Dr D Ross – Lyme Disease in British Forces Germany

What I do want to do is to perhaps to address what I call the ‘pink and fluffy’ side, something that David (Owen) alluded to in the first talk about are we taking this seriously? And, to try to demonstrate to you in Germany why we began to take this seriously. I have to say, it was prompted by the fact that we had a complaint from a patient and also I then did an interview which, I have to say, I think was factually inaccurate on what I advised about how to remove ticks. So there is some background work why we did that.

We have got a population of about 55,000 in Germany. Of which a third are soldiers, a third are children. We live in very rural areas like this, on the whole, and so, it was because of this, the fact that we’d had a complaint, I’d given a bit of what I think was probably wrong, not the current advice, that we realised that we needed to do something about this. And what we really needed to do was first off quantify the problem. How big a problem was Lyme Disease in Germany ? and then think about what we could do about raising awareness.

Because as I have said we have a population of about 55,000. It is a very mobile population. The populations turns over by a third every year. It is spread over a geographical area the size of Scotland. So it is quite difficult to keep awareness up. And equally a third of our healthcare staff change over.

What we do have, though, in the military, Lyme Disease is a notifiable disease. Equally, we have a very young population, a third of them being children and, of the Lyme Disease cases that I have been involved with, we have seen quite a large proportion presenting with facial palsy.

Doctors, I am sure, are taught wrongly, that if you’ve got this rash then it must be Lyme Disease; if you haven’t got the rash, then it’s not Lyme Disease and that was one of the big areas that we had to target was the believe of our healthcare professionals on how Lyme Disease can present.

So looking at the Data: 2002 we saw about 40 cases. I think, even though it is a notifiable disease, there is a lot of under-reporting that goes on. Only this week, I am aware of a case in a medical centre not far from where I work because I have heard it talked about in the community of a case of Lyme Disease, proven Lyme Disease, yet I have not yet been notified.

But we had 40 cases, 23 were in the military and 17 in the civilian - quite a large proportion of those in children. Last year, we only had 28 cases. I would like to say, it was because some of the work that we have done around raising awareness, of which I’ll show you how we did that in a second, was the reason for that. But, in fact, it probably wasn’t at all because we had, as everyone knows, a large deployment to Iraq last year, so therefore we didn’t see many military cases at all of Lyme Disease but what we did in fact see was an increase in the number of civilian cases.

What we also know is that Lyme Disease in Germany tends to increase from the north to the south. Most of our population is based in the north. You will note the anomaly between 38 and 40 that I have shown that’s because I was slightly lazy and couldn’t be bothered to update the slide. But what we are seeing is probably about 50 cases a year. This is a better map at showing distribution of how it changes across Germany.

And what I want to show now is so, we have managed to quantify the problem, what we then wanted to do was to decide how we could raise awareness. And we decided to take a two - pronged approach to this. The first was to raise awareness amongst healthcare professionals. So in March every year for the last two years we have run what we call a road-show whereby we take some of the slides that I have shown and some of the German information about Lyme Disease and go around to all of the medical centres in Germany, of which there are 18 of them just so that we are raising awareness amongst health professionals of what to do.

The second thing was, we needed to get the message home to our populations and we felt it was quite important to split it between our two types of populations. First, the military population, who may be more prone to being bitten by ticks because they are living out in the field on exercise, they are living in conditions where you know hygiene isn’t the best. So we wanted to aim something at them and then we wanted to aim it also at our civilian population particularly young children and educating parents what to do because, I think, there is evidence in the literature that suggests that even if you are bitten by a tick as long as that tick is removed within 24 hours your chances of developing chronic disease are much less.

So we wanted to do that and the way we did it was to develop two sets of leaflets: one aimed specifically at the military and one aimed specifically at the civilian population. But the thrust of it, really, which I think was key, was ensuring that individuals during the tick season which particularly in Germany really runs probably from March through till probably September is that people should regularly check themselves. So soldiers if they are on exercise should get their buddy (because we use this buddy-buddy system quite often) to check themselves for ticks in exposed areas and we believe that education is a strong method of prevention because if people know about a problem they are more likely to avoid it. So we have produced these leaflets, one is aimed at the military, hence the it is on a black background and one is aimed at the civilian population which is a bit more pink and fluffy.

So what have we seen? Well, as I said, we have seen a reduction in the number of ? cases in 2003 and 2002 but there were more civilian cases. This could be because we have raised awareness so therefore people are taking their children along to the medical centre. The number of military cases decreased because of operational reasons. We’ve also seen cases being reported slightly earlier. I mentioned the tick season starts in March. Again, I wonder whether that’s because we have raised awareness.

The key, I think, is that why are we taking this approach in raising awareness? With a bit of luck we won’t necessarily stop the incidence of Lyme Disease but we will hopefully get people to get more appropriate and quicker access to treatment.