Motivations and Experiences of Canadians Seeking Treatment for Lyme Disease Outside of the Conventional Canadian Health-Care System

Lyme borreliosis and medical wandering: what do patients think about multidisciplinary management? A qualitative study in the context of scientific and social controversy

INTRODUCTION

To answer to patients' medical wandering, often due to "unexplained symptoms" of "unexplained diseases" and to misinformation, multidisciplinary care centers for suspected Lyme borreliosis (LB), such as the 5 Tick-Borne Diseases (TBDs) Reference Centers (TBD-RC), were created a few years ago in France, the Netherlands and Denmark. Our study consisted of a comprehensive analysis of the satisfaction of the patients managed at a TBD-RC for suspected LB in the context of scientific and social controversy.

METHODS

We included all adults who were admitted to one of the TBD-RC from 2017 to 2020. A telephone satisfaction survey was conducted 12 months after their first consultation. It consisted of 5 domains, including 2 free-text items: "What points did you enjoy?" and "What would you like us to change or to improve?". In the current study, the 2 free-items were analyzed with a qualitative method called reflexive thematic analysis within a semantic and latent approach.

RESULTS

The answer rate was 61.3% (349/569) and 97 distinctive codes from the 2-free-text items were identified and classified into five themes: (1) multidisciplinarity makes it possible to set up quality time dedicated to patients; (2) multidisciplinarity enables seamless carepaths despite the public hospital crisis compounded by the COVID-19 pandemic; (3) multidisciplinarity is defined as trust in the team's competences; (4) an ambivalent opinion and uncertainty are barriers to acceptance of the diagnosis, reflecting the strong influence of the controversy around LB; and (5) a lack of adapted communication about TBDs, their management, and ongoing research is present.

CONCLUSION

The multidisciplinary management for suspected LB seemed an answer to medical wandering for the majority of patients and helped avoid misinformation, enabling better patient-centered shared information and satisfaction, despite the context of controversy.

Perinatal transmission of Lyme disease: A qualitative study investigating the research priorities of patients with Lyme disease in pregnancy

INTRODUCTION

Lyme disease is one of the most prevalent vector-borne disease in North America, yet its implications during pregnancy are poorly understood. Our knowledge of perinatal transmission of Lyme disease is limited due to the lack of robust epidemiological studies and longitudinal follow-up.

OBJECTIVES

This study aimed to understand the research priorities of people who have experienced Lyme disease in pregnancy and the feasibility of recruiting this population for future studies on perinatal transmission of Lyme disease. We also sought to understand the barriers and enablers to participating in research on perinatal transmission of Lyme disease.

METHODS

We conducted a qualitative study using focus groups and interviews with people who had experienced Lyme disease during pregnancy. English speaking participants were recruited through an online survey. There was no geographic restriction on participation. The focus groups and the interview were recorded and transcribed. Data were analyzed using interpretive content analysis.

RESULTS

Twenty people participated in four semi-structured focus groups and one semi-structured individual interview. The majority of participants were from North America. Participants' research priorities fell into five categories: transmission, testing, treatment, disease presentation, and education. All study participants expressed interest in future participation in research on Lyme disease in pregnancy and highlighted barriers and enablers to participation that could be addressed to facilitate future study recruitment.

CONCLUSION

The research priorities identified in this research would be well addressed through prospective research. People who experience Lyme disease in pregnancy are invested in continued research into perinatal transmission of Lyme disease.

"I Get It, I'm Sick Too": An Autoethnographic Study of One Researcher/Practitioner/Patient With Chronic Illness

This autoethnographic research utilizes reflexivity as a method to explore my self-experience of Lyme disease while holding co-occurring identities as a researcher, health professional, and mother. Awareness of self is central in psychotherapy so that therapists do not adversely impact their clients. This is similar for researchers who are ethically required to acknowledge and reduce any potential risk(s) of harm to their participants. In this study, I describe and systematically analyze my experiences as a patient with symptom-persistent Lyme disease, contextualized through co-occurring identities as a mother, a regulated (mental) health professional, and a scholar investigating the embodied experience of being a Lyme disease patient in the Canadian context. The central research question guiding this study is: "What are my experiences with symptom-persistent Lyme disease?" The results of this study suggest reflexivity is an important practice in both health research and healthcare. Relationships with health professionals have a significant impact on patients' healthcare experiences, and engaging in reflexive practice may improve the responsivity of healthcare professionals toward patients' needs and embodied experiences and serve as a check on pre-existing power relations in healthcare. Further, this research contributes to the current academic knowledge on symptom-persistent Lyme disease by offering a reflexive representation of my experiences as a researcher who is also a health professional and a patient within the Canadian healthcare system. Representations of patients' experiences are critical in advancing health research and ensuring equitable care for patients. Autoethnography offers important insights into patients' disease experiences.

