the spirochetes in the tick's gut before they are transmitted to the dog. treatment antibiotics are the primary treatment. the specific approach to their use is dependent on the individual affected and the stage of the disease. for most people with early localized infection, oral administration of doxycycline is widely recommended as the first choice, as it is effective against not only borrelia bacteria but also a variety of other illnesses carried by ticks. people taking doxycycline should avoid sun exposure because of higher risk of sunburns. doxycycline is contraindicated in children younger than eight years of age and women who are pregnant or breastfeeding; alternatives to doxycycline are amoxicillin, cefuroxime axetil, and azithromycin. azithromycin is recommended only in case of intolerance to the other antibiotics. the standard treatment for cellulitis, cephalexin, is not useful for lyme disease. when it is unclear if a rash is caused by lyme or cellulitis, the idsa recommends treatment with cefuroxime or amoxicillin/clavulanic acid, as these are effective against both infections. individuals with early disseminated or late lyme infection may have symptomatic cardiac disease, lyme arthritis, or neurologic symptoms like facial palsy, radiculopathy, meningitis, or peripheral neuropathy. intravenous administration of ceftriaxone is recommended as the first choice in these cases; cefotaxime and doxycycline are available as alternatives. treatment regimens for lyme disease range from 14 days in early localized disease, to 14–21 days in early disseminated disease to 14–28 days in late disseminated disease. neurologic complications of lyme disease may be treated with doxycycline as it can be taken by mouth and has a lower cost, although in north america evidence of efficacy is only indirect. in case of failure, guidelines recommend retreatment with injectable ceftriaxone. several months after treatment for lyme arthritis, if joint swelling persists or returns, a second round of antibiotics may be considered; intravenous antibiotics are preferred for retreatment in case of poor response to oral antibiotics. outside of that, a prolonged antibiotic regimen lasting more than 28 days is not recommended as no evidence shows it to be effective. igm and igg antibody levels may be elevated for years even after successful treatment with antibiotics. as antibody levels are not indicative of treatment success, testing for them is not recommended. facial palsy may resolve without treatment; however, antibiotic treatment is recommended to stop other lyme complications. corticosteroids are not recommended when facial palsy is caused by lyme disease. in those with facial palsy, frequent use of artificial tears while awake is recommended, along with ointment and a patch or taping the eye closed when sleeping. about a third of people with lyme carditis need a temporary pacemaker until their heart conduction abnormality resolves, and 21% need to be hospitalized. lyme carditis should not be treated with corticosteroids. people with lyme arthritis should limit their level of physical activity to avoid damaging affected joints, and in case of limping should use crutches. pain associated with lyme disease may be treated with nonsteroidal anti-inflammatory drugs (nsaids). corticosteroid joint injections are not recommended for lyme arthritis that is being treated with antibiotics. people with lyme arthritis treated with intravenous antibiotics or two months of oral antibiotics who continue to have joint swelling two months after treatment and have negative pcr test for borrelia dna in the synovial fluid are said to have post-antibiotic lyme arthritis; this is more common after infection by certain borrelia strains in people with certain genetic and immunologic characteristics. post-antibiotic lyme arthritis may be symptomatically treated with nsaids, disease-modifying antirheumatic drugs (dmards), arthroscopic synovectomy, or physical therapy. people receiving treatment should be advised that reinfection is possible and how to prevent it. prognosis lyme disease's typical first sign, the erythema migrans (em) rash, resolves within several weeks even without treatment. however, in untreated people, the infection often disseminates to the nervous system, heart, or joints, possibly causing permanent damage to body tissues. people who receive recommended antibiotic treatment within several days of appearance of an initial em rash have the best prospects. recovery may not be total or immediate. the percentage of people achieving full recovery in the united states increases from about 64–71% at end of treatment for em rash to about 84–90% after 30 months; higher percentages are reported in europe. treatment failure, i.e. persistence of original or appearance of new signs of the disease, occurs only in a few people. remaining people are considered cured but continue to experience subjective symptoms, e.g. joint or muscle pains or fatigue. these symptoms usually are mild and nondisabling. people treated only after nervous system manifestations of the disease may end up with objective neurological deficits, in addition to subjective symptoms. in europe, an average of 32–33 months after initial lyme symptoms in people treated mostly with doxycycline 200 mg for 14–21 days, the percentage of people with lingering symptoms was much higher among those diagnosed with neuroborreliosis (50%) than among those with only an em rash (16%). in another european study, 5 years after treatment for neuroborreliosis, lingering symptoms were less common among children (15%) than adults (30%), and in the latter was less common among those treated within 30 days of the first symptom (16%) than among those treated later (39%); among those with lingering symptoms, 54% had daily activities restricted and 19% were on sick leave or incapacitated. some data suggest that about 90% of lyme facial palsies treated with antibiotics recover fully a median of 24 days after appearing and most of the rest recover with only mild abnormality. however, in europe 41% of people treated for facial palsy had other lingering symptoms at followup up to 6 months later, including 28% with numbness or altered sensation and 14% with fatigue or concentration problems. palsies in both sides of the face are associated with worse and longer time to recovery. historical data suggests that untreated people with facial palsies recover at nearly the same rate, but 88% subsequently have lyme arthritis. other research shows that synkinesis (involuntary movement of a facial muscle when another one is voluntarily moved) can become evident only 6–12 months after facial palsy