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Epidemiology of Lyme disease

Epidemiology of Lyme disease
Author:
Paul Mead, MD, MPH
Section Editor:
Allen C Steere, MD
Deputy Editor:
Keri K Hall, MD, MS
Literature review current through: Apr 2025. | This topic last updated: Mar 31, 2025.

INTRODUCTION — 

Lyme disease is a spirochetal infection transmitted by the bite of infected Ixodes spp ticks. It is caused primarily by Borrelia burgdorferi in the United States and primarily by Borrelia afzelii, Borrelia garinii, and to a lesser extent by B. burgdorferi in Europe and Asia. The spirochete is maintained in nature through enzootic cycles involving small mammals and birds.

Lyme disease is the most common tick-borne infection in the United States and Europe. Because the ticks that transmit Lyme disease are frequently encountered in backyards and outdoor recreational areas, a high degree of public health awareness of Lyme disease must be maintained wherever the disease is known to occur.

The epidemiology of Lyme disease and the ecology of Ixodes species ticks will be reviewed here. The microbiology of Lyme disease; the evaluation of a tick bite for possible Lyme disease; and the clinical manifestations, diagnosis, treatment, and prevention of Lyme disease are discussed separately. (See "Microbiology of Lyme disease" and "Evaluation of a tick bite for possible Lyme disease" and "Clinical manifestations of Lyme disease in adults" and "Lyme disease: Clinical manifestations in children" and "Diagnosis of Lyme disease" and "Treatment of Lyme disease" and "Prevention of Lyme disease".)

The epidemiology of other tick-borne diseases is reviewed elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of Rocky Mountain spotted fever" and "Human ehrlichiosis and anaplasmosis" and "Southern tick-associated rash illness (STARI)" and "Babesiosis: Microbiology, epidemiology, and pathogenesis" and "Tick paralysis" and "Microbiology, pathogenesis, and epidemiology of relapsing fever".)

DISCOVERY — 

Lyme disease was first recognized clinically in 1977 as "Lyme arthritis" during studies of a cluster of children in Lyme, Connecticut, who were thought to have juvenile rheumatoid arthritis [1]. In the early 1980s, the etiologic agent was discovered to be a spirochete [2,3]. (See 'Borrelia species' below.)

BORRELIA SPECIES — 

Lyme disease is caused by spirochete microorganisms of the Borrelia (also called Borreliella) genus. (See "Microbiology of Lyme disease".)

Several species of Borrelia account for most cases of Lyme disease in the world:

●In North America, B. burgdorferi is the primary species. A second genospecies, Borrelia mayonii, has also been described as a cause of human illness in the upper midwestern United States [4].

●In Europe and Asia, B. afzelii, B. garinii, and B. burgdorferi, to a lesser extent, are the predominant species that cause human illness.

The diversity of Borrelia species in different geographic regions is discussed in greater detail separately. (See "Microbiology of Lyme disease", section on 'Geographic distribution'.)

Specific strains of the organism may influence the local incidence of Lyme disease. A particularly virulent strain of B. burgdorferi called OspC type A is prevalent in the northeastern United States [5,6]. This genotype has a high transmission frequency among ticks and may be increasing in frequency in nature. These characteristics and other virulence factors may have been important in the emergence of Lyme disease in the northeastern United States during the late 20th century [7]. (See "Microbiology of Lyme disease", section on 'Relationship to clinical manifestations'.)

EPIDEMIOLOGY

Incidence — Lyme disease is the most common tick-borne infection in the United States and Europe [8,9].

In the United States, the disease was designated as a nationally notifiable condition in 1991, and since then, the incidence and geographic distribution of cases in the United States have substantially increased [10-14]. In 2022, over 60,000 cases of Lyme disease were reported in the United States, equivalent to an overall annual incidence of 18 cases per 100,000 population (figure 1) [15]. Routine surveillance does not capture all cases, and underreporting is common; one study of billing records estimated that approximately 476,000 people are diagnosed and treated for Lyme disease in the United States each year. This larger figure includes patients treated presumptively, some of whom may not have been infected [16].