Healthcare costs and outcomes associated with laboratory-confirmed Lyme disease in Ontario, Canada: A population-based cohort study

BACKGROUND

The objective of this study was to estimate the economic burden attributable to laboratory-confirmed Lyme disease (LD) in Ontario, Canada and assess health outcomes associated with LD.

METHOD

We conducted a cohort study using laboratory-confirmed LD cases accrued between 2006 and 2018. The exposed cohort was matched 1:3 to the unexposed cohort using a combination of hard and propensity score matching. We used phase-of-care costing methods to calculate attributable costs for four phases of illness: pre-diagnosis, acute care, post-acute care, and continuing care in 2018 Canadian dollars. We used ICD-10-CA and OHIP billing codes to identify emergency department visits, physician billings and hospitalizations related to LD sequelae to assess health outcomes.

RESULTS

A total of 2,808 cases were identified with a mean age of 46.5 (20.7) years and 44% female. Within 30-days, 404 (14.3%) cases required an ED visit and 63 (2.4%) cases required hospitalization. The mean (95% CI) total costs for LD cases in pre-diagnosis, acute, and post-acute care phases were $209 ($181, 238), $1,084 ($956, $1,212), and $1,714 ($1,499, $1,927), respectively. The highest mean attributable 10-day cost was $275 ($231, $319) during acute care. At 1-year post-infection, LD increased the relative risk of nerve palsies by 62 (20, 197), and polyneuropathy by 24 (3.0, 190). LD resulted in 16 Lyme meningitis events vs. 0 events in the unexposed.

CONCLUSION

Individuals with laboratory-confirmed LD have increased healthcare resource use pre-diagnosis and up to six months post-diagnosis, and were more likely to seek healthcare services related to LD sequelae.

Nurses' perceptions of climate sensitive vector-borne diseases: A scoping review

OBJECTIVE

Nurses are well positioned to play an integral role in the mitigation of climate change and climate-driven vector-borne diseases, however, they lack awareness and knowledge about their role. The purpose of this scoping review was to map existing literature on nurses' perceptions, knowledge, attitudes, and experiences with vector-borne diseases, specifically Lyme disease and West Nile virus.

DESIGN

A scoping review was conducted using Joanna Briggs Institute (JBI) scoping review methodology. CINAHL, ProQuest Nursing & Allied Health Premium, MEDLINE, APA PsycINFO, ProQuest Dissertations & Theses, and Web of Science were searched for English-language publications. The PRISMA-ScR was used. After initial screening as per study protocol, a total of 33 items were reviewed independently by four reviewers.

RESULTS

Thirty-three articles, including seven sources from grey literature, met the criteria for this scoping review. Results were mapped according to the five domains of the Guidelines for Undergraduate Nursing Education on Climate-Driven Vector-Borne Diseases.

CONCLUSIONS

Findings from the review indicate that nurses play a role in climate-related health effects and should be knowledgeable about vector-borne diseases. However, scant literature exists on nurses' knowledge, perceptions, attitudes toward vector-borne diseases, and practice readiness, signifying a need for further research on this emerging topic.

Seeking Care for Long COVID: A Narrative Analysis of Canadian Experiences

The goal of this study was to explore the experiences of individuals seeking care for long COVID-19 in the Canadian healthcare system. Recorded virtual interviews were carried out with 8 participants and narrative analysis was used to examine the stories produced and identify the central narratives that defined participants' experiences. Care-seeking experiences were characterized by (1) often debilitating multi-system symptoms for which little information about prognosis was available and no effective treatments were provided, (2) compounded by the frustration of trying to convince family, friends, and health care practitioners of the legitimacy of their illness, (3) access to medical care was severely limited by the global pandemic and associated higher thresholds for care, (4) like others suffering from complex, multi-system conditions, people with long COVID are often struggling with a health-care system ill-suited for dealing with long-term and possibly chronic conditions. To make system-level improvements to better serve those with chronic conditions, it is critical that we understand the care-seeking experiences of chronic illness patients, including the unique experiences of those with long COVID.