appears to be resolved, as damaged nerves regrow and sometimes connect to incorrect muscles. synkinesis is associated with corticosteroid use. in longer-term follow-up, 16–23% of lyme facial palsies do not fully recover. in europe, about a quarter of people with bannwarth syndrome (lyme radiculopathy and lymphocytic meningitis) treated with intravenous ceftriaxone for 14 days an average of 30 days after first symptoms had to be retreated 3–6 months later because of unsatisfactory clinical response or continued objective markers of infection in cerebrospinal fluid; after 12 months, 64% recovered fully, 31% had nondisabling mild or infrequent symptoms that did not require regular use of analgesics, and 5% had symptoms that were disabling or required substantial use of analgesics. the most common lingering nondisabling symptoms were headache, fatigue, altered sensation, joint pains, memory disturbances, malaise, radicular pain, sleep disturbances, muscle pains, and concentration disturbances. lingering disabling symptoms included facial palsy and other impaired movement. recovery from late neuroborreliosis tends to take longer and be less complete than from early neuroborreliosis, probably because of irreversible neurologic damage. about half the people with lyme carditis progress to complete heart block, but it usually resolves in a week. other lyme heart conduction abnormalities resolve typically within 6 weeks. about 94% of people have full recovery, but 5% need a permanent pacemaker and 1% end up with persistent heart block (the actual percentage may be higher because of unrecognized cases). lyme myocardial complications usually are mild and self-limiting. however, in some cases lyme carditis can be fatal. recommended antibiotic treatments are effective in about 90% of lyme arthritis cases, although it can take several months for inflammation to resolve and a second round of antibiotics is often necessary. antibiotic-refractory lyme arthritis also eventually resolves, typically within 9–14 months (range 4 months – 4 years); dmards or synovectomy can accelerate recovery. reinfection is not uncommon. in a u.s. study, 6–11% of people treated for an em rash had another em rash within 30 months. the second rash typically is due to infection by a different borrelia strain. people who have nonspecific, subjective symptoms such as fatigue, joint and muscle aches, or cognitive difficulties for more than six months after recommended treatment for lyme disease are said to have post-treatment lyme disease syndrome (ptlds). as of 2016 the reason for the lingering symptoms was not known; the condition is generally managed similarly to fibromyalgia or chronic fatigue syndrome. epidemiology countries with reported lyme disease cases lyme disease occurs regularly in northern hemisphere temperate regions. an estimated 476,000 people a year are diagnosed and treated for the disease in the united states. this number is likely an overestimate due to overdiagnosis and overtreatment. over 200,000 people a year are diagnosed and treated in europe. there is a suggestion that tick populations and lyme disease occurrence are increasing and spreading into new areas, due in part to the warming temperatures of climate change. however tick-borne disease systems are complex, and determining whether changes are due to climate change or other drivers can be difficult. africa in northern africa, b. burgdorferi sensu lato has been identified in morocco, algeria, egypt and tunisia. lyme disease in sub-saharan africa is presently unknown, but evidence indicates it may occur in humans in this region. the abundance of hosts and tick vectors would favor the establishment of lyme infection in africa. in east africa, two cases of lyme disease have been reported in kenya. asia b. burgdorferi sensu lato-infested ticks are being found more frequently in japan, as well as in northwest china, nepal, thailand and far eastern russia. borrelia has also been isolated in mongolia. europe in europe, lyme disease is caused by infection with one or more pathogenic european genospecies of the spirochaete b. burgdorferi sensu lato, mainly transmitted by the tick ixodes ricinus. cases of b. burgdorferi sensu lato-infected ticks are found predominantly in central europe, particularly in slovenia and austria, but have been isolated in almost every country on the continent. number of cases in southern europe, such as italy and portugal, is much lower. diagnosed cases in some western countries, such as iceland, are rising. lyme disease is rare in iceland. on average around 6 to 7 cases are diagnosed every year, primarily localised infections presenting as erythema migrans. none of the cases had a definitive icelandic origin and the yearly number of cases has not been increasing. united kingdom in the united kingdom the number of laboratory confirmed cases of lyme disease has been rising steadily since voluntary reporting was introduced in 1986 when 68 cases were recorded in the uk and ireland combined. in the uk there were 23 confirmed cases in 1988 and 19 in 1990, but 973 in 2009 and 953 in 2010. provisional figures for the first 3 quarters of 2011 show a 26% increase on the same period in 2010. it is thought, however, that the actual number of cases is significantly higher than suggested by the above figures, with the uk's health protection agency estimating that there are between 2,000 and 3,000 cases per year, (with an average of around 15% of the infections acquired overseas), while dr darrel ho-yen, director of the scottish toxoplasma reference laboratory and national lyme disease testing service, believes that the number of confirmed cases should be multiplied by 10 "to take account of wrongly diagnosed cases, tests giving false results, sufferers who weren't tested, people who are infected but not showing symptoms, failures to notify and infected individuals who don't consult a doctor." despite lyme disease (borrelia burgdorferi infection) being a notifiable disease in scotland since january 1990 which should therefore be reported on the basis of clinical suspicion, it is believed that many gps are unaware of the requirement. mandatory reporting, limited to laboratory test results only, was introduced throughout the uk in october 2010, under the health protection (notification) regulations 2010. although there is a greater number of cases of lyme disease in the new forest, salisbury plain, exmoor, the south downs, parts of wiltshire and berkshire, thetford forest and the west coast and islands of scotland, infected ticks are widespread, and can even be found in the parks of london. a 1989 report found that 25% of forestry workers in