In Europe, Lyme disease is widespread, but overall incidence is difficult to determine due to lack of standardized surveillance [17,18]. Rates exceeding 100 per 100,000 population have been reported in areas of several countries [19,20] (see 'Geography' below). The European Union has designated neuroborreliosis a notifiable condition and has developed a standard case definition [21,22]. This should facilitate incidence comparisons across countries when fully implemented.

Although all age groups are affected by Lyme disease, the distribution of cases in the United States is distinctly bimodal with peaks among children 5 to 14 years old and adults over 50 years old (figure 2) [11]. Males account for over one-half of reported cases. This age and sex pattern may reflect the amount of time certain groups spend outdoors in contact with forested habitats. (See 'Geography' below.)

Geography — Lyme disease infections in humans occur in the areas where the specific tick vector resides [23]. (See 'Tick vectors' below.)

Forested areas, including suburbs of large cities, have been associated with higher rates of infection [24,25].

The ongoing emergence of Lyme disease appears to be driven in part by environmental factors. As an example, in Europe and Canada, climate change is expanding the geographic areas where Ixodes ticks can survive [26-28]. In the United States, changes in land use practices and a marked increase in the deer population have increased the risk of exposure to infected ticks in certain regions [29-31].

United States — In the United States, most cases occur in the northeastern states, Wisconsin, and Minnesota. In 2022, 14 states accounted for over 94 percent of confirmed cases: Connecticut, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, and Wisconsin (figure 3) [32]. The reported number of cases by state or locality can be found on the United States Centers for Disease Control and Prevention (CDC) website.

Europe and Asia — The risk of Lyme disease in Europe is widespread (figure 4), but rates of reported disease vary widely among countries. In general, rates appear to be highest in northeastern and central Europe and substantially lower in Italy, Spain, and the British Isles [19]. Rates exceeding 100 per 100,000 population have been reported in areas of Austria, Belgium, the Czech Republic, France, Finland, Estonia, Germany, Lithuania, Poland, Slovenia, Switzerland, Sweden, the Netherlands, and Norway (figure 5) [17,19,20,33].

Lyme disease also occurs in Russia, Japan, and China (figure 4) [34-37].

Seasonal variation — In the United States, humans usually acquire the infection during the spring and summer seasons, when the nymphal form of the tick vector is most active [15]. (See 'Tick lifecycle' below.)

Since the incubation period between the acquisition of infection and onset of symptoms is approximately two to three weeks, most patients with Lyme disease present during the summer months of June, July, and August (figure 6). Late manifestations of infection (eg, arthritis) may present at any time of year.

TICK VECTORS — 

Ticks spread numerous infectious diseases by acting as vectors that carry microorganisms from one host to another. The pathogens are spread to and from the tick via the tick's bite.

Lyme disease is the most common tick-borne infection in the United States; from 2004 to 2016, Lyme disease was responsible for 82 percent of all reported tick-borne infections [8].

Ixodes tick species — Lyme disease is transmitted by various species of Ixodes ticks, depending on geography (figure 4) [38]:

●Ixodes scapularis in eastern and north central regions of North America (picture 1 and figure 7 and figure 8)

●Ixodes pacificus in western North America (eg, northern California, Oregon, and Washington) (figure 8)

●Ixodes ricinus in Europe and Western Asia (figure 9)

●Ixodes persulcatus in Eastern Europe and Asia (figure 10)

The distribution of these ticks is Holarctic (confined to the northern hemisphere), spanning both the Old World (Palearctic Region) and the New World (Nearctic Region) (figure 4) [38]. Because of the preferred habitat of these ticks, Lyme disease in humans is associated with heavily forested areas of the northern hemisphere.

In the United States, three tick species commonly bite people: Ixodes spp (the black-legged tick, deer tick) (picture 1), Amblyomma americanum (the lone star tick), and Dermacentor variabilis (American dog tick) (figure 7) [39]. Of these three, only Ixodes species are competent vectors of B. burgdorferi [40-43].

