ld is a nationally notifiable condition , and cases are reported by state and local health departments to the centers for disease control and prevention ( cdc ) through the national notifiable diseases surveillance system in accordance with previously established protocols ( 7 ) .
, a revised case definition was implemented that altered the laboratory criteria and distinguished between confirmed and probable cases ; cases reported during 20082013 included both categories ( 8) .
weighting was applied to state- and county - specific numbers of cases to account for variations in completeness of ethnicity data .
descriptive statistics and comparisons were calculated by using sas version 9.3 ( sas institute , cary , nc , usa ) .
we compared median age of hispanics and non - hispanics with ld using the kolmogorov - smirnov 2-sample test .
cdc human subjects review of the protocol determined it was not research involving human subjects .
a total of 374,338 ld cases were reported to cdc , of which 148,444 ( 39.7% ) reports contained information about ethnicity and were included in this analysis . among these ,
most ( 54.8% ) hispanics with ld were male ; median age was 32 years ( interquartile range 1546 years ) .
annual incidence of reported ld among hispanics was 0.8 cases/100,000 persons , compared with 4.0/100,000 among non - hispanics . during 20002001 , hispanics comprised 2.8% of all persons with ld , whereas during 20092013 , hispanics comprised 3.7%4.9% of persons with reported ld . in comparison , the proportion of hispanics in the us population increased slightly during this period , from 13% in 2000 to 16% in 2010 ( 5 ) . although a bimodal age distribution was evident among both hispanics and non - hispanics with ld , the peak in children was less pronounced among hispanics ( figure ) .
highest incidence among hispanic children was in boys 1014 years of age , whereas among non - hispanic children , incidence was highest in boys 59 years of age . in adults ,
highest incidence among both hispanics and non - hispanics was in men 6574 years of age .
age- and sex - specific incidence of lyme disease among hispanics ( a ) and non - hispanics ( b ) , united states , 20002013 . for persons
hispanics were significantly less likely than non - hispanics to have disease onset during the summer months ( rr 0.85 , 95% ci 0.830.88 ) and more likely to have disease onset during the fall months ( rr 1.15 , 95% ci 1.071.24 ) ( table 1 ) . although erythema migrans was the most commonly reported clinical feature for both groups , it was less commonly reported among hispanics than non - hispanics ( rr 0.83 , 95% ci 0.800.86 ) .
manifestations of disseminated disease , such as arthritis and facial palsy , were more commonly reported among hispanics than non - hispanics ( table 1 ) .
iqr , interquartile range ; ld , lyme disease ; rr , risk ratio . 
percentage of persons with ld for whom sex is known ( n = 5,442 hispanics , n = 142,625 non - hispanics ) . 
the substantial difference in median age between the us hispanic population ( 27 y ) and the us non - hispanic population ( 42 y ) most likely accounts for the difference seen here . 
 defined as 1 of the 13 highest - incidence states that accounted for 95% of all reported confirmed cases of ld in 2010 : connecticut , delaware , maine , maryland , massachusetts , minnesota , new hampshire , new jersey , new york , pennsylvania , vermont , virginia , and wisconsin .
overall were reported from high - incidence states , although hispanics with ld were slightly less likely to report residence in a high - incidence state ( rr 0.90 , 95% ci 0.820.98 ) .
all of the statistical associations were similar when analysis was restricted to confirmed cases only , with the exception of residence in a high - incidence state , which became nonsignificant ( rr 0.99 , 95% ci 0.891.10 ) .
after weighting , nearly half of all estimated cases of ld among hispanics were from new york or new jersey ( table 2 ) . among counties with
at least 75 estimated ld cases among hispanics during the study period , highest incidence among hispanics occurred in columbia county , new york ( 170.4 cases/100,000 persons ) ; sussex county , new jersey ( 111.4/100,000 ) ; and hunterdon county , new jersey ( 106.3/100,000 ) .
after correcting for missing ethnicity data . calculated as follows : ( no . reported cases)/x = ( % with ethnicity information)/100 , where x is the weighted number of cases . 
incidence calculated as number of annual estimated cases in county/100,000 hispanic residents in county . only counties with a substantial number of cases were included in this comparison .
overall , the epidemiology of ld among hispanics was similar to that among non - hispanics : bimodal age distribution , slight predilection in males , and clustering in states to which ld is highly endemic were apparent ( 10 ) .
most notably , hispanics with ld were significantly more likely than non - hispanics with ld to have signs of disseminated infection and symptom onset during fall months .
although the overall incidence of ld in hispanics was lower than that in non - hispanics , additional research is needed to determine the reasons underlying these differences and the extent of any ld underdiagnosis in the hispanic population .
inadequate healthcare access , language barriers , and lack of ld awareness could cause both underdiagnosis and delays in diagnosis in the hispanic population . during 20092013 ,
a total of 41.5% of hispanics lacked health insurance , compared with 15.1% of non - hispanic whites ; 15.5% of hispanics described delay in or nonreceipt of medical care because of cost ( 11 ) . furthermore , whether the predilection toward symptom onset in the fall months for hispanics results from delays in medical care or other factors , such as seasonal outdoor labor patterns , is unclear .
lastly , because a larger proportion of hispanics than the overall us population live in urban areas ( 12 ) , the risk for ld might be differentially diluted in hispanics .
first , we had to exclude more than half of reported ld cases because of missing ethnicity data .
although we have no reason to believe that case reports with missing ethnicity data differed otherwise from those included in this study , we can not exclude this possibility .
finally , surveillance data are limited by underreporting and reporting bias , which might differ by state and between hispanic and non - hispanic populations .
although some educational materials about prevention of tickborne diseases have been translated to spanish ( 13,14 ) , additional translations and modifications to address cultural differences would be helpful . furthermore , targeted educational campaigns could enhance use of these materials and improve the reach , retention , and overall impact of prevention education .
direct and more in - depth assessments regarding prevention practices , knowledge , and ld epidemiology on local and national scales will further the understanding of ld risk in this population and guide future targeted prevention and education efforts .
 hispanics comprise a growing portion of the us population and might have distinct risk factors for tickborne diseases . during 20002013 , 
 a total of 5,473 lyme disease cases were reported among hispanics through national surveillance . 
 hispanics were more likely than non - hispanics to have signs of disseminated infection and onset during fall months . 
The Study
Conclusions