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Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Lyme disease and post-treatment Lyme disease syndrome: the neglected disease in our own backyard L.A. Crowder a, V.A. Yedlin a, E.R. Weinstein a, K.B. Kortte b, J.N. Aucott b,* a b
Lyme Disease Research Foundation, Inc., Lutherville, MD 21093, USA The Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
article info
abstract
Article history:
Objectives: A survey was developed to assess experience and opinions about Lyme disease
Received 10 September 2013
and post-treatment Lyme disease syndrome (PTLDS) among faculties in public health. No
Received in revised form
previous surveys of public health faculties have been found in the literature.
11 June 2014
Study design: This is a cross sectional study of public health school faculty members
Accepted 12 June 2014
designed to measure knowledge and experience with Lyme disease and PTLDS using an
Available online 9 September 2014
internet survey instrument. Methods: Participants were recruited using all the publicly available e-mail addresses of
Keywords:
faculty members in all the 50 accredited Schools of Public Health in the United States.
Lyme disease
Results: A 15% response rate was seen for the survey. 50% of respondents were from Lyme
Post-treatment Lyme disease syn-
endemic states. Less than 5% of faculty members consider themselves expert in Lyme or
drome
PTLDS. Many faculty members had known someone with Lyme disease or PTLDS, but few
Public health
had been diagnosed themselves. Most believe that PTLDS can be severe and chronic, is not
Faculty
easy to treat, and does not resolve on its own, but were uncertain about its aetiology. Most
Survey research
respondents also felt that the incidence of Lyme disease will increase and that more education is needed. Conclusions: The need for further understanding and communication presents an opportunity for public health research and education in Lyme disease and the sequelae of PTLDS. © 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Lyme disease is a worldwide emerging infectious disease with hundreds of thousands of new cases each year in the United
States1 and across temperate regions of Eurasia.2 Lyme disease is the most common vector-borne disease in the US and the second most commonly reported infectious disease in the North East US, with over 300,000 new cases estimated by the CDC each year.1 With proper diagnosis and treatment, the
* Corresponding author. The Johns Hopkins School of Medicine, 10755 Falls Road, Suite 200, Lutherville, MD 21093, USA. Tel.: þ1 410 583 7124; fax: þ1 410 583 7125. E-mail addresses:
[email protected] (L.A. Crowder),
[email protected] (V.A. Yedlin),
[email protected] (E.R. Weinstein),
[email protected] (K.B. Kortte),
[email protected] (J.N. Aucott). http://dx.doi.org/10.1016/j.puhe.2014.06.016 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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majority of acute cases resolve; 15e20% of treated patients report persistent symptoms of fatigue, musculoskeletal pain and cognitive complaints after treatment.3 However, there is a subset of individuals who experience persistent symptoms for six months or longer; this is termed post-treatment Lyme disease syndrome (PTLDS).4e6 PTLDS is most often referred to as chronic Lyme disease by the public7 and remains a significant problem in those with delayed diagnosis, those who receive non-ideal initial treatment, and those with initial neurologic Lyme disease.8,9 The aetiology of PTLDS is not yet clear and little is understood about the true number of cases or the health care burden of this illness.10 Despite the recognition of Lyme disease in Connecticut over three decades ago, the debate over PTLDS continues, with 48% of physicians surveyed in Connecticut remaining undecided about its existence.11 In contrast, in a survey of nonphysician residents of New England, 67% responded that they knew someone who still suffered from Lyme disease symptoms after treatment, and 80% of those surveyed believed that Borellia burgdorferi, the bacteria causing Lyme disease, can persist in the body after antibiotic treatment.12 This discrepancy between physicians and the public may result from several factors including differences in perspectives of individuals vs healthcare providers and scientific unknowns. Even regarding general principles of prevention, there is evidence of a lack of basic knowledge in the general public.13 Schools of Public Health (SPHs) have traditionally played the central role in research, advocacy, and education related to vector-borne infections such as Lyme disease. A goal of SPHs is to drive public policy and to catalyse health initiatives and knowledge campaigns. SPH faculties are best positioned to bridge the large gaps in opinions and differing perspectives of patients and the medical community. Hence, it is important that public health personnel have knowledge of Lyme disease and PTLDS. However, a search of the literature did not reveal any public health studies in the last decade investigating PTLDS. It is not clear why this common illness has received so little attention. To the authors' knowledge, no prior surveys have assessed the knowledge base about Lyme disease and PTLDS among this cohort. In order to better understand the potential reasons for this lack of attention, the faculty of 50 accredited SPHs was surveyed. The authors hypothesize (1) that SPH faculties would report little experience teaching and researching Lyme disease and PTLDS and (2) that their personal experience, more so than self-assessed knowledge of Lyme disease, would be related to their certainty in opinions expressed regarding Lyme disease and PTLDS.
