Abstract
Lyme disease arises from infection with pathogenic Borrelia species. In Canada, current case definition for confirmed Lyme disease requires serological confirmation by both a positive first tier ELISA and confirmatory second tier immunoblot (western blot). For surveillance and research initiatives, this requirement is intentionally conservative to exclude false positive results. Consequently, this approach is prone to false negative results that lead to underestimation of the number of people with Lyme disease. The province of New Brunswick (NB), Canada, can be used to quantify under-detection of the disease as three independent data sets are available to generate an estimate of the true human disease prevalence and incidence. First, detailed human disease incidence is available for the US states and counties bordering Canada, which can be compared with Canadian disease incidence. Second, published national serology results and well-described sensitivity and specificity values for these tests are available and deductive reasoning can be used to query for discrepancies. Third, high-density tick and canine surveillance data are available for the province, which can be used to predict expected human Lyme prevalence. Comparison of cross-border disease incidence suggests a minimum of 10.2 to 28-fold under-detection of Lyme disease (3.6% to 9.8% cases detected). Analysis of serological testing predicts the surveillance criteria generate 10.4-fold under-diagnosis (9.6% cases detected) in New Brunswick for 2014 due to serology alone. Calculation of expected human Lyme disease cases based on tick and canine infections in New Brunswick indicates a minimum of 12.1 to 58.2-fold underestimation (1.7% to 8.3% cases detected). All of these considerations apply generally across the country and strongly suggest that public health information is significantly under-detecting and under-reporting human Lyme cases across Canada. Causes of the discrepancies between reported cases and predicted actual cases may include undetected genetic diversity of Borrelia in Canada leading to failed serological detection of infection, failure to consider and initiate serological testing of patients, and failure to report clinically diagnosed acute cases. As these surveillance criteria are used to inform clinical and public health decisions, this under-detection will impact diagnosis and treatment of Canadian Lyme disease patients.
Highlights
Lyme borreliosis, is a serious disease resulting from infection with Borrelia species of the Lyme borreliosis group, formerly known as Borrelia burgdorferi sensu lato [1,2]
This difference, demarked by a political border that does not influence the biology of ticks or their hosts, strongly suggests impaired detection of Lyme disease in Canada, as the US incidences are not corrected for the documented under-reporting [22,23]
To assess the difference in disease incidence across the border that could be attributed solely to geographic causes, we focused on reported Lyme disease incidences between Maine, ME, USA and New Brunswick (NB), Canada
Summary
Lyme borreliosis, is a serious disease resulting from infection with Borrelia species of the Lyme borreliosis group, formerly known as Borrelia burgdorferi sensu lato [1,2]. Canada including the prairie provinces (Manitoba, Saskatchewan, and Alberta) Ixodes scapularis and in British Columbia Canada mainly, Ixodes pacificus The ticks are both introduced by migratory animals such as birds [1,13,14,15,16] and arise from locally established, breeding (endemic) tick populations [1,17,18]. In Canada, a confirmed diagnosis of disseminated (non-acute Lyme disease in which the bacteria have disseminated through the body from the site of initial infection, as defined by the Public Health Agency of Canada [19]) Lyme disease requires positive laboratory evidence, usually two-tiered serology, whereas a probable case requires physician-documented erythema migrans rash and exposure to a designated endemic site [19]. Because of the complex interplay between the health care system, biology, and diagnostics, this approach under-detects and under-reports the true prevalence and incidence of human Borrelia infections
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