title: A prospective study among patients presenting at the general practitioner with a tick bite or erythema migrans in The Netherlands.
abstract: BACKGROUND
  We performed a nationwide prospective study on the transmission risk for Borrelia to humans, investigating symptoms and serology at enrolment and three months after tick bites, and after standard treatment for erythema migrans (EM). Aiming to quantify the infection risk at point of care by physicians, we explored risk factors such as tick testing for Borrelia and assessment of the duration of the tick's blood meal.
  
  
  RESULTS
  Questionnaires, blood samples and ticks from patients who consulted one of 307 general practitioners for tick bites (n = 327) or EM (n = 283) in 2007 and 2008, were collected at enrolment and three months later at follow-up. Borrelia burgdorferi sensu lato DNA was detected in 29.3% of 314 ticks, using PCR/reverse line blot and real-time PCR on the OspA gene. Seroconversion in C6 ELISA, IgM or IgG immunoblots for Borrelia-specific antibodies was observed in 3.2% of tick bite cases. Fourteen tick bite cases had evidence of early Borrelia infection, of which EM developed among seven cases. The risk of developing EM after tick bites was 2.6% (95%CI: 1.1%-5.0%), and the risk of either EM or seroconversion was 5.1% (95%CI: 2.9%-8.2%). Participants with Borrelia-positive ticks had a significantly higher risk of either EM or seroconversion (odds ratio 4.8, 95%CI: 1.1-20.4), and of seroconversion alone (odds ratio 11.1, 95%CI: 1.1-108.9). A third (34%) of the cases enrolled with EM did not recall preceding tick bites. Three EM cases (1%) reported persisting symptoms, three months after standard antibiotic treatment for EM.
  
  
  CONCLUSIONS
  One out of forty participants developed EM within three months after tick bites. The infection risk can be assessed by tick testing for Borrelia at point of care by physicians. However, further refining is needed considering sensitivity and specificity of tick tests, accuracy of tick attachment time and engorgement.
authors.affiliation: Epidemiology and surveillance unit, Centre for Infectious Disease Control Netherlands, National Institute for Public Health and the Environment, Bilthoven, The Netherlands. Agnetha.Hofhuis@rivm.nl
authors.forename: Agnetha
authors.initials: A
authors.lastname: Hofhuis
authors.forename: Tineke
authors.initials: T
authors.lastname: Herremans
authors.forename: Daan W
authors.initials: DW
authors.lastname: Notermans
authors.forename: Hein
authors.initials: H
authors.lastname: Sprong
authors.forename: Manoj
authors.initials: M
authors.lastname: Fonville
authors.forename: Joke W B
authors.initials: JW
authors.lastname: van der Giessen
authors.forename: Wilfrid
authors.initials: W
authors.lastname: van Pelt
mesh_terms: D000818:Animals; D001898:Borrelia / Q000472:pathogenicity; D058005:General Practitioners; D005929:Glossitis, Benign Migratory / Q000175:diagnosis*; D006801:Humans; D009426:Netherlands; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D064927:Tick Bites / Q000175:diagnosis*