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Lyme Disease

Lyme Disease

The following presentation is an introduction to Lyme disease, a bacterial infection spread by ectoparasites, namely ticks. Lyme disease is common in North America, Europe, and is rapidly spreading around the world. This lecture features more advanced topics, such as the immune system, molecular diagnostic methods, and scientific contention.

Lyme Disease © 2022 by E. Nomi is licensed under CC BY-NC-SA 4.0

The University of Nomi

February 06, 2024
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  1. Lyme Disease
    Lyme Disease
    August 2022. Photo: readersdigest.ca/health/conditions/tick-borne-diseases

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  2. Lyme Disease
    The most common zoonotic disease carried by ticks world-wide, particularly
    in North America and Europe1, 2, 3
    – ≈476,000 people in USA diagnosed annually (data from 2010-2018)3
    Estimated global prevalence in blood: ≈14.5%1
    Photos: modified from © Todd Gipstein on gettyimages.com, © Brenda Leal, Aug 13, 2020, on entomologytoday.org

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  3. Lyme Disease – The Bacterium
    Caused by Borrelia bacterial spirochaetes4
    – In North America: B. burgdorferi4
    – In Eurasia: B. burgdorferi, B. afzelii, and B. garinii4
    Photos: modified from © Jamice Haney Carr, Claudia Molins, USCDCP on pixnio.com, © Juergen Berger/science Photo Library on pixnio.com
    Borrelia burgdorferi

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  4. B. burgdorferi Morphology
    Gram negative, but has immunoreactive glycolipids instead of LPS layer5
    Photos: Kelesidis, 2014, Figure 1., Chandler et al., 2017 Figure 2.d.
    outer membrane
    inner membrane
    peptidoglycan
    periplasmic space
    Glycolipid LPS
    glycolipids/LPS
    Gram negative cell wall
    lipoprotein
    Sugar
    Glycerol
    Fatty acid
    Fatty acid

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  5. B. burgdorferi Morphology
    Motile, using multiple internal flagella6
    – Flagellar proteins (common antigens) hidden from immune detection7
    Photos: Kelesidis, 2014, Figure 1., Charon et al., 2012, Figure 1.a-b.
    Gram negative cell wall
    periplasmic space

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  6. B. burgdorferi Morphology
    Spirochete:
    Morphology under
    favourable
    conditions8
    Helical, motile,
    active form6
    Round body:
    Induced by poor
    conditions, presence
    of penicillin8
    Cyst-like, low
    metabolic rate,
    resistant to
    antibiotics, may
    evade immune system5
    Photos: Meriläinen et al., 2015, Figures 1.a and 1.c.
    Changes morphology in response to environmental conditions5
    5 μm
    5 μm

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  7. Lyme Disease – The Tick
    Carried by the bite of an Ixodes genus tick (“hard ticks”)4,9
    Photo: blog.healthywildlife.ca/lyme-disease-hits-close-to-home
    Adult
    stage
    Nymph
    stage
    Larva
    stage
    Engorged
    adult
    Ixodes scapularis (deer tick, common in N. America)
    Can have up to 3
    different hosts, one
    at each life stage9
    Parasitize wide range
    of animals9
    B. burgdorferi
    transmission most
    likely during nymph
    stage9


    (cm)

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  8. Ixodes scapularis Lifecycle
    Photo: health2016.globalchange.gov/low/ClimateHealth2016_05_Vector_small.pdf, Figure 3.
    Larvae and nymphs acquire
    B. burgdorferi by feeding
    on small mammals and
    birds in spring and
    summer, carry infection
    for life10
    Adult ticks feed mainly
    during cold months;
    nymphs in warm months10

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  9. Geographical Distribution
    Climate change and increasing temperatures causing expansion
    of tick habitat and higher transmission of disease10
    Photo: modified from bewareofthebugs.com/diseases/lyme-disease

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  10. The Tick Bite
    Step 1. Questing
    – Ticks climb vegetation and wait with limbs outstretched3,11
    Photo: blog.kittykono.com/2011/05/hard-questing-tick.html

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  11. The Tick Bite
    Step 2. Attachment
    – Ticks detect animals´ breath, body odours, body heat, moisture, and
    vibrations, latch on when host brushes by3
    Photos: blog.kittykono.com/2011/05/hard-questing-tick.html, dreamstime.com