Knowing the entire story – a focus group study on patient experiences with chronic Lyme-associated symptoms (chronic Lyme disease)

Background

Healthcare providers frequently struggle to provide effective care to patients with chronic Lyme-associated symptoms (chronic Lyme disease, CLD), potentially causing these patients to feel misunderstood or neglected by the healthcare system. This study is the first to use a combined medical and communication science approach, and aims to assess patients’ experiences with CLD & CLD-related care, identify themes and repertories in these patients’ narrations, and provide potential ways to improve communication with them.

Methods

Informed by the principles of ‘clean language’, we conducted focus groups with self-identified CLD patients (N = 15). We asked participants about their experiences with CLD and CLD-related healthcare. We performed thematic analyses using a bottom-up approach based in discourse analysis. We also sought to identify specific types of verbalizations (repertoires) across themes.

Results

Participants thematised a heterogeneous set of CLD-associated symptoms, which they frequently labelled as ‘invisible’ to others. Their illness significantly affected their daily lives, impacting their work, social activities, relationships with loved ones, hobbies and other means of participating in society. Negative experiences with healthcare providers were near-universal, also in patients with short-lived CLD-associated symptoms. Verbalizations were notable for frequent use of communicative modes that implicitly create common ground between participants and that give a certain validity to personal experiences (impersonal ‘you’ and other forms of presupposition).

Conclusion

Central themes found in CLD patients’ communication are 1. the experience of significant symptoms, 2. for which adequate relief is only rarely found from conventional medical practitioners, and 3. that are largely invisible to the outside world. Verbalizing these themes, patients use various repertoires for their shared experiences, such as a feeling of abandonment or not being heard by the medical system, feelings of loss with respect to their previous health, and the idea that they might have been better off had they been diagnosed sooner. Working with these repertoires will enable healthcare providers to establish a shared perspective with their CLD patients, thus engaging in more fruitful doctor-patient communication. We hypothesize that these findings are not unique to CLD, but may also be applicable to other conditions with an uncertain aetiology, such as Long COVID.

Multidisciplinary Management of Suspected Lyme Borreliosis: Clinical Features of 569 Patients, and Factors Associated with Recovery at 3 and 12 Months, a Prospective Cohort Study

Introduction. Because patients with a suspicion of Lyme borreliosis (LB) may have experienced difficult care paths, the Tick-Borne Diseases Reference Center (TBD-RC) was started in 2017. The aim of our study was to compare the clinical features of patients according to their final diagnoses, and to determine the factors associated with recovery in the context of multidisciplinary management for suspected LB. Methods. We included all adult patients who were seen at the TBD-RC (2017-2020). Four groups were defined: (i) confirmed LB, (ii) possible LB, (iii) Post-Treatment Lyme Disease Syndrome (PTLDS) or sequelae, and (iv) other diagnoses. Their clinical evolution at 3, 6, and 9-12 months after care was compared. Factors associated with recovery at 3 and at 9-12 months were identified using logistic regression models. Results. Among the 569 patients who consulted, 72 (12.6%) had confirmed LB, 43 (7.6%) possible LB, 58 (10.2%) PTLDS/sequelae, and 396 (69.2%) another diagnosis. A favorable evolution was observed in 389/569 (68.4%) at three months and in 459/569 (80.7%) at 12 months, independent of the final diagnosis. A longer delay between the first symptoms and the first consultation at the TBD-RC (p = 0.001), the multiplicity of the diagnoses (p = 0.004), and the inappropriate prescription of long-term antibiotic therapy (p = 0.023) were negatively associated with recovery, reflecting serial misdiagnoses. Conclusions. A multidisciplinary team dedicated to suspicion of LB may achieve a more precise diagnosis and better patient-centered medical support in the adapted clinical sector with a shorter delay, enabling clinical improvement and avoiding inappropriate antimicrobial prescription.

Personal Agency and Community Resilience: Narratives of Women Navigating Health Care With Chronic Lyme Disease

