Tuesday, December 12, 2006

An Increase in Incidence: Massachusetts Public Health Department Failure to Prioritize Lyme Disease Awareness and Prevention- Kristen Calcagni

Over the past fifteen years, Lyme Disease has become one of most common vector-transmitted diseases in the United States (1). The sole method of transmission is through infected ticks, which must bite an individual and feed on their blood to transmit the disease (1). It is commonly characterized by erythema migrans (rash) and flu-like symptoms (2). When left untreated, Lyme Disease can cause arthritis and cardiovascular or neurologic damage in its later stages, which can have detrimental effects on a person’s health (2). Prevention of tick bites and early treatment are the only way to prevent late-stage Lyme (2). When the disease was first recognized in the late 1970s, no national awareness and education campaign was implemented, leaving prevention efforts to either state or local public health departments. Limited funding for education and research, along with increasing incidence of the disease and a focus on disease prevention as an individual problem instead of a statewide problem, have caused Lyme Disease to affect a large portion of Massachusetts’ population. Massachusetts has failed to prioritize Lyme Disease awareness and prevention.

Despite current education and prevention efforts, the occurrence of Lyme Disease is drastically increasing in Massachusetts. In 1995, 189 cases of Lyme Disease were reported, compared with 2336 in 2005 (3). Over the last ten years, the Massachusetts incidence rate of 36.5 cases per 100,000 has grown to 4.6 times the national incidence rate of 7.9 cases per 100,000 (4). The majority of cases have onset in June, July, and August (4), with a higher incidence in males, especially in those ages 5-14 (4). Elderly males are also at a higher risk than the general population of contracting the disease (4). Occurrence is not limited to one particular area of the state, although Cape Cod (especially Nantucket and Dukes counties) and in Berkshire county have the highest incidence (1). Residents of these areas are at a higher risk of contracting Lyme Disease, since the highest incidence in the state occurs there.

With the current incidence rates suggesting that in every group of 100,000 people, 36 of them will develop the disease over the course of a year (4), it is becoming a larger threat to the health of residents. Vaccines are unavailable for Lyme Disease (1), so personal measures, such as tick checks, are the only way for prevention. Social behavioral research on factors that influence an individual’s willingness to take preventative measures to protect one’s self from Lyme disease show prevention is dependent on several factors (5). One’s perception of personal risk and general knowledge about the disease and its severity (5) are important factors that affect the steps an individual takes to prevent contracting it. More importantly, the incidence of Lyme Disease in the state of residence has a large effect on how an individual does or does not protect himself or herself from the disease (5). Awareness of the disease plays a major role in how large of a threat an individual perceives Lyme Disease (5).

Both research (5) and the Health Belief model imply people will only take preventative measures if they believe they are at risk of contracting the disease and that these preventative actions would decrease their risk of getting Lyme Disease. Therefore, Massachusetts residents do not believe they are at risk or they do not believe that checking for tick presence will decrease their risk of contracting the disease. Education efforts about how to protect oneself against tick bites and the effects of Lyme Disease, focused especially on those living in high risk areas such as the Berkshires or young males and the elderly, could help decrease incidence in the state.

Along with a lack of personal knowledge about Lyme and its severity, funding for Lyme Disease research and education by the state is also poor. In 2001, approximately $156,000 of the $8.5 billion (6) budgeted by Massachusetts to the Department of Health and Human Services was set aside for Lyme Disease research, treatment, and education programs. Four years later, about $11 billion was budgeted to the Department of Health and Human Services, with only $594,000 (7) of that allocation going towards Lyme Disease research, treatment, and education programs. In those intervening four years, the number of cases of Lyme Disease reported per year increased from 1164 to 2336 cases (4), while the budget only increased by $400,000, despite an increase in the Health and Human Services budget by over 3 billion (7). Prevention is the only way to stop the spread of Lyme, yet the state is not providing a large amount of money for research or education efforts. Without enough funding, researchers cannot develop more effective methods to treat those with Lyme Disease or develop more efficient ways to kill ticks or prevent tick bites. More funding would allow the Public Health Department to expand resident education and awareness to implement a statewide campaign to stop the spread of Lyme Disease. For an increase in the number of cases of approximately 200% in four years, the State is not recognizing the problem with a proportional increase in funding for research and prevention programs.