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  12. The Tick Bite
    Step 3. Feeding
    – Occurs within 10 minutes to 2 hours after attachment3
    – Grasps the skin, cuts into the surface, and inserts feeding tube3
    Photos: blog.kittykono.com/2011/05/hard-questing-tick.html, dreamstime.com, kuusinc.com/be-ticked-off-lyme-disease-is-preventable

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  13. The Tick Bite
    “Feeding tube” – hypostome and chelicerae
    Photos: emlab.uconn.edu/gallery/head-of-a-deer-tick, "Mouth Parts 50x, Ixodes scapularis (Deer Tick)" © Mark Smith, Daniel Saftner, and Annette Evans from Macroscopic Solutions, LLC on flickr.com
    I. scapularis head I. scapularis feeding tube

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  14. B. burgdorferi Infection
    Tick acquires infection from small mammal host, commonly mice12
    Bacteria population maintained in the tick midgut, disseminates throughout
    tick body12
    Photos: mammals.carnegiemnh.org/pa-mammals/white-footed-mouse-peromyscus-leucopus, modified from Šimo et al., 2017, Figure 1., Edwards et al., 2009, Step 9.
    White-footed mouse
    (Peromyscus leucopus)
    Tick midgut
    (Amblyomma maculatum)

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  15. B. burgdorferi Infection
    Environmental changes in pH and temperature induce bacteria to
    differentially express >19 adhesive outer surface proteins that assist in
    infection7,12
    – Bind to host cells, complement system regulatory factors, or aid in
    vascular and tissue colonization12
    Photo: Modified from Šimo et al., 2017, Figure 1.
    Mammal Host7:
    Temperature
    regulated at
    37–39°C
    pH = neutral
    Tick Host7:
    Temperature
    varies with
    environment
    pH = basic

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  16. B. burgdorferi Infection
    After 24–48 hours of feeding, bacteria migrate to the salivary glands and
    enter new host7,13
    – Saliva acts as a vasodilator, anticoagulant, anti-inflammatory, and
    immunosuppressive, facilitating the flow of blood14
    Photos: Modified from Šimo et al., 2017, Figure 1., Edwards et al. 2009, Step 8.
    Tick salivary glands
    (Amblyomma maculatum)
    Tick salivary glands
    (Amblyomma maculatum)

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  17. B. burgdorferi Infection
    Bacteria disseminate via bloodstream using “drag” and “tether”
    interactions with blood vessel endothelia12
    Bind host molecules that mediate endothelial interactions:
    – Fibronectin and integrins15
    Photo: Modified from Niddam et al., 2017, Figure 1.a.

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  18. Stage 1: Localized Disease
    Symptoms occur within 1–28 days following tick bite3,4
    – Erythema migrans develops in 60%-80% of patients4,16
    – Muscle pain, neck stiffness, paralysis
    – Low-grade fever, fatigue, and flu-like symptoms
    Photos: aad.org/public/diseases/a-z/lyme-disease-signs, medicalnewstoday.com/articles/323457
    Classic cases of erythema migrans (bull’s-eye rash)

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  19. Stage 2: Disseminated Disease
    Develops 3–12 weeks after the initial infection3,4
    Symptoms may last 12–20 weeks3,4,17
    – Damage to central nervous system in 20% of patients4
    – Joint inflammation, pain and swelling, muscle pain3,4
    – Carditis (inflammation of the heart) in 3–4% of patients17
    MRI showing
    damage to
    bilateral
    cranial nerve
    Tissue sample
    from a patient
    who died of Lyme
    carditis3
    Photos: Blackwell, 2017, Figure 2., cdc.gov/lyme/treatment/lymecarditis.html

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  20. Stage 3: Late Disease
    Symptoms can develop months/years after initial infection and last for
    years3,4:
    – Poor cognition, persistent fatigue, seizures, mental illness18
    – Meningitis, Bell’s palsy, dysesthesias, fibromyalgia-like symptoms3,4
    – Arthritis, especially in the knees3,4
    Photos: modified from prepareformedicalexams.blogspot.com/2017/06/regarding-bells-palsy.html, ayurbethaniya.org/images/multiplescelorosis.jpg, cdc.gov/lyme/treatment/LymeArthritis.html
    Bell’s palsy Arthritis
    Fibromyalgia