Chronic Lyme disease can manifest as a debilitating illness with symptoms that change over time. With its varied presentation, timeline variation, diagnostic difficulty, and lack of definitive treatment, clinical recognition of chronic Lyme disease remains controversial. At the same time, patients face challenges in finding a provider who is supportive and knowledgeable about diagnosing and treating Lyme. We examined the ways the medical system may have affected the lived experiences of chronic Lyme patients. In this article, we communicate the personal, health care, and community illness experiences of 14 women navigating the medical system with chronic Lyme disease through a qualitative community-based participatory research study using interviews and narrative reflection in a rural community setting. The women were interviewed by a researcher living with chronic Lyme disease and the transcripts were analyzed for themes. All participants described navigating multiple allopathic and nonallopathic care modalities to find satisfactory care. They struggled with physical and emotional burdens of chronic, nonlinear illness, as well as disbelief and discrimination by medical providers. Their lives followed patterns of illness and wellness, trust and mistrust of medical treatment, and community connection and disengagement. They learned to become their own advocates to seek affirmative care. They are aware of the controversial nature of their illness, and many have channeled their frustrations into caring for one another through their Lyme community. Women living with controversial diagnoses like chronic Lyme disease experience increased challenges navigating the medical system to find satisfactory care and thus create communities with each other for mutual aid and support. In understanding these challenges, the medical community can improve care for people living with contested chronic illnesses.

Lyme Disease Training and Knowledge Translation Resources Available to Canadian Healthcare Professionals: A Gray Literature Review

Introduction:

Lyme Disease (LD) is the most common tick-borne disease in North America. With the number of cases increasing yearly, Canadian healthcare professionals (HCP) rely on up-to-date and evidence-informed guidelines, instruction, and resources to effectively prevent, diagnose, and treat Lyme disease (LD). This review is the first of its kind to examine gray literature and analyze the diversity of recommendations provided to Canadian HCP about the prevention, diagnosis, and treatment of Lyme disease.

Methods:

A gray literature review consisting of 4 search strategies was conducted to retrieve materials targeted to Canadian HCP. Searches within targeted websites, targeted Google searches, and gray literature databases, and consultation with content experts were done to look for continuing medical education (CME) events, clinical flow charts, webinars, videos, and reference documents that discussed the prevention, diagnosis, and treatment of Lyme disease.

Results:

A total of 115 resources were included in this study. Recommendations surrounding prevention strategies were less varied between materials, whereas diagnosis and treatment recommendations were more varied. Our findings suggest that Canadian HCP are met with varying and sometimes contradictory recommendations for diagnosing and treating LD.

Conclusions:

Due to the increasing incidence of LD in Canada, there is a greater need for resource consistency. Providing this consistency may help mitigate LD burden, standardize approaches to prevention, diagnosis and treatment, and improve patient outcomes.

Consumption of healthcare services and antibiotics in patients with presumed disseminated Lyme borreliosis before and after evaluation of an infectious disease specialist

Our objective was to study the consumption of healthcare services and antibiotics in patients with suspicion of disseminated Lyme borreliosis (LB) before and after consultation of an infectious disease specialist. We evaluated retrospectively all presumed disseminated LB patients (n = 256) with a referral to the Department of Infectious Diseases (DID) in Helsinki University Hospital in 2013. Medical records from all healthcare providers in the area were reviewed and the number of physician contacts because of symptoms leading to LB suspicion and antimicrobial purchases were calculated 1 year before and after consultation or treatment at the DID. Patients were divided into three groups according to certainty of LB: unlikely, possible or probable/definite LB. The number of healthcare contacts 1 year before referral was higher among 121 patients with unlikely LB (6; interquartile range [IQR] 3-10), than 65 possible (4; IQR 2.5-7; p = 0.018) or 66 probable/definite LB patients (4; IQR 2.8-7; p = 0.010). The median number of contacts to healthcare during one year after consultation or treatment was 3 (IQR 0.5-7), 1 (IQR 0-3) and 0.5 (IQR 0-2.3), respectively, with a statistically significant difference between the groups (p<0.001). Antibiotics were purchased by 151 (60%) patients one year before referral and by 127 (50%) patients year after consultation or treatment at DID without statistically significant difference between groups with different LB certainty. These antibiotic purchases do not include the treatments prescribed by infectious disease specialists. In the case of 27 patients, an antimicrobial treatment was recommended in the consultation reply. In conclusion, patients with unlikely LB used more healthcare services than patients with possible or probable/definite LB. Antimicrobial consumption was similar between groups of different LB certainty.

Perceptions, Representations, and Experiences of Patients Presenting Nonspecific Symptoms in the Context of Suspected Lyme Borreliosis

BACKGROUND

Some subjective symptoms may be reported at all stages of Lyme borreliosis (LB) and may persist for several months after treatment. Nonspecific symptoms without any objective manifestation of LB are sometimes attributed by patients to a possible tick bite. The aim of our study was to explore the perceptions, representations, and experiences that these patients had of their disease and care paths.