Methods Instrument development A literature review was performed to identify previous studies examining the knowledge, attitudes, behaviours, and treatments relating to acute and chronic Lyme disease among physicians and the public.11e15 No prior surveys were identified that focused on PTLDS specifically or that examined the public health faculty and their perspectives. SPH faculty
785
members were specifically chosen to be addressed because of their unique perspective and potential experience with Lyme disease and PTLDS. Issues regarding treatment were not addressed because the focus was aimed at the epidemiology, pathophysiology, and sequelae of PTLDS. A survey instrument was developed based upon a literature review and interviews with Lyme disease experts in the fields of medicine and public health with the goal of determining the experience and opinions of SPH faculties regarding Lyme disease and PTLDS. The questionnaire was piloted in a local population of healthcare professionals and modified based on their feedback. Survey questions were divided into four sections: survey respondent demographics, acute Lyme disease, PTLDS, and public health significance. Demographic questions included the state of residence, so that respondents could be grouped into those from Lyme disease endemic and non-endemic states. Questions regarding Lyme and PTLDS were asked separately as they are distinct clinical phenotypes with a potentially different knowledge base among those surveyed. Additional questions examined opinions regarding the prevalence, aetiology and severity of PTLDS.
Administration Participants were recruited using all the publicly available email addresses of faculty members in all the 50 accredited SPHs, as determined by the Association of Schools of Public Health in the United States as of March 1, 2012. Emails were received by 8962 faculty members. Only those emails available in the public domain were targeted. The message included a brief description of the research project, as well as a link to the survey. The survey was administered via http://www. surveymonkey.com/. The survey included seven questions about the survey-taker’s demographic characteristics, as well as fifteen questions on their understanding, experiences, and opinions related to Lyme disease and PTLDS. There were 22 questions in total. The survey was conducted between March 1, 2012 and June 30, 2012. This study was approved by the Johns Hopkins Institutional Review Board (NA_00071911).
Statistical analysis Survey questions were grouped into those influenced by the geographic incidence of Lyme disease and those that the authors hypothesized would be influenced by personal experience or self-assessed level of knowledge. Geography dependent questions in Table 2 are directly related to the prevalence of Lyme disease and are expected to be directly dependent on whether the respondent lives in a Lyme endemic or non-endemic state. Responses related to the natural history and pathophysiology of Lyme disease and PTLDS were examined in relationship to the respondents' personal and self-reported knowledge in order to better understand this relationship independent of the respondents' geographic residence. Statistical analyses using chi-square tests were conducted using SPSS v. 20 (IBM Corporation, Armonk, NY).
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Results The survey was transmitted to a total of 9468 unique email addresses at 50 schools (30% in Lyme endemic states, 70% in non-endemic states). Five hundred and six error messages were received in return, suggesting the actual population reached was 8962 faculty members (Fig. 1). Of the 8962 faculty members with active emails, 1297 participants took the survey, resulting in a 15% response rate. Sample descriptive data is captured in Table 1. The majority of respondents are in the Epidemiology department. All academic ranks are represented in the sample with fairly equal dispersion of respondents within the four groups. Fortyfive percent of respondents have been in their current field for more than 20 years. Approximately 24% responded from Lyme endemic states compared to about 10% from non-endemic states. The absolute number of respondents was evenly split between those in Lyme endemic statesc and those in non-endemic states (50.3% vs 49.7%). The majority of faculty members are not experts in Lyme disease. Only 3% of the cohort self-reported to have an ‘expert’ level knowledge of Lyme disease. Fewer faculty members, 2%, reported having an expert level of knowledge about PTLDS. Twenty-four percent self-reported knowing ‘a lot’ about acute Lyme disease and 7% self-reported knowing ‘a lot’ about PTLDS. Only 16% of faculty members have taught about Lyme disease, and 6% have taught about PTLDS. Roughly 66% of respondents reported that they had no professional experience with Lyme disease in their own training, in patient care activities, or in research, while 83% had no experience with PTLDS. Among all respondents, personal experience with Lyme was rather common. Six percent report a personal diagnosis of acute Lyme disease, 34% in a family member or close friend, and 68% have known someone diagnosed. Personal experience with PTLDS was much less common, with less than 1% having been diagnosed themselves, 13% with a family member or close friend, and 38% knowing someone diagnosed with PTLDS.
