Lyme controversy

Timeline of the Lyme controversy

1883 Erythema Chronicum Migrans (ECM) identified which we would call Lyme disease today.

1955 proved that ECM can be treated with antibiotics

1968 first American Lyme case treated successfully with antibiotics

1970 Lyme, Conneticut citizens become sick. Allan Steere (Yale) and William Mast and Burrows from the Naval Submarine Medical Center (NSMC) take patients

1976 NSMC declares citizens have ECM, treat patients with antibiotics

1977 Allan Steere declares disease is a new viral disease which he named Lyme disease, not ECM. 50% of his patients still sick after his antibiotic treatment. Uses steroids on patients which hinder immune system.

1982 Dr. Burgdorfer identified Lyme to be a spirochete: Borrelia Burgdorferi. Eventually declares Borrelia becomes persistant and chronic if not treated in time which requires longer courses of antibiotics

1983 Allan Steere changes his conclusion of his data from Lyme being a virus to Lyme being a bacteria that can be treated with 10 to 20 days of antibiotics (50% of his patients on his treatment plan still remained sick with Lyme disease)

1992 Assessment studies: Dr. Burgdorfers chronic Lyme disease would cost on average $100,000. Insurance companies attempt to curb costs by rejecting long term care for Lyme patients.

1993 Allan Steere publishes Lyme is treated with 10 to 30 days of antibiotics. He also changed his belief in chronic Lyme to Post Lyme Disease syndrome to explain why his patients were still sick. Insurance companies nationwide can legally cut off treatment for Lyme after 30 days.

1998 Lyme vaccine Lymerix launched using 2 proteins including Osp A. Allan Steere published warnings on Osp A being similar to a human protein. Once released, people who took the vaccine became sick and a lawsuit won that required the vaccine to be taken off the market.

2006 Attorney General Richard Blumenthal of Conneticut conducts investigation of IDSA and finds major conflicts of interests. American Journal of Law and Medicine in 2012 explains "The authors of the guidelines not only had significant connections to drug companies, related patents, and Lyme diagnostic tests, several were also being paid by insurance companies to corroborate treatment plans that denied treatment for chronic Lyme disease".

2012 A) Brown University: IDSA's sources to deny treatment to Lyme patients may be flawed.

B) Dr. Luc Montaigner (discovered HIV a year after Dr. Burgdorfer discovered Borrelia Burgdorferi) declares chronic Lyme denialism is the same as AIDS denialism.

Understanding the Lyme controversy
The Lyme controversy is about whether or not Lyme disease can become a chronic disease (called chronic Lyme) that requires longer courses of antibiotics to cure patients. The Infectious Disease Society of America (IDSA) claims that all patients are cured within 10 to 30 days of antibiotics and declares that any patient who claims they still are sick with Lyme disease symptoms are either hypochondriacs, have other non-Lyme medical conditions, have Post Lyme Disease Syndrome with lingering symptoms of fatigue, pain, or joint and muscle aches (the IDSA claims that their own theory of Post Lyme Disease Syndrome is unproven), or should be referred to psychologists because patients are imagening they are still sick, while the International Lyme and Associated Diseases Society (ILADS) claims that 30 days of antibiotics will only cure Lyme in its early stages, but if treatment is not started soon after being infected with Lyme, their Lyme disease will become chronic that requires longer durations of antibiotics until the patients Lyme symptoms disappear. Members of the IDSA continue to claim they have not seen any evidence that suggests Borrelia becomes chronic claiming a 95% cure rate. Follow up patient studies indicate that 35% of IDSA patients still have Lyme symptoms, and that these statistics only are taken from patients with early Lyme disease which indicates the Lyme treatment fail rate for the IDSA is way above 40%. The ILADS points out that at least twelve different human studies confirmed that Borrelia persists in humans after treatment proven by way of culture or molecular testing, and there are hundreds of animal studies that proves Lyme persists in animals even after standard antibiotic treatment. For further information between these two opposing medical groups, the ILADS website shows a comparison between the treatment guidelines between IDSA and ILADS.  