Another method to control Lyme incidence that is costly would be to target the tick population itself. If the State allocates more money towards research and education, then in areas such as Cape Cod and Berkshire county with a higher incidence of Lyme Disease (1), it might be possible for communities to spray pesticides (8) to kill tick populations in public areas, such as parks and recreation areas. Without increased funding to provide for such programs, the majority of local communities cannot afford pesticide spraying on their own. The State needs to take initiative to start pesticide spraying programs and further education campaigns, since leaving it to the local public health departments has only increased the incidence of Lyme Disease.

In addition to hurting research and education efforts, the State is also sending out a message about Lyme. By failing to invest more money in research and education efforts, the State does not demonstrate to its residents that it considers Lyme Disease a significant threat to the public’s health or that the state is capable of controlling the disease. According to the Theory of Reasoned Action, the social norm regarding a certain behavior affects a person’s intention to perform a behavior. In terms of Lyme Disease, an individual needs to believe that society perceives prevention of the disease as important in order for one to take actions to prevent it. Seeing the limited funding for Lyme Disease may cause residents to believe that either the state does not think the disease is a serious threat to their health or that the state does not believe it is a threat that they can control. If the state is not worried about the increasing incidence of Lyme, then why should its residents?

The problems of the increasing incidence of Lyme and the lack of funding for research and education programs are both the result of a lack of public awareness of the disease. A social behavioral approach can increase awareness, which would result in a successful intervention. Individuals need to believe that Lyme is a threat, the severity of Lyme Disease would impair their lives, and checking for ticks would benefit them by saving them from the disease (8, Health Belief Model). Since in reality, no single approach will lead to preventing the transmission of Lyme to residents, the State should attack the problem on both the individual and the community level by using the mass media is to raise awareness of Lyme (9).

Massachusetts must start getting people to think about Lyme disease again before residents will believe that it is a threat to their health. The media plays a major role in creating public awareness of certain diseases (9), yet has ignored the current increase in Lyme Disease incidence in the state. According to Agenda-Setting Theory, the media has the power to tell people what to think about (10). Residents will think and talk about Lyme Disease if they see it often enough in the news and in newspapers.

The media has the power to influence how residents think about Lyme Disease, in addition to causing them to think about it(10). By concentrating on a certain issue, the media can shape public perception of an issue’s importance (9). Agenda-Setting Theory can be used to promote Lyme as an issue that should be on the public agenda. Use of the news to create public awareness and interest in controlling the spread of Lyme will help Massachusetts put Lyme Disease on the agenda. Once Lyme becomes an issue of importance to residents and decreasing its incidence is on their agenda, they will then put pressure on policy makers to increase funding for Lyme research and prevention efforts. If Lyme Disease remains on the agenda long enough, it will cause residents to create a large enough stir to show its prevention is an important matter to the public. Legislators will be more likely to increase funding because of the residents’ demands that the State to do more to decrease Lyme incidence.

As a result of using the Agenda Setting Theory, funding for research and prevention efforts will increase. Residents will also believe they should perceive Lyme as a threat because of the media attention given to it, and they will be more likely to exercise preventative actions (Health Belief Model, Theory of Planned Behavior). In addition to now seeing Lyme as a threat to their health, residents will see how simple it is to protect themselves from ticks by checking after being in a situation where one is in contact with ticks. Self-efficacy is an important part of the Theory of Planned Behavior since people are more likely to perform an action if the social norms regarding prevention have changed and if they believe that they are able to do prevent Lyme through these actions. If people realize how simple it can be to check for ticks, which will also result if the State frames the problem correctly in the media (10), they might begin to do so on a more frequent basis. Many people will be spared from contracting Lyme Disease as a result of using the media to place the disease on the public agenda.