Residence in Lyme disease endemic state To understand if there were any sub-group differences, the survey cohort was divided in two groups: those residing in Lyme endemic states and those residing in non-endemic states (Table 2). These two groups did not differ on demographics or academic experience (data not shown). Both groups were mostly represented by faculty members in the epidemiology department. Both groups had approximately 3% of respondents with ‘expert’ level of knowledge of Lyme disease (3.2% for endemic, 3.1% for non-endemic). Thirty percent of faculty members from endemic states reported having ‘a lot’ of knowledge compared to 19% of members from non-endemic states. c
States included as ‘Lyme endemic’ include: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and Wisconsin.
Fig. 1 e Reach and responses to survey of public health faculty on their knowledge and experiences of early Lyme disease and post-treatment Lyme disease syndrome.
Fifty-three percent of faculty respondents from Lyme endemic states vs 27% from non-endemic states reported that they or a close associate had been diagnosed with Lyme disease. Personal experience with PTLDS was less common with 17% of faculty members from Lyme endemic states and 10% from non-endemic states having experienced PTLDS either themselves or through a family member or close friend. More than 90% of faculty respondents from both Lyme endemic and non-endemic regions agree that Lyme disease is common in certain regions of the US. Most faculty members (88%) agree that the geographical range of Lyme disease will increase in the future. The majority do not have professional experience, defined as having been taught about, cared for patients with, or done research on, Lyme disease (66%) or PTLDS (83%). While many are unsure of the research funding environment for Lyme disease and PTLDS (82%), 17% believe that these diseases are underfunded. Likewise, 85% of surveyed faculty members believe that more public health education is needed surrounding Lyme disease and PTLDS. Pvalues indicating statistically significant differences between the Lyme endemic and non-Lyme endemic groups for these analyses are shown at the bottom of Table 2.
Experience with acute Lyme disease and PTLDS Respondents were classified as having had personal experience with acute Lyme disease or PTLDS if they or a close associate had the disease (Table 3). Three groups were formed from this information: those with no personal experience with Lyme disease or PTLDS; those with personal experience with Lyme disease, but not PTLDS; and those with personal experience with PTLDS with or without personal experience with Lyme disease. All groups agree that PTLDS can be severe and chronic condition that can last for many years. Less than 5% in
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Table 1 e Demographic characteristics of the cohort of public health faculty members who responded to the survey, n ¼ 1297. Characteristic
%
a
Sex Male Female
42.7 57.3
Age Groupb 20e29 30e39 40e49 50e59 60e69 70þ
2.2 17.9 21.9 29.1 23.1 5.8
State of Residencec Lyme endemic state Non-Lyme endemic state
50.3 49.7
Academic Departmentd Behavioral/Community Health Biostatistics Environmental Health Sciences Epidemiology Health Policy and Management Global/International Health Other
14.2 7.7 15.2 26.8 12.0 5.1 14.5
Academic Ranke Instructor Assistant Professor Associate Professor Professor
11.1 31.2 25.1 32.6
Years in Current Fieldf 1e2 3e5 6e10 11e20 20þ
2.5 8.7 16.4 26.9 45.5
Professional experience questions Self-reported knowledge e acute LD I know a little I know a lot I have an expert level knowledge
%
g
72.7 24.1 3.2
Professional experience e acute LDh Taught about LD Cared for patients with LD Experience doing research studies No professional experience
29.7 10.1 5.1 65.9
Do you teach about acute LD?i None Some A lot
78.6 20.1 1.4
Self-reported knowledge e PTLDSj I know a little I know a lot I have an expert level knowledge
91.2 7.2 1.6
Professional experience e PTLDSh Taught about PTLDS Cared for patients with PTLDS Experience doing research studies No professional experience
14.3 4.6 1.6 82.5
Do you teach about PTLDS?k None Some A lot
91.5 8.5 0.0
Missing data: a 9 missing sex, b 10 missing age group, c 29 missing state, d 41 missing department, e 117 missing academic rank, f 11 missing years in field, g 42 missing knowledge acute, h Values add to more than 100% due to multiple answers, i 336 missing teach acute, j 194 missing knowledge PTLDS, k 439 missing teach PTLDS.
