Lyme disease preventable by taking steps to avoid tick bites

Lisa M Faust is seen with her Lyme medicines at home in Charlton [ T & G Staff/Christine Peterson]

By Elaine Thompson
Telegram & Gazette Staff 

Pest control experts who began seeing ticks in early February because of a warm winter and an abundance of acorns now say this will be one of the worst tick seasons in years - which may lead to an increase in Lyme disease.

While that may be true, health experts point out that in Massachusetts and other parts of the Northeast, where Lyme disease is endemic, every year is a bad tick season. Their advice is to not focus on how many ticks there might be this year, but instead, become educated on how to prevent tick bites.

Dr. Catherine M. Brown, deputy state epidemiologist and state public health veterinarian with the state Department of Public Health, said she's not sure if the prediction is helpful because there are always thousands of cases of Lyme every year.

"We're considered endemic for Lyme, which means we have it all over the Commonwealth, and we have it all the time," she said. "I want people to be aware and to take steps to prevent tick bites, not just in the year when people say it might be bad."

Chris G. Ford, president of Ford's Hometown Services on Grove Street in Worcester, said he and other pest control folks learned of the hearty rodent population at the Central Massachusetts Pest Control Association's seminar in Sturbridge last month.

Some small animals, particularly the white-footed mouse, carry the bacteria that causes Lyme. When a tick, usually in the nymph stage, attaches to the carrier for a blood meal, it becomes infected and passes the infection on to humans and other animals.

Mr. Ford said the number of phone calls from people signing up for the company's four-application tick protection program spiked during the warm spell in February when people began seeing ticks. April through September is when the greatest risk of being bitten exists. But, adult ticks are out in search of a host in winter when temperatures climb above freezing.

"We've had multiple calls coming in already regarding people's pets and children getting ticks on them," he said. Mr. Ford, who is also president of Massachusetts Association of Lawn Care Professionals, said mosquito and tick control has grown to be the largest segment of the 75-year-old family company.

Massachusetts ranked fourth in the nation (behind Pennsylvania, New Jersey and New York) in the incidence of Lyme cases reported to the Centers for Disease Control and Prevention in 2015, the last year for which the data is available. Ninety-five percent of the confirmed cases of were reported in 14 states - including all of New England - where the black-legged tick is found. There were 2,922 confirmed cases and 1,302 probable cases in Massachusetts in 2015.


But, as the CDC first announced at an international conference in Boston in 2013, Dr. Brown said the actual number of cases each year is likely 10-fold what is reported.

The 4,000 to 6,000 confirmed and probable cases of Lyme reported each year in Massachusetts are the only ones where there is enough information to assign them based on the current surveillance system, Dr. Brown said. As a result of the limitations, the department is developing a new system of counting Lyme cases which should be available before the end of the year.

"There are 14,000 to 16,000 positive lab results, and yet we don't often have enough clinical information to count these people based on the (current system)," she explained.

Other states are also using different methods, which makes it impossible to compare states. Dr. Brown said some counties in New York had so many Lyme cases that they are following up on and reporting only a sampling of cases. According to the CDC, New York had a total of 4,314 confirmed and probable cases of Lyme in 2015.

"All of this speaks to why we're looking at the old way and thinking it is not really accurate and appropriate," she said. "We're looking at trying to use other data sources and evaluate the data we have more creatively to provide a better assessment of the true risk and burden that Lyme disease places on Massachusetts residents, as well as the health care system."

More Lyme disease than mosquito-borne diseases

Lyme disease is the most prevalent vector-borne disease in the country. It affects many more people than Eastern equine encephalitis and West Nile virus combined. Dr. Brown, with the DPH, said the state, like some in other parts of the country, has considered a program to spray for ticks, similar to the current mosquito control program. She said one of the reasons that has not been established is because of a CDC study involving four other high Lyme incidence states that didn't show to fix the problem. The study looked at pairs of neighborhoods: one sprayed yards with insecticide; the other sprayed water. She said the properties that used insecticide did end up having fewer ticks. But the number of Lyme cases were the same for both pairs of neighborhoods.

"People don't get exposed to infected ticks only in their yard," Dr. Brown said. "The other factor that could be involved is, if you know your yard has been sprayed for ticks, maybe you are not as concerned about using repellent and doing tick checks."

Lyme disease is difficult to diagnose. If not treated early, it can spread to many organs and systems in the body, including the central nervous system, cardiovascular system, the eyes, the liver and muscles, and joints.

Treatment is controversial. There are two schools of thought. The Infectious Disease Society of America has expressed concern about over-treatment of antibiotics and recommends limited treatment options, usually up to four weeks. The International Lyme and Associated Disease Society recommends treatment determined by clinical judgment. In some cases, that means long-term treatment with antibiotics.

Most health insurance companies only paid for the limited treatment until last year, after a years-long battle by Lyme victims and other advocates led to the Legislature enacting a law requiring private health insurers to cover the cost of long-term treatment for the disease.

