Dutch Serology

Medical topics with questions, information and discussion related to Lyme disease and other tick-borne diseases.
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hv808ct
Posts: 256
Joined: Wed 30 Jul 2008 4:11

Dutch Serology

Post by hv808ct » Tue 20 May 2014 15:03

Coumou J, Hovius JW, van Dam AP. Borrelia burgdorferi sensu lato serology in the Netherlands: guidelines versus daily practice. Eur J Clin Microbiol Infect Dis. 2014 May 17

Our study clearly shows that the far majority of sera sent to our laboratories—72% coming from GPs—originate from patient populations in which B. burgdorferi s.l. serology has a low [positive predictive value] PPV for LB. Based on our study, we estimate that 82% of the requests sent to our laboratories are not supported by recommendations in established guidelines, i.e. requests for patients with typical EM (5%), for patients with atypical symptoms (73%), or for patients having no symptoms at all (4%). The requests that were based on guideline recommendations consisted of symptoms compatible with disseminated LB (7%), an untreated EM in the past (2%) and requests for laboratory support for an atyptical skin lesion (10%).

Apparently, due to anxiety concerning ‘chronic LB’ in the Netherlands, many patients are tested in the absence of clinical symptoms compatible with LB. Despite a low a priori chance of LB, a positive serological test might make a physician consider antibiotic treatment, which is unlikely to result in cure of the patient when LB is not the cause of the symptoms, and has the risk of complications and delayed treatment of the actual diagnosis. Whether false positive tests in our database actually lead to unnecessary antibiotic treatment or incorrect diagnosis is unknown and—to our knowledge—there are no other data available on this issue. Since many guidelines, i.e. the European ESGBOR, the North-American IDSA and the Dutch CBO are, to a large extent, in accordance with each other on two-tier testing and case definitions, and since the incidence of LB in the Netherlands is similar to other European countries, our results most likely could be extrapolated to other European countries.

A recent expert meeting of the European Centre for Disease Control on laboratory diagnosis of LB recommended an improved dialogue between clinicians and medical microbiologist about the difficulties that both groups face when dealing with LB. With this study we hope to contribute to this dialogue by describing the patient population in which Dutch physicians consider LB in their differential diagnosis. Only in few cases, serological testing contributed to the final diagnosis of LB. Apparently, many physicians perform serological testing for LB on individuals with a low a priori chance of LB. Although a negative result lowers the suspicion of LB, the fact that around 5–10% of these cases will be positive due to either false-positivity or previous exposure to B. burgdorferi s.l unrelated to the current clinical symptoms could lead to over diagnosis of LB.

Future tests that can better distinguish between past and current infection would contribute to improved care for patients suspected of LB. Until such tests are available, we recommend better implementation of current guidelines and more education on the low PPV of current serologic tests for LB when not cautiously used. This will lower costs and prevent unnecessary antibiotic treatment.

duncan
Posts: 1370
Joined: Wed 5 Sep 2012 18:48

Re: Dutch Serology

Post by duncan » Tue 20 May 2014 15:32

Deja Vu all over again?

"Hard to get, easy to cure"?

In light of the recent admission in the United States that the annual incidence of Lyme had been UNDER ESTIMATED by a factor of 10 (300,000 vs 30,000), doesn't this discussion strike anyone as a little, I don't know, out of synch? ;)

hv808ct
Posts: 256
Joined: Wed 30 Jul 2008 4:11

Re: Dutch Serology

Post by hv808ct » Tue 20 May 2014 20:51

In light of the recent admission in the United States that the annual incidence of Lyme had been UNDER ESTIMATED by a factor of 10 (300,000 vs 30,000), doesn't this discussion strike anyone as a little, I don't know, out of synch?
Counting fingers and pennies is easy. Counting dynamic variables is another matter. The inability to provide an exact number of persons who have or once had disease X—instantly--is not the result of indifference, incompetence or conspiracy, but rather is due to the very real limitations of time, money, personnel, science, behavior, records access, infrastructure and various other things. A random sample of underestimations of other infectious diseases is noted below.

FLU
Bird Flu Prevalence Underestimated. Pooled data from H5N1 bird flu studies suggests that the World Health Organization may be underestimating infection and overestimating fatality.
The Scientist, By Hannah Waters | February 23, 2012

AIDS
Are we underestimating the proportion of virally-suppressed patients in the US?
AIDSMap, Gus Cairns, 15 March 2013.
Several presentations at the recent 20th Conference on Retroviruses and Opportunistic Infections in Atlanta suggest that previous estimates of the proportion of people with HIV in the USA who are on antiretroviral therapy (ART) and with an undetectable viral load may have been too low and may be closer to the proportion virally suppressed in Europe.

Valley Fever
A Disease Without a Cure Spreads Quietly in the West
NYT, By PATRICIA LEIGH BROWN
July 4, 2013
Dr. Benjamin Park, a medical officer with the C.D.C., said that the numbers of cases [of Valley Fever] are “under-estimates” because some states do not require public reporting. They include Texas, where valley fever is endemic along the Rio Grande.

