Lyme Disease:Our Lurking Predator

byGrover Davenport

10 December 2015

Davenport 1

Grover Davenport3 December 2015Lyme Disease: Our Lurking Predator

Heidi Buono and her husband, Michael, live in East Greenbush, NY, near Albany, with their three children. Its about a stones throw from where I live. The family spent many wonderful times hiking throughout their bucolic woods behind their house and in the region. Heidi, the mom, began to experience many unexplained health problems, migraines, aches, pains, thyroid issues. She found ticks on her children frequently. The pediatrician told her not to worry about it. When her youngest daughter was two, Heidi removed an embedded tick. Within a week, her daughter was running a fever. The pediatrician said it was nothing and did not treat her child. Four years ago, Heidis health took a turn for the worse. She slept most days, barely able to leave her bed. She clung to the walls of her home just to get around. The internist tested Heidi for everything, but results were negative. She was declared healthy. But, of course, Heidi knew something was wrong. She couldnt afford any additional testing, and she could not visit specialists because they would not accept her insurance. Unable to work, she had to abandon her plans for returning to work to help pay for her childrens college education. Heidis oldest son was an honor student at Columbia High School, and after the first week of his sophomore year, he became anxious, depressed, achy, and fatigued. He could not attend school. Like his mom, his blood work came back normal. He was put on anti-depressants and anti-anxiety medicines. Within 2 days, he was having suicidal thoughts, and the doctors wanted to place him in a

