Dr. Bartley Cryan:

I will finish if I the Deputy does not mind. In Cork University Hospital, we use the most internationally validated test available. Our laboratory was accredited by a UK body, Clinical Pathology Accreditation or CPA, until recently when we changed over to Irish National Accreditation Board, INAB, accreditation. The laboratory was visited recently by INAB. All the medical microbiology laboratories in the country had INAB visitations last year or will have them this year and all are being accredited. As part of this accreditation, they must all have in place a quality system that includes the use of a CE marked assay system and must be validated internationally and locally to ensure international standards apply. We are also part of a quality control system under which we receive anonymised specimens from a central laboratory in the United Kingdom. These are tested and the results compared. This is done on an ongoing basis in all areas.

All the medical staff in the department undergo full continuing medical education and so forth. Teaching and knowledge of Lyme disease are widespread in medicine. As I stated, I work in an area where there are four highly active neurologists for adults and one for children. In many cases, they want to find a diagnosis of Lyme disease because it is a treatable condition, whereas many neurological conditions are difficult to treat or can be treated inadequately. As many of them are relapsing-remitting and autoimmune, they are hard to treat. Lyme disease is a diagnosis that is sought because it can be treated.

The condition is generally treated with antibiotics, either tetracycline in the early stages or intravenous antibiotics in the later stages. Three weeks of treatment is generally adequate. There are no studies showing benefit beyond that period. For instance, if people are treated for six months on intravenous antibiotics, it is necessary to have intravenous access for the entire period, which brings its own pathologies. There have been cases of people acquiring candida bloodstream infections from which some have died. Long-term use of cephalosporins can result in C. diff infections, which are serious and increasing in number. People can also experience gallbladder problems from the build-up of biliary sludge as a complication of using these antibiotics. For this reason, the use of antibiotics is not a trivial matter.

The reason we use validated tests is obvious. Our main goal is obtain the correct diagnosis. The same circumstance used to arise in respect of brucella which, thankfully, is no longer a problem. In north County Cork, half the farmers and all of the veterinarians had antibodies to brucellosis 20 years ago. If a farmer or vet experienced depression or backache, his or her condition was not necessarily caused by the brucella, however. They had antibodies to brucella in their blood all the time. One must take this into consideration when diagnosing any infection.

In New England, where there is a high incidence of Lyme disease, one would have to say that a background population - it is probably between 9% to 10% in this country, depending on the area - will have antibodies to borrelia that are probably not causing any problems and may not be the cause of any current symptoms. For instance, if we obtain positive serology in a patient who has a neurological condition, we will do a lumbar puncture to look for the presence of antibodies in the cerebral spinal fluid which would go with neurological Lyme disease. We will then do some further testing on it to make sure it is being produced in the cerebral spinal fluid. We also do this in other scenarios.

Generally speaking, one has a list of differentials with different priorities. If one has a list of illnesses causing a neurological condition, including Lyme disease, and nothing is becoming obvious, the patient will be retested several times and may even be treated to ensure Lyme disease is ruled out of the diagnosis. There is, therefore, a bias towards having treatable conditions ruled out.

We were asked whether chronic Lyme disease exists. It is definitely the case that people who are not treated for Lyme disease can develop chronic complications. People who have been treated for Lyme disease can get what is called a post-Lyme syndrome. Post-infective syndromes are relatively common. For example, Epstein-Barr virus is tremendously common among teenagers at the moment and many of them will experience a protracted period of fatigue post having the infection. This is well described after a number of viral and bacterial infections.

There is a syndrome, so-called chronic Lyme disease, which is described in the literature I have been reading as causing excessive fatigue, neurocognitive issues, aches, pains, joint pains and muscle weaknesses. It is a relatively weak syndrome in terms of clinical syndromes. Senator Crown asked whether it could be associated with Lyme disease and the absence of antibodies. I do not believe there is evidence in the literature to support such a position.

What would be the etymology of the condition if Lyme disease were associated with it? Is it persistent infection? If a person had persistent infection, antibodies would be produced.

The problems with the antibodies and false negatives are early in the infection, within the first two months where somebody has the rash. When they are tested, 30% are found to be negative. The rash is so characteristic that there is very little else it can be. In New England such people get tetracycline and the person may repeat the serology in a month to confirm that it has become positive.

As I said, there is a drive towards getting treatable diagnoses on an ongoing basis with the clinician we are dealing with, and Lyme disease is one of those. On education, all the GPs in our area are very well aware of Lyme disease, as are all the neurologists in our area. Most have trained in the United States. Generally speaking, most of the physicians in the country will have trained in the United States. They will be very cognisant of Lyme disease.

We do not have specific Lyme disease specialists in the country. We have infectious disease consultants, although not very many, and neurologists who will deal with the vast majority of Lyme disease cases. Rheumatologists are involved to a lesser extent, but that would usually be an American associated Lyme disease.