Lyme disease and preventive behaviors in residents of Nantucket Island, Massachusetts

doi:10.1016/S0749-3797(00)00315-9

American Journal of Preventive Medicine

Volume 20, Issue 3, April 2001, Pages 219-224

https://doi.org/10.1016/S0749-3797(00)00315-9 Get rights and content

Abstract

Background: To determine the age-specific prevalence of Lyme disease and whether preventive behaviors on Nantucket Island correlate with Lyme disease, we surveyed island residents.

Methods: A survey with questions on Lyme disease symptoms, history, and preventive behaviors was mailed to all residents. Respondents were stratified by likelihood of having had Lyme disease. A subsample was selected for examination, and then classified according to the Lyme disease national surveillance case definition.

Results: The overall lifetime prevalence of Lyme disease for Nantucket residents was 15% (CI, 10%–19.8%): 19% among females, and 11% among males. The prevalence was highest among age groups 0–16 and 30–49 years. Overall, 86% of the population practiced at least one behavior. The most frequently reported preventive behavior was checking oneself for ticks (80%), followed by wearing protective clothing (53%), avoiding tick areas (34%), and using tick repellent (11%). Younger individuals practiced fewer preventive behaviors than older individuals (p=0.001). Although males reported greater tick exposure than females, females uniformly practiced preventive behaviors more frequently (p=0.001). The practice of preventive behaviors was not associated with a history of Lyme disease, but finding more than 5 ticks per year on oneself was (p=0.001).

Conclusion: Lyme disease is highly prevalent on Nantucket Island. Young people are particularly at risk and health education should emphasize preventive behaviors less frequently practiced: using tick repellent, avoiding tick areas, and wearing protective clothing.

Introduction

L yme disease is caused by the tick-borne spirochete, Borrelia burgdorferi. In 1982, the then Centers for Disease Control (CDC) initiated surveillance for Lyme disease and it has been a nationally notifiable disease since 1990.1 It is the most commonly reported vectorborne infection in the United States. In 1996, 16,461 cases from 45 states and the District of Columbia were reported to the CDC, a 41% increase from 1995 and a record since surveillance began in 1982. The highest proportions occurred among children aged 0–14 years, and adults aged 40–79 years. Fifty-three percent of the cases reported were male.2

Passive surveillance of infectious diseases is an important epidemiologic tool, but may underestimate the true burden of the illness in a population.3, 4 Reporting depends on (1) occurrence of clinical disease severe enough that medical care is sought, (2) ability of the provider to diagnose the illness correctly, and (3) reporting of the disease to the health department. Active surveillance obtains standardized information not included in reports to the CDC, and is critical in identifying populations at risk and setting priorities for prevention efforts.

The reported surveillance surveys of Lyme disease assess selected groups such as students,5 outdoor workers,6, 7 and orienteers.8 Large population examination surveys have not been reported. We describe the results of an examination survey of all permanent residents of Nantucket Island, which has one of the highest reported incidences of Lyme disease in the United States,2 to determine lifetime prevalence and demographic patterns of Lyme disease and to assess the prevalence of associated risk behaviors for disease.

Section snippets

Study site

Nantucket Island, located southeast of Cape Cod, Massachusetts, is 14 miles long and about 3 miles wide. With large expanses of open land and one third of the island protected from development, Nantucket has large areas to support deer, the preferred host of the adult tick vectors that carry Lyme disease.

According to the island’s town clerk office, Nantucket has a population of roughly 7600 year-round residents that expands to over 30,000 during the summer season. The population’s medical care

Results

The survey was mailed to 6993 individuals (adults and children) and completed by 4671 (67%). Respondents had a mean age of 38 years (+/−22), were 47% male, and a mean 11 years of island residence (Table 1). Ninety-six percent reported knowing about Lyme disease, 14% thought they had had Lyme disease, 10% had been diagnosed with Lyme disease, and 16% had received treatment for Lyme disease.

A total of 533 survey respondents (11%) reported a prior diagnosis or positive blood test for Lyme disease

Discussion

A population examination survey of Lyme disease on Nantucket Island, representing 67% of the Island population, yielded an estimated 15% lifetime prevalence of Lyme disease among children and adults. The prevalence was highest in females and among the 0–16 and 30–49 age groups.