Davenport 2psychiatric hospital. Finally, Heidi pleaded to have her son retested for tick-borne diseases. The test came back positive for Lyme and several other tick-borne diseases. Heidis middle son has been sick since birth, has eye problems, and was diagnosed with learning disabilities. At 5 years old, he asked his mother, Why cant I remember things? Heidi believes he may have contracted tick-borne diseases in utero. This family is just like any other family throughout New York State and our Nation who are afflicted by tick-borne diseases and do not have answers. This heart-breaking true story was told by United States Senator Kirsten Gillibrand at a congressional hearing in 2012, in which the Senate Committee on Health, Education, Labor, and Pensions addressed the epidemic nature of Lyme Disease (3-4). The author's situation is much the same, over 23 years, being diagnosed as having hypoglycemia, chronic fatigue syndrome, depression, anxiety, adrenal insufficiency, ADHD, bipolar disorder, Hypochondriasis, sublaxations, low thyroid, irritable bowel syndrome, fibromyalgia, and myoclonus, and being prescribed over fifty different medications, most of which did not help. Since the early 1980's, a growing awareness of Lyme Disease, its dangers, and potential for destroying peoples lives, and our vulnerability has been exposed, but we are just beginning.Lyme Disease is an inflammatory sickness that affects all the body's systems either directly or indirectly, causing mononucleosis symptoms, flu-like symptoms, severe fatigue, weakness, low-grade fever, sore muscles, sore throat, painful joints, mental illness (bipolar disorder, anxiety, depression), insomnia, memory and concentration difficulties, and many other health problems. When left untreated, it can cause neurologic, cardiac, and articular complications. While most cases in the United States occur in the New England states, Lyme Disease has been reported all over the country in 48 states and the District of Columbia. The ticks that carry the bacteria are much smaller and difficult to see than the common brown dog ticks that we often see. As adults, they are not much larger than a pinhead, which makes them Davenport 3difficult to detect and therefore more dangerous. Named after the city of Old Lyme Connecticut where it was first discovered, Lyme Disease has become a controversial topic. While diseases such as malaria are easy to diagnose and cure, Lyme Disease is difficult to diagnose and often difficult to cure. Some people suffer its torment for decades before it is diagnosed and treated. Making things worse, and heart-breaking, is that from the time they contract the disease, they often go from doctor to doctor for years, only to hear that nothing is wrong or The blood-work is okay. So don't worry about anything, or See a psychiatrist. Victims of the disease face not only the foul scrutiny of medical experts, but also the persecution of friends, family members coworkers, and employers. They may often hear things like You just need a vacation, You don't look sick, It's all in your head, Don't call in! Crawl in! or the cruel inconsideration of someone who says I haven't felt good lately either. Maybe I have the same thing you have.Lyme Disease can easily be divided into two categories: acute and chronic. It is considered acute during the first few weeks of when the symptoms begin, when it is easily diagnosed and treated, usually with 100 percent success. Most of the time, when it is described as a gruesome illness, the reference is to the chronic version. The tell-tale sign of Lyme Disease is an erythema migrans rash around the bite, which is also known as a bulls-eye rash, because it is a red ring with a red dot in the middle, resembling a bulls-eye target. Lyme Disease is considered to be acute during the first few weeks of contraction, from when the bulls-eye rash appears till the bodily symptoms occur, when it is easily conquered with antibiotics. If untreated, after a few weeks, it becomes chronic. Chronic Lyme Disease refers to the illness when symptoms occur for years or decades after contraction. Sometimes chronic Lyme Disease appears after the acute version is treated and has symptoms that come and go. Most often, however, chronic Lyme Disease appears after having the acute Davenport 4version for weeks without treatment. Since it is often difficult to diagnose, Lyme Disease often goes untreated for years, creating chronic disease with the same severity as acute, and often does not respond to treatment. Lyme Disease in this paper refers to chronic unless otherwise noted.Adding to the problems created by Lyme Disease on the central nervous system, there is often an injurious effect on the hypothalamic-pituitary-adrenal (HPA) axis, a complex set of direct influences and feedback interactions among the three endocrine glands. Diverse amounts of pituitary insufficiency are often detected, which when corrected has resulted in the resolution of low energy, libido, and stamina, and resolution of persistent low blood-pressure. Sadly, not all physicians notice pituitary insufficiency, because of the difficulty in making the laboratory diagnosis. Nevertheless, the potential benefits of diagnosing and treating HPA axis injury justify the labor needed for full assessment. (Burrascano 4)Added to the problems of the disease are other bacteria, often transmitted by the tick that carried the Lyme Disease bacteria. Some of the more common are Anaplasmosis, Ehrlichiosis, Bartonella, and Mycoplasmas, which cause symptoms similar Lyme Disease. And, as such bacteria wear down the immune system, chronic viral infections such as HHV-6, CMV, and EBV