History of the Lyme controversy
The Lyme controversy started in the 1970s when the Connecticut Department of Health realized that a community in Lyme, Conneticut all developed junior rheumatoid arthritis (JRA). They began asking for help to investigate why this community became sick. Allan Steere, a Yale University affiliated rheumatologist began looking into the case, and at the same time William E. Mast and William M. Burrows from the Naval Submarine Medical Center (NSMC) started to investigate as well. The NSMC team linked the disease with Erythema Chronicum Migrans (ECM) and treated their patients with antibiotics which they published their findings in the Journal of the American Medical Association in August 1976. [1] Allan Steere rejected the notion that this disease could be ECM because 50% of his patients kept relapsing once he took his patients off antibiotics. Since the relapse rate was so high, he believed he discovered a new viral disease that had 2 different stages of infection; early and late manifestations. Allan Steere began publishing his first articles in 1977 naming this disease "Lyme" prescribing aspirin and steroids to his patients. [2] (Steroids significantly hinder the immune system which temporarily masks the symptoms for Lyme patients, and it also makes being cured much more difficult because it allows Lyme to spread even further throughout the body with little to no competition from the immune system.)

In 1982 Dr. Willy Burgdorfer identified the cause of Lyme to be a spiraled shape bacteria known as a spirochete that would be named after himself; Borrelia Burgdorfori. Dr. Burgdorfer believed that if Borrelia was not treated in the early stages of the disease, the disease would become persistent and harder to cure which would require longer courses of antibiotics to treat. Steere's definition of Lyme being caused by a virus had to be changed so that it matched the findings of Dr. Burgdorfer. Using his same data he collected treating Lyme disease patients that made him conclude Lyme was a virus, he published his new conclusion in the Annals of Internal Medicine in 1983 [3] which explained Lyme was a bacteria that can be treated in 10 days to 20 of antibiotics. In order to make this conclusion, Steere used his 2 stage viral infection theory that included the early viral infection and late manifestation infection (severe arthritic and neurological symptoms). [4] and divided late stage manifestations into 2 different categories; major and minor. Major included meningoencephalitis (severe headache, stiff neck, elevated white blood cell count) and minor included facial palsy, unusual heart rhythm, headache, joint pain, severe fatigue, mental confusion and memory loss. Over 50% of his patients still had these "minor" symptoms of Lyme disease, but now he could brush off those patients by claiming they were cured because they only had "minor" symptoms. To analyze why his patients were still sick, Steere theorized that they had chronic Lyme disease (although his definition differed from Dr. Burgdorfer's definition). He would later change his belief to Post Lyme Disease Syndrome explaining that Borrelia could cause permanent damage to joints and other parts of the body causing permanent pain in patients forever. Steere also theorized that many of his patients complaining they were still sick with Lyme disease either suffered from other non-Lyme related health conditions, or his patients had psychological issues.

Although these two competing ideologies existed in the medical community, many doctors treated patients with months of antibiotics (including stronger antibiotics such as Rocephin) which would not become controversial until 1992 when insurance companies began realizing that paying for Lyme disease was becoming costly. Assessment studies were indicating that treating a chronic Lyme disease patient described by Dr. Burgdorfer would cost an estimated $100,000 USD [5]. Many insurance companies including Prudential Metropolitan Life and Blue Cross Blue Shield of New Jersy began imposing a 28 day limit of antibiotics for Lyme disease patients in 1992. A year later, Allan Steere backed this policy by publishing his treatment guidelines in the Transactions of the American Academy of Insurance Medicine. Since these guidelines were backed by the insurance companies, Allan Steere had the support he needed to become the leading expert on Lyme disease and eventually had his guidelines adopted by the Infectious Disease Society of America's (IDSA) which would require doctors across the United States to follow. Steere now claimed that all stages of the disease can be treated with 10 to 30 days of antibiotics, allowing insurance company's to effectively set up cost containment policies to cut off funding for patients when they believed their costs were becoming too expensive. [6] Many patients were reporting that they had seen improvements in their health while on antibiotics, but once they were taken off their medication their symptoms came back. A recent examination of the sources that the IDSA has been using to justify cutting off treatment to patients was conducted in 2012 by Brown University. They concluded that the IDSA sources may be flawed because the sources they used did not match up with their conclusions. Brown University also found that 2 of their sources they quoted to disprove long term treatment actually showed patients significantly improving on long term antibiotic treatment.[7] Another study published in The Open Neurology Journal also had similar findings to the Brown University study. [8] 

