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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. …..2 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