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Nordic Consensus on the Management of Tick-borne Diseases
Infektionsveckan & Mikrobiologiskt vårmöte Jønkøping mai 2019
On behalf of the Nordic Consensus working group on the Management of Tick-borne Diseases
Randi Eikeland, MD, PhD, neurologist and Medical director of the Norwegian National Advisory Unit on Tick-borne Diseases, Sørlandet Hospital
Anna J Henningsson, MD, PhD, Medical director, Clinical Microbiology and the National Reference Laboratory for Borreliosis, Region Jönköping County and Assoc. Prof, Department of Clinical and Experimental Medicine, Linköping University
Sweden Anna J HenningssonPia Forsberg, professor in meritus, MD infect.dis., Linköping UniversityBjörn Olsen, professor, MD infect. dis., Uppsala UniversityKatharina Ornstein, PhD, MD infect.dis., Region SkåneBarbro Hedin Skogman, PhD, MD pediatric, Landstinget i DalarnaMats Reimer, MD pediatric, Mölnlycke vårdcentral, Västra GötalandThomas Åkerlund, Chief of Department, Folkhälsomyndigheten Christian Franke, Medical advisor, SocialstyrelsenDenmark Sigurdur Skarphedinsson, PhD, MD infect.dis., Odense Univ. HospitalAnne-Mette Lebech PhD,DMSc, MD infect. Dis., RigshospitaletRam Dessau, PhD, MD, microb., Slagelse Hospital, Ålborg UniversityKaren Angeliki Krogfeld, professor, Statens Serum InstituttThøger Gorm Jensen, PhD, MD, clin. micr., Odense Univ. HospitalFinland Marika Nordberg PhD, MD infec.dis., Åland borrelia groupJukka Hytönen PhD, MD, Turku University Mari Kanerva MD infect. dis. Helsinki UniversityDag Nyman professor, MD, Åland borrela group Olli Vapalahti professor Helsinki UniversityJarmo Oksi, Professor, MD inf.dis., Turku Univ. hospitalNorway Ingeborg Aaberge PhD, MD immunology mikrobiol., Norwegian Institute of Public HealthAudun Aase PhD MD microb., Norwegian Institute of Public Health Harald Reiso PhD, GP, senior advisor Norwegian National Advisory Unit on Tick-borne Diseases Sølvi Noraas MD Microbiol. Leader of Norwegian reference lab. on borrelia, Sørlandet HospitalRandi Eikeland PhD, MD neurology, Medical director Norwegian National Advisory Unit on Tick-borne Diseases Svein H Henrichsen MD GP, senior advisor the Norwegian Directorate of Health Tone Synnestvedt Norsk Lyme borreliose foreningYvonne Kerlefsen managing director Medical director Norwegian Advisory Unit on Tick-borne Diseases Knut Erik Eliassen PhD, GP, Vossavangen legesenterInger Johanne Wedding Hansen MD rheumatology, Sørlandet hospital Kjersti Widding medical doctor in physical medicine and rehabilitation, Sørlandet rehabiliteringDag Tveitnes PhD, MD Pediatric Stavanger University Hospital Pascal Brügger-Synnes MD infect. Dis. ÅlesundSvein Erik Valle Prinz Physioterap. Lister Oddgeir Tjomsland advisor Norwegian Labour and Welfare Administration
BeLivTicks
Why do we need a Nordic consensus group?
• Tick-borne diseases (TBD) emerging in the Nordic countries/Europe• Tests improving, but still need for better tests• New pathogens in ticks• Disagreement on long-term complaints • Lack of knowledge (public, health workers, policy makers)• Patients feeling abandoned/lack of trust in the healthcare system• Alternative non-scientific pathways flourish• Huge costs for the patients and the society, including use of antibiotic
treatment in humans and animals
October 2015: Nordic prepatory meeting. A Nordic Consensus on the diagnosis & treatment of
Tick-borne diseases Kristiansand, Norway
Agreement 2016
There is no need for new Nordic guidelines on the treatment of acute borreliosis and TBE Knowledge and diagnostics of new emerging TBD such as anaplasmosis, rickettsiosis, bartonellosis, babesiosis, neoehrlichiosis is lackingRecommendations of assessment and follow-up of patients with chronic complaints after TBD, or suspected TBD – without laboratory confirmation -are lacking
The Norwegian Directorate of Health Mandate: a Nordic consensus for medical assessment
and follow-up of patients with suspected TBDClarification and recommendations for care of persons where TBD are suspected, but where no active TBD are found Assessment, treatment and follow-up of persons with tick-borne diseasesThe patient's organizations and Norwegian Institute of Public Health must be included in the Nordic consensus working group
Consensus conference
WG 2:Develop, present & publish a Nordic patients’ pathway
WG 1: Provide systematic scientific literature to support Working Groups 2, 3 & 4
WG 3:Develop, present & publish
a Nordic diagnostic pathway
WG 4:Develop, present & publish
a Nordic rehabilitationpathway
Nordic consensus for medical assessment and follow-up of persons with suspected tick-borne diseases (TBD)
• Assessment, treatment and follow-up of persons with TBDs• Clarification and recommendations for care of persons where TBDs are suspected, but where no TBDs are found
Including persons with persistent complaints after suspected TBDs
Publish inpeer reviewed journals
Consensus document
Nordic consensus congressPersistent symptoms in patiens with
suspected tick-borne diseases15.-16. oktober 2018, Hotell Continental, Oslo
Norwegian referencecenter for Borrelia
The results presented here:
• literature grading• mandate protocol • algorithm currently under revision by the working groups and the editor group
Patients TBD pathway-what do we want
• Find the right patients and receive a good referral from primary care
