Expiration Date: December 31, 2001. No CE credit will be given after this date.

Made possible through a grant by CDC to the American Nurses Foundation. Table of Contents Abstract and Objectives Introduction Geographic Distribution Demographic Distribution Transmission The Deer Tick Clinical Symptoms Diagnosis Assessment Laboratory Tests Treatment Alternative Treatments Personal Protection Other Preventive Measures to Consider Vaccination Other Tick-Borne Diseases Summary References The deadline for completion of this module is Dec. 31, 2001. Abstract More than 15,900 cases of Lyme disease were reported in the U.S. in 1998 -- a 31-fold increase since 1982 (CDC, 1997). In fact, Lyme disease is recognized as one of the most rapidly growing infectious diseases in the U.S. (CDC, 1997). The purpose of this program is to help prepare nurses to meet the challenges posed by this disease. Specifically, this program will provide basic facts about Lyme disease including: how it is transmitted, diagnosed, treated, and how it can be prevented. Recent advances in vaccination as well as some controversial issues surrounding this illness will also be covered. Objectives Describe the epidemiology of Lyme disease, including its worldwide, national, regional, and local distribution, especially endemic areas Explain how the life cycle of a tick impacts exposure to Lyme disease Describe the three stages of the signs & symptoms of Lyme disease Describe current diagnostic tests and their limitations Describe antibiotic treatment regimens Identify other tick-borne illnesses Identify five Lyme disease prevention strategies Identify which patient populations are most appropriate to receive the Lyme disease vaccination Introduction By Peggy Veroneau, MPH, RN Contributors: Rachel Dildilian, MPS, RN, CIC, CRNI Elizabeth Pantelick, MPH, RN, CIC Marcia Robert, MPH, RN Signs and symptoms of Lyme disease can mimic those associated with other illnesses, such as rheumatoid arthritis, multiple sclerosis, fibromyalgia and chronic fatigue syndrome — leading to misdiagnosis and inappropriate treatment. If treated early, recovery is usually quick and complete (U.S. DHHS, 1997). If left untreated, however, Lyme disease has potentially disabling and irreversible effects. Nurses can play a significant role in diminishing the effects of this disease through assessment, treatment and prevention education efforts. Geographic Distribution Since its recognition in 1975, Lyme disease has become the most common tick-borne infectious disease in the United States. Reported in at least 48 states, the disease has also been reported in parts of Europe, Russia and the republics of the former Soviet Union, the People's Republic of China and Japan (Willis, 1991). In the U.S., Lyme disease is most prevalent in the Northeast, particularly coastal areas from Massachusetts to Maryland; upper Midwest, especially Wisconsin and Minnesota; and the West, especially in Pacific coastal Northern California (Figure 1). Figure 1: Lyme disease became a nationally notifiable disease in 1990. The Centers for Disease Control and Prevention (CDC) adopted a uniform national case definition for surveillance purposes in 1991. (Figure 2). Figure 2: Lyme Disease Surveillance Case Definition (revised September 1996) Clinical description A systemic, tick-borne disease with protean manifestations, including dermatologic, rheumatologic, neurologic, and cardiac abnormalities. The best clinical marker for the disease is the initial skin lesion, erythema migrans, that occurs among 60%-80% of patients. Clinical case definition Erythema migrans, or At least one late manifestation, as defined below, and laboratory confirmation of infection Laboratory criteria for diagnosis Isolation of Borrelia burgdorferi from clinical specimen, or Demonstration of diagnostic levels of IgM and IgG antibodies to the spirochete in serum or CSF, or A two-test approach using a sensitive enzyme immunoassay or immunofluorescence antibody followed by Western blot is recommended (1). Case classification Confirmed: a case that meets one of the clinical case definitions above Comment: This surveillance case definition was developed for national reporting of Lyme disease; it is NOT appropriate for clinical diagnosis. Definition of terms used in the clinical description and case definition: A. Erythema migrans (EM) For purposes of surveillance, EM is defined as a skin lesion that typically begins as a red macule or papule and expands over a period of days to weeks to form a large round lesion, often with partial