With the increased funding that will result from Lyme Disease being on the public agenda, communities will be able to fund programs, such as pesticide spraying in areas that have high tick concentrations, that target the actual tick population. By decreasing the tick population with pesticides, or like in Cape Cod where there is a trial program in place to spray deer feeding in certain areas with pesticides that kill ticks the deer carry (11), the number of infected ticks will decrease over time. Many communities will not be able to afford such programs on their own, so the State will need to provide funds for communities to set up pesticide programs. With some of the extra funding for Lyme prevention going towards pesticide spraying, the tick population will begin to decrease.

In the long run, decreasing the incidence of Lyme Disease will result from increasing education and awareness efforts by the State. Increasing awareness of Lyme should not only be an individual problem, but also a community problem. In order for incidence to begin to decrease, Massachusetts needs to integrate both individual and community level interventions to target not only knowledge and perceptions about Lyme Disease, which will create greater intention to take preventative measures against Lyme, but also target the actual cause of the problem, which is the infected tick population. Successful interventions will only happen with increased State funding for these programs. Using the Agenda-Setting Theory will allow the State to influence public perception of Lyme, which in turn will put the disease on the agenda. Once Lyme is on the public agenda, both individual and community preventative actions will increase, which will decrease the number of people contracting Lyme. Prioritizing Lyme Disease awareness and prevention in Massachusetts will have to start with the State use of the media to further its goals, which will ultimately lead to a decrease in incidence of Lyme in the future.

1.Commonwealth of Massachusetts, Department of Public Health. Lyme Disease in Massachuetts: An Update for Health Care Providers 2002. Available at: http://www.mass.gov/dph/cdc/epii/lyme/lymedis.pdf. Accessed October 1, 2006.

2.Commonwealth of Massachusetts, Department of Public Health. Tickborne Diseases in Massachusetts: A Physician’s Reference Manual. Available at: http://www.mass.gov/dph/cdc/epii/lyme/physician_manual.pdf.Accessed October 1, 2006.

3.Commonwealth of Massachusetts, Department of Public Health. Tickborne Disease Website. Available at: http://www.mass.gov/dph/cdc/epii/lyme/lymehp.htm.Accessed October 10, 2006.

4.Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. Lyme Disease Statistics. Available at: http://www.cdc.gov/ncidod/dvbid/lyme/ld_statistics.htm. Accessed October 4, 2006.

5.Harrington, JE, Campbell, GL, Bailey, RE, et al. Predisposing Factors for Individuals’ Lyme Disease Prevention Practices: Connecticut, Maine, and Montana. American Journal of Public Health. 1997;87; 2035-2038.

6.Commonwealth of Massachusetts, Office of the Comptroller. Available at: http://www.mass.gov/bb/fy2001h1/budget_recommendations/departments/dph.htm. Accessed October 13, 2006.

7.Commonwealth of Massachusetts, Office of the Comptroller. Available at: http://www.mass.gov/eoaf/budget/fy05/budrec05/dept/hdph.htm. Accessed October 13, 2006.

8.Centers for Disease Control and Prevention. Programs in Brief: Infectious Diseases, Lyme Disease. Available at: http://www.cdc.gov/ncidod/dvbid/lyme/lyme_brochure.pdf - search=%22LYME%20DISEASE%20PUBLIC%20HEAL. Accessed October 15, 2006.

9.Wikipedia. Important Aspects of Theory. Available at: http://en.wikipedia.org/wiki/Agenda-setting theory. Accessed December 4, 2006.

10.McCombs, M.E., & Shaw, D.L. (1972). The Agenda-Setting Function of Mass Media. Public Opinion Quarterly, 36 (Summer), 176-187.

11.Cape Cod Cooperative Extension. Deer Ticks and Lyme Disease on the Cape and the Islands. Available at: http://www.capecodextension.org/doc.php?22,,4919p,www1917,0,0,Index,ck_deerticklyme.html. Accessed October 23, 2006.


Blogger Leah said...

I think that you shed light on a very important issue. I don't believe that disease severity is really understood (unless you or a friend/family member have suffered through it)...but Lyme often has a delayed diagnosis (imperfect testing + ambiguous symptoms)- and its chronic untreated symptoms (fatigue, arthritis) can have a pervasive affect on someone's ability to hold their job, take care of their family, etc. Great critique!

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