Are there connections between COVID-19 and Lyme disease?
by Timothy J. Sellati, Chief Scientific Officer, GLA
There is only one region on the globe with no cases of COVID-19. Except for Antarctica, every continent has confirmed cases of disease. Total cases in the rest of the world are quickly nearing one million, according to data from Johns Hopkins University, with nearly 50,000 deaths reported due to the virus. COVID-19, caused by the novel SARS-CoV-2 virus, is a pandemic of the highest magnitude, and was officially declared as such by the World Health Organization (WHO) on March 11, 2020.1
What defines a pandemic?
According to the Centers for Disease Control and Prevention (CDC), infectious diseases are defined by the number of cases usually present in a community. The starting point or baseline is the endemic level of the disease. On the other end of the spectrum, highly transmissible and/or deadly infections that spread across the globe and can impact tens or hundreds of millions are considered pandemic diseases. Throughout history, a rogue’s gallery of pathogens have caused pandemics that include influenza, cholera, HIV/AIDS, and smallpox, to name a few.
Believe it or not, two infectious diseases from which interesting parallels can be drawn are COVID-19 and Lyme disease. Both began as sporadic, clusters of disease, referring to an aggregation of cases grouped in place and time that are suspected to be greater than the number expected. COVID-19 emerged in Wuhan, within Central China’s Hubei province, and Lyme disease in Lyme, Connecticut in the northeastern U.S. Both rapidly evolved to become hyperendemic, characterized by persistent, high levels of disease occurrence. When the amount of disease in a community rises above an expected level, it becomes epidemic in nature, with sudden increases in the number of cases over a larger geographic area than anticipated. Sometimes, an epidemic stays contained to a specific area—but when it extends into other countries and spreads across continents, it becomes a full-blown pandemic. That was the case in 2003 with the outbreak of severe acute respiratory syndrome (SARS), the 2009 outbreak of swine flu caused by the H1N1 flu virus, and now SARS-CoV-2 in 2020, which is a close ‘cousin’ of SARS.
Is Lyme disease a pandemic like COVID-19?
While Lyme disease clearly meets the definition of an epidemic one could persuasively argue it too has achieved the level of a pandemic. Although Lyme disease lacks the mortality rates associated with COVID-19 it certainly meets the definition of a pandemic with regard to its global distribution, along with other tick-borne diseases (TBDs), and its annual case incidence rate of hundreds of thousands of people globally is estimated to be as high as 500,000. According to WHO, in addition to the U.S. there are concentrated areas of Lyme disease cases in northwestern, central and eastern Europe, and forested areas of Asia.2 It’s estimated that as many as 427,000 cases may occur annually in the U.S.
How are pandemics treated differently?
When epidemics evolve into pandemics, the biggest difference is that more governments are involved in and more financial resources – public and private – dedicated to preventing the progression of the disease and, potentially, treating the people who have it. Unfortunately, this is where similarities between COVID-19 and Lyme disease diverge. Unlike for COVID-19, there is no concerted and comprehensive effort to stem the global increase in TBDs or to treat patients suffering from them.
Despite this difference, another unfortunate commonality between COVID-19 and Lyme disease is the fear, anxiety, and confusion experienced by individuals who are unsure whether they are infected or not. Do the sometimes subjective, non-specific symptoms they are experiencing mean they are infected, or are they suffering from something else? This is true of both SARS-CoV-2 or Borrelia burgdorferi, the causative agent of Lyme disease. Where can they get tested, how accurate are the tests, what treatment options are available and will they work for everyone, etc.? Can tests distinguish uninfected from asymptomatic infected individuals and how about people who are actively infected vs. those with prior exposure who have recovered?
The medical community is rallying to develop a set of rapid and reliable direct diagnostic tests for SARS-CoV-2 or indirect tests to detect antibodies raised against the virus. Although many clinics still lack access to a robust, accurate and sensitive SARS-CoV-2 test, impressive progress has been made in a matter of weeks. In contrast, it took almost six months to identify and establish assays for the coronavirus responsible for the 2002–2003 SARS outbreak.3 Following the 1995 recommendation of the CDC, the majority of laboratory tests performed for diagnosis of Lyme disease are based on a two-tiered test algorithm that detects antibodies against B. burgdorferi in serum of suspected Lyme patients.4 These original recommendations for serodiagnosis of Lyme disease relied on an initial enzyme immunoassay (EIA, 1st tier) followed by separate IgM and IgG Western blots (2nd tier), if the EIA test result is positive or borderline. While the two-tiered test algorithm works well for later stages of the infection, it has low sensitivity during early infection. With accuracy ranging between ~43% to 65% for early Lyme disease diagnoses, as many as 57% of these patients may receive a false negative result.5 Such poor diagnostic performance would be devastating to current efforts to stem the spread of SARS-CoV-2 across the globe!
Recently revised CDC recommendations now allow for replacing the Western immunoblot assay with a second EIA6 and efforts are underway to develop tests with improved accuracy in early detection of Lyme disease. This is important as it is recognized that early detection increases the likelihood of effective treatment with antibiotics such as Doxycycline. Another significant draw back to existing indirect, Lyme diagnostic testing, which looks for the presence of antibodies against B. burgdorferi, is that it cannot distinguish active vs. prior infection. In the latter case, people have been successfully treated and no longer experience symptoms associated with the original infection. Not knowing whether someone is actively infected or not makes the medical decision to continue or alter treatment particularly difficult.
Many of these same diagnostic shortcomings in the Lyme disease field also hamper efforts to fully understand who is infected with SARS-CoV-2 and likely to be shedding virus, who is not, and who has recovered. This uncertainty results in a great deal of fear, anxiety, and confusion on the part of those seeking diagnosis and treatment. Although Lyme disease patients do not suffer the same mortality rates as those with COVID-19, the long-term consequences of prior infection associated Lyme disease can encompass arthritis, carditis, and neurological complications, particularly cognitive deficit and neuropsychiatric disorders. Collectively, such debilitating and chronic symptomatology leads to diminished quality of life and the increased likelihood of depression and suicidality. And in rare cases, Lyme disease can result in death.7
In summary, while Lyme does not share the same rate of infection and death as other pandemics it can have a negative impact on patients by imposing long-term health and immune-compromising challenges that can linger for years. It is important to appreciate that diminished immunity, as a result of Lyme disease and other TBDs, can make patients more susceptible to a pandemic like COVID-19. Ideally, investment of sufficient resources to mount a concerted and comprehensive effort to stem the global increase in Lyme disease and other TBDs would be made, as it is being made to combat COVID-19.
References: 1https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 2https://www.who.int/ith/diseases/lyme/en/ 3https://www.nejm.org/doi/full/10.1056/NEJMoa030747 4https://www.cdc.gov/mmwr/preview/mmwrhtml/00038469.htm 5https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0168613 6https://www.cdc.gov/mmwr/volumes/68/wr/mm6832a4.htm 7https://academic.oup.com/cid/article/52/3/364/307928
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