central clearing. A solitary lesion must reach at least 5 cm in size. Secondary lesions may also occur. Annular erythematous lesions occurring within several hours of a tick bite represent hypersensitivity reactions and do not qualify as EM. For most patients, the expanding EM lesion is accompanied by other acute symptoms, particularly fatigue, fever, headache, mild stiff neck, arthralgia, or myalgia. These symptoms are typically intermittent. The diagnosis of EM must be made by a physician. Laboratory confirmation is recommended for persons with no known exposure. B. Late manifestations Late manifestations include any of the following when an alternate explanation is not found: Musculoskeletal system: Recurrent, brief attacks (weeks or months) of objective joint swelling in one or a few joints, sometimes followed by chronic arthritis in one or a few joints. Manifestations not considered as criteria for diagnosis include chronic progressive arthritis not preceded by brief attacks and chronic symmetrical polyarthritis. Additionally, arthralgia, myalgia, or fibromyalgia syndromes alone are not criteria for musculoskeletal involvement. Nervous system : Any of the following, alone or in combination: Lymphocytic meningitis; cranial neuritis, particularly facial palsy (may be bilateral); radiculoneuropathy; or, rarely, encephalomyelitis. Encephalomyelitis must be confirmed by showing antibody production against B. burgdorferi in the cerebrospinal fluid (CSF), demonstrated by a higher titer of antibody in CSF than in serum. Headache, fatigue, paresthesia, or mild stiff neck alone are not criteria for neurologic involvement. Cardiovascular system: Acute onset, high-grade (2nd or 3rd degree) atrioventricular conduction defects that resolve in days to weeks and are sometimes associated with myocarditis. Palpitations, bradycardia, bundle branch block, or myocarditis alone are not criteria for cardiovascular involvement. C. Exposure Exposure is defined as having been in wooded, brushy, or grassy areas (potential tick habitats) in a county in which Lyme disease is endemic no more than 30 days before onset of EM. A history of tick bite is NOT required. D. Disease endemic to county A county in which Lyme disease is endemic is one in which at least two definite cases have been previously acquired or in which a known tick vector has been shown to be infected with B. burgdorferi E. Laboratory confirmation As noted above, laboratory confirmation of infection with B. burgdorferi is established when a laboratory isolates the spirochete from tissue or body fluid, detects diagnostic levels of IgM or IgG antibodies to the spirochete in serum or CSF, or detects a significant change in antibody levels in paired acute- and convalescent-phase serum samples. States may determine the criteria for laboratory confirmation and diagnostic levels of antibody. Syphilis and other known causes of biologic false-positive serologic test results should be excluded when laboratory confirmation has been based on serologic testing alone. References: CDC. Case definitions for infectious conditions under public health surveillance. MMWR 1997;46(RR-10):20. CDC. Recommendations for test performance and interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease. MMWR 1995;44:590-1. Reporting of Lyme disease is now mandatory in all 50 states and accounts for more than 95 percent of all reports of vector-borne infectious diseases in the United States. Table 1 provides a breakdown of cases reported by state of residence, not necessarily state where exposure occurred. Table 1: State Total Number Cases Reported 1989-1998 Annual Incidence per 100,000 persons New York 39,370 21.6 Connecticut 17,728 54.2 Pennsylvania 14,870 12.3 New Jersey 13,428 16.9 Wisconsin 4,760 9.3 Rhode Island 3,717 37.5 Maryland 3,410 6.8 Massachusetts 2,712 4.5 Minnesota 1,745 3.8 Delaware 1,003 14.0 Source: CDC Demographic Distribution Persons of all ages and both sexes are equally susceptible, although the highest rates are in children up to 15 years of age and in adults 30 years and older (Figure 3). Race-specific rates appear to approximate the general population racial breakdown in the geographic areas with tick vectors. Figure 3 Transmission Lyme disease is caused by a spirochete bacterium Borrelia burdorferi (Bb) transmitted by the Ixodes scapularis tick (commonly known as the deer tick) in the eastern U.S. and the Ixodes pacificus tick along the Pacific coast of the U.S. Spirochetes are transmitted through the saliva of feeding ticks and possibly by regurgitation