Lyme Disease in Camp Nursing Practice

Alex Egan, LPN, EMT-B

As always, I am not an expert. All information presented below is correct as I understand it, however I possess no degrees or certifications in infectious diseases. I recommend you do your own research using the links at the end of this article, or other peer reviewed materials.

History

First identified in 1975 in the towns of Lyme and Old Lyme Connecticut, the history of Lyme disease has been quite muddled. To quote Dr. Ed Masters, a noted researcher in tick borne illness, the "track record" of the "conventional wisdom" regarding Lyme disease is not very good: "First off, they said it was a new disease, which it wasn't. Then it was thought to be viral, but it isn't. Then it was thought that sero-negativity didn't exist, which it does. They thought it was easily treated by short courses of antibiotics, which sometimes it isn't. Then it was only the Ixodes dammini tick, which we now know is not even a separate valid tick species. If you look throughout the history, almost every time a major dogmatic statement has been made about what we 'know' about this disease, it was subsequently proven wrong or underwent major modification.

This confusion and frequent changes in the nature of the disease has led to a lot of public confusion and mistrust. Over the last 40 years of research, a general consensus has been reached for the diagnosis and treatment of Lyme disease. However outlying opinions and treatment regimes continue to add controversy to the topic.

Transmission

It is known for sure that Lyme disease is transmitted to humans through the bite of ticks. Previously it was thought Lyme disease was only carried by the deer tick, however it is now believed that other types of ticks of the genus lxodes may be carriers based on the discovery of the bacteria B. burgdorferi in ticks in the Pacific Northwest, as well as Europe, Asia, and Australia. The disease remains most prevalent in the northeastern United States, but pockets of cases are found just about anyplace.

Stages

Lyme disease affects multiple body systems and presents with a host of symptoms. It has three stages, with symptoms generally becoming more severe and debilitating as the disease progresses.

Stage I, known as early localized Lyme disease, occurs days or weeks after infection. It presents with the most common, and most recognizable symptom, erythema migrans. This distinctive bullseye rash is red and painless with raised borders and a firm indurated center. Erythema migrans is present in 80% of Lyme cases and occurs 3-30 days after the initial tick bite. It should be noted that erythema migrans may not present as a bullseye but as a patchy plaque-like rash that is painless. The indurated center and raised boarders remain the tell tail sign. Other symptoms include chills,fever, malaise, headache, joint pain, joint swelling, muscle pain, stiff neck. Obviously in the 20% of cases that do not present with a erythema migrans the diagnosis of Lyme disease can be hard to make, as the disease can easy be mistaken for many common aliments. If a routine illness is not following it's routine course, Lyme should always be considered, especially if you're in an at risk area.

Stage 2, known as early disseminated Lyme disease, occurs weeks to months after infection. Symptoms include numbness or pain in the nerves around the infection. Paralysis or weakness of the face known as Bell's Palsy. Heart issues such as palpitations, or chest pain. It should be noted that the erythema migrans present in stage 1 may be faded or completely resolved.

Stage 3, known as late disseminated Lyme disease, occurs months or years after the initial infection. It is characterized by abnormal muscle movement, joint swelling, muscle weakness, neuropathic pain or sensation, speech and cognitive problems have also been reported.

Diagnostic Tests

Blood tests for Lyme disease and their reliability remain controversial. There are two common serological tests. The ELISA test is recommended first to be followed by the western blot test if results are positive or questionable, in a two tiered protocol. However, this protocol is only 64% sensitive in the early stages of the disease, but nearly 100% in stage 2 or cases with arthritic symptoms.

The general unreliability of blood testing in the early stages of infection and the urgency with which Lyme must be treated to prevent progression to a more advanced stage, has made the diagnosis of Lyme one based primarily on clinical exam.

Treatment

Treatment recommendations for Lyme disease focus on the the early application of antibiotic treatment to treat the causative organism B. burgdorferi before the disease progresses. Presently, the recommendation from the CDC for adults and children 8 and up is the Doxycycline 100 mg BID for 10 to 21 days, amoxicillin 500 mg TID for 14-21days, or cefuroxime axetil 500 mg BID or between 14 and 21 days. IV antibiotics and more intense regimes would be reserved for advanced cases, who's symptoms would certainly make them not candidates for camp.

