Erythema migrans-like rash illness at a camp in North Carolina: a new tick-borne disease?

BACKGROUND: Borrelia burgdorferi, the causative agent of Lyme disease, has never been isolated from a patient thought to have acquired Lyme disease in any southeastern state. OBJECTIVE: To investigate 14 cases of an erythema migrans (EM)-like rash illness that occurred during 2 summers at an outdoor camp in central North Carolina in an effort to determine the etiologic, epidemiological, and clinical aspects of this illness. METHODS: Using active surveillance, we identified cases of clinically diagnosed EM in residents and staff of the camp. We collected clinical and demographic information; history of exposure to ticks; acute and convalescent serum antibodies to B. burgdorferi, Rickettsia rickettsii, and Ehrlichia chaffeensis; and cultures for spirochetes from biopsy specimens of skin lesions. Serum samples from a group of residents and staff who did not develop rashes were tested for the same antibodies. We speciated ticks removed from people and collected from vegetation. RESULTS: We identified 14 cases of EM-like rash illness during the 2 summers. Of the 14 case-patients, 10 had associated mild systemic symptoms and 1 had documented fever. All 14 case-patients had removed attached ticks, and 8 remembered having removed a tick from the site where the rash developed a median of 12 days earlier (range, 2-21 days). One tick removed from the site where a rash later developed was identified as Amblyomma americanum, the Lone Star tick; 97% of ticks collected from vegetation and 95% of ticks removed from people were A. americanum. No spirochetes were isolated from skin biopsy specimens. Paired serum samples from 13 case-patients did not show diagnostic antibody responses to B. burgdorferi or other tick-borne pathogens. CONCLUSIONS: This investigation suggests the existence of a new tick-associated rash illness. We suspect that the disease agent is carried by A. americanum ticks. In the southern United States, EM-like rash illness should no longer be considered definitive evidence of early Lyme disease.

Eliminating access to anonymous HIV antibody testing in North Carolina: effects on HIV testing and partner notification.

Anonymous HIV testing may attract persons who might otherwise not be tested but may hinder partner notification. We evaluated the effects on North Carolina's HIV testing and partner notification programs of policy changes that eliminated and later restored anonymous testing in 82 counties. We used an interrupted time-series design to compare counties eliminating with counties retaining anonymous testing. We analyzed HIV testing and partner notification data from before, during, and after elimination of anonymous testing. After elimination of anonymous testing in 82 counties, the mean monthly level of testing (+/- SE) increased by 45%, or 548 (+/- 123) tests per month, while in 18 counties that retained anonymous testing, there was a 63% increase, or 802 (+/- 162) tests per month (p > .05). Among men of all races, testing increased by 16%, or 155 (+/- 35) tests per month, in counties that eliminated anonymous testing; and by 51%, or 305 (+/- 42) tests per month (p < .05), in counties that retained anonymous testing. After elimination of anonymous testing, both county types experienced similar increases in the rate of partners notified. However, partner notification was more successful if the index patient was tested confidentially; 2.7 times as many partners per index patient were notified and counseled. There was no effect on testing or on partner notification rates following restoration of anonymous testing. Substantial community opposition to eliminating anonymous testing was encountered. The policy change appeared to result in a slight decrease in testing among men and a slight increase in partners notified. Programs considering the elimination of anonymous testing should weigh these potential gains and losses, as well as the impact on relationships between the public health and advocacy communities