Dáil Éireann Debate, Wednesday - 2 November 2016
316. Deputy Éamon Ó Cuív asked the Minister for Health his plans to commission an independent inquiry into Lyme disease to review the evidence of the epidemiology of Lyme disease here, particularly at the level of symptoms recognition, diagnostic testing and the treatment of Lyme disease; and if he will make a statement on the matter. [32703/16]
Amharc ar fhreagraLyme disease is an emerging condition which is being increasingly recognised as causing hardship, if the diagnosis is missed. Over the last number of years, there has been a marked increase in awareness of the condition among GPs and hospital doctors in Ireland. Each of the HSE’s hospital Groups have a number of Infectious Disease Consultants who are expert in the diagnosis and management of Lyme disease. Our laboratories operate to high levels of quality. Anyone who has been bitten by a tick or has other reasons to strongly suspect Lyme disease should discuss their concerns with their GP in the first instance.
Lyme borreliosis was made been statutorily notifiable in Ireland by the Infectious Diseases (Amendment Regulations) Regulations 2011 (S.I. no 452 of 2011). The notifiable entity is Lyme neuroborreliosis, the more severe neurological form of Lyme borreliosis. The Health Protection Surveillance Centre (HPSC) of the HSE collects and collates surveillance data on notifiable infectious diseases. The number of annual neuroborreliosis notifications over the last few years is as follows:
- 2012 – 8 cases;
- 2013 – 13 cases;
- 2014 – 18 cases; and
- 2015 – 12 cases.
The Weekly Infectious Disease Report, published by the HPSC on 26 October 2016, indicated that for week 42-2016 (16-10/16-22-10/16) there have been 16 cases notified so far in 2016 – an increase of 5 on the same period last year.
This gives an annual incidence rate of about 2.7 cases per million population. The number of people affected by milder forms of Lyme disease is not known. The ratio of neuroborreliosis to standard Lyme disease ranges from 5%-20%, so it is quite possible that Ireland could have between 100-200 cases of Lyme disease per annum.
HPSC Lyme Borreliosis Sub-Committee
The HPSC is responsible for the surveillance of notifiable infectious diseases such as Lyme Disease. The Scientific Advisory Committee of the HPSC has established a Lyme Borreliosis Sub-Committee, the aim of which is to develop strategies to undertake primary prevention in order to minimise the harm caused by Lyme Borreliosis in Ireland. In addition to staff from the HPSC, the membership of the Sub-Committee includes specialists in Public Health Medicine, Consultants in Infectious Diseases, Clinical Microbiology, Occupational Health an Entomologist from the Parks and Wildlife Service, a representative from the Local Government Management Agency and an Environmental Health Officer.
The Terms of Reference of the Sub-Committee are:
- To raise awareness in Ireland of Lyme Borreliosis amongst clinicians and the general public;
- To identify and highlight best international practice in raising awareness about Lyme Borreliosis for the general public;
- To develop policies of primary prevention of Lyme Borreliosis in Ireland based on best international practice;
- To explore ways in which to improve surveillance of neuroborreliosis in Ireland;
- To develop strategies to raise awareness among the general public particularly in areas of higher tick populations; and
- To produce a Final Report covering all the above areas.
The initial work of the Lyme Borreliosis Sub-committee involves a survey of laboratory methods for the diagnosis of Lyme borreliosis in Ireland, the development of Lyme borreliosis guidance for general practitioners, the publication of medical media articles to highlight diagnostics and laboratory methods relating to Lyme borreliosis available in Ireland for general practitioners, and ongoing work in drawing together the Final Report of the Sub-committee. The Sub-committee includes representation from Tick Talk, an independent Lyme disease support group set up to encourage awareness, prevention and treatment of the disease in Ireland.
The Sub-Committee first met on 6 May 2015 and it is expected to report in 2017.
Testing for Lyme Disease
Irish microbiology laboratories that test for Lyme disease all comply with internationally recognised quality assurance schemes. There schemes are designed to monitor how the laboratories operate and to ensure that the quality of laboratory reports can be guaranteed. These quality assurance schemes involve the operation of the laboratories being independently monitored and assessed by Irish and international specialist microbiology reviewers to examine the laboratories use of accredited examination procedures and methods that will ensure the highest achievable quality of all tests performed and thus to ensure that the laboratories operate to a the highest possible standards of quality.