There are also therapies being practiced in the treatment of Lyme disease that are presently not recommended: first-generation cephalosporins, fluoroquinolones, carbapenems, vancomycin, metronidazole, tinidazole, amantadine, ketolides, isoniazid, trimethoprim-sulfamethoxazole, fluconazole, benzathine penicillin G, combinations of antimicrobials, pulsed-dosing, long-term antibiotic therapy, anti-Bartonella therapies, hyperbaric oxygen, ozone, fever therapy, intravenous immunoglobulin, cholestyramine, intravenous hydrogen peroxide, and specific nutritional supplements.

The nurse would have to evaluate their comfort with administering therapies that are not presently recommended, especially in the practice environment of a summer camp where close medical supervision would be challenging. A discussion with your camps physician, possibly including your camp director may be required when dealing with off label or alternative medical treatment ordered by an outside physician of a camper. There are many "Lyme Literate" doctors who prescribe therapies not presently recommended, or supported by strong scientific study.

In advanced Lyme disease the symptoms can persist even after treatment is concluded. This is often referred to at post Lyme disease syndrome. There is no well-accepted definition of post-Lyme disease syndrome, which has led to much confusion and controversy around it. Further study is underway at this time, and presently no treatment recommendations exist for post-Lyme disease syndrome.

Prevention

As always in camp nursing, prevention is just as, if not more important than early detection. A strong education, prevention, and monitoring program is critical to good outcomes for campers and staff alike. Some actions to take include:

Educate staff about ticks and Lyme symptoms. Remember staff may be from areas where Lyme disease is rare or unheard of. Education keeps them alert for symptoms at camp but may also be useful if they develop the disease at home where physicians are not familiar with the diagnosis and treatment of Lyme.
Encouraging the application of bug repellent containing 20% DEET, especially before activities that will involve walking through tall grass or brush.
Encourage long pants and boots when taking part in high risk activities like hiking.
Consider treating camping gear with permethrin. One application to gear at the start of the summer season may provide protection all summer. Treated tents and boots will help prevent stowaway ticks.
Make sure grass around sports fields and other camp areas is trimmed low. Ticks live in tall grass, they do not fall from trees or blow in the wind. Keeping grass short makes the environment less hospitable and will lessen the tick population.
Get staff and campers in the habit of tick checks. Visually inspect the skin every 24 hours. This can generally be done during established shower times. Get everyone in the habit of checking armpits, hair, behind the ears, behind the knees, between the legs, and around the waist for embedded ticks.

Tick Removal

Remove ticks as soon as possible after they are located. Use fine tipped tweezers to grasp the tick close to the skin's surface, avoid compressing the tick's body. Pull the tick upward, if the skin tents pause briefly and allow the tick to let go. Try and avoid twisting or jerking, as this is likely to leave the head of the tick in the skin. If the head remains in the skin after tick removal, remove it with tweezers if it is easy to do so. If not, simply leave it alone and let the skin heal. After removal wash the skin with soap and water. Consider having ticks removed only by nursing or other designated staff to ensure proper technique. Improperly removing a tick may increase the chance of infection by leaving, or forcing infected tick saliva into the victim.

Note: infection is much less likely if the tick is identified and properly removed within 24 hours of attachment.

Prophylactic Treatment

Work with your physician to determine if prophylactic treatment for confirmed tick bites will be recommended. Current recommendations for prophylactic treatment is a single dose of doxycycline 200mg for adults and 4mg/kg up to 200mg for children greater than eight within 72 hours of the removal of the tick. Presently this treatment is only recommended in high risk situations such as the removal of an engorged tick, or in areas the have a high prevalence of Lyme disease in the community.

Work with your camp director to plan for parental notification in cases of suspected Lyme disease. As with all disease contracted at camp, parents can overreact and create a panic among the community of camp parents. Work with management to make sure that they are educated about Lyme, aware of any suspected or treated cases, and have correct and easy to understand information to provide concerned parents of non infected children if they contact the office in a panic.

While Lyme disease if not a challenge unique to camp nurse practice it is of special concern. Our population is constantly involved in high risk activities, more so than the average population. The camp setting makes the nurse the main observer for Lyme symptoms, and the leading advocate for prevention. Using the information above I hope you are more prepared to address Lyme disease diagnosis, treatment, and prevention in your practice.

References

Clinical Infectious Diseases | Oxford Academic

http://www.idsociety.org/uploadedfiles/idsa/guidelines-patient_care/pdf_library/lyme%20disease.pdf

Bicentennial: Close to Home: A History of Yale and Lyme Disease