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  21. Spirochaetes can permeate tissue to reach immunoprivileged sites with
    less immune activity19
    Evidence of biofilm formation, allowing adhesion to tissues20, 21, 22
    Immune Evasion
    Photo: modfied from asbmb.org/asbmb-today/science/100320/viruses-that-come-to-stay, Sapi et al., 2012, Figure 1.a-b.
    Borrelia burgdorferi aggregates in vitro21
    Immunoprivileged sites

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  22. Immune Evasion
    Borrelia produces cell surface proteins that
    allow evasion from the complement cascade,
    including12:
    – BBK32 – binds part of C1, inhibits attack
    complex formation
    – CspA – interacts with C7 and C9, inhibits
    attack complex formation
    – ErpP – interacts with other proteins to
    inactivate C3b
    Complement pathways
    Photo: Stone and Brissette, 2017, Figure 2.a.

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  23. Immune Evasion
    Has high number of genes encoding
    virulence factors, including:
    – ospC – expression required for host
    colonization and resistance to innate
    immunity7, 23
    – vlsE – antigenic variation system
    whereby variable surface lipoproteins
    are expressed to resist adaptive
    immunity and to establish persistent
    infection7, 23, 24
    Variable expression of vlsE
    Photos: innate-pharma.com/science/innate-immunity-nk-cells, Stone and Brissette, 2017, Figure 2.a

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  24. Diagnosis
    Serology: standard two-
    tiered testing16, 25: IgM antibodies raised against B.
    Burgdorferi can be detected
    within 2-4 weeks of initial
    infection; IgG at 4-6 weeks13,26
    Photos: modified from APHL, 2021 Figure 1., Lecture "Lyme Disease Serologic Testing" by Centers for Disease Control and Prevention (CDC) from https://www.youtube.com/watch?v=Dei-8na9wZU

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  25. Diagnosis
    Serology: standard two-
    tiered testing16, 25: The 1st tier test uses an enzyme-
    linked immunosorbent assay
    (ELISA) to screen for infection
    Photos: modified from APHL, 2021 Figure 1., immunology.org/public-information/bitesized-immunology/experimental-techniques/enzyme-linked-immunosorbent-assay
    Whole-cell
    preparation of
    B. burgdorferi
    or recombinant
    antigens25

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  26. Diagnosis
    Serology: standard two-
    tiered testing16, 25: The 2nd tier test uses a more
    specific western blot to confirm
    a positive or inconclusive 1st
    tier test result
    Photos: modified from APHL, 2021 Figure 1., "Researcher Checks Western Blots" by NIAID on commons.wikimedia.org

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  27. Diagnosis
    Serology: standard two-
    tiered testing16, 25:
    + Clinical symptoms:
    – Erythema migrans rash
    Patient History:
    – Time spent in endemic
    areas
    Photos: modified from APHL, 2021 Figure 1., "Doctor and Patient Illustration" by Chris Cherry on dribble.com

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  28. Problems with Diagnosis
    Detection of early Lyme prone to
    false negatives16
    Recovery from disease is not
    trackable using antibody tests
    – IgM antibodies can persist after
    infection is cleared27
    Dispute over the frequency of false
    positives due to cross-reactivity of
    antigens26
    Organs may be infected even if
    antibody tests are negative28
    Photo: lymescience.org/lyme-disease-tests-science/sensitivity-of-lyme-tests-waddell/

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  29. Problems with Diagnosis
    Koch’s Postulates:
    – Used to prove a microbe
    causes a disease29
    – Isolated microbe in culture
    should produce the same
    disease in new host, and be
    the same microbe when re-
    cultured29
    B. burgdorferi does not fit
    this paradigm:
    – Difficult and time
    consuming to culture30
    Photo: modified from Neville et al., 2018, Figure 1.

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  30. Xenodiagnosis
    Testing the vector for presence of pathogens
    to indicate exposure in host31,32
    – PCR used to detect Borellia DNA in Ixodes
    tick
    Already used in Lyme research to prove a
    host’s infection status31,32
    Not currently used in clinical diagnoses, but
    clinical trial using tick larvae on humans
    completed on May 4, 2022 (NCT01143558)32
    Photos: danielcameronmd.com/test-lyme-disease-using-tick, Marques et al., 2014, Figure 1.

