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Martha’s Vineyard Boards of Health Tick-Borne Illness

InitiativeMDPH Internship 2012Hannah Emily Nichols

Martha’s Vineyard

Martha’s Vineyard is an island off the coast of MA Year-round population: 20,000 Summer population: 100,000

Tick-borne illnesses are endemic on the island High deer population Mild climate Vast undeveloped land

Tick-Borne Illness Initiative

Mission: To reduce the incidence and medical consequences of tick-borne illnesses through public education and modification of disease transmission vectors Island-Wide Board of Selectman Resolution Public Education

Resident population, tourist population, website and videos Medical Education

Standard of care: Prophylatic vs. symptomatic treatment Environmental

Outside workers; landscape of the island, deer populationwww.MVBOH.org

MDPH Internship

Assess under-reporting of Lyme disease on Martha’s Vineyard

2010 25 confirmed cases of Lyme disease reported to

CDC Island pharmacies filled enough Doxycycline

prescriptions to treat >1200 patients for Lyme disease

Confirmed Cases

Patient must have “Bulls Eye” or Erythema migrans rash (<40% of Island cases have the EM rash)

OR have positive lab testing (many cases are diagnosed and treated based on symptoms, without lab testing)

Positive Results are often reported to public health department of patient’s primary residence

Physician offices lack time and financial resources to do the paperwork

Incidence Data for TBI: A New Approach

Goal: Retrospectively collect incidence data of Tick-borne illnesses (TBI)

Methods: Total number of Doxycycline prescriptions and total numbers of doses (tablets and pills) were collected from island pharmacies for years 2008-2011. Number of prescriptions and doses were unavailable for one

pharmacy; wholesaler information was used to estimate numbers*

TBI Incidence FindingsMethodology 2008 2009 2010 2011CDC Confirmed Cases

47 28 25 N/A

Doxycycline Doses

50914 50521 49090 57825

Doxycycline Pills Per Rx

30.8 30.5 31.2 27.5

Doxycycline Prescriptions

1654 1647 1582 2089

90% Probability of Prescriptions

1489 1482 1424 1880

Payor Database

Using Doxycycline Rxs as a surrogate for Lyme Disease

Physicians and pharmacists interviewed on the island estimated that >90% of Doxycycline prescriptions were used for TBIs

Doxycycline Rxs by month for all 5 Island zipcodes, available 2 weeks after the end of the month Rx for <14 days or >14 days Primary Residence: Martha’s Vineyard, MA, or out-of-state

Incidence Data for TBI:An Old Approach

Methods: A Linelist/Spreadsheet approach to Lyme disease was implemented in three private physician offices. Lyme disease patient information was collected from medical records from the Martha’s Vineyard Hospital Emergency Department.

Linelist/Spreadsheet

Spreadsheet included the following information: Patient Name, Permanent Address, DOB, Gender,

MV Town Prophylaxis for Tick Bite Only (Y/N) Date of Symptom Onset, EM Rash (Y/N), Arthritis

(Y/N), Bells Palsy (Y/N), Radiculoneuropathy (Y/N), Lymphocytic Meningitis (Y/N), 2nd or 3rd Degree Heart Block (Y/N), Other Lyme Symptoms, Labs Sent (Y/N)

Linelist/Spreadsheet Conclusions

The approach identified approximately 100 Lyme disease patients for the month of July Out-of-state residents were identified

Time constraints and volume of patients were major barriers for physician offices

MV Hospital Findings

136 patients were tested for Lyme disease in the Emergency Department in July 2012

60 of the patients tested were treated with Doxycycline or Amoxicillin and identified as probable Lyme patients to the MDPH

Lab Results: 21/60 tested positive for Lyme disease Symptoms: 11/60 EM Rash, 2/60 Bell’s Palsy

Other symptoms: unexplained weakness, joint pain, fatigue, malaise, fever, tick bite

Hospital Findings Cont’d

Residence: 27/60 permanent Martha’s Vineyard residents 18/60 off-island MA residents 45/60 total MA residents 15/60 out-of-state residents

Other Diagnoses: 11/60 patients were treated with either 21 or 28 days of Doxycycline and were not diagnosed with Lyme but the following: Lyme Disease Risk, Unexplained Weakness, Febrile Illness,

Myalgia, Rash

Conclusions

Vast discrepancy between reported cases of Lyme and suspected cases of Lyme disease are evident

Linelist/Spreadsheet approach increased the number of cases reported and included out-of-state patients

Payor Database/Prescription approach is a new way to capture estimated real-time incidence data

Moving Forward

Widening the definition of “confirmed” Lyme disease case; or promote reporting of “suspected” cases

Apply payor database approach to other diseases in the future; can also capture other trends from the information: Prophylatic vs. therapeutic treatment