Tick lifecycle — I. scapularis and I. pacificus ticks undergo a lifecycle that consists of four life stages: egg to larva to nymph to adult. The lifecycle for I. scapularis lasts two years (figure 11), whereas the lifecycle for I. pacificus lasts three years (figure 12) [44].

After hatching from eggs, ticks must obtain a blood meal from a vertebrate host during each stage of their lifecycle to survive through to adulthood [44]. Ixodes ticks need a new host during every stage.

During the lifecycle of I. scapularis ticks, each stage occurs during a different season (figure 11) [45-48]:

●In the early summer, six-legged larvae hatch from their eggs. In late summer, each larva begins questing for a host in the leaf litter of the forest floor. The most common hosts during this stage are mice, other small mammals, or birds (see 'Reservoir hosts' below). After its blood meal, the tick larva falls off its host, molts, and re-emerges the next spring as an eight-legged nymph.

●During late spring or early summer, the nymph attaches to a second host (eg, mouse, vole, chipmunk) to obtain its blood meal (see 'Reservoir hosts' below). Once fed, the nymphal tick drops off the host, molts, and re-emerges in the fall as an eight-legged adult.

●During warm days in the fall, winter, and early spring, the adult tick attaches to a third host. Their preferred host is the white-tailed deer (see 'Reservoir hosts' below). While residing on the third host, adult ticks feed and mate. The adult female tick falls to the forest floor but does not lay eggs in the leaf litter until the next spring, and the two-year lifecycle repeats itself.

Ixodes ticks are forest dwellers, spending most of their time hiding in the leaf litter of the forest floor where humidity is high, and the risk of desiccation is low. When seeking a meal, they reside on the underside of low-lying shrubs or grass. Ticks sense warmth and carbon dioxide, and they latch on to a mammal with these attributes that brushes against them.

Infection of ticks — Tick larvae are uninfected with Lyme Borrelia when they first hatch, even in hyperendemic areas. They acquire the pathogen when they feed on infected animals and transmit it to other animals (including humans) during subsequent blood meals [44].

Once a tick ingests B. burgdorferi from an infected animal, the organism disseminates within the tick in a biphasic process [49]. In the first phase, spirochetes in the gut replicate and form networks of nonmotile organisms. In the second phase, which begins as the tick takes a blood meal, the spirochetes become motile, penetrate the wall of the tick's gut, enter the tick's main body cavity (hemocoel), and then enter the tick's salivary glands. Once in the salivary glands, the organisms can be transmitted to animal hosts via the tick bite.

Prevalence of infected ticks — Within highly endemic regions, the percentage of ticks carrying pathogens can vary greatly depending upon local ecologic features. As an example, among over 11,000 I. scapularis collected from 27 sites in New York's Hudson Valley from 2003 to 2006, rates of B. burgdorferi tick infection ranged from 2 to 30 percent among nymphs and from 17 to 52 percent among adult ticks [50]. In another study of over 1700 ticks from a suburb of New York City in 1989, 25 percent of nymphs and 50 percent of adult female ticks were infected [40].

Ixodes ticks infected with B. burgdorferi can also be infected with other pathogens, such as Anaplasma phagocytophilum, Babesia microti, Powassan virus, and the agent of hard tick relapsing fever, Borrelia miyamotoi. In the aforementioned survey of 1700 ticks in suburban New York City, the rate of adult tick coinfection was 6 percent with A. phagocytophilum and 2 percent with B. microti (0.5 and 1.0 percent of B. burgdorferi-infected nymphs were infected with A. phagocytophilum and B. microti, respectively) [40]. (See "Human ehrlichiosis and anaplasmosis" and "Babesiosis: Microbiology, epidemiology, and pathogenesis".)

Reservoir hosts — Reservoir hosts vary by geography and Ixodes tick species.

●North America – In the northeastern United States, the primary reservoir hosts for B. burgdorferi are rodents. In particular, the white-footed mouse, Peromyscus leucopus, was identified as the primary reservoir of B. burgdorferi soon after Lyme disease was described [51]. In hyperendemic areas of the northeastern United States, the majority of white-footed mice are infected with B. burgdorferi. Infected white-footed mice remain healthy but are persistently infectious.