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  31. Post-Treatment Lyme Disease Syndrome (PTLDS)
    Clinical definition endorsed by the CDC and NIH: unresolved symptoms
    lasting >6 months following antibiotic treatment3, 33, 34
    Develops in 10–20% of patients treated for Lyme disease35
    Treated with 3–4 weeks of additional antibiotic therapy33
    Hypothesized causes35,36:
    – Persistance of antimicrobial-resistant B. burgdorferi
    – Reactivity with components of dead B. burgdorferi
    – Co-infections such as Anaplasma phagocytophilum and Babesia microti
    – Dysfunctional immune response

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  32. Chronic Lyme
    A more casual term lacking consistent clinical definition37, 34
    – Includes patients with negative serology for B. Burgdorferi
    Considerable contention between patients/advocacy groups and medical
    authorities over legitimacy of condition
    Demonstrators at Worldwide Lyme Disease Awareness Protests, 2013
    Photos: worldwidelymediseaseprotest.blogspot.com/

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  33. Contention
    – Both overuse of antibiotics and untreated Lyme are dangerous3
    – Complicated disease progression and diverse presentation of
    symptoms can complicate and delay diagnosis38, 39
    – Testing methods may not be sensitive enough for reliable diagnosis
    and cannot track disease recovery27, 40, 41, 42
    – Lack of information can allow pseudoscience to take advantage43
    – These factors can foster distrust between physicians and patients
    who believe they could have Lyme disease

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  34. Contending
    Perspectives
    Two general schools of thought about diagnosis and treatment of Lyme:
    – 1.) Methodology-centered – focusing on standardization of diagnostic tests
    and treatment to prevent misuse of antibiotics and false insurance claims
    – 2.) Patient-centered – focusing on patient interest in well-being and
    recovery from illness, especially where serological tests can be unreliable
    and disease progression is not fully understood

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  35. – Methodology-centered
    – Does’nt recognize chronic Lyme disease41, 43
    – Localized to well-defined areas of the
    world41
    – Lyme is hard to catch and easy to cure
    with short course of antibiotics41
    – Discourages tick-testing43
    – Laboratory diagnosis is accurate43
    – Encourages prophylaxis43
    – Patient-centered
    – Recognizes chronic Lyme disease39
    – Unpredictably distributed world-
    wide41
    – Illness is not rare, requires longer
    courses of antibiotics41, 39
    – Considers tick-testing39
    – Laboratory diagnosis is inaccurate39
    – Discourages prophylaxis39
    Contending
    Organizations

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  36. Erythema migrans: oral antibiotic therapy with doxycycline for 10 days, or
    amoxicillin or cefuroxime axetil for 14 days[Lantos]
    Neurological symptoms: intravenous ceftriaxone, cefotaxime, penicillin G, or
    oral doxycycline for 14–21 days[Lantos]
    Lyme arthritis: oral antibiotic therapy with doxycycline, amoxicillin,
    cefuroxime axetil, or azithromycin for 28 days[Lantos]
    Prophylaxis: single dose of oral doxycycline within 72 hours of tick
    removal, 200 mg for adults and 4.4 mg/kg for children [Lantos]
    Treatment Failure: no additional antibiotics, referral to rheumatologist[Lantos]
    Symptom Treatment guidelines (2020)43:
    Erythema migrans Oral antibiotic therapy with doxycycline for 10 days, or
    amoxicillin or cefuroxime axetil for 14 days
    Neurological symptoms Intravenous ceftriaxone, cefotaxime, penicillin G, or oral
    doxycycline for 14–21 days
    Lyme arthritis Oral antibiotic therapy with doxycycline, amoxicillin,
    cefuroxime axetil, or azithromycin for 28 days
    Prophylaxis Single dose of oral doxycycline within 72 hours of tick removal,
    200 mg for adults and 4.4 mg/kg for children
    Treatment failure No additional antibiotics, referral to rheumatologist
    + +

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  37. Symptom Treatment guidelines (2014)39:
    Erythema migrans Minimum of 4-6 weeks of doxycycline, amoxicillin or cefuroxime,
    or a minimum of 21 days of azithromycin
    Neurological symptoms No explicit recommendation
    Lyme arthritis No explicit recommendation
    Prophylaxis 100–200 mg of doxycycline twice daily for 20 days for tick bite
    with evidence that feeding occurred
    Treatment failure Additional 4-6 weeks of antibiotics, then no further treatment

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  38. – Located in UK
    – Emphasizes communication between patient and healthcare
    professionals, including difficulty of diagnosis44
    – Advocates early recognition of Lyme for earlier treatment44
    Happy Medium?