any of the groups think that PTLDS is either easy to treat or resolves on its own. The uncertainty ratings for these questions were particularly interesting to see. In general, uncertainty was high in the groups with no experience with PTLDS. Uncertainty regarding the severity and chronic nature of PTLDS was higher in those with no experience with either disease (34%) and those with experience with Lyme disease, but not PTLDS (30%) compared with those faculty members with experience with PTLDS (9%). A similar pattern was seen for the question of ease of treatment and resolution of disease (Table 3). Respondents were asked to give their opinion regarding the aetiology of PTLDS. The most frequently chosen answer was ‘an ongoing host inflammatory response triggered by previous Lyme disease but not due to persistent infection’ regardless of group. In contrast, a large minority, as high as 39% of respondents with a personal experience with PTLDS, selected ‘continued infection’ as a potential aetiology of PTLDS.
Discussion Post-treatment Lyme disease syndrome (PTLDS) is emerging as a well-recognized set of persistent symptoms that may follow the antibiotic treatment of Lyme disease and which may have a measurable immune pathophysiology.6,16e18 There is a wide divergence in opinion between physicians and the public regarding Lyme disease and its relationship to PTLDS.11e13,15 In this survey, the authors chose to focus on the non-treatment, public health aspects of the disease, which is the unique position that the public health community can contribute to. The uncertainty and unknowns regarding PTLDS are rarely discussed in the medical literature, leaving the public without leadership.19 Patients may be left feeling that there is no professional advice to follow, and often seek information from available public sources, such as the internet.20 SPH faculties are uniquely poised to conduct
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Table 2 e Responses to survey by Endemic State classification. Lyme endemic state n ¼ 638
Non-lyme endemic state n ¼ 630
Total n ¼ 1268
10.4% 42.1% 78.9%
2.3% 24.8% 57.6%
6.3% 33.5% 68.3%
1.3% 15.2% 42.5%
0.0% 9.9% 32.9%
0.6% 12.6% 37.6%
83.7% 8.5% 7.8%
29.3% 20.1% 50.6%
56.7% 14.4% 28.8%
96.1% 2.6% 1.3%
92.8% 4.4% 2.8%
94.5% 3.5% 2.1%
32.3% 54.2% 13.5%
11.7% 44.1% 44.2%
22.2% 49.4% 28.4%
48.3% 42.4% 9.3%
51.6% 38.9% 9.5%
49.9% 40.8% 9.4%
19.6% 62.7% 17.7%
21.7% 64.7% 13.6%
21.0% 63.6% 15.4%
90.0% 10.0%
86.0% 14.0%
87.9% 12.1%
1.7% 80.5% 17.8%
1.7% 82.9% 15.4%
1.8% 81.6% 16.5%
Personal experience Personal experience with acute LDa You yourself have ever been diagnosed?*** Family member/close friend diagnosed?*** Known anyone diagnosed?*** Personal experience with PTLDSa You yourself have ever been diagnosed?** Family member/close friend diagnosed?** Known anyone diagnosed?*** Public health aspects of Lyme disease Acute LD common in the state I liveb*** Agree Uncertain Disagree Acute LD common in certain regionsc* Agree Uncertain Disagree PTLDS common in the state I lived*** Agree Uncertain Disagree PTLDS common in certain regionse Agree Uncertain Disagree Public health implications Education by health departmentsf Lacking More needed Sufficient Incidence will spreadg Agree Disagree Funding atmosphere of LDh Overfunded Unsure Underfunded
Missing data: a Values add to more than 100% due to multiple answers, b 37 missing, c 61 missing, d 89 missing, e 90 missing, f 222 missing, g 268 missing, h 94 missing. Group difference significance levels: * ¼ p < 0.05, ** ¼ p < 0.01, *** ¼ p < 0.001.