Although the white-footed mouse is central to the Lyme disease enzootic cycle, immature I. scapularis feed on a wide variety of hosts, including other rodents, insectivores, lagomorphs, medium-sized mammals, birds, and reptiles. In suburban settings, where human dwellings exert a strong influence on the environment, other hosts such as chipmunks, squirrels, raccoons, skunks, and even shrews may play a larger role than white-footed mice as reservoirs of B. burgdorferi [52-55]. Indeed, in certain areas of the north central United States, chipmunks may be more important than white-footed mice as reservoirs of B. burgdorferi [56].

In the southern United States, I. scapularis ticks are rarely infected with B. burgdorferi, likely due to both ecologic and phenotypic factors. Immature I. scapularis ticks feed frequently on lizards, which are refractory hosts for B. burgdorferi [29].

In northern California, two intersecting cycles occur [57,58]. One cycle involves western gray squirrels and I. pacificus ticks, which can transmit B. burgdorferi to humans (figure 12) [59-61]. Another cycle involves the dusky-footed wood rat and Ixodes spinipalpis (formerly Ixodes neotomae) ticks, which do not bite humans but maintain the cycle of Borrelia bissettii in nature (B. bissettii does not cause Lyme disease in North America) [62]. (See "Microbiology of Lyme disease", section on 'Diversity of Lyme Disease species'.)

Birds may play a special role as reservoirs of B. burgdorferi, but not as enzootic reservoirs. Rather, they may be phoretic hosts, carrying infected ticks to regions where I. scapularis and B. burgdorferi are not well established. In Canada, birds have been identified as a likely source of infected ticks in southern Quebec, where the Lyme disease spirochete enzootic cycle is not well established [63].

●Europe and Asia – In certain areas of Europe, where B. garinii is the predominant spirochete infecting humans, song birds may play a key role as reservoirs [64]. In Japan, rodents are the main reservoir host of B. garinii strains that cause disease in humans [35].

Role of deer — Adult I. scapularis ticks feed and mate preferentially on larger animals, particularly deer [65]. Indeed, although the accepted common name for I. scapularis is the blacklegged tick, it is known colloquially in many areas as the deer tick.

The dramatic rise in white-tailed deer populations during the second half of the 20th century played a key role in supporting the expansion of I. scapularis and prompting, in part, the rapid emergence of Lyme disease that began in the 1980s [29,30]. While deer are required to support I. scapularis populations, they do not play a role as reservoirs of the Lyme disease spirochete; indeed, deer appear to have immunity to B. burgdorferi infection [66].

In summary, deer are important for the survival and propagation of the ticks that transmit Lyme disease but do not support the spirochetes themselves.

Transmission to humans — An infected I. scapularis tick must generally be attached for more than 24 hours before transmission of B. burgdorferi can occur. Daily tick checks to find and remove ticks can therefore reduce the risk of transmission. Transmission occurs more rapidly with I. ricinus and some European Borrelia species.

The nymphal stage of I. scapularis is the primary vector of transmission of infection to humans. One reason may be that the small size of the nymph (<2 mm, or the size of a poppy seed) makes them harder to detect than the size of adult ticks, so it is more likely a nymph will stay attached long enough to transmit infection (figure 7 and picture 2) [47,67]. (See "Evaluation of a tick bite for possible Lyme disease", section on 'Tick attachment'.)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Lyme disease (The Basics)")

●Beyond the Basics topic (see "Patient education: Lyme disease symptoms and diagnosis (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Incidence – Lyme disease is the most common tick-borne infection in the United States and Europe.

In the United States, over 60,000 cases were reported in 2022 (figure 1). In Europe, rates exceeding 100 per 100,000 population have been reported in several countries. (See 'Incidence' above.)

●Geographic and seasonal variation

•In the United States, most cases occur in the northeastern states, Wisconsin, and Minnesota (figure 3). Infections peak during the spring and summer, when the nymphal form of the tick vector is most active (figure 6). (See 'United States' above and 'Seasonal variation' above.)