The main opposition group that the IDSA and Allan Steere had always faced had been their very own patients that kept complaining they were still sick with Lyme disease. In 1999 a legislative hearing was called in the State of Connecticut on this issue with patients writing heartbreaking stories of how horrible living with this disease was, not being able to receive medication for the disease, and selling their houses due to hospital bills. [9] Allan Steere was receiving private letters from Lyme patients as well. One of these personal letters was written by Robyn Greco who explained her Lyme story to Steere. Greco explained that she was 29 years old living in northern New Jersey who had been suffering from Lyme disease for over 7 years. Her Lyme test was positive in 1990 and received 2 weeks of antibiotics and her symptoms improved, but came back when she stopped taking antibiotics. Four years later her symptoms were at its worst. She was diagnosed by a doctor in 1994 with chronic Lyme disease and she started antibiotics for a second time. For over a year she received antibiotics and the majority of her symptoms were disappearing. In 1996 her doctor became worried that he could lose his license if he continued to prescribe long term antibiotics to his Lyme patients so he stopped treating Lyme disease patients, which included Greco. By 1999 her health was collapsing and in desperation she wrote to Allan Steere in hopes that she could explain to him why she needs to be put back on treatment. Steere did not respond to Greco, nor did he bother meeting her in person to diagnose her, but instead he published what she wrote in the New York Times and diagnosed her stating "What I suspect is that she doesn’t have Lyme disease but some kind of psychiatric illness." [10] [11] 

Further patient outrage occurred when the IDSA published their 2006 guidelines which was a reiteration of Allan Steere's 1990s guidelines. Due to the outrage, the Attorney General Richard Blumenthal of the State of Conneticut conducted an investigation of the IDSA and their guidelines and released their report in 2008. The Attorney General found several flaws in how the IDSA operates which included their sources for their guidelines, IDSA members were hand picked and not elected according to the rules of the IDSA, and there were major conflicts of interests with 13 out of the 14 members of the IDSA benefiting financially on keeping the current definition of Lyme disease the same. Nine IDSA members received money from vaccine manufacturers and four were funded to create test kits. During the investigation, several key members of the IDSA wrote the guidelines for the American Academy of Neurology (AAN) on Lyme disease, and then quoted that same AAN study as their source (quoting themselves) while also failing to mention that they were being investigated by the Attorney General. [12] Again in October of the same year, several IDSA members including Allan Steere wrote against the existence of chronic Lyme disease and published their findings in the New England Journal of Medicine (NEJM) hailing the IDSA guidelines [13]. This study was sent to most doctors in the United States without explaining that several authors were also IDSA members, which made the study look independent of the IDSA. An article published in the American Journal of Law and Medicine in 2012 also explains that "The authors of the guidelines [IDSA] not only had significant connections to drug companies, related patents, and Lyme diagnostic tests, several were also being paid by insurance companies to corroborate treatment plans that denied treatment for chronic Lyme disease" [14].

According to the IDSA, 95% of their patients are cured following their guidelines, but many patient follow up studies would indicate that at least 35% of their Lyme patients treated would relapse and their Lyme symptoms would come back. [15] Since these follow up studies only take patients who's Lyme was treated right after infection in the early stage of the disease, the IDSA treatment fail rate/relapse rate may be significantly higher than 40%, which would explain why many IDSA Lyme patients are angry at the IDSA guidelines claiming they do not work. Since they write the official guidelines that are sent to doctors across the United States, as well as their articles they publish in the NEJM and AAN, most doctors only read IDSA articles which means many doctors are still uneducated on Lyme disease. If doctors independently study this disease and they refuse to follow the IDSA guidelines, insurance companies file complaints against these doctors where many have their licenses revoked. Several states have created laws protecting doctors that wish to deviate from the IDSA guidelines, but many doctors have to treat patients in secret so that they do not lose their license. These doctors that treat chronic Lyme disease are called Lyme Literate Medical Doctors (LLMD) who are trained by the International Lyme and Associated Diseases Society (ILADS) which recognizes and treats chronic Lyme disease and the co-infections that come with Lyme.