METHODS

We performed a qualitative study through individual interviews (October 2017-May 2018), based on grounded theory, following the COREQ checklist. A balanced sample of patients with diverse profiles was recruited at consultations with general practitioners and infectious disease physicians.

RESULTS

Twelve patients were interviewed. Data saturation was reached at the twelfth interview. For codes, 293 were identified, and classified into 5 themes: (1) the experience of disabling nonspecific symptoms, especially pain, causing confusion and fear, (2) long and difficult care paths for the majority of the patients, experienced as an obstacle course, (3) a break with the previous state of health, causing a negative impact on every sphere of the patient's life, (4) empowerment of the patients and the self-management of their disease, and (5) the strong expression of a desire for change, with better listening, greater recognition of the symptoms, and simpler care paths.

CONCLUSIONS

This study allows for the understanding of a patient's behaviours and the obstacles encountered, the way they are perceived, and the necessary solutions. The patients' expectations identified here could help physicians better understand the doctor-patient relationship in these complex management situations, which would reduce the burden of the disease. The current development of specialised reference centres could help meet the patients' demands and those of family physicians.

Experience and knowledge of Lyme disease: A scoping review of patient-provider communication

There has been limited research on patient-provider communication dynamics regarding Lyme disease (LD) diagnosis and treatment. Evidence suggests communication in the clinical encounter improves when both patient and healthcare provider (HCP) have concordant orientations (or beliefs) on discussed topics, resulting in higher patient satisfaction and care outcomes. The purpose of this scoping review was to characterize and summarize current research findings on patient and provider knowledge and experiences regarding LD - two factors that may influence the orientation of both patients and providers toward LD in the clinical setting. None of the articles included in the review specifically addressed patient-provider interaction and relationships as the main objective. However, the existing literature indicates notable HCP uncertainty regarding LD diagnosis, treatment, and applied practice patterns. Current research also describes limited knowledge of LD among patient populations and a high prevalence of negative perceptions of care received in mainstream healthcare settings among individuals with persistent symptoms. We identified a critical gap in research that seeks to understand the dynamic of patients and HCPs communicating on the topic of LD in the clinical setting. Future research may identify opportunities where the patient-provider communication dynamic can be improved.

Lyme Disease Patient Outcomes and Experiences; A Retrospective Cohort Study

Lyme disease is a vector-borne illness caused by Borrelia spp. bacterium spread by ticks to humans and other mammals. Despite being prevalent in many regions of the world, there remains considerable uncertainty surrounding many aspects of the disease, and consensus on the most appropriate and effective means of treating the illness remains to be achieved. Recommendations published by the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS), the primary guidelines followed by health care professionals treating Lyme disease, diverge in many of their key recommendations, including treatment duration. Given this lack of consensus, surprisingly little research has been conducted on patient outcomes following different treatment approaches. In this study, patient outcomes were evaluated from a cohort of 210 Canadian Lyme disease patients seeking treatment at one US Lyme disease clinic following a treatment regimen conforming to the ILADS treatment guidelines. It was found that the majority of Lyme disease patients at the clinic responded positively to treatment and a significant (p < 0.05) decrease in symptoms was observed over time. This study, along with related studies, may help to guide physicians to provide their patients with the most effective care.

Clinical and economic outcomes evaluated in Lyme disease: a systematic review

BACKGROUND

The financial implications of Lyme disease (LD) can vary widely for both the health system and the individual patients experiencing the disease. The aim of this review was to summarize published data on clinical and economic outcomes associated with LD.

METHODS

A literature review was conducted to identify all studies of LD that incorporate both clinical outcomes and costs. Included studies were described and categorized based on costs consistent with best practices used in economic evaluation.

RESULTS

The most frequent costs identified focused on formal health costs and productivity losses were the most common costs identified outside of the health system. Travel and informal care costs were less frequently reported. Clinical and economic outcomes of LD are primarily studied through economic models or observational analyses and focus on formal health care.

CONCLUSIONS

This review provides and overview of existing evidence and recommendations for future economic analyses in LD.