•In Europe, the risk of Lyme disease is widespread; rates appear to be highest in northeastern and central Europe and substantially lower in Italy, Spain, and the British Isles (figure 5). In Asia, infections have been reported in Russia, Japan, and China. (See 'Europe and Asia' above.)

Forested areas, including suburbs of large cities, have higher rates of infection. (See 'Geography' above.)

●Borrelia species – Lyme disease is caused by spirochetal bacteria of the Borrelia (also called Borreliella) genus. Certain species of Borrelia account for most cases:

•In North America, Borrelia burgdorferi sensu stricto is the primary species. A second species, Borrelia mayonii, is an additional cause in the upper midwestern United States.

•In Europe and Asia, Borrelia afzelii, Borrelia garinii, and, to a lesser extent, B. burgdorferi are the predominant causes. (See 'Borrelia species' above.)

●Tick vector – Lyme disease is transmitted by various species of Ixodes ticks, depending on geography (figure 4):

•Ixodes scapularis in eastern and north central regions of North America (picture 1 and figure 7 and figure 8)

•Ixodes pacificus in western North America (eg, northern California, Oregon, and Washington) (figure 8)

•Ixodes ricinus in Europe and Western Asia (figure 9)

•Ixodes persulcatus in Eastern Europe and Asia (figure 10) (see 'Ixodes tick species' above)

●Transmission to humans – An infected I. scapularis tick must generally be attached for more than 24 hours before transmission of B. burgdorferi can occur. Transmission occurs more rapidly with I. ricinus and some European Borrelia species.

For I. scapularis, ticks in the nymphal stage are the primary vector of transmission, possibly because their small size (<2 mm, the size of a poppy seed) makes them harder to detect than adult ticks (figure 7 and picture 2). (See 'Transmission to humans' above.)

ACKNOWLEDGMENTS — 

The UpToDate editorial staff acknowledges Joseph Piesman, DSci, C Benjamin Beard, PhD, and Amy Schwartz, MPH, who contributed to earlier versions of this topic review.

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  59. Salkeld DJ, Leonhard S, Girard YA, et al. Identifying the reservoir hosts of the Lyme disease spirochete Borrelia burgdorferi in California: the role of the western gray squirrel (Sciurus griseus). Am J Trop Med Hyg 2008; 79:535.
  60. Ley C, Davila IH, Mayer NM, et al. Lyme disease in northwestern coastal California. West J Med 1994; 160:534.
  61. Lane RS, Foley JE, Eisen L, et al. Acarologic risk of exposure to emerging tick-borne bacterial pathogens in a semirural community in northern California. Vector Borne Zoonotic Dis 2001; 1:197.
  62. Brown RN, Peot MA, Lane RS. Sylvatic maintenance of Borrelia burgdorferi (Spirochaetales) in Northern California: untangling the web of transmission. J Med Entomol 2006; 43:743.
  63. Ogden NH, Lindsay LR, Hanincová K, et al. Role of migratory birds in introduction and range expansion of Ixodes scapularis ticks and of Borrelia burgdorferi and Anaplasma phagocytophilum in Canada. Appl Environ Microbiol 2008; 74:1780.
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Topic 7901 Version 31.0

References

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51 : Culturing Borrelia burgdorferi from spleen and kidney tissues of wild-caught white-footed mice, Peromyscus leucopus.

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55 : Conspicuous impacts of inconspicuous hosts on the Lyme disease epidemic.

56 : Role of the eastern chipmunk (Tamias striatus) in the epizootiology of Lyme borreliosis in northwestern Illinois, USA.

57 : The emergence of Lyme disease.

58 : Biology of Borrelia species.

59 : Identifying the reservoir hosts of the Lyme disease spirochete Borrelia burgdorferi in California: the role of the western gray squirrel (Sciurus griseus).

60 : Lyme disease in northwestern coastal California.

61 : Acarologic risk of exposure to emerging tick-borne bacterial pathogens in a semirural community in northern California.

62 : Sylvatic maintenance of Borrelia burgdorferi (Spirochaetales) in