Analyzing the evidence of the IDSA

It is impossible to disprove the existence of chronic Lyme disease scientifically in humans because there are no tests that can indicate whether or not a Lyme patient had been cured from their Lyme disease. Since there are hundreds (if not thousands) of peer reviewed studies that indicate Borrelia persists standard antibiotic treatment in animals [16], the IDSA first attempt to either disprove these studies or completely ignore them, or they admit that there is still a Borrelia infection in Lyme patients, but the antibiotics have changed the Borrelia spirochetes which makes them insignificant to patients persisting symptoms. A 2012 study published in the NEJM [17] (Wormser is an author of this study and a member of the IDSA) stated that 17 people with extended Lyme disease symptoms had been reinfected with Lyme disease (by being bit by another tick) indicating that chronic Lyme does not exist, but rather explained patients are being reinfected with Lyme disease. Although their study sample was small and hand picked, major news websites from NPR to ABC took this study seriously. The patients in the study did not remember coming in contact with ticks, but they became sick with Lyme disease at least a year later since they were treated. These assumptions are problematic because Borrelia is an opportunistic parasite that changes, and can hibernate in a patient for years while waiting for the immune system to weaken before it activates itself again. There is no way of knowing if these cases were caused by reinfection (which is possible, even though there is no evidence that these patients came in contact with ticks), or Borrelia hibernated and reactivated itself (which is also possible). 

Another recent 2012 Yale [18] study claimed that Borrelia can form both cysts and biofilms, but they concluded that because Borrelia did not leave its biofilm form after they temporarily made conditions better for the spirochete, they assumed the Borrelia spirochetes died. They then used this assumption to prove that Post Lyme disease syndrome exists and not chronic Lyme, but the study did not examine the biofilms long enough to prove that the spirochetes died, especially if some strands of Borrelia can survive up to 2.5 years in their biofilm.

Analyzing the evidence for chronic Lyme disease
Borrelia's closest spirochete relatives are the Syphilis spirochetes which have about a 40% similarity in genome structure. It is well established that Syphilis becomes chronic if it is not treated in its early stages of the disease and because of how similar Syphilis is to Borrelia, Borrelia becomes a candidate for having the potential for becoming chronic. Many Lyme researchers also believe that since Borrelia can form cysts and biofilms [19] like other chronic diseases, it automatically becomes a chronic disease. [20] Biofilms are shields that Borrelia builds around themselves that protect them from the host's immune system and antibiotics.The link between biofilms and chronic diseases is well established within the scientific community, especially when the US Center for Disease Control estimates that 80% of chronic diseases are caused by pathogens that form biofilms. [21]

Other researchers like Stephen Barthold (Researched Lyme disease for over 25 years for the National Institute of Health) believe that it does not matter that Borrelia can form biofilms or cysts because he can take rats or mice that had been infected for a year, treat them with antibiotics, and recover live, healthy spirochetes in the skin where neither antibiotics nor the immune system can reach which proves that the longer Borrelia lives in the host, the more persistent the disease becomes. Borrelia also has self defence mechanisms that are able to evade antibiotics and the immune system without needing to be in their cyst or biofilm. Stephen Barthold further explains that there is a misconception about how antibiotics work stating that

"antibiotics are not disinfectants, they only reduce bacterial numbers by working against dividing bacterial populations. They can never sterilize a person of every last vestige of an infection. Effective therapy with antibiotics still needs the immune system of the host—the mouse, the dog, the person—to clean up the rest of the infection and effectively eliminate the invading organism.” With Lyme, that’s not always possible. “In the late stages of infection you have organisms inhabiting extracellular spaces like the skin, which do not get well-perfused by blood. So antibiotics do not reach them. In addition, the spirochetes are not in a state where they are particularly vulnerable.” In order to take up the antibiotic, they’ve got to divide, “yet they’re quiescent.” Since they’re not dividing, the antibiotic doesn’t impact them. Therefore, “to be effective in the chronic phase of Lyme disease you have to treat the individual for more and more time with increasingly higher levels of antibiotic for a cure. You are working with an organism which, at least in experimental animals, causes one hundred percent persistence in the face of totally effective host immunity. This is true for dogs, mice, monkeys, rats, hamsters. In any species we have ever studied, this bacteria is evolutionarily designed to persist in completely immune-competent hosts. We know that with mice, with dogs, and with monkeys, you can establish infection, you can treat these animals with antibiotics, and you can cure them by all indices,” including culture, antibody response, or detection of DNA. “But then, if you sit back and wait, they become antibody-positive again, because you have not completely eliminated the infection. “When a perfectly immune-competent host cannot eliminate the spirochete you are bound to have survival of the organism. All these factors, together, mean that the chances of not having an effective cure for patients in the late stages of infection are pretty high." [22]