TBE
Ticks Tick Borne Dis. 2012 Jun;3(3):197-201. Kunze U; ISW-TBE.
Tick-borne encephalitis (TBE): an underestimated risk…still: report of the 14th annual meeting of the International Scientific Working Group on Tick-Borne Encephalitis (ISW-TBE).

Hanta
Hantaviruses: Underestimated Respiratory Viruses?
Jan Clement, Piet Maes, Geneviève Ducoffre, Frank Van Loock, and Marc van Ranst.
Clin Infect Dis. (2008) 46 (3): 477-479.

Rabies
Although there is debate about the estimated health burden of rabies, the estimates of direct mortality and the DALYs due to rabies are among the highest of the neglected tropical diseases. Poor surveillance, underreporting in many developing countries, frequent misdiagnosis of rabies, and an absence of coordination among all the sectors involved are likely to lead to under-estimation of the scale of the disease. WHO Expert Consultation on Rabies - World Health Organization, 2013. apps.who.int/iris/.../9789240690943_eng.pdf.

H1N1
Previous CDC estimates of H1N1 swine flu cases have been based on laboratory-confirmed infection. But not everyone who gets the flu is hospitalized with the flu, and not everyone who dies of the flu was tested. And the tests miss many people who actually do have flu. To correct these underestimates, the CDC bases the new estimates on detailed clinical information reported by the Emerging Infections Network, a collaboration of 62 counties in 10 states, and on aggregate data reported from all states. This data is the used to derive estimates for the entire U.S. "This is not a switch or a change, just a bigger picture," Schuchat said.
“22 Million Cases of Swine Flu in U.S.”
Up to 6,100 Deaths -- and Counting -- as Flu Hits
By Daniel J. DeNoon, WebMD Health News, Nov. 12, 2009.

CHIK
It is likely that we have underestimated the number of CHIK cases in the United States, because (1) patients may not present for medical care, (2) healthcare providers may not recognize the clinical features of CHIK or submit specimens for appropriate testing, and (3) testing may miss cases if performed early (before production of IgM) or late (after IgM levels wane). In addition, we have reported cases identified at CDC, 1 state public health laboratory, and 1 commercial laboratory only. As far as we are aware, these are the only laboratories in the United States that offer testing for CHIKV.
Chikungunya Fever in the United States: A Fifteen Year Review of Cases.
Katherine B. Gibney, et al. Clinical Infectious Diseases 2011;52(5):e121–e126.

Q Fever
…because Q fever may resemble other diseases, be mild, or even cause no symptoms in some people, cases of human Q fever are likely under recognized in the United States and elsewhere. Around 3% of the healthy adult U.S. population and 10-20% of persons in high-risk occupations (veterinarians, farmers, etc.) have antibodies to C. burnetii, suggesting past infection.
“Annual Cases of Q Fever in the United States.”
November 13, 2013
Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)

duncan
Posts: 1370
Joined: Wed 5 Sep 2012 18:48

Re: Dutch Serology

Post by duncan » Tue 20 May 2014 21:01

Understood. Over the years, through many diseases, we've refined under-reporting or under estimating to a level that has resulted in the ten-fold error in Lyme estimation in the U.S.

Shouldn't that be a cautionary tale for other countries?

Margherita
Posts: 192
Joined: Thu 27 Sep 2012 18:22

Re: Dutch Serology

Post by Margherita » Tue 20 May 2014 21:20

@hv808ct,
Coumou J, Hovius JW, van Dam AP. Borrelia burgdorferi sensu lato serology in the Netherlands: guidelines versus daily practice. Eur J Clin Microbiol Infect Dis. 2014 May 17
Would you mind to procure me a link of the official article (Dutch serology)? For some reason I can't find it on the internet.

Thanks ;)

hv808ct
Posts: 256
Joined: Wed 30 Jul 2008 4:11

Re: Dutch Serology

Post by hv808ct » Wed 21 May 2014 13:52


RobertF
Posts: 65
Joined: Wed 25 Jul 2007 23:29
Location: The Netherlands
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Re: Dutch Serology

Post by RobertF » Sat 24 May 2014 22:06

This is a manipulated study with the objectiv to cut future cost of testing. Doctors should more often follow the Dutch guidelines and reduce bloodsample examination because the majority came out negativ with the C6 test. Only patients with specific LD symptoms like fasial paresis, arthritis and ACA should be tested

IN this study the C6 test was used with a cut off OD of >1,using the manufacturers calibrationsample although it is not clear if this suites the Dutch situation. At least a relaible elisa should have been performed together with the C6, then false negatieves had been detected.
The patients were tested with the C6 and positives were confirmed with Elisa and blot. There was no test performed on negative C6 patients although it is known that the European borelia strains react different with IR6 variants.

If somebody is interted in the full text please mail

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