may attack the chronic patient (5).The existence of chronic Lyme Disease, an often gruesome illness, faces the skepticism of many individuals and organizations in the medical field. Therefore, only a few Lymies are considered qualified for disability income, when they are too sick to work even part-time. The author, a victim of 23 years, after seeing over 40 doctors, finally received disability benefits due to a diagnosis of bipolar-disorder, which is only one of the many problems caused by Lyme Disease. Until then, he was often criticized as being lazy and irresponsible, which brought embarrassment, feelings of guilt, and disappointment, due to not marrying, not working, depending on others, poor work performance, and filing bankruptcy due to medical bills and low Davenport 5or no income.Dr. Robert C. Bransfield is a highly respected psychiatrist in the Lyme community, who is considered as being in the forefront of understanding and treating patients with the neuropsychiatric symptoms of Lyme Disease. While attention deficit disorder, panic disorder, and obsessive-compulsive disorder are all associated with chronic Lyme disease, Bransfield states that in his database, depression is the most common psychiatric syndrome associated with late stage Lyme disease. Although depression is common in any chronic illness, it is more prevalent with Lyme patients than in most other chronic illnesses. There appears to be multiple causes, including a number of psychological and physical factors (Bransfield par. 2). Bransfield has determined that most Lyme Disease victims are psychologically overcome by a plethora of symptoms. While most illnesses only affect one part of the body, or only one organ system, Lyme Disease is a multi-system disease. Diseases such as Lyme can penetrate into multiple aspects of a person's life, since there is no escape from its torment (3). Often, severe insomnia does not allow someone to go to bed looking forward to tomorrow's fresh start, because all days run together. In many cases, this creates a vicious cycle of chronic stress, demoralization, disappointment, and grief (3). Depression is not only caused by psychological elements; it is often caused by dysfunction of endocrine glands such as the pituitary, hypothalamus, adrenals, and thyroid, causing mood controlling hormones such as serotonin, norepinephrine, and dopamine to be off balance (6). Such physiological factors make it impossible for depression to be relieved simply by counseling, or cognitive behavioral therapy. In such situations, psychiatric drugs such as selective serotonin re-uptake inhibitors (e.g. Prozac) must be applied to alleviate depression. Bransfield says that his patients' records indicate that suicidal tendencies occur in approximately 33% of Lyme patients with encephalopathy, a brain disorder in most people with Davenport 6Lyme. This is comparatively lower in individuals with other chronic illnesses, such as cancer, cardiac disease, and diabetes (7). Chronic suicide risk is particularly associated with anhedonia, an inability to enjoy life's pleasure. Sick people can tolerate pain without becoming suicidal, but an inability to appreciate the pleasures of life strongly correlates with prolonged suicidal tendency (8). A vector borne illness, which means it is spread by animals or parasites from one plant or animal to another (like malaria), Lyme Disease is the most common vector-borne illness in the United States. It is carried by the deer tick (Ixodes scapularis), which is also known as the black-legged tick. According to the Occupational Safety and Health Administration (OSHA): Lyme Disease currently accounts for more than 95% of all vector-borne diseases reported in the United States. There have been more than 128,000 cases reported since 1982 [as of 2000]. In 1998, the estimated incidence of Lyme disease was about 6 per 100,000 people in the U.S. However, there may be considerable under reporting. In addition, incidence rates vary considerably from state to state and even within states and counties. In a few highly endemic counties, incidence rates exceed 100 per 100,000 people. State and local health departments can be consulted for more information regarding risk in particular areas (2).According to Amiram Katz, M.D., Assistant Clinical Professor of Neurology of Yale University: This chronic condition will vary in severity, from a very debilitating affliction to one with occasional aches and pains. The very sick individuals cannot be gainfully employed, are usually bedridden and in addition to their physical ailments, may suffer from a severe cognitive deficit, with difficulties of memory and concentration along with psychiatric manifestations (depression, anxiety, OCD and even psychosis) which are part of the neurologic complication of this condition (brain disease rather than a psychiatric condition). The percentage of chronic conversion in the undiagnosed (and untreated) cases is probably much higher. The chronic Davenport 7condition can be managed (but not cured) in varying degrees of success. (U.S. Congress. Senate. Committee on Health, Education, Labor, and Pensions 25). Many of the undiagnosed, and therefore untreated cases will go on to develop a chronic illness, which is usually no longer responding to short or long courses of antibiotics, since it becomes an ill-defined autoimmune disease (26).A small percentage of patients with well-documented Lyme disease may develop disabling musculoskeletal pain, neurocognitive symptoms, or fatigue along with or soon after symptoms of the infection. This postLyme disease syndrome, or chronic Lyme disease (the terms are used interchangeably), which is similar to chronic fatigue syndrome or fibromyalgia, persists for months or years after standard antibiotic treatment of the infection. In a study of such patients who then received intravenous ceftriaxone for 30 days followed by oral doxycycline for 60 days, or intravenous or oral placebo preparations for the same duration, no significant differences were found between the groups in the percentage of patients who said that their symptoms had improved, gotten worse, or stayed the same. Therefore, it is hypothesized that B. burgdorferi [the bacteria which causes Lyme Disease], may trigger immunologic or neurohormonal processes in the brain that cause persistent pain, neurocognitive, or fatigue symptoms, despite spirochetal killing with antibiotic therapy (Steere, Coburn, and Glickstein. 