No laboratory test will however be 100% accurate 100% of the time, and, occasionally, diagnoses can be missed, but the purpose of the quality assurance scheme for laboratories is to ensure that the likelihood of a misdiagnosis is minimised. This will involve minimising the number of false positive results (i.e. people being diagnosed as having Lyme disease when they in fact do not have the disease) and false negative results (i.e. people being diagnosed as not having Lyme disease when they in fact have the disease).
It is important that patients who are concerned about Lyme disease seek help and a firm diagnosis in Ireland. There have been many instances of patients travelling to other countries to undergo extremely expensive testing only to be given an incorrect diagnosis of Lyme disease, when they most likely had a completely unrelated condition which could be diagnosed simply and accurately within the Irish health system.
There is a real danger in looking at Lyme disease in isolation (i.e. looking at only the results of a Lyme blood test). When a doctor takes a history and examines a patient, he/she does so with an open mind. He/she is gathering evidence (in terms of the patient’s clinical history, physical examination and laboratory tests) to determine which diagnoses are most likely. It is the combination of careful clinical history, examination and appropriate laboratory testing that will lead a doctor to making a correct diagnosis.
To ensure that Lyme testing is applied in a valid and accurate, a two stage system is used.
First stage (EIA Testing): This test detects antibodies to Lyme disease (Lyme antibodies are markers that show that a person has been exposed to the bug causing Lyme disease at some stage in the past). However studies that have tested large groups (populations) of people have found that anything from 5% to 20% of these groups can have positive Lyme tests. What this means is that a significant minority people have been, at some stage in their lives, exposed to Lyme Borrelia. The initial screening EIAs can be quite inaccurate, giving false-positive reactions (i.e. the tests indicate the patient has had Lyme disease when in fact they have not). Infections such as syphilis, certain viral infections including glandular fever and certain inflammatory conditions can give positive Lyme disease tests and if these results are not double checked, the patient will have been falsely diagnosed as having Lyme disease when they in fact do not have the disease. To get around this problem, the second stage of testing – Western Blot – is used.
Second Stage (Western Blot): If a patient’s blood test results come back as being positive (or questionable) for Lyme disease, their blood is tested using the Western Blot method. Using the Western Blot greatly increases the specificity of the testing (i.e. the very specific Western Blot out-rules false positives and identifies a very high proportion of true Lyme disease cases making the two tier system very accurate).
Treatment
Lyme disease can be very successfully treated using common antibiotics. These antibiotics are effective at clearing the rash and helping to prevent the development of complications. Antibiotics are generally given for up to three weeks. If complications develop, intravenous antibiotics may be considered.
In Ireland, treatment by most clinicians is based on that laid out in evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis published by the Infectious Diseases Society of America (IDSA) in 2006. This pharmacological regime can be summarised thus:
- Doxycycline, amoxicillin or cefuroxime for the treatment of adults with early localised or early disseminated Lyme disease associated with erythema migrans, in the absence of specific neurologic manifestations (ceftriaxone in early Lyme disease for adults with acute neurologic disease manifested by meningitis or radiculopathy);
- Doxycycline, amoxicillin, or cefuroxime for adults with Lyme arthritis but without clinical evidence of neurologic disease;
- For late neurological disease in adults - intravenous ceftriaxone, cefotaxime or Penicillin G.
Prevention
Prevention is better than cure and there are a number of measures people can take to protect themselves from catching this disease. The best protection is to prevent tick bites, when walking in grassy, bushy or woodland areas, particularly between May and October:
- Arms and leg should be covered; wearing long trousers tucked into socks or boots, and long-sleeved shirts with cuffs fastened is advised. Shoes or boots should be worn rather than open-toed sandals.
- The use of insect repellent on clothes is recommended, or on limbs if it is not practicable to cover up. DEET or permethrin (insect repellents) can be used – advice can be obtained from pharmacies.
- Skin and clothing should be inspected for ticks every three to four hours and children's skin and clothes checked frequently.
- Ticks should be removed as soon as they are seen attached to the skin. Further advice on tick removal can be obtained from the HPSC website.
- It is not recommended that antibiotics are given to prevent the transmission of Lyme disease following a tick bite. Only if the area becomes inflamed may treatment be required; and advice should be sought from a doctor.
- People should see their doctor if they develop a rash or become unwell with other symptoms, letting the doctor know of exposure to ticks.
Further advice can be obtained from the HPSC website (www.hpsc.ie) and where the leaflet “Protecting Yourself Against Tick Bites and Lyme Disease” is available for the public to download.
I hope this reply has comprehensively addressed the Deputy's concerns.
