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American Journal of Epidemiology Vol. 153, No. 7 : 718
Copyright © 2001 by The Johns Hopkins University School of Hygiene and Public Health

LETTERS TO THE EDITOR

RE: "RACIAL DIFFERENCES IN REPORTED LYME DISEASE INCIDENCE"

Isobel El-Shanawany, Ruth Liebling, Katy Roué, Peter Jeffery and Iain Robbé

Centre for Applied Public Health Medicine University of Wales College of Medicine Cardiff CF14 4XN, United Kingdom


   INTRODUCTION
TOP
 INTRODUCTION
REFERENCES
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We would like to congratulate Fix et al. (1Go) on a clear study about the reported incidence of Lyme disease. The study was well carried out, especially the section on surveillance procedure. It shows that there is a decrease in the discrepancy of reported incidence between Whites and African Americans when looking at a focus of endemicity. However, there is still a significant difference in the reported incidence of Lyme disease among Whites and African Americans in Maryland's focus of endemicity, the Upper Eastern Shore. The authors explain away this difference by saying that there may be a similar actual incidence rate, although the reported rates are different. It is suggested that African Americans do not notice one of the major signs–erythema migrans. Indeed, on the Upper Eastern Shore, erythema migrans has an incidence rate ratio of 5.7 (95 percent confidence interval: 2.4, 13.9) whereas, for other symptoms, such as extracutaneous manifestations and arthritis, the incidence rate ratios are only 0.9 (95 percent confidence interval: 0.6, 1.5) and 0.7 (95 percent confidence interval: 0.4, 1.1), respectively.

We would like to know whether the difference between reported incidence of Lyme disease among Whites and African Americans is truly because African-American people are indeed suffering from erythema migrans but do not notice it because of their dark skin. Have the authors looked into the state of health care in Maryland? It may be a common situation for African Americans to notice the erythema migrans, but they might be unaware of the significance of the rash or inhibited from consulting a doctor because of a lack of health insurance. This issue was not discussed by the authors.

The authors could have adjusted for the income status of cases or compared the findings with those from another state with different health care services. A study within the African-American population alone would be interesting in order to see how many people there are who have not registered as having Lyme disease but who do, in fact, have erythema migrans. It may then be possible to see whether or not the erythema migrans was noticed and, if so, why nothing was done about it.


   REFERENCES
TOP
 INTRODUCTION
 REFERENCES
INTRODUCTION 
 REFERENCES 
 

  1. Fix AD, Penã CA, Strickland GT. Racial differences in reported Lyme disease incidence. Am J Epidemiol 2000;152:752–6.[Abstract/Free Full Text]
 

THE AUTHORS REPLY

Alan D. Fix, G. Thomas Strickland and César A. Peña

Department of Epidemiology and Preventive Medicine University of Maryland School of Medicine Baltimore, MD 21201
Epidemiology and Disease Control Program Maryland Department of Health and Mental Hygiene Baltimore, MD 21201


   INTRODUCTION 
TOP
 INTRODUCTION
 REFERENCES
 INTRODUCTION 
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We agree with El-Shanawany et al. (1Go) that our data allow us only to speculate about the reasons for the difference in reported erythema migrans (EM) between Whites and African Americans. There are likely multiple factors responsible for the difference. As noted in the Discussion section of our paper (2Go), we recognize that racial differences in the reporting of EM may be due to lack of awareness of the significance of the rash or to difficulties in access to care. Although adjustment for income status may provide some insight, our data do not contain such information. Certainly, further study would be necessary to specifically explore discrepancies between actual incidence and report of EM.


   REFERENCES 
TOP
 INTRODUCTION
 REFERENCES
 INTRODUCTION 
 REFERENCES 
 

  1. El-Shanawany I, Liebling R, Roué K, et al. Re: "Racial differences in reported Lyme disease incidence." (Letter). Am J Epidemiol 2001;153:718.[Free Full Text]
  2. Fix AD, Penã CA, Strickland GT. Racial differences in reported Lyme disease incidence. Am J Epidemiol 2000;152:756–9.[Abstract/Free Full Text]

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I. El-Shanawany, R. Liebling, K. Roue, P. Jeffery, I. Robbe, A. D. Fix, G. T. Strickland, and C. A. Pena
RE: "RACIAL DIFFERENCES IN REPORTED LYME DISEASE INCIDENCE"
Am. J. Epidemiol., April 1, 2001; 153(7): 718 - 718.
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