Dr. Armin Schwarzbach:

I thank members for their questions. We could spend two or three hours discussing all the points that have been made. I will focus on the key points. A clinical diagnosis is needed in this case. The diagnosis must be made on the basis of the symptoms, which is very difficult. One needs to give time to the patient. An hour or more is needed to ask him or her about his or her medical history. One must then find a correlation with a possible tick bite or other differential diagnosis. That means it is a speaking medicine. This is not done in universities or hospitals because of a lack of time. This is done by general practitioners or by ambulance personnel. That is how it is done in Germany.

The doctors trust the ELISA technique. The HIV ELISA was founded in 1980. The antigenicity of borrelia burgdorferi is so complicated that it was a big problem to develop a good ELISA that is sufficiently sensitive. There are several working groups in this area. The EU knows about the problem. That is why €1.1 million was provided to improve the sensitivity of the test. We developed new antigens as part of this new test system. More subspecies have been found. Borrelia is not one bacteria. It consists of several subspecies. Borrelia miyamotoi is a brand new subspecies which has been detected in Russia and the USA.

We have to look for several subspecies. The ELISA technique is a very weak technique because one could just put some antigens on the ELISA particle. The immunoblot technique is a better technique. On the other hand, not all patients develop antibodies in the body. The next problem can arise if the patient is treated at an early stage with doxycycline, which is normally used. In such circumstances, no antibody production will start in the body, which makes it complicated to diagnose. If a clinical diagnosis is required, one must do a good anamnesis and a good symptomatology, including the differential diagnosis. One needs to give the patient time. It is not possible to do all of this in ten minutes.

University studies that were done in the 1980s and 1990s do not accept chronic Lyme disease because they do not see chronic Lyme disease. If patients go to their GP, rather than a hospital, with symptoms like those of fibromyalgia, rheumatoid arthritis or multiple sclerosis, they will be sent to a neurologist for spinal fluid analysis. If that test is negative for Lyme disease, it will be excluded from consideration. Neurologists also use spinal fluid for a very weak ELISA technique to exclude this. That is impossible. It cannot be diagnosed by laboratory tests. A clinical diagnosis is required. This needs experience. It cannot be done by a normal GP without any experience.

The universities do not teach students about Lyme disease. Like other doctors of my age, I did not hear anything about this when I was a student. Lyme disease is a very young disease. It started in 1981. The oldest patient is a 5,000 year old iceman. It has existed for a very long period. There are two different tendencies in the medical world. The first of them relates to those with chronic infections. The second of them relates those in the acute or subacute stages, who tend to go to hospitals. In the other cases, they tend to go to GPs. We have to care more for those with chronic infections rather than those in the acute or subacute stages. It would be good to do this.

The therapies are definitely too short. One cannot tell someone they have been healed of a bacteria after four weeks. This is what we do not see in our patients' group. If one treats a patient with doxycycline for two or three weeks, one has to monitor the patient. One cannot leave the patient alone. One has to keep an eye on what happens afterwards. It can be a very traumatic disease. The committee has heard some examples. This is my daily work in the hospital and the laboratory.

Ireland is not alone in having this problem. There is a strong move in this direction in the Czech Republic, Poland and Finland, which I will visit soon. Each of those countries plans to do something about this problem to help chronically infected patients who have received tick bites. Not everybody sees the tick bite. That is what it makes it complicated. Not everybody has the typical symptoms. Some 10% of patients have the summer flu, for example. Nobody asks whether one has received a tick bite when one has the summer flu. It is not a typical question for a GP. One has to know about this. One has to learn about it.

This can be a life-threatening disease at the end. Chronic Lyme disease is not a disease for the hospital. It is a matter for rheumatologists and neurologists. The psychiatric question is very important at the end. If one spends one's whole life suffering from pain, if one uses many painkillers and immunosuppressive medicines and if there is an explosion of bacteria in one's body, one will feel hopeless, particularly if one loses one's place in the workforce. We need to consider what happens in such circumstances from a psychiatric perspective. It is typical for patients to be sent to a psychiatric specialist. I have seen thousands of such cases - not just in Ireland - in recent years. It is not an Irish problem.

I was also asked about the definition of a post-Lyme disease symptom. Most doctors postulate. That is not an explanation for me because I do some special tests. I have been asked about these tests. They came from the tuberculosis world. One such test is the lymphocyte transformation test, which is the gold standard for tuberculosis. Many patients - I do not know the exact number - do not react on the antibodies used in the immunoblot or ELISA techniques. They react on the T cells. I think we have to look increasingly at the T cells in the coming years. There is a tendency in the scientific world and in laboratories-----