of tick midgut contents into the bite site. In northeast and north central states deer ticks can be found especially on white-footed mice and chipmunks, and in the Pacific coastal regions on dusky wood rats and kangaroo rats. The Deer Tick Figure 4 Ixodes scapularis is a small, reddish brown tick. The tick has three active stages: immature larval, nymphal, and mature adults. Larvae are extremely minute and possess only six legs; all other stages have eight legs. Larvae are not infected with the Borrelia bacteria. Nymphs of Ixodes scapularis are about the size of a pinhead, adults are larger, about the size of a sesame seed. Females have a reddish brown dorsal "shield" located behind the mouth parts and, when engorged, have a reddish brown body. Males are smaller than females and completely brown (Figure 4 ). Figure 5 depicts the 2-year life cycle of ticks in the eastern United States. The tick life cycle is 2-3 years. Figure 5 Exposure to Lyme disease is greatest in spring and summer months when nymphal ticks are most active, and much less in late fall and very early spring when adult ticks are active. Most cases of Lyme disease are caused by the nymphal tick. Clinical Symptoms Clinical presentation of Lyme disease and progression of symptoms can vary widely among individuals. After an infected tick bite, most individuals (70-80%) initially present the characteristic large, red, expanding rash of Lyme disease known as erythema migrans. It often, but not always, takes on the appearance of a bull's eye target (Figure 6). Average appearance is between 4 and 14 days, but a range of 3 to 30 days is possible. Figure 6 Some infected individuals present with acute illness manifested by fever, fatigue, aches and pains, with or without the erythema migrans rash, and less often with specific neurological or musculoskeletal manifestations. Others may not manifest any signs or symptoms of disease other than erythema migrans, some develop only flu-like symptoms and in some cases there are no recognizable symptoms. Typically, the symptoms of Lyme disease are divided into three stages. (Figure 7) Figure 7 The clinical manifestations of illness can be divided into three stages as follows: Stage 1 is predominantly characterized by: erythema migrans (EM), a skin rash at the site of the tick bite that classically begins as a single small red spot that expands to resemble a bull's-eye target — only 70%-80% of infected individuals have this sign. flulike symptoms — malaise and fatigue, headache, fever and chills, myalgia, and arthralgia Early signs and symptoms are typically intermittent and changing Stage 2 is characterized by: hematogenous dissemination; neurological involvement (particularly meningoencephalitis) which is most often manifest by headache and neck pain and stiffness; and, cardiovascular involvement (endocarditis). Stage 3 is characterized by: persistent infection; recurrent migratory arthritis, primarily of the large joints — this the classic feature of stage 3 infection; other musculoskeletal syndromes including: myositis, diffuse fasciitis, osteomyelitis, and panniculities; and, chronic neurological involvement. Diagnosis Lyme disease can be difficult to diagnose because many of its symptoms mimic those of other disorders. Although a tick bite is an important clue in diagnosis, many patients cannot recall a recent tick bite, since the nymphal stage of the tick is so tiny and a tick bite is usually painless (Figure 8). Figure 8 When a patient does not develop the distinctive erythema migrans rash, the health care provider must rely on a detailed medical history and a careful physical examination for essential clues to diagnosis, with laboratory tests playing a supportive role. Assessment Assessment — a cornerstone of nursing practice — is one of the most critical skills nurses can apply to the early diagnosis and treatment of Lyme disease. Some key questions to consider: Does the patient live, play or work in an area endemic for tick infestation? Has the patient traveled to other areas where Lyme disease ticks are endemic (refer to map)? Does the patient remember being bitten by a tick? If so, was the tick removed properly using tweezers? What are the patients outdoor activities — gardening, clearing brush or leaves from wooded areas of property, hiking, camping, etc.? Have other household members or neighbors been diagnosed with a tick-borne illness? Does the patient have pets? If so, is there a history of tick borne diseases or tick attachments with these pets? Could the patient's presenting