1093-1101). About 60% of untreated Lyme Disease patients develop the chronic version with chronic joint pain and arthritis, and perhaps neuropathy, chronic encephalopathy manifesting as memory deficits, concentration problems and fatigue, which are common in both early and late stages of untreated illness (Aucott, Rebman, Crowder, Kortte 76). It has recently increased across the nation, causing devastating illness from the west coast to the east coast, where it was first discovered. It is the fastest growing infectious disease in America, causing mild to severe illness. Davenport 8The DNA of B. burgdorferi has been identified in museum specimens of ticks and mice from Long Island, New York dating from the late 19th and early 20th centuries, and has probably been in North America for millennia. However, the earliest known American cases occurred in Cape Cod in the 1960's. During the last 55 years, the infection has continued to spread in the northeastern United States. It has caused outbreaks in some coastal areas, and now affects suburban areas near Baltimore, Boston, New York, and Philadelphia.. Connecticut is the state with the most Lyme Disease infections reported, which in 2000, had 111 per 100,000 residents (Steere, Coburn, and Glickstein 10931101).Although approximately 40,000 cases of Lyme Disease are reported each year, as of 2012, the actual number is probably around 400,000 nationwide because of under-reporting, which is caused by under-detection and lack of adequate diagnosis, leading to divisions, schisms and disagreement within the scientific and medical community (U.S. Congress. Senate. Committee on Health, Education, Labor, and Pensions 1). The CDC reported 30,000 cases of Lyme disease in 2009, but acknowledges that actual numbers may be over, as Senator Blumenthal said, ten times as high, due to under-reporting (2). Those who live in suburban residential developments close to forested areas, and those with rural homes in woodland environments and grassy fields, where there are abundant deer and mice, have the highest risk for Lyme disease.Like HIV, when it was a new illness in the mid-eighties, Lyme Disease has managed to be transmitted from one person to another through Lyme positive blood donors. The American Red Cross has now confirmed at least 12 deaths in the United States from blood containing B. burgdorferi. When considering under-reporting, there have probably been 24 or more such cases. Therefore, we are not safe, until the blood of our donors is thoroughly tested to prevent such contractions (2-3). The frightening thing is that many people with the disease get negative blood-work results, which means that even if the blood supply is tested, many people are still Davenport 9vulnerable.According to OSHA, most B. burgdorferi infections occur in non-occupational situations when people are performing residential activities such as property maintenance, recreation, or leisure activity. Non-occupational exposures also affect people when they are away from home when hiking, fishing, hunting, or camping, which can make it difficult to understand which areas are endemic. At the same time, occupations that require outdoor activity in areas where the disease is endemic can place an individual at increased risk of exposure to an infected tick and therefore to Lyme disease (McCully 3). According to OSHA, The prevalence of Lyme Disease from occupational exposure has not been precisely defined (McCully 5-6). Common sense, however, says that any labor done in grassy fields, woods, or thickets greatly increases risk of infection. Landscaping, forestry, surveying, and farming are just a few examples. People, whose occupation puts them in various terrains and locations, might have difficulty determining exactly where they acquired the tick that infected them. In fact, the majority of infected persons do not recall being bitten by a tick (2). OSHA believes that an employers own field staff and consultation personnel should be aware of the potential for Lyme Disease transmission to outdoor workers in areas endemic for B. burgdorferi infected ticks, so that employers and employees can take proper action for prevention (6). It is the author's experience that sometimes a small area of land (maybe an acre) can have perhaps 10 times as many ticks as its 50 surrounding acres. Although any ticks seen in such an area were not deer ticks or black-legged ticks, this still seems to indicate that there can be similar areas housing Lyme-carrying ticks.According to Amiram Katz M.D., With the 1 to 10 ratio of the reported versus diagnosed, we have another 1 to 10 ratio which is quite acceptable by the mainstream scientific community. This is the number of patients that, in spite of early diagnosis and adequate treatment, will develop chronic illness. So, best case scenario, if you have a bulls-eye rash, and Davenport 