By comparison, a prevalence of 8.8% was reported by Alpert18 in a 1989 study of 114 residents of Chappaqua, New York. Feder5 reported a 7% prevalence in a Connecticut school population in 1990–1992. Hanrahan19 reported

Acknowledgements

We acknowledge the invaluable help of Nancy Tanner, who prepared the survey mailouts; Cheryl Bartlett and Susan Fernald, who helped coordinate our research efforts on Nantucket Island; the Nantucket Cottage Hospital and Drs. Lepore, Voorhees, Butterworth, Pearl, and Briggs for supporting this research and providing us with space for evaluations in their facility; Mary Scamman for her expertise in preparing the manuscript; Drs. Eric Logigian, Richard Kaplan, and Robert Sundel for reviewing the

References (29)

N.A Shadick et al.
Determinants of tick avoidance behaviors in an endemic area for Lyme disease
Am J Prev Med
(1997)
Centers for Disease Control and Prevention. Case definition for public health surveillance. MMWR Morb Mort Wkly Rep...
Centers for Disease Control and Prevention. Lyme disease—United States, 1996. MMWR...
B.S Coyle et al.
The public health impact of Lyme disease in Maryland
J Infect Dis
(1996)
J.L Meek et al.
Underreporting of Lyme disease by Connecticut physicians, 1992
J Public Health Management Prac
(1996)
H.M.J Feder et al.
Prospective assessment of Lyme disease in a school-aged population in Connecticut
J Infect Dis
(1995)
M.D Goldstein et al.
Lyme disease in New Jersey outdoor workersa statewide survey of seroprevalence and tick exposure
Am J Public Health
(1990)
C Parrott et al.
Lyme disease in outdoor workers on Assateague Islandhigh tick-exposure but low disease risk
Md Med J
(1993)
R Gustafson et al.
Two-year survey of the incidence of Lyme borreliosis and tick-borne encephelitis in a high-risk population in Sweden
Eur J Clin Microbiol Infect Dis
(1992)
I.S Szer et al.
The long-term course of Lyme arthritis in children
N Engl J Med
(1991)

A.C Steere et al.

Lyme arthritisan epidemic of oligoarticular arthritis in children and adults in three Connecticut communities

Arthritis Rheum

(1977)

L.R Petersen et al.

Epidemiological and clinical features of 1,149 persons with Lyme disease identified by laboratory-based surveillance in Connecticut

Yale J Biol Med

(1989)

N.A Shadick et al.

Musculoskeletal and neurologic outcomes in patients with previously treated Lyme disease

Ann Intern Med

(1999)

O Sangha et al.

Lack of cardiac manifestations among patients with previously treated Lyme disease

Ann Intern Med

(1998)

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Research articleLyme disease and preventive behaviors in residents of Nantucket Island, Massachusetts

Abstract

Introduction

Section snippets

Study site

Results

Discussion

Acknowledgements

Am J Prev Med

The public health impact of Lyme disease in Maryland

J Infect Dis

Underreporting of Lyme disease by Connecticut physicians, 1992

J Public Health Management Prac

Prospective assessment of Lyme disease in a school-aged population in Connecticut

J Infect Dis

Lyme disease in New Jersey outdoor workersa statewide survey of seroprevalence and tick exposure

Am J Public Health

Lyme disease in outdoor workers on Assateague Islandhigh tick-exposure but low disease risk

Md Med J

Two-year survey of the incidence of Lyme borreliosis and tick-borne encephelitis in a high-risk population in Sweden

Eur J Clin Microbiol Infect Dis

The long-term course of Lyme arthritis in children

N Engl J Med

Lyme arthritisan epidemic of oligoarticular arthritis in children and adults in three Connecticut communities

Arthritis Rheum

Epidemiological and clinical features of 1,149 persons with Lyme disease identified by laboratory-based surveillance in Connecticut

Yale J Biol Med

Musculoskeletal and neurologic outcomes in patients with previously treated Lyme disease

Ann Intern Med

Lack of cardiac manifestations among patients with previously treated Lyme disease

Ann Intern Med

Research article
Lyme disease and preventive behaviors in residents of Nantucket Island, Massachusetts