research and promote general public education about Lyme disease and PTLDS, but there is little evidence that such contributions are being made. The current study aimed to identify knowledge and opinion data to better understand why this gap exists. It could be hypothesized that personal experience with Lyme disease and/or PTLDS may alter opinions on the frequency, pathophysiology, and severity of PTLDS. Many faculty members have known someone with Lyme disease. Those with a personal experience with PTLDS were less likely to express uncertainty regarding their opinions and were more likely to feel that PTLDS was a severe, chronic and difficult to treat illness. Personal experience with Lyme and PTLDS was more common than professional experience. This lack of professional experience may impair efforts to prevent, control, and manage Lyme disease as a public health concern. Faculties report that information about Lyme disease and
PTLDS is rarely included in the curriculum that they teach. Although 95% of faculty members agree that Lyme disease is a problem in endemic regions of the US, only 16% teach about it. This is surprising, given that Lyme disease is an example of a preventable vector-borne disease where education on personal protection and early recognition and diagnosis could decrease the long term health impact of the disease. The survey of SPH faculties shows that there may be a middle ground in the opinions of this population. Roughly 50% of SPH faculty members believe that PTLDS is common in endemic areas of the United States. Very few felt that PTLDS did not exist. The willingness of respondents to answer uncertain to questions about the natural history, severity and response to therapy suggests a healthy openness to changes in future opinions as more research in the field becomes available.
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Table 3 e Responses to survey by experience with Lyme disease (LD) or PTLDS. Personal Personal experience High selfLow selfNo personal with PTLDS ± reported knowledge of reported experience experience with LD, but not personal experience Lyme disease or knowledge of with LD or PTLDSb with LDc PTLDSd Lyme disease or PTLDSa (n ¼ 806) (n ¼ 286) (n ¼ 161) (n ¼ 320) PTLDSe (n ¼ 769) PTLDS can be a severe and chronic illness that lasts for many years. Agree Uncertain Disagree PTLDS is easy to treat. Agree Uncertain Disagree PTLDS is an acute illness that usually resolves on its own. Agree Uncertain Disagree
63.5% 33.6% 2.8%
65.5% 29.5% 5.0%
87.4% 8.8% 3.7%
73.6% 17.2% 9.2%
70.0% 28.8% 1.2%
4.9% 47.0% 48.2%
2.9% 42.0% 55.1%
2.5% 16.3% 81.3%
4.2% 22.0% 73.8%
4.1% 44.9% 51.0%
1.9% 41.5% 56.7%
2.2% 37.3% 60.5%
3.8% 16.4% 79.9%
4.5% 22.5% 73.0%
1.2% 38.7% 60.1%
35.9%
34.6%
44.1%
44.7%
38.1%
21.9%
22.4%
38.5%
26.6%
26.7%
6.7%
14.3%
9.9%
20.9%
5.1%
1.6%
4.5%
1.9%
5.6%
1.2%
13.2% 24.0%
11.2% 20.3%
6.8% 8.7%
5.6% 8.4%
14.3% 18.1%
What do you consider to be the most likely aetiology of PTLDS? An ongoing host inflammatory response A chronic incompletely treated ongoing infection Patient symptoms are incorrectly attributed History of mental illness causing symptoms of depression/anxiety Did not know Did not answer question
Missing data: a 45 missing for severe and chronic, 50 missing for easy to treat, 51 missing for resolves on own; b 8 missing for severe and chronic, 10 missing for easy to treat, 12 missing for resolves on own; c 2 missing for severe and chronic, 1 missing for easy to treat, 2 missing for resolves on own; d 6 missing for severe and chronic, 9 missing for easy to treat, 11 missing for resolves on own; e 12 missing for severe and chronic, 14 missing for easy to treat, 15 missing for resolves on own.
