Incidence and management of Lyme disease: a Scottish general practice retrospective study.

BACKGROUND: The true burden of Lyme disease in primary care in Scotland is unknown. Epidemiological data is currently based on laboratory confirmed reports as there is no mandatory reporting of clinical cases AIM: To analyse data from general practice in NHS Highland (North) over a six year period to assess the incidence and management of Lyme disease in primary care. DESIGN & SETTING: This was a retrospective descriptive study. Study data was extracted from all 63 general practices within NHS Highland (North) from 2017 to 2022. METHOD: Lyme disease consultations were identified via Lyme-related clinical read codes, borrelia test requests, free text 'tags' and/or Lyme disease antibiotic scripts. RESULTS: Using read codes to identify patients with Lyme disease/ suspected Lyme disease gave an estimated average annual incidence of 124/100,000 population, which was 2.1-fold more than those based on laboratory confirmed reports only. Incidence figures increased to 5.2-fold more (362/100,000 population) when those patients with Lyme disease/ suspected Lyme disease (identified via readcodes, laboratory test requests and free text 'tags') who were given antibiotic treatment were taken into account. Local 'hotspots' of infection were identified. Analysis of the antibiotic data indicates that antibiotic prescribing in NHS Highland largely follows NICE guidelines. CONCLUSION: This data analysis pathway can, and should, be rolled out to assess the incidence and management of Lyme disease in primary care throughout the whole of Scotland to allow appropriate resources to be allocated.

Tick-borne diseases in the North Sea region-A comprehensive overview and recommendations for diagnostics and treatment.

As part of the NorthTick project, co-funded by the European Union through the European Regional Development Fund and the North Sea Region Programme, specialists in the field of tick-borne diseases from seven North Sea countries co-operated with patient organisations and governmental health care institutions to provide this comprehensive overview of diagnostics and treatment recommendations in the region for Lyme borreliosis, Borrelia miyamotoi infection, tick-borne encephalitis, human granulocytic anaplasmosis, rickettsiosis, neoehrlichiosis and babesiosis. The main conclusion is that the recommendations in these northern countries are essentially the same, with very few differences. This overview presents the current diagnostics and provides useful clinical guidance.

Tick-borne diseases under the radar in the North Sea Region.

The impact of tick-borne diseases caused by pathogens such as Anaplasma phagocytophilum, Neoehrlichia mikurensis, Borrelia miyamotoi, Rickettsia helvetica and Babesia species on public health is largely unknown. Data on the prevalence of these pathogens in Ixodes ricinus ticks from seven countries within the North Sea Region in Europe as well as the types and availability of diagnostic tests and the main clinical features of their corresponding diseases is reported and discussed. Raised awareness is needed to discover cases of these under-recognized types of tick-borne disease, which should provide valuable insights into these diseases and their clinical significance.

Longitudinal variation in SARS-CoV-2 antibody levels and emergence of viral variants: a serological analysis.

BACKGROUND: Serological assays are being used to monitor antibody responses in individuals who had SARS-CoV-2 infection and those who received a COVID-19 vaccine. We aimed to determine whether such assays can predict neutralising antibody titres as antibody levels wane and viral variants emerge. METHODS: We measured antibody levels in serum samples from a cohort of 112 participants with SARS-CoV-2 infection using ten high-throughput serological tests and functional neutralisation assays. Serum samples were taken at baseline and at up to four subsequent visits. We assessed the effects of time and spike protein sequence variation on the performance and predictive value of the various assays. We did correlation analyses for individual timepoints using non-parametric Spearman correlation, and differences between timepoints were determined by use of a two-tailed Wilcoxon matched-pairs signed rank test. FINDINGS: Neutralising antibody titres decreased over the first few months post-infection but stabilised thereafter, at about 30% of the level observed shortly after infection. Serological assays commonly used to measure antibodies against SARS-CoV-2 displayed a range of sensitivities that declined to varying extents over time. Quantitative measurements generated by serological assays based on the spike protein were better at predicting neutralising antibody titres than those based on nucleocapsid, but performance was variable, and manufacturer positivity thresholds were not able to predict the presence or absence of detectable neutralising activity. Although we observed some deterioration in correlation between serological measurements and functional neutralisation activity, some assays maintained an ability to predict neutralising titres, even against variants of concern. INTERPRETATION: The ability of high-throughput serological assays to predict neutralising antibody titres is likely to be crucial for evaluation of immunity at the population scale. These data can facilitate the selection of the most suitable assays as surrogates of functional neutralising activity and suggest that such measurements might be useful in clinical practice. FUNDING: US National Institutes of Health and National Health Service Research Scotland BioResource.

