Download June 10, 2014 letter to NS physicians from Dr. Robert

424-2358
424-4716
June 10, 2014
Dear Physicians:
We are writing to update you on Lyme Disease (LD) and bring your attention to two related issues
regarding the diagnosis and treatment of LD, which is becoming more common in Nova Scotia.
The Department of Health and Wellness (DHW) has a LD response plan developed by the interdepartmental Vector-Borne Disease working group that provides evidence-based advice and guidance to
the provincial government. Nova Scotia has several infectious disease and medical microbiology experts
who diagnose and treat LD, along with their colleagues in rheumatology, neurology, and cardiology.
They have been supporting the work of family physicians who have been managing patients with LD in
areas where it is endemic (i.e. are part of the local ecology) and educating physicians to be able to
recognize LD should it appear in, as yet, non-endemic areas. We work closely with our federal partners
at the Public Health Agency of Canada (PHAC) and the National Microbiology Laboratory who provide
expert recommendations for the prevention and surveillance of LD and ticks.
Currently, there are six areas where blacklegged ticks carrying the bacteria Borrelia burgdorferi are
known to be endemic. These endemic locations are in Halifax Regional Municipality, Yarmouth County,
Shelburne County, Lunenburg County, Pictou County and Queens County:
http://novascotia.ca/dhw/CDPC/lyme.asp
LD is a notifiable disease under the N.S. Health Protection Act. This means that health care professionals
must report clinical or laboratory confirmed cases of LD to Public Health. In 2013, there were 154 cases
of LD reported. We know the number of LD cases will increase over time as the tick population increases
and expands its geographical range.
The N.S. Infectious Diseases Expert Group (IDEG) has developed a document: “Statement for Managing
Lyme Disease in Nova Scotia” along with a diagnostic algorithm. These documents are based on current
evidence and follow the guidelines published by the Infectious Disease Society of America (IDSA) and
endorsed by the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. They can
be found online at:
http://novascotia.ca/dhw/CDPC/documents/IDEG/Statement-For-Managing-Lyme-Disease.pdf
http://novascotia.ca/dhw/CDPC/documents/Outline-for-Lyme-Disease-Management.pdf
A recent case series of 17 paediatric patients in NS with arthritis as the presenting symptom of LD is a
reminder of the variety of rheumatologic, neurologic, and cardiac manifestations of early disseminated
and late LD.
Laboratory testing for LD that is used across Canada follows the evidence-based guidelines established
by PHAC and the U.S. Centers for Disease Control and Prevention (CDC). These guidelines have been
endorsed by the Canadian Public Health Laboratories Network.
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Some patients may request to have LD testing done at private laboratories in the United States. We
advise against this as these laboratories may not use an accepted testing methodology and, therefore,
results from these labs cannot be accepted as reliable evidence of LD. Testing for LD, as recommended
in the IDEG document, can be readily obtained through laboratories in Nova Scotia. Physicians are
reminded that the sensitivity of testing early in the infection is poor and, therefore, laboratory testing is
not recommended in patients presenting with erythema migrans, which is a clinical diagnosis. However,
the sensitivity of serology for late LD, such as arthritis, is high and a negative test can rule out LD in most
patients.
Some patients may be on or request long term antibiotic therapy for what they believe to be chronic LD
or post-Lyme syndrome. Current evidence does not support the long term use of antibiotics in the
treatment of LD and is advised against by the IDSA treatment guidelines.
The May 29, 2014 Canada Communicable Disease Report has detailed information on LD diagnosis and
treatment and is on-line at:
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/14vol40/dr-rm40-11/dr-rm40-11-lyme-1-eng.php
There is also good information on a full range of topics related to LD on the PHAC website:
http://www.phac-aspc.gc.ca/id-mi/tickinfo-eng.php
If you have additional questions regarding LD, please contact your local Public Health office which can
be found here: http://novascotia.ca/dhw/publichealth/phs-offices.asp
Sincerely,
Dr. Robert Strang
Chief Public Health Officer
Dr. Lynn Johnston
Chair, Infectious Disease Expert Group