• Find the best individual patient diagnostic pathway• Examine for the relevance of TBD and other differential
diagnosis• Rule inn TBD as an explanation for the patients
complaints• Rule out TBD as an explanation for the patients
complaints• Find other explanations for the complaints• Treat complaints at the right specialty and level of care• Recommend rehabilitation paths when desirable
TBD diagnostics - what to do
1. Gather diagnostic pathways/flow charts from specialist centres concerning TBD and long-term complaints
2. Gather ”laboratory pathways” for other relevant diseases (such as ME/CFS)
3. Systemic literature-review of diagnostic for new TBD4. Publish review methods & diagnostic
recommendations
Literature review
3916 references new TBD excluded: TBE / acute
borreliosis
1221 possible relevant
562 included for sorting and grading
Screening by two independent persons using Covidence
More accurate screening
Sort by kind of infection
DiagnosticsTBDMicroorganism Current diagnostics Diagnostic recommendations
Serology PCR Other First choice test When acute infection is suspected
Confirmational test
A. phagocytophilum Yes Yes Microscopy Serology PCR; Whole blood PCR
Ca. Neoehrlichiamikurensis
No Yes PCR/Whole blood PCR; Whole blood/Skin biopsies
SequencingFollow-up test
Babesia spp. Yes Yes Microscopy Serology PCR; Whole blood PCR
Rickettsia helvetica Yes* Yes Serology PCR; Whole blood, skin biopsies, CSF
PCR, sequencing
Borrelia miyamotoi Yes** Yes (Serology) PCR; Whole blood, CSF PCR, sequencing
Differencial-diagnostic tests
– Hb, HbA1c, SR, leuk., tromb., fe, transferrin, transferrinsaturation, transferrin receptor, ferritin, Na, k, Ca, P, Mg, Glu, Alb, CRP, ASAT, ALAT, GT, bil., ALP, LD, kreat., CK, vit. B12, folat, vit. D, fri T4, TSH og Cortisol
– Optionally Immunological tests
– Optionally other infections
References: Odense, Uppsala, Amsterdam, Åland, CFS/ME Diagnostic pathway Norway
Contact patient - primary carephysician
1. Acute/Late Lymeborreliosis
2. Persistent symptoms >6 months after treatment ofLyme borreliosis (PTLBS)
3. Persistent symptoms >6 months of unknownorigin, with suspicion oftick-borne infection. Persistent
symptoms ofunknownorigin
Checklist
Dedicated unit for examinationand treatment of tick-borneinfection.
Additional diagnostics:Blood samplesLumbar punctureClinical examinationJoint affection:- Arthrocentesis and synovial biopsy
Relevant diagnostic
tests(Checklist of
symptoms vs. suspected
infection to test for
Persistent symptoms > 6 mos. aftertreatment(PTLBS)
Checklist
Suspectedlate Lymeborreliosis* or other tick -borne disease
Checklist
Other relevant examinationsand/or referral to other relevant specialty clinic, according to patient’s symptoms and objectivefindings.
Referral to rehabilitation
National advisoryunit for diagnosisand treatment oftick-borneinfections.
Diagnosis late borreliosis/ othertick-borne disease:
Treatmentaccordingto guidelines
No findingsindicative of Lymeborreliosis or othertick-borne infection
Referral inclusioncriteria ≥ 3/6
Diagnosis and treatmentof not tick-borne disease
Persistent non-spesificsymptoms withoutsuspicion of tick-borneorigin
X
Investigation flowchart for patients withpersistent symptoms, suspected to be fromtick-borne infection
*) Suspected late LB should be diagnosed more locallywhen thought of. Make sure all relevant testing has beendone and reconsider need of referral: Antibodies. lumbarpuncture, MRI of CNS, ECG, joint- and skin evaluation.
Reevaluation of
primarydiagnostics
and treatment
Reconsider
referralafter
relevant primary
diagnostics
DD?
Referral• GP starts the investigation and decides if the patients
should be referred to a specialist center • Other sources of fatigue/ chronic complaints easily
diagnosed / needed to be seen by other specialist checked out first
• No minor testing for TBD before referral• Gather information on symptoms/ previous diagnosis/
treatments • Encourage the patient to write down their symptoms
and what they think are the causes of their complaints• Patient should give permission to gather further
relevant medical information
General recommendation independent of long-term complaints
• Post infectious medical control at 3 months, and if necessary 6 months, after treated disseminated borreliosis
• Check for sequela, post infectious complaints to avoid chronification and reduce the possibility of interpretation of the symptoms as chronic borreliosis
• Think need for second opinion/rehabilitation
Check list
Investigation steps tailored for the individual patient
The referral First meeting
InterviewPhysical examinationRelevant blood samples Spinal puncture? Supplementary joint examination? Referral to other dedicated specialist
Second meetingInformationResults, both laboratory, and any results from relevant referral.Treatment?Multidisciplinary discussion
Follow upProgression/Effect of treatment, or status quo?
Rehabilitation?
Rehabilitation of persistent complaints after TBD
• Huge variation in prevalence, symptoms and function loss• Most common causes of functional disturbances are pain,
fatigue, cognition deficits, reduced ability to work• Rehabilitation of persistent complaints after TBD in the
Nordic countries are unorganized, scarce and not concrete (exception: Odense)
• No specific rehabilitation recommendations for persisting complaints after TBD exist
• Recommendations follow common rehabilitation principles
Questions?