The high overall level of uncertainty expressed by the respondents regarding the natural history of PTLDS could be interpreted as reflecting their unfamiliarity with the literature vs an actual uncertainty in the literature. The high levels of uncertainty in the respondents with low levels of selfreported knowledge may reflect their unfamiliarity in the literature. In contrast, the low levels of uncertainty (23%) with high levels of self-reported knowledge may represent uncertainty in the literature itself.21 Uncertainty may arise because of controversy surrounding the need for chronic antibiotic therapy for some patients. Many in the survey did not know the cause of PTLDS or chose to skip this question (31%, overall), but the plurality (36%) felt that PTLDS is due to an ongoing inflammatory process, while 24% felt PTLDS is due to persistent infection. Public health officials may be less involved in controversies over antibiotic use and the focus of many authorities on antibiotic resistance and antimicrobial stewardship.22 SPH faculties may be more attuned than physicians to research mechanisms and animal models of disease, where evidence has emerged suggesting a role of
persistent inflammation and/or infection in PTLDS.23,24 Of note, few of the respondents felt that PTLDS was a psychosomatic illness, which has been widely discussed in the literature.25,26 Public health faculties had a range of opinions about the severity of PTLDS. The majority of faculty members agree that PTLDS can be severe and chronic and that PTLDS is a difficult disease to treat. These opinions conflict with the Infectious Disease Guidelines on tick-borne infections, which suggest that PTLDS is self-limited and of mild severity.6,27 The surveyed faculty may reflect a sample of health professionals who are removed from the controversy over PTLDS. Under-estimation of the importance of PTLDS and Lyme disease could account for the lack of teaching about it. The impression that Lyme disease is easily diagnosed and treated and that it rarely results in death or long term sequelae may contribute to lack of attention when compared to other infections such as less common infections like West Nile virus. The slower pace with which Lyme disease spreads may make it seem less threatening than viral infections such as
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influenza and SARS which can cause pandemics with high rates of mortality. The dramatic nature of rapidly spreading and potentially lethal infections such as influenza and SARS may overshadow more insidious and chronic illnesses such as PTLDS. Lyme disease was conspicuously absent in one article on the importance of biomedical research in new and reemerging infectious diseases.28
Public health implications The public health focus in the US towards Lyme disease has diminished since withdrawal of the Lyme vaccine in 2002. Lyme disease was in Healthy People 2010 with the target to reduce incidence in endemic states to 9.7 cases per 100,000 population.29 This goal was not met; in fact, the incidence between the baseline years (1992e1996) and the final year (2008) increased by 187.9% to a rate of 50.1 per 100,000 without any change in the diagnostic criteria or improvement in diagnostic tests to account for this increase. Despite this public health failure, Lyme disease was deleted from Healthy People 2020 because achievement of the goal, ‘was dependent on the availability of the vaccine for Lyme disease which was pulled off the market by the manufacturer’.29 This may have the unintended consequence of sending a message that Lyme disease is not important. However, Lyme disease impact can be reduced by prevention, early recognition, and proper treatment. Among the faculty surveyed, over 80% indicated that Lyme disease is likely to grow in importance in the coming years and that more public education is needed. It is unclear how state Departments of Health will be able to meet this challenge.30,31
Study limitations Limitations of this study are primarily related to the response rate of the survey (15%). Due to the low number of published studies of public health faculties using internet based surveys, it is unclear if this is an acceptable response rate or how it compares to other unpublished studies of this population. It is hypothesized that respondents may have been more likely to have an interest or personal experience with Lyme disease, meaning that their answers may not be representative of others in the field. Nevertheless, few of the respondents reported working in the field or having PTLDS themselves. There are many schools of public health located in the northeastern US, however schools in Lyme endemic states represent only 30% of all schools surveyed and 40% of all emails sent were to schools in endemic states. An equal number of respondents from both endemic states and non-endemic states show that a greater percentage of respondents from endemic state schools responded to the survey. However, this would cause us to hypothesize that there would be an overestimation of understanding about the diseases in question, an overestimate of teaching rates, and more personal and professional experience. Despite the higher response rates from those in the endemic states, the data still show much uncertainty.
Conclusions More attention is needed to address the gaps in knowledge of Lyme disease and PTLDS that have been identified. Faculty members who took the survey agree that Lyme disease is common in certain areas of the country, that PTLDS can be severe, chronic and hard to treat, and that the geographical area of both will spread in the coming years. The prevalence of PTLDS may be in the tens of thousands of cases each year using conservative assumptions of a 5e10% risk of PTLDS and an annual incidence of approximately 300,000 new cases of Lyme disease each year.32 Engagement of public health educators and researchers with the public is urgently needed, in order to control the disease and reduce the polarization of patients from physicians.33 As the prevalence of PTLDS grows over time in various regions of the US, it will be of greater importance for public health faculties to understand and appreciate this disease. Public health faculties can play a critical role in the discussion of Lyme pathophysiology and symptoms, even if therapy remains controversial. It is only by having open discussions and debate that research will progress and new discoveries will be made. Despite the limitations seen in this survey, it is believed that the data presented show an opportunity for improvement in education about the disease that presents an emerging global health problem. Public health researchers and educators have a unique opportunity to address the challenge of Lyme disease and PTLDS, a global health problem in their own backyard.
Author statements Ethical approval Ethical approval was obtained from The Johns Hopkins School of Medicine Institutional Review Board #NA_00071911.
Funding Funding for this study was generously provided by the Lyme Disease Research Foundation, Inc.
Competing interests None declared.
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