Introduction of IgM testing for the diagnosis of acute Lyme borreliosis: a study of the benefits, limitations and costs.

Testing for IgM antibodies to Borrelia burgdorferi in Scottish patients with suspected Lyme borreliosis was introduced in 2018 to supplement the IgG testing already in situ. Results from 2018 to 2020 were assessed alongside available clinical data to evaluate the utility of IgM testing in serum. An estimated false positive rate of 25.5% was observed with IgM immunoblot vs 80.1% for IgM chemiluminescent immunoassay (CLIA). IgM testing can aid earlier diagnoses if used within a selective two-tier testing protocol: only patients with acute onset of symptoms should be tested for IgM CLIA but confirmation by immunoblot and consideration of clinical picture is necessary.

Longitudinal variation in SARS-CoV-2 antibody levels and emergence of viral variants: implications for the ability of serological assays to predict immunity.

BACKGROUND: Serological assays are being deployed to monitor antibody responses in SARS-CoV-2 convalescents and vaccine recipients. There is a need to determine whether such assays can predict immunity, as antibody levels wane and viral variants emerge. METHODS: We measured antibodies in a cohort of SARS-CoV-2 infected patients using several high-throughput serological tests and functional neutralization assays. The effects of time and spike protein sequence variation on the performance and predictive value of the various assays was assessed. FINDINGS: Neutralizing antibody titers decreased over the first few months post-infection but stabilized thereafter, at about 30% of the level observed shortly after infection. Serological assays commonly used to measure antibodies against SARS-CoV-2 displayed a range of sensitivities that declined to varying extents over time. Quantitative measurements generated by serological assays based on the spike protein were better at predicting neutralizing antibody titers than assays based on nucleocapsid, but performance was variable and manufacturer positivity thresholds were not able to predict the presence or absence of detectable neutralizing activity. Even though there was some deterioration in correlation between serological measurements and functional neutralization activity, some assays maintained an ability to predict neutralizing titers, even against variants of concern. INTERPRETATION: The ability of high throughput serological assays to predict neutralizing antibody titers is likely crucial for evaluation of immunity at the population scale. These data will facilitate the selection of the most suitable assays as surrogates of functional neutralizing activity and suggest that such measurements may have utility in clinical practice.

Comparison of SARS-CoV-2 serological assays for use in epidemiological surveillance in Scotland.

Background: Sero-surveillance of SARS-CoV-2 is crucial to monitoring levels of population exposure and informing public health responses, but may be influenced by variability in performance between available assays. Methods: Five commercial immunoassays and a neutralising activity assay were used to detect antibodies to SARS-CoV-2 in routine primary care and paediatric samples collected during the first wave of the pandemic in NHS Lothian, Scotland as part of ongoing surveillance efforts. For each assay, sensitivity and specificity was calculated relative to consensus results (majority of immunoassays positive = overall positive) and neutralising activity. Quantitative correlation was performed between serological and neutralising titres. Results: Seroprevalence ranged from 3.4-7.3 % in primary care patients and 3-5.9 % in paediatric patients according to different immunoassays. Neutralising activity was detectable in 2.8 % and 1.3 % respectively. Relative assay performance changed depending on comparison to immunoassay consensus versus neutralising activity and qualititative versus quantitative agreement. Cross-reactivity with endemic seasonal coronaviruses was confirmed by neutralising assay in false positives for one immunoassay. Presence of false positives for another assay was found specifically in paediatric but not adult samples. Conclusions: Five serological assays show variable accuracy when applied to the general population, impacting seroprevalence estimates. Assay performance may also vary in detection of protective neutralising antibody levels. These aspects should be considered in assay selection and interpretation in epidemiological studies.