symptoms be attributable to Lyme disease? With this historical and travel background and a complete physical exam, a practitioner can use disease onset and current status of signs and symptoms to arrive at a diagnosis. If Lyme disease is considered likely, the practitioner will determine which laboratory tests may be necessary. Figure 9 Assessment Questions Where do you live/work? Were you bitten by a tick? What are your outdoor activities? Do you have a pet (dog or cat)? Has anyone in your home had a tick-borne illness? Laboratory Tests The serological tests currently available to determine the presence of Lyme disease lack sufficient sensitivity and specificity to be relied upon for diagnosing Lyme disease. This makes obtaining a medical history and conducting a physical examination crucial. Serologic tests are not "diagnostic tests." They are used as "confirmatory tests." Spirochetes are a highly specialized group of motile, gram-negative, spiral-shaped bacteria having a slender and tightly helically-coiled structure. One of the unique features of spirochetes is their rotational motility, often associated with a flexing or undulating movement. The spirochetes are a fastidious group of bacteria and are difficult to grow, requiring highly specialized media and culture conditions. Bb is difficult to routinely isolate or culture from body tissues or fluids. Most health care providers look for antibodies against the spirochete in the blood to confirm the role of Bb as the causative agent of the patient's symptoms. Antibodies (or immunoglobulins) are small protein molecules produced by the immune system which "lock" on to or destroy specific microbial invaders or their products (Figure 10). Some patients with suspected neuro-borreliosis may also undergo a spinal tap to test for intrathecal antibody production. Figure 10 Antibody Production IgM Indicates new infection First antibody produced Peaks at approximately 4 weeks Some individuals maintain IgM antibodies for many years; indicates a poor prognosis Does not cross placental barrier IgG Indicates older infection Are produced several weeks following infection Peaks at 6-8 weeks Crosses placental barrier Antibody tests, while greatly improved, are less than optimal. These inadequacies can make it difficult to establish clearly whether or not Bb is truly involved in the patient's symptoms. In the first few weeks following infection, antibody tests are not reliable since the patient's immune system has not produced a high enough antibody titer for detection. Antibiotics given to the patient early in the infection may prevent the antibody level from reaching a detectable level even when Lyme disease bacterium is the cause of the patient's symptoms. Because some tests cannot distinguish Lyme disease antibodies from antibodies of similar organisms, patients may test positive for Lyme disease, but their symptoms actually are caused by another bacterial or viral agent, e.g., a false-positive result. If the initial antibody test, the Enzyme-Linked Immunosorbent Assay (ELISA) is positive, another, more specific test (called the Western blot test) is performed to assist the health care provider in making a diagnosis. The ELISA test is used to detect if Bb antibodies are present in the blood. Specifically, if either IgG or IgM antibodies are present, a western blot test is performed to identify specific IgM or IgG protein bands. A false-negative test can occur if: the sample was obtained too soon after infection for antibody production antibiotics were given early in the disease and antibody production was aborted the test lacks sensitivity there was a laboratory error A false-positive test can occur if: the test lacks specificity cross-reacting antibodies are present, i.e., syphilis The following tests must be considered investigational, and their routine use in the clinical setting is NOT recommended: polymerase chain reaction — replication or amplification of bacterial DNA urinary antigen test — spirochete shed in urine borreliacidal antibody assay immune complex disruption T-cell proliferative responses Other tests that may be conducted include: a Complete Blood Count (CBC) sedimentation rate liver enzyme assays radiological exams: X-rays CAT Scans MRIs SPECT Scans Because the signs and symptoms of Lyme Disease mimic those of other illnesses, a differential diagnosis must be made. Diseases/conditions needing to be ruled out include: other tick-borne illnesses, such as ehrlichiosis and babeosis viral diseases such as mononucleosis and Epstein Barre