10you get antibiotics in a timely manner, still 1 out of 10 will go on to develop a chronic illness, which we believe is autoimmune in nature (U.S. Congress. Senate. Committee on Health, Education, Labor, and Pensions 25). Katz goes on to say, More effort should be made to develop better assays, of course, to diagnose the tick disease when it is acute, but also to diagnose the chronic illness and to give it a better term than fibromyalgia, chronic fatigue, or thats best case scenarioor psychiatric for this when they are not finding answers (25).According to the CDC (Centers for Disease Control), when the national surveillance of Lyme Disease cases began in 1982, 497 cases were reported, compared to 17,730 cases reported in 2000. Cases have been reported in 48 of the 50 states and the District of Columbia, and Twenty-five percent of states include at least one area with moderate to high risk of tick infection with the B. burgdorferi bacterium. The northeastern U.S., from Massachusetts to Maryland; the northcentral region including Wisconsin and Minnesota; and an area in northern California in the pacific-coastal region contain the highest risks. Not all deer ticks, or black-legged ticks carry B. burgdorferi, but in these areas, more ticks carry it, which greatly increases the risk. The CDC also claims that the remainder of the states have no or few infected ticks and have low, minimal, or no risk for Lyme disease. (McCully 3). The Lyme disease case definition currently adopted by the CDC considers endemic those counties with at least two confirmed, locally acquired cases or in which established populations of a known tick vector are infected with B. burgdorferi (CDC par. 3). The author's opinion is that many areas considered as low-risk areas, have greater risk than supposed, due to three acquaintances who were confirmed infected in Greene County, Tennessee. Evidently, these cases were not reported.In order to assess a person's risk of exposure to B. burgorferi on the job, during recreation, or in outdoor home maintenance, several factors must be considered. One's daily, seasonal, and yearly schedule of activities and their duration determine the risk more than any other factor. Davenport 11While adult ticks can carry and can transmit the bacteria to humans, most cases occur via bites from nymphs, which feed mostly in the late spring and early summer, varying slightly on climate. Not only do the time of exposure and the percentage of ticks infected determine the risk involved; the actual number of ticks in general also affect the situation. State and local health departments can give the best advice concerning local areas (McCully 3-4).The best way to prevent Lyme Disease is to be aware and avoid the ticks that carry it. The CDC recommends avoiding grassy, brushy, and wooded areas in the spring and early summer, the removal of as much grass, brush, and leaves from these area as possible, and by applying EPA approved tick-toxic chemicals. Since it is impossible to avoid all presence of ticks, personal protection can provide additional safety. Wearing light-colored clothing, long-sleeved shirts, and boots or closed shoes with pants tucked under one's socks gives them a longer and more visible path to travel before they can reach your skin (McCully 4), therefore making them easily discarded. Since tucking one's pants into his or her socks looks unattractive and might damage the socks' elastic, it is the idea of the author that white leg-wraps covering the calf and ankle be promoted. White or other bright colors are the best colors because they allow ticks on the wraps to be easily seen. Such leg-wraps are used as part of the uniform worn for training in the martial art of ninjutsu, and are readily available at most martial arts supply stores. One should make sure that he or she buys those that are heavy duty (for actual martial arts training) and not those used in ninja costumes for Halloween.Perhaps the most lacking and discouraging characteristic of Lyme Disease is the often seen inability to diagnose it. Epidemic diseases are not near as frightening when a visit to the doctor's office reveals the reason for feeling bad and provides its proper treatment. Unfortunately B. burgorferi is often undetectable with blood-work, and at the present, in such cases, erythema migrans or bulls-eye rash, which disappears a few weeks after infection, is the only symptom Davenport 12that will satisfy most doctors in giving a positive diagnosis for acute or chronic infection. Lyme Disease and its co-infections mimic several other diseases which include chronic fatigue syndrome, fibromyalgia, rheumatoid arthritis, lupus, and multiple sclerosis, and can mimic any mental disorder in the Diagnostic Statistical Manual (DSM), the bible of mental health diagnoses (Horowitz 57). Doctors familiar and aware of chronic Lyme Disease and its signs and symptoms can adequately diagnose it without positive blood work, often through a clinical diagnosis (a diagnosis based solely on the patient's symptoms). There are several blood tests that can be used for diagnosis, or to confirm a diagnosis. The two most common ones are: enzyme-linked immunosorbent assay (ELISA), and the western blot test. Lesser common, but more dependable, are the polymerase chain reaction (PCR), and culture test. A western blot test implements electricity to separate proteins called antigens into separate bands, producing a read-out resembling a bar code. The lab then compares the pattern produced with a template pattern representing known cases of Lyme disease. If the blot's bands are in the right places, and have the right number of bands, the test