Since the beginning of the controversy, scientists have been able to extract live and healthy spirochetes from human Lyme patients after standard antibiotic treatment [23]. This scientifically proves that Borrelia survives standard antibiotic treatment in humans and indicates that Lyme can become a chronic disease, but since these studies were only conducted on small groups of Lyme patients (due to a lack of funding), and the Borrelia strand was a common European strand, these studies are not taken as serious as they should be. The greatest ally of chronic Lyme denialists is that research for this disease is not very well funded, and since Borrelia has to be studied en vivo (just like Syphilis) Borrelia is more expensive to research. If these studies had more funding, researchers could extract live healthy spirochetes from larger groups of Lyme patients with different strands of Borrelia after they received standard antibiotic treatment instead of the small groups of Lyme patients they had to use. 

Even if a person did not understand the evidence for chronic Lyme disease, all we have to look at are the Lyme patients themselves. It is clear that ILADS patients are healthy and are able to return to their normal lives working and raising families which proves the ILADS guidelines work, where as over 50% of IDSA patients are bed sickened and labelled as hypochondriacs unable to hold normal lives.


Conclusion
From the beginning Dr. Burgdorfer had enough evidence to prove that Lyme is a chronic disease if left untreated. Interestingly, a year after Dr. Burgdorfer identified Borrelia Burgdorferi, Dr. Luc Montagnier discovered the Human Immunodeficiency Virus (HIV) which soon after the popular AIDS denialist movement that dominated many medical communities tried to disprove his work after he proved a link between HIV and AIDS. During an interview for La Nutrition in 2012 at the UNESCO in Paris, Dr. Montagnier was interviewed on Lyme disease. He publicly stated that Lyme disease is a chronic disease that is similar to AIDS in that research was not being very well funded, and nobody is taking the disease seriously as they should. He replied "it's a global disease, not just in France, the infection can be found throughout the whole world. I don't want to compare it to AIDS, but it's almost like AIDS. In fact this bacteria is a close relative to the syphilis spirochete”. [24]


Although the chronic Lyme denialists won and dominate our medical communities today, there is no denying that ILADS is becoming more popular among the population and the scientific community, and more media coverage is making people aware of the dangers of this disease. Dr. Burton Waisbren who is one of the founding fathers of the IDSA explained that chronic Lyme disease does exist in his book titled Treatment of Chronic Lyme Disease: Fifty-One Case Reports and Essays in Their Regard. The chronic Lyme documentary Under Our Skin has become widely watched, even by celebrities who are currently being treated for Lyme disease [25]. Dr. Phil hosted a show on chronic Lyme [26], and even the discovery channel series Monsters Inside Me had a segment on a patient who suffered from chronic Lyme disease plus a co-infection [27]. Not only is there overwhelming evidence that chronic Lyme disease is real [28], the entire world is starting to speak out with protests occurring in over 30 countries. [29]

It is only a matter of time until the chronic Lyme denialists lose their foothold in our medical community just like the AIDS denialists did, and Lyme patients will one day be able to receive the medicine they so desperately need.


[1] Weintraub, Pamela (2010-04-01). Cure Unknown: Inside the Lyme Epidemic (p. 45). Macmillan. Kindle Edition.

[2] Weintraub, Pamela (2010-04-01). Cure Unknown: Inside the Lyme Epidemic (p. 51). Macmillan. Kindle Edition.

[3] Steere, Allan. "The Early Clinical Manifestations of Lyme Disease", Annals of Internal Medicine, 1 July 1983, Vol 99, No1 http://annals.org/article.aspx?articleid=696718

[4]Weintraub, Pamela (2010-04-01). Cure Unknown: Inside the Lyme Epidemic (p. 92). Macmillan. Kindle Edition.

[5] Weintraub, Pamela (2010-04-01). Cure Unknown: Inside the Lyme Epidemic (p. 200). Macmillan. Kindle Edition.