viral disease other types of arthritis and joint injury stress-related illnesses such as chronic fatigue syndrome and myalgia multiple sclerosis Treatment Antibiotic therapy is the treatment of choice for Lyme disease. The antibiotic used, route of administration and duration of antibiotic therapy is determined by stage of infection. For example, patients diagnosed with Stage I infection will often experience relief from symptoms after a three to four week course of oral antibiotic therapy. By contrast, Stage II infection usually is system specific and may require IV antibiotic treatment. Table 2 outlines a typical treatment schedule based upon the presenting symptoms associated with Lyme disease (ACP, 1999). Table 2: Lyme disease Treatment Schedule Treatment of Dosing Early infection — uncomplicated erythema migrans or multiple erythema migrans Adults: Amoxicillin 500 mg tid for 21 days OR Doxycycline 100 mg bid for 21 days* Children under age 10: Amoxicillin 40 mg/kg qd in three divided doses for 21 days (max dose 500 mg) Children over age 10: Amoxicillin 40 mg/kg qd in three divided doses for 21 days (max dose 500 mg) OR Doxycycline 100 mg bid for 21 days Erythema Migrans in Pregnancy Amoxicillin 500mg tid for 21 days Cranial Neuropathy alone/Facial Palsy Meningitis/Acute Radiculopathy Amoxicillin 500 mg tid for 21 days OR Doxycycline 100 mg bid for 21 days OR Ceftriaxzone 2 g q 8 hours for 21 - 28 days** OR Cefotaximine 2 g q 8 hours for 21 -28 days Ceftriaxzone 2 g qd for 21 - 28 days OR Cefotaximine 2 g q 8 hours for 21 -28 days Lyme Arthritis Amoxicillin 500 mg tid for 28 days (with or without probenecid) OR Doxycycline 100 mg bid for 28 days OR Ceftriaxzone 2 g iv qd for 21-28 days OR Cefotaxime 2 g q 8 hours for 21 - 28 days Lyme Encephalopathy/Chronic Radiculoneuritis Ceftriaxzone 2 g iv qd for 21-28 days OR Cefotaxime 2 g q 8 hours for 21 - 28 days *Doxycycline and tetracycline are contraindicated in children under age ten and pregnancy. **Pediatric dose: Ceftriaxzone 40 mg/kg qd for 21 - 28 days. All doses for children must be adjusted appropriately. SOURCE: American College of Physicians (ACP, 1999) Alternative Treatments In recent years, alternative therapies have received greater attention in the popular press as a means of either supplementing or replacing more traditional medical interventions, e.g., acupuncture, herbs, etc. The efficacy of these alternative therapies has been the subject of much debate in the scientific community and are not proven to be effective treatment strategies, and in some cases are considered outright dangerous. This is for information purposes only, and in no way is intended to advocate the use of any of these therapies. Hyperbaric Oxygen Therapy: Patient enters an enclosed chamber having a high concentration of oxygen and increased atmospheric pressure. It has been postulated that increased oxygen levels could debilitate Bb and that increased atmospheric pressure could also enhance antibiotic action by facilitating deeper tissues penetration. It has been proposed that overall immune functioning is enhanced, increasing a patients ability to recuperate from Lyme disease. Malariotherapy: Chronic Lyme patients have infected themselves with the parasite that causes malaria believing that the high fevers associated with this illness will ultimately kill the spirochetes in the body. Hydrotherapy: As with malariotherapy, patients try to raise their temperatures through hot baths to kill spirochetes. Immunotherapy: A small amount of Bb antigen — not the whole organisms but just fragments of it — is used to reduce an overactive immune response to the spirochete. This treatment is said to cause the immune system to become accustomed, or "desensitized," to the material and therefore not overreact to it. Other unproven and potentially dangerous therapies include: injecting patients with the vaccine for dogs; administering the "transfer factor," e.g., using a serum obtained from the milk of a vaccinated cow that was injected with Bb and had developed immunity; the use of heavy metals such as silver and mercury; and homeopathic medicine and nutrition therapy. Personal Protection The need for health care providers to quickly and accurately detect and treat Lyme is extremely important. Their role in the prevention of this illness is equally important. Their role in prevention strategies that reduce exposure to infected ticks can significantly reduce the incidence of this illness. Nurses, often the first point of contact in the health care system, can play a