Trish McCleary, a longtime Lyme victim and co-founder of Sturbridge Lyme Awareness of Massachusetts and the Massachusetts Lyme Coalition, who helped get the law passed, estimates that she had paid more than $100,000 for treatment of the disease. But, the law is not perfect, she said. The law does not cover hundreds of thousands of people on MassHealth, as well as state and some municipal employees, their families and retirees who are covered by insurance administered by the Group Insurance Commission.

State Rep. David P. Linsky, D-Natick, sponsor of the legislation, said not including those people was not his first choice, but a compromise to get the bill passed. He said it was a budgetary decision because taxpayers pay 50 percent of MassHealth costs and all the cost for government workers' insurance administered by the Group Insurance Commission.

"It's fair to say that healthcare insurance throughout the country is in a gigantic state of influx right now," Rep. Linsky said. "As much as I would like to see expanded coverage for Lyme, anything Massachusetts does has to be in accordance with federal law and we simply don't know right now."
Lisa M. Faust, 53, of Charlton, said the law is having a "life-saving" effect for her.

Prior to passage of the law, she was paying more than $3,000 a month out of pocket for Bicillin, an intramuscular injectable antibiotic, she needs to fight Lyme disease that she likely contracted in 2013.
After the law passed, Mrs. Faust said she had to "fight tooth and nail" for several weeks, and get state Sen. Anne Gobi involved, before Harvard Pilgrim complied with the new law. She now only pays a monthly co-pay of $250. The lower cost allows her to take the medication once a day as prescribed, as opposed to every other day.

"Being able to stay on this medication has changed my life in a very dramatically positive way. I haven't had a fever in months. I have more energy," she said. "I really feel I'll be off (the antibiotic) by summer. I'm so happy that law passed. It's really life changing."

Prevention is the best medicine

Many health experts throughout the country stress that the most important tool available to prevent getting the devastating disease is to take proven steps to prevent tick bites.

Dr. Sam R. Telford, III, an expert on tick-borne diseases and a professor in the department of infectious diseases and global health at the Cummings School of Veterinary Medicine at Tufts University in North Grafton, said measures to significantly reduce the number of deer will also greatly reduce Lyme cases. Deer is the primary host for the adult tick to feed, and lay thousands of eggs. He also pointed out that tremendous strides were made in reducing exposure to Lyme a few years ago, because of a CDC grant that paid the salary of a person to educate residents on Cape Cod about reducing their risk to Lyme and other tick-borne infections. The work stopped when the grant ran out, he said.

"Education is really the only way we're going to get a handle on this," he said. "We can wait and wait for a vaccine."

There is a vaccine for dogs, but there is no longer one for humans. The only human vaccine against Lyme disease, called LYMERix, was licensed in 1998, and taken off the market in 2002 because there was not enough demand for it, and some reported side effects.

Scientists affiliated with University of Massachusetts Medical School are currently developing a medicine that could prevent people from getting the disease.

Dr. Mark S. Klemper, professor of medicine at UMass Medical School and executive vice chancellor of the school's MassBiologics, where Lyme pre-exposure prophylaxis or Lyme PrEP was developed, said excellent progress has been made.

He said that unlike a vaccine which causes the body's immune system to make a lot of antibodies, this medicine is a single human antibody that prevents infection from tick bites. Once the scientists have confirmed that the antibody provides protection for at least six months, clinical trials in people will begin.

Dr. Nancy A. Shadick, a rheumatologist at Brigham and Women's Hospital, is convinced that education is key in reducing the state's Lyme epidemic. She conducted a study called A School-Based Intervention to Increase Lyme Disease Preventive Measures Among Elementary School-Aged Children, that involved 3,570 students in nine school districts in Essex County, on the North Shore, which is highly endemic for Lyme disease. There is a higher incidence of the disease in children ages 5 to 9, because they are less likely to find the tick and have it removed in time to prevent transmission. According to the CDC, the tick must be attached for 36 to 48 hours or more before the Lyme disease bacterium can be transmitted.The study taught about half of the children about the disease and preventive behaviors that decrease their chances of getting sick. The remaining elementary school students in the study did not get that education.

Dr. Shadick, in an email Thursday, said she would recommend that a similar program be expanded to all public elementary schools in the state.

"The children increased their knowledge of Lyme disease and reported that they took more tick bite precautions," she said. "They had an improved attitude toward taking precautions and had more self-confidence that they could find a tick on themselves compared with the control group of children who did not get the in-school curriculum."

The Massachusetts Health Officers Association (MHOA) is working to develop a toolkit for municipal health departments to use to educate communities about Lyme and precautions for people to take. Sam Wong, public health director in Hudson who is MHOA's vice president, said while Lyme is the most prevalent tick-borne disease in Massachusetts, there are others, including Babesiosis and Powassan virus, that we are beginning to see.

"We're seeing the number of cases trending up over the years. With the climate change, we expect to see those numbers going even higher," he said. "Local health departments and the state health department can do a lot on educating the public on these issues."