Original Research ArticleLyme disease in Poland – A serious problem?
Introduction
Lyme disease (LD) is one of the most known tick borne diseases in USA and in Europe. The disease is caused by Borrelia burgdorferi sensu lato and transmitted by Ixodes ricinus or related ticks. There are many possible clinical manifestations of LD which can be divided into early localized LD (Erythema migrans – EM, Borrelial lymphocytoma), early disseminated LD (Lyme arthritis – LA, Neuroborreliosis – NB, Lyme carditis) and late LD (Acrodermatitis chronica atrophicans – ACA, late forms of NB and LA) [1], [2], [3].
Various Borrelia species possess different organotropisms and may preferentially cause distinct clinical manifestations of the disease. In Europe, where B. afzelii and B. garinii are the most common causes of LD NB is the most common manifestation of disseminated LD, occurring in 10–15% of all LD cases [1], [4], [5] while the symptoms of arthritis are present in 3–15% of cases of LD [6].
In Poland the prevalence of Borrelia species varies depends on the region. Stańczak et al. who examined ticks in eight different polish provinces reported B. afzelli to be the dominant species in Poland. However B. burgdorferi sensu stricto seems to be the most frequent species in Lubelskie Province and in Western Pomerania region [7], [8], [9].
There is no accurate data of LD epidemiology in Europe because few countries have made this disease mandatorily notifiable. It is estimated that the annual number of cases in Europe is 65,400 (incidence rates per country range from less than one per 100,000 population to about 350 per 100,000 population) [10], [11].
In Czech Republic the average incidence is 29 per 100,000 population, in Germany – 25/100,000, Lithuania – 25/100,000, Slovenia – 150/100,000, Slovakia – 18.4/100,000, Norway – 2.8/100,000 [12].
In Poland LD is mandatorily notifiable to the Epidemiologic Station, therefore more precise data are available.
According to National Hygiene Institute in 2013 there were 12,779 cases of Lyme disease reported (incidence 33.12) while in 2012 it was 8783 cases (incidence 22.8) and in 2011–9170 cases (incidence 23.8). On the base of these numbers one can conclude that LD is a serious problem in Poland. Moreover its incidence rose significantly between 2012 and 2013 [13].
Podlaskie Voivoidship is a region of highest incidence of LD in Poland (2013–100.2/100,000).
Bialystok is the main city in Podlaskie Voivoideship. Department of Infectious Diseases and Neuroinfections of Medical University of Bialystok is a reference center for tick-borne diseases. Each year a few hundred patients are admitted with a suspicion of LD for diagnosis and treatment (90–95% of these patients are inhabitants of Podlaskie Voivoidship).
Even though in Europe NB is a more frequent clinical form than LA, the majority of patients suspected of LD suffers from joint pain. Many of these patients have been previously treated for LD although they have not fulfilled diagnostic criteria. Also no differential diagnosis was performed even if patients did not improve after antibiotic treatment.
In our opinion, as these patients were reported to the Epidemiologic Stations, it is possible that it significantly biased the statistics of LD in Poland.
The main goal of the study was the evaluation of clinical picture of patients hospitalized with LD.
Additionally, we tried to analyze the possible cause of sudden rise in LD incidence in Poland.
Section snippets
Patients and methods
We retrospectively analyzed the medical documentation of patients admitted to the Department of Infectious Diseases and Neuroinfections, Medical Universty in Bialystok in 2013 with a suspicion of LD. Podlaskie Region is an endemic region for tick borne diseases with the highest incidence of LD in Poland and most of these patients are at some point diagnosed and treated in – the Department or Outpatient Department.
All patients were tested for presence of anti B. burgdorferi IgM and IgG
General results
The analysis of yearly changes in reported cases of LD and TBE shows that there are significant differences in the epidemiology of LD in Poland and either TBE in Poland or LD in Podlaskie Voivoidship (Table 1).
The number of patients with LD and past LD (discharged with ICD10 code A69.2 and reported to Epidemiologic Station) in 2013 was lower than in 2012 (328 vs 334 cases). The highest number of patients reported from our Department was in 2007 – 511 cases (Fig. 2).
Clinical results
In 2013 overall 378 patients
Discussion
The sudden increase in LD incidence in Poland in 2013 should be mirrored in the biggest endemic area which is Podlaskie Voivoidship. Although we observed a 23% increase in reported cases from this region in 2013, it was significantly lower than the 45% increase in Poland (Fig. 1) (Table 1).
Therefore the total increase in LD incidence in Poland is caused by the fact, that more cases are reported in other regions (e.g. number of reported cases from Małopolskie Voivoidship rose from 831 cases in
Conclusions
The observed increase in reported LD incidence in Poland is not in accordance with changes in incidence of other tick borne diseases e.g. TBE and may be biased by overreporting and overdiagnosis. Therefore the reporting system of LD in Poland needs verification.
Nonspecific musculoskeletal and join pain are the most frequent cause of LD suspicion and hospitalization. There is a necessity of better tests for confirmation of active LD (especially in patients with musculoskeletal pain) as the
Conflict of interests
The authors declare no conflict of interests.
Financial disclosure
The authors have no funding to disclose.
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