significant role in patient education, as well as in educating the larger community because they are viewed as approachable sources of health-related information. Whether providing this type of community education informally on an individual basis, or formally by offering community education programs, the nurse needs to be familiar with currently recommended prevention strategies. Precautions people can take to avoid exposure to infected ticks are: Avoid tick infected areas; avoid unkempt brush and grassy areas. Be aware of seasonality of risk — greatest in the spring and summer when nymphal ticks are most active and in the late fall and very early spring when adult ticks are active. Wear light-colored clothing. Wear long sleeves to see ticks better and tuck pant legs into socks to keep ticks on the outside of clothing. Wear high rubber boots when gardening and/or working outside in the yard. Inspect yourself and family members daily for ticks following outside activities, particularly when vacationing in tick-infested areas. Apply insect repellents containing 20 - 30% DEET (N, N-diethyl-m-toluamide) to clothes and exposed skin other than the face. Apply permethrin compounds (which kill ticks on contact) to clothing. Remove attached ticks promptly using tweezers to grasp the tick mouthparts and remove with steady, gentle traction (Studies show transmission of Bb from an infected tick is not likely to occur before 48 hours of attachment). Know the signs and symptoms of early Lyme disease or other tick-borne infections (Figure 7) and, if present, seek medical attention without delay. Consider modifying the residential landscape, by clearing leaf litter, brush, and tall grass; creating a woodchip border between lawn and grassy areas where infected ticks are know to exist; pruning shrubs and trees to open up shaded areas to sunlight; removing stone walls and woodpiles; erecting deer barriers. Other Preventive Measures to Consider Area application of acaricides (pesticides specific for ticks) to residential properties is highly effective in suppressing vector ticks but raises environmental toxicity concerns. Control of ticks on deer using self-dosing systems for applying topical and systemic acaricides is being evaluated in pilot trials. Vaccination A vaccine designed to prevent Lyme disease is approved by the U.S. Food and Drug Administration (FDA) and is available. The vaccine is based on the development of protective antibodies against a specific protein of the Lyme disease bacteria and has the effect of killing the disease-causing spirochete within the tick before it can enter the human bloodstream. The vaccine is a preventive agent and cannot be used to treat Lyme disease after it has been contracted. The vaccine is recommended for persons 15 - 70 years of age that reside, work, recreate in or travel to areas of the country considered at high or moderate risk of exposure to tick infested habitats as well as persons having a previous history of Lyme disease. It is not recommended for those that do not have frequent or prolonged exposure to tick habitats, persons less than 15 years of age, pregnant women or persons with treatment resistant Lyme arthritis. (CDC, 1999) The primary vaccine series requires three doses administered through intramuscular injection, for optimal protection. First dose is followed by a second dose a month later and a third dose administered 12 months after the first dose. Vaccine administration should be timed so that the second and third doses are given several weeks in advance of the peak transmission season, usually April. The need for boosters beyond 3 is not yet known, but data regarding antibody levels during a 20-month period after the first injection indicate that boosters bay be necessary (CDC, 1999). People at high risk should discuss the possibility of vaccination with their health care provider. Other Tick-Borne Diseases Table 3 shows numerous tick-borne illnesses, some very similar in nature to Lyme disease. Understanding these other illnesses, including the causative agent, symptoms, diagnostic tests and treatment will enable providers to differentiate Lyme disease from other illnesses, and implement the most appropriate course of action. Possible infection with more than one tick-borne disease makes differentiation crucial and underscores the importance of prevention messages. Table 3: Other tick-borne illnesses Disease Tick Vector Causative Agent Incubation Period Classic Symptoms Lyme Disease Deer Tick (Ixodes scapularis) Western Pacific black-legged