Dr. Paul McKeown:

I thank the Chairman for the opportunity to respond. I will discuss the toolkit first. It was an initiative developed between the European Centre for Disease Control, ECDC, which is the equivalent of the CDC in the United States of America. It is an overarching infectious control forum for the member states in managing infectious diseases. Across Europe there are a range of vector borne diseases, that is, diseases carried largely by insects or insect-like creatures. Lyme disease is carried by ticks, which are not insects. They are like beetles. Tick borne diseases are very common across Europe. Lyme disease is the most common, but there are other diseases such as tick borne encephalitis which is extremely common in eastern Europe but not in central Europe. We do not see any cases unless they are imported.

I refer to these diseases because whenever we examine them we try to take a holistic approach because what will prevent one disease may reduce the incidence of a number of diseases. The ECDC has always had an interest in this, as has HPSC, and in 2012 a notifiable entity of neuroborreliosis was introduced. In doing so we followed ECDC advice that it was best to count those forms of diseases of which one is very sure. We know from evidence that about 10% of cases of Lyme disease end up as neuroborreliosis. We have been seeing about ten cases, on average, a year since we started collecting the figures in a systematic way. That would suggest we have ten or 15 times that number of erythema migrans Lyme disease, which is the milder form. I will return to the toolkit.

Chronic Lyme disease exists. As a locum GP 25 years ago I worked in Bristol which is, I understand, quite near the New Forest. Deputy McLellan referred to it. I saw it very regularly. Lyme disease is extremely interesting. Dr. Cyran referred to serology. We know from studies undertaken in different countries and Ireland that blood tests will show up Lyme disease. One will be left with a ghost of Lyme disease in one's blood if one was infected in the past. Studies would suggest that urban areas have relatively low levels of people with these antibodies, whereas rural areas have quite high levels. One study in Ireland showed that about 1% of a sample of the Dublin population had antibodies to Lyme disease, whereas parts of the west had 15%.

That indicates that many people are bitten by ticks and exposed to the Lyme bug which is carried in the saliva of these ticks. Whenever they feed they have a blood feast. Only a small proportion go on to develop erythema migrans, and an even smaller percentage go on to develop the more serious forms. The more serious forms are very debilitating and difficult to live with.

We consider it extremely important to raise awareness of this issue. We were very happy to become deeply involved with the ECDC initiative, namely, the development of its toolkit which has material that was pre-prepared. We made it relevant for GPs, other clinicians and the general public in Ireland. In previous years we produced material for national parks and linked with support groups that contacted us. We identified which organisations could provide literature, material and advice on what to do. HPSC has a lot of information on its website. We are in the process of bringing together a group of the scientific advisory committee which will extend and carry on this work.

The toolkit was designed to raise awareness, and the awareness raising for Lyme disease has to take place across a spectrum. It is something of which we can all be aware. There is quite a high degree of awareness of Lyme disease among our GPs and clinicians, but that can be continued.

I was also asked about specific age groups. We know from our cases and serological studies that individuals who are most likely to be bitten by a tick and have a positive Lyme disease test or go on to develop Lyme disease are those who come in close contact with ticks in their habitat. Ticks live outside in woodland and heathland and people who are in those areas, because of their job or leisure interests, are those most likely to come into contact with them.

We see about ten cases of neuroborreliosis a year. We have a pretty good idea of the number of cases. Our departments of public health are keenly aware of the condition, link closely with GPs and report back data from their areas to GPs. One step I was very pleased to see and which I am grateful to the department for was that Lyme disease as neuroborreliosis became notifiable. The act of making something notifiable brings it to people's attention.

We were asked whether the general public was aware of Lyme disease. I do not think we can ever be totally happy with our awareness of many diseases. The awareness raising we have undertaken in HPSC will continue because it is important for people to have the information at the back of their heads, in particular since it is seasonal. Lyme disease can be contracted throughout the year, but whenever people are out more and in contact with nature more they need to take more precautions. On our website we have a lot of information about how people can minimise the chances of being bitten by a tick and developing Lyme disease.