Knowledge and Knowledge Needs about Lyme Disease among Occupational and Recreational Users of the Outdoors

As the prevalence of Lyme disease increases across Canada, it is imperative that the educational needs of at-risk groups be identified. The current study compared the level of knowledge and the knowledge needs about Lyme disease among individuals that spend time outdoors for work and for recreational purposes. Between December 2018 and February 2019, a survey was distributed to outdoor organizations across New Brunswick, Canada. Within the current sample of 137 individuals, 36% spent time outdoors for their occupation and 64% for recreational activities. Results showed no significant difference between these groups with regard to their level of knowledge, perceived efficacy and performance of various methods of prevention, and educational needs. Overall, the entire sample reported a low level of knowledge about Lyme disease. Participants perceived each prevention behavior to be at least somewhat effective, and behaviors perceived to be more effective were more likely to be carried out, but the performance of the behaviors varied. The most frequently performed behaviors included wearing long pants and protective footwear. Participants identified several aspects of Lyme disease about which they would like to have more information. The findings call attention to the specific needs of at-risk groups that must be considered when developing educational interventions.

Parenting When Children Have Lyme Disease: Fear, Frustration, Advocacy

Increasing numbers of Canadians, including children and adolescents, are being infected with Borrelia burgdorferi and contracting Lyme disease. In the present study, we provided a qualitative analysis of written correspondence produced by 23 parents of children and adolescents with Lyme disease. The goal of this study was to investigate how medical and psychological issues were highlighted by parents describing their family’s Lyme disease experiences. The results suggest a series of four stages in these families where satisfactory treatment had not been obtained over months or years. The experiences of parents evolved from feelings of worry for the child to frustration with the lack of a helpful treatment, to mistrust of physicians’ actions, and, in some case, to a rejection of the conventional health care system as a whole. Improved diagnostic testing and treatment guidelines, as well as family-centered practices of medical care were proposed as important features for improving the experiences of families living with Lyme disease.

A Multiple Streams Approach to Understanding the Issues and Challenges of Lyme Disease Management in Canada's Maritime Provinces

This study examines potential challenges facing Lyme disease patients in Canada’s Maritime provinces—New Brunswick, Nova Scotia, Prince Edward Island—and considers how issues could be addressed. Reviews of both the academic and grey literature are complemented by surveys targeting both medical professionals and decision makers in government. Combined, the literature reviews and surveys demonstrate that there is considerable debate surrounding the effectiveness of testing, treatment options, and the existence of chronic Lyme disease. As the focus on the Maritimes demonstrates, these debates often pit the medical community against patients and patient advocates and, thus far, governments have been unable to produce policy that entirely pleases either side. Moving forward, this study recommends the creation of a discussion forum via a federal Commission of inquiry to review best practise guidelines for Lyme disease. The key is to foster an unbiased probe of central issues surrounding treatment and diagnosis without alienating stakeholders. This course of action will not necessarily solve the issue of Lyme disease, but would foster a greater understanding through dialogue that includes and validates the experiences of stakeholders, which is something that is currently missing.

Under-Detection of Lyme Disease in Canada

Lyme disease arises from infection with pathogenic Borrelia species. In Canada, current case definition for confirmed Lyme disease requires serological confirmation by both a positive first tier ELISA and confirmatory second tier immunoblot (western blot). For surveillance and research initiatives, this requirement is intentionally conservative to exclude false positive results. Consequently, this approach is prone to false negative results that lead to underestimation of the number of people with Lyme disease. The province of New Brunswick (NB), Canada, can be used to quantify under-detection of the disease as three independent data sets are available to generate an estimate of the true human disease prevalence and incidence. First, detailed human disease incidence is available for the US states and counties bordering Canada, which can be compared with Canadian disease incidence. Second, published national serology results and well-described sensitivity and specificity values for these tests are available and deductive reasoning can be used to query for discrepancies. Third, high-density tick and canine surveillance data are available for the province, which can be used to predict expected human Lyme prevalence. Comparison of cross-border disease incidence suggests a minimum of 10.2 to 28-fold under-detection of Lyme disease (3.6% to 9.8% cases detected). Analysis of serological testing predicts the surveillance criteria generate 10.4-fold under-diagnosis (9.6% cases detected) in New Brunswick for 2014 due to serology alone. Calculation of expected human Lyme disease cases based on tick and canine infections in New Brunswick indicates a minimum of 12.1 to 58.2-fold underestimation (1.7% to 8.3% cases detected). All of these considerations apply generally across the country and strongly suggest that public health information is significantly under-detecting and under-reporting human Lyme cases across Canada. Causes of the discrepancies between reported cases and predicted actual cases may include undetected genetic diversity of Borrelia in Canada leading to failed serological detection of infection, failure to consider and initiate serological testing of patients, and failure to report clinically diagnosed acute cases. As these surveillance criteria are used to inform clinical and public health decisions, this under-detection will impact diagnosis and treatment of Canadian Lyme disease patients.