[6] (303-4)

[7] Brown University, "Lyme retreatment guidance may be flawed", August 30, 2012  http://news.brown.edu/pressreleases/2012/08/lyme

[8] The Open Neurology Journal, 2012, 6, (Suppl 1-M2) 79-87, A Reappraisal of the U.S. Clinical Trials of Post-Treatment Lyme Disease Syndrome, Dr. Brian A. Fallon http://benthamscience.com/open/toneuj/articles/V006/SI0078TONEUJ/79TONEUJ.pdf

[9] Attorney General Blumenthal, "Public Hearing on Lyme Disease", February 24, 1999, 
http://www.ct.gov/ag/cwp/view.asp?A=2130&Q=294656

[10]  Grann, David. "Stalking Dr. Steere over Lyme Disease" The New York Times, June 17, 2001
http://www.nytimes.com/2001/06/17/magazine/17LYMEDISEASE.html?pagewanted=4

[11] Weintraub, Pamela (2010-04-01). Cure Unknown: Inside the Lyme Epidemic (p. 18). Macmillan. Kindle Edition. "   

[12] Connecticut Attorney General's Office, "Attorney General's Investigation Reveals Flawed Lyme Disease Guideline Process, IDSA Agrees To Reassess Guidelines, Install Independent Arbiter," May 1, 2008
http://www.ct.gov/ag/cwp/view.asp?a=2795&q=414284

[13] New England Journal of Medicine, A Critical Appraisal of “Chronic Lyme Disease”, October 4, 2007 http://www.nejm.org/doi/full/10.1056/NEJMra072023

[14] American Joumal of Law & Medicine, 38 (2012): 196-224 American Society of Law, Medicine & Ethics Boston University School of Law Cure Unwanted? Exploring the Chronic Lyme Disease Controversy and Why Conflicts of Interest in Practice Guidelines May Be Guiding Us Down the Wrong Path, Johanna Ferguson http://www.keepandshare.com/doc/3830829/cure-unwanted-j-ferguson-2012?da=y&dnad=y

[15] Buhner, Stephen Healing Lyme, Silver City: Raven Press, 2005. Print p.56

[16] Lyme Info, Persistence of Lyme Disease Dispite Antibiotic Treatment; 77 Peer-Reviewed Studies, 1977-2012
http://www.lymeinfo.net/medical/LDPersist.pdf

[17] Neighmond, Patti. "Recurring Lyme Disease Rash Caused By Reinfection, Not Relapse". NPR, November 14, 2012
http://www.npr.org/blogs/health/2012/11/14/165115733/reinfection-with-lyme-disease-may-cause-chronic-symptoms

[18] Yale University, Spirochete antigens persist near cartilage after murine Lyme borreliosis therapy. Journal of Clinical Investigation, July 2nd, 2012 http://www.jci.org/articles/view/58813

[19] Plos One, "Characterization of Biofilm Formation by Borrelia burgdorferi In Vitro"
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0048277

[20] Perspective Series, The application of biofilm science to the study and control of chronic bacterial infections, 2003 http://www.jci.org/articles/view/20365/files/pdf

[21] Walkey, Marylin MD. Biofilms, the Key to Understanding Chronic Disease
http://www.flyingcraneacupuncture.com/docs/biofilms.pdf

[22] Weintraub, Pamela (2010-04-01). Cure Unknown: Inside the Lyme Epidemic (p. 256). Macmillan. Kindle Edition.

[23] Weintraub, Pamela (2010-04-01). Cure Unknown: Inside the Lyme Epidemic (pp. 247-248). Macmillan. Kindle Edition.

[24] Montagnier, Luc. "Lyme disease, autism and chronic infections" March 10, 2012 http://www.youtube.com/watch?v=LRQ-NhEkLXU

[25] CALDA, “Real Housewife” Yolanda Foster under treatment for Lyme disease December 8, 2012 http://lymedisease.org/news/lyme_disease_views/news-real-housewife-yolanda-foster-under-treatment-for-lyme-disease.html

[26] Dr. Phil, Deadly Consequences April 14, 2012 http://www.youtube.com/watch?v=reqyYSAFb9I

[27] Monster's Inside Me, "Teenager contracts Lyme disease" 2012 http://animal.discovery.com/tv-shows/monsters-inside-me/videos/teenager-contracts-lyme-disease.htm

[28] Cameron, Daniel, MD. "Proof That Chronic Lyme Disease Exists"  May 25, 2010 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876246/


[29] Peter Russel, WebMD Boots, "Lyme disease treatment sparks Whitehall protest" 10th May 2013
" http://www.webmd.boots.com/travel/news/20130510/lyme-disease-treatment-protest



The German Federal Government, Tick bites: do not underestimate and trivialize, Friday 13, August 2010 http://www.bundesregierung.de/Content/DE/Artikel/2010/08/2010-08-13-zeckenbisse.html