET, such as OFF! and Cutter.
Prompt tick removal is even better. "Removing ticks within 36 to 48 hours is the best way to prevent the infection," says David Weld, executive director of the American Lyme Disease Foundation. But the ticks that transmit the bacteria are often small and hard to detect.
Weld tells WebMD that many ticks are found on the back of the neck and should be removed carefully. "Remedies like matches, petroleum jelly, and nail polish remover can cause the tick to inject bacteria," he adds. "The best method is to lay a pair of tweezers on the skin and grab the tick by its neck, rather than its body."
To settle the debate about Lyme disease treatment, new research is underway. New York City's Columbia University recently received almost $5 million from the National Institutes of Health to study persistent memory and attention problems in Lyme disease victims. To determine whether a repeat course of antibiotics improves brain function in adults, MRIs and other imaging studies will be conducted afterward.
As the FDA reviews data about the safety of the Lyme disease vaccine in children, SmithKline is conducting a four-year study of those vaccinated with LYMErix.