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  39. NICE Guidelines[Cruickshank]
    Erythema migrans:
    Neurological symptoms:
    Lyme arthritis:
    Prophylaxis:
    Additional antibiotic therapy after treatment failure
    Symptom Treatment guidelines (2018)38, 44:
    Erythema migrans Oral antibiotics: 200 mg doxycycline per day for 21 days;
    amoxicillin: 1 g 3 times per day for 21 days; azithromycin: 500
    mg daily for 17 days
    Neurological symptoms Oral doxycycline: 200-400 mg per day for 21 days
    Intravenous ceftriaxone: 4 g per day for 21 days
    Lyme arthritis Oral doxycycline: 200 mg per day for 28 days
    Oral amoxicillin: 3 g per day for 28 days
    Intravenous ceftriaxone: 2 g per day for 28 days
    Prophylaxis No explicit recommendation
    Treatment failure After 2 courses of antibiotics, no further treatment, referral
    to a specialist appropriate to the patient’s symptoms

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  40. More Research
    is Needed
    Without reliable tools to diagnose and monitor Lyme, consensus can tend
    towards the personal and political rather than the scientific
    Photo: fs.blog/elephant

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  41. Objectivity?
    In 2007, science writer Kris Newby sent an information request under the
    Freedom of Information Act to the CDC to obtain emails and resumes from
    three employees45, 46, 47
    – The CDC took >5 years to fulfil request; legally, request should take ≈1
    month47
    – 3,000 pages of emails were provided, ≈1,200 pages were whited out47
    – Within the FOIA emails, Lyme patients and their treating physicians were
    called “loonies” and “quacks”48
    Photo: camdenarknews.com

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  42. Safe stewardship of antibiotics less
    contentious for other diseases, including:
    – Acne: < 6 months49
    – Tuberculosis: 6 months50
    – Recurring UTI: > 6 months51
    – Rheumatic fever: prophylaxis for 5
    years to entire life52
    Objectivity?
    Photos: pinimg.com, acne.org/whats-the-best-treatment-for-cystic-acne.html, ethnomed.org/wp-content/uploads/2020/04/ethnomed-tb-treatment-meds.jpg
    Common antibiotics for acne
    Common antibiotics for TB

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  43. Objectivity?
    Predatory lab testing:
    – Money made by taking
    advantage of weaknesses in
    current diagnostic tools and
    patient discomfort
    – Tests often involve unproven
    methods53
    Photo: lymescience.org

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  44. Objectivity?
    Predatory pseudoscience:
    – Money made from unproven and even dangerous cures
    Photos: sciencebasedmedicine.org/miracle-mineral-supplement-as-a-cure-all, https://www.fda.gov/news-events/press-announcements
    MMS, sold as a Lyme disease cure43

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  45. Consensus ≠ Removing Dissent
    The Scientific Method:
    – Create hypothesis
    – Test hypothesis by trying to disprove it
    – When hypothesis can’t be disproven after vigorous testing,
    consider true until proven otherwise
    Conflicting paradigms of Lyme disease suggest incomplete
    hypothesis testing
    Lack of consensus suggests new research questions are needed

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  46. Prevention is Key
    Always check for ticks after being in grassy or
    wooded areas
    – Check nightly in endemic areas13
    Consider use of insect repellents3:
    – 0.5% permethrin on clothing and gear
    – Oil of Lemon Eucalyptus and para-menthane-diol
    (found in Corymbia citriodora)
    – Picaridin (found in black pepper)
    – 2-undecanone (found in bananas, cloves,
    ginger, and Houttuynia cordata)
    Photo: modified from hikingthemidwest.com

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  47. Prevention is Key
    Remove attached ticks immediately and monitor for symptoms
    Photo: modified from [cdc]

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    Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis. BMJ
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