tick, (Ixodes pacificus) Borrelia burgdorferi 3 days - 6 months Erythema migrans (EM), fever, swelling of the joints, neurological manifestations, cardiac arrythmias Babesiosis Deer Tick (Ixodes scapularis), Other Ixodes ticks possible Babesia microti 1 - 52 weeks Fever, hemolytic anemia, constitutional symptoms, possible death Human Granulocytic Ehrlichiosis Deer Tick (Ixodes scapularis), American Dog Tick (Dermacentor variables), Lone Star Tick (Amblyomma americanum) Ehrlichia equi 1 - 30 days Fever, headaches, constitutional symptoms, possible death Human Monocytic Ehrlichiosis Lone Star Tick (Amblyomma americanum) Ehrlichia chafeenis 1 - 30 days Fever, headache, constitutional symptoms, possible death Powassan Virus Encephalitis Woodchuck Tick (Ixodes cookei) flavivirus (specific strain) 7 - 14 days fever, meningoencephalitis, 10% fatality rate, 50% neurological sequella Rocky Mountain Spotted Fever American Dog Tick (Dermacentor voriadilis), Rocky Mountain Wood Tick (Dermacentor andersonii) Rickettsia rickettsia 3 - 14 days Sudden fever, maculopapular rash on soles of hands and feet that spreads over entire body, 3-5% fatality rate Tick Paralysis American Dog Tick (Dermacentor voriadilis), Rocky Mountain Wood Tick (Dermacentor andersonii), Lone Star Tick (Amblyomma americanum) Neurotoxin (excreted from the tick's salivary gland) 5 - 7 days Fatigue, flaccid paralysis, tongue and facial paralysis, convulsion, death Tularemia American Dog Tick (Dermacentor voriadilis), Rocky Mountain Wood Tick (Dermacentor andersonii), Lone Star Tick (Amblyomma americanum) Francisella tularensis 1 - 14 days Indolent ulcers, swollen lymph nodes, death Q-fever Brown Dog Tick (Rhipicephalus sanquineness), Rocky Mountain Wood Tick (Dermacentor andersonii), Lone Star Tick (Amblyomma americanum) Coxiella burnetii 2 - 3 weeks Acute fever, sweats, chills Tick Relapsing fever Relapsing-fever tick Borrelia hermsii 5 - 15 days Intermittent fevers, petechial rashes, 2 - 10% fatality rate Colorado Tick Fever Rocky Mountain Wood Tick (Dermacentor andersonii) Colorado Tick Fever virus 4 - 5 days Fevers with remission, followed by a second bout of fever Source: New York State Department of Health Summary Whether acting in the capacity of primary care provider, advocate or educator, nurses can take an active role in the prevention and control of Lyme disease. To do this effectively, nurses need to understand issues related to the diagnosis, treatment and prevention of Lyme disease. Nurse's ability to recognize the signs and symptoms of Lyme disease can have a significant impact on the chronic morbidities associated with this illness. Likewise, nurses' ability to educate patients about Lyme disease may be one of the best tools available to prevent exposure to this illness. The purpose of this continuing education program is to provide nurses with the information they need to take on these roles with confidence. References American College of Physicians. (1999, May). Lyme disease treatment schedule. [Online]. Available http://www.acponline.org/lyme/dosingtb.htm Barbour, Alan G., MD. (1996). Lyme disease: The cause,the cure and the controversy. 180-182. The Johns Hopkins University Press. Bushmich, S.L. (1997, July 15). Answers to commonly asked questions about Lyme disease. [Online]. Available http://www.inform.umd.edu/EdRes/Topic/AgrEnv/ndd/health/ QUESTIONS_ABOUT_LYME_DISEASE.html. Centers for Disease Control and Prevention. (1999). Lyme disease: A public information guide. [Online]. Available http://www.cdc.gov/ncidod/dubid/lymeinfo.htm. Centers for Disease Control and Prevention. (1997, July 15). Information on Lyme disease. [Online]. Available http://www.cdc.gov/ncidod/diseases/lyme/lymegen.htm. Hoffman, Robert L. MD. (1994). Lyme disease: How to avoid, detect and treat this dangerous tick borne plague, 43. Keats Publishing. Lang, D.L., DeSilva, D. (1993). Coping with Lyme disease. 4-6, 9, 201. New York: Henry Holt and Company. Morbidity and Mortality Weekly Report (MMWR). (1999, June 4). Recommendations for the use of Lyme disease vaccine. 6-7, 11-13. Atlanta, GA: Centers for Disease Control and Prevention. Willis, D. (1991). Lyme disease. J Neurosci Nurs. 23(4): 211-7. [Online}. Available http://openseason.com/annex/cic/X0056_lymedis.txt.html. U.S. Department of Health and Human Services. (1998, April). Lyme disease: the facts, the challenge. [Online]. Available http://www.niaid.nig.gov/publications/lyme/default.htm Previous: Return to table of contents Next: Take test

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