The development of an IgG avidity Western blot with potential to differentiate patients with active Lyme borreliosis from those with past infection.

OBJECTIVES: Current serological methods cannot distinguish active from past infection with Borrelia burgdorferi sensu lato. The aim of this study was to develop an IgG avidity Western blot and assess its potential to differentiate patients with early and late Lyme borreliosis (LB) i.e. active disease, from those infected in the past. METHODS: An IgG avidity Western blot was developed. Penalized linear discriminant analysis (PLDA) was employed to compare the Western blot/avidity Western blot profiles of an evaluation panel consisting of 75 sera from patients with early (n = 26) and late (n = 24) LB and past infection (n = 25). The PLDA models produced were used to predict infection stage for 20 well characterised sera from the Centers for Disease Control and Prevention (CDC) Lyme disease serum repository and 112 routine seropositive sera (disease stage unknown), to validate and assess the usefulness of the avidity Western blot/avidity Western blot and PLDA approach. RESULTS: PLDA correctly classified 40/51 (78%) of patients when early LB and past infection groups in the evaluation panel were compared. Likewise, when late LB and past infection groups were compared, 34/49 (69%) were correct. The resultant PLDA models correctly predicted infection stage for 18/20 (90%) of the CDC sera, validating the use of the avidity Western blot/avidity Western blot and PLDA approach. When tested with the routine sera, 21/29 (72%) tested with the early LB vs. past infection model were correct but only 32/83 (39%) with the late LB vs. past infection model. Past infection was predicted for 40/112 (35%) of the routine sera, 80% of which correlated with the clinical picture. CONCLUSION: The Western blot/avidity Western blot with PLDA approach shows exciting potential for being able to predict disease stage in some patients with LB, which could improve patient management.

More specific bands in the IgG western blot in sera from Scottish patients with suspected Lyme borreliosis.

AIMS: To identify further Western blot bands that may be specific in the diagnosis of Lyme borreliosis. METHODS: The Borrelia burgdorferi antibody profiles of 270 western blot positive patients and 241 western blot negative patients from 2008 were examined. RESULTS: 27 different non-specific bands were detected in both groups. Six of 27 (22%) of the non-specific bands were detected significantly more in the western blot positive patients compared to the western blot negative patients (20 kDa, p<0.0001; 28 kDa, p<0.002; 36 kDa, p<0.002; 37 kDa, p<0.007; 48 kDa, p<0.023; 56 kDa, p<0.028; two-tailed F test). CONCLUSION: Results suggest that the 20, 28 and 48 kDa bands should be regarded as specific.

Audit of the laboratory diagnosis of Lyme disease in Scotland.

An audit was performed on the laboratory diagnosis of lyme disease in Scotland. The problem of a significant number of patients with clinical symptoms of lyme disease being reported as seronegative or equivocal by the confirmatory Western blot test was identified. Comparisons of current practice were made with American and European standards, and the Western blot scoring system revised. When applied retrospectively (April 2003 to March 2004), 39 (33 %) of 116 serum samples previously negative or equivocal became weak positive or stronger. Thirty-one (80 %) of these 39 samples were from patients with clinical details suggestive of early lyme disease. The changes were implemented and assessed prospectively for 6 months. There was a significant increase in the proportion of equivocal results, with fewer negatives compared to the same time period 1 year previously. This audit has helped clinicians in the diagnosis of lyme disease and the management of these patients in Scotland.