is positive. An ELISA test is an analytic biochemistry study that uses a solid phase enzyme immunoassay to detect the presence of a substance, usually an antigen (a chemical that causes antibody production), in a body-fluid sample. PCR testing uses chemicals to multiply a key portion of certain DNA from any Lyme bacteria so that it can be detected. Many Lyme literate physicians consider culture testing to be the gold standard test for identifying B. burgdorferi, because it actually identifies any present Lyme Disease bacteria, rather than checking for the body's reaction to the bacteria. In this procedure, the lab takes a sample of blood or other fluid from the patient and attempts to proliferate Lyme spirochetes in a culture medium. According to Dr. Joseph J. Burrascano Jr., board member of International Lyme and Associated Disease Society (ILADS), the foremost experts on Lyme Disease, the best serologic Davenport 13test for Lyme is the western blot test. Although insensitive, antigen detection tests are very specific and are especially valuable in evaluating the seronegative patient and those who are ill or relapsing after treatment. Often, these antigen detection tests are the only positive markers of Lyme infection, as seronegativity has been reported to occur in as many as 30 to 50% of cases. However, active Lyme B. burgorferi can be present even if all of these tests are negative. Therefore, clinical diagnosis is also required (Burrascano 5). The presence of antibodies does not mean that the bacteria are present, but that there has been exposure in the past, causing the body to stay armed to defend itself against its former attacker. Since serology tests are often inconsistent, physicians should use only well-known reference laboratories. Many physicians recommend two-tiered testing by first using the ELISA as a screening tool, and if positive, then using the western blot test as a confirmation. According to Burrascano, however, this method makes no sense, because the ELISA is not sensitive enough to serve as an adequate screen, and there are many patients with Lyme who test negative by ELISA yet have fully diagnostic western blots (Burrascano 7).Although blood-work often shows a false negative, it can be helpful as a backup in confirming a positive clinical diagnosis, but nothing more. The CDC has determined that the best test for Lyme Disease is seeking the presence of B. burgdorferi in the blood, skin, a joint, or cerebral spinal fluid, which must be performed by a qualified laboratory, which makes it impossible for more than a few suspected Lyme cases to be confirmed (Horowitz 60). Guidelines for a clinical diagnosis are given by The International Lyme and Associated Diseases Society (ILADS), which is one of the few organizations that is up to date on Lyme research, and provides training for physicians, designed to enhance expertise for those clinicians who already have an established clinical practice. However, no type of certification is given, because chronic Lyme Disease is not officially recognized by the American Medical Association (Shor, Davenport 14http://www.ilads.org/education/physician-training.php). When applying treatment, a doctor must be aware that B. burgdorferi penetrates the central nervous system in just twelve hours after contraction. Therefore, full-strength antibiotics should be administered immediately, and the longer it has been since contraction, the longer the duration of treatment should be. Since chronic Lyme Disease is in both tissue and fluids, two types of antibiotics should be used, one for fluids and one for tissue, such as azithromycin and a penicillin (Burrascano 12). It has also been reported that B. Burgdorferi produce neurotoxins that can be stored in fat tissue, of which Burrascano says These compounds reportedly can cause many of the symptoms of encephalopathy, cause an ongoing inflammatory reaction manifested as some of the virus-like symptoms common in late Lyme, and also potentially interfere with hormone action by blocking hormone receptors, but as for now, there is no way to detect such neurotoxins, but if present, they can be bound in the intestine and then excreted by the use of two medications: cholestyramine resin and Welchol pills (Burrascano 13). Since the results of Lyme Disease treatment can take months or even years to appear, most doctors also treat the symptoms that are caused by it. Over-the-counter pain medications are recommended to stop aches and pains, digestive problems are treated, achy joints and muscles are treated, and psychiatric problems are treated by a psychiatrist. Unfortunately, Lyme Disease remains a lurking predator waiting to sink its teeth into unsuspecting victims, not only when a tick is licking his lips, about to bite them, but when the infection becomes chronic and undiagnosed, when medical professionals cannot find anything wrong. Although we are gradually learning more about it, we still know very little, and most physicians are still in the dark. Even the best diagnostic methods available are wanting, and treatment is far from adequate. The biggest obstacle, however, is not testing or treatment; it is unawareness. Although it was said to be recognized in the 1970's, the true nature of Lyme Davenport 15Disease remains a mystery. Many doctors still consider chronic Lyme Disease and its research to be a pseudoscience. Hopefully, as awareness is gradually progressing and knowledge is increasing, someday perhaps in a few decades, the lurking predator, will become simply a predator, a predator that is easy to defeat. Until then however, many will continue to suffer the vicious appetite of Lyme Disease.

Davenport 16Works CitedAucott, John N., Rebman, Alison W., Crowder, Lauren A., Kortte, Kathleen B. Post-Treatment Lyme Disease Syndrome Symptomatology and the Impact on Life Functioning: Is There Something Here? Quality of Life Research 22.1 (2013) 75-84. pdf.

Bean, Constance A., Fein, Lesley Ann. Beating Lyme : Understanding and Treating This Complex and Often Misdiagnosed Disease. New York: Amacom, 2008. Print.

Bransfield, Robert C. Lyme, Depression, and Suicide. mentalhealthandillness.com. Web. 1998.

Burrascano, Joseph. Advanced Topics in Lyme Disease: Diagnostic Hints and Treatment Guidelines for Lyme and Other Tick Borne Illnesses. International Lyme and Associated Diseases Society. Oct. 2008.

Center for Disease Control and Prevention, 2015. Reported cases of Lyme diseaseUnited States, 2015. Available at: http://www.cdc.gov/lyme/faq/index.html. Accessed December 1, 2015.

Horowitz, Richard. Why Can't I Get Better? Solving the Mystery of Lyme and Chronic Disease. NewYork: St. Martin's Press, 2013. Print.

McCully, Ruth. OSHA. Potential for Occupational Exposure to Lyme Disease. Safety and Health Information Bulletin

Davenport 17National Capital Lyme Disease Association. N.p. 2015. Web. 13 Oct. 2015

Shor, Samuel M., pres. International Lyme and Associated Diseases, http://www.ilads.org/education/physician-training.php, 4 Dec 2015

Steere, Allen C., Coburn, Jenifer, Glickstein, Lisa The emergence of Lyme disease. The Journal of Clinical Investigation 113.8 (2004): 10931101. Print.

United States. Congress. Senate. Committee on Health, Education, Labor, and Pensions. Lyme Disease a Comprehensive Approach to an Evolving Threat: Field Hearing of the Committee on Health, Education, Labor, and Pensions, United States Senate, One Hundred Twelfth Congress, Second Session on Examining Lyme Disease, Focusing on a Comprehensive Approach to an Evolving Threat August 30, 2012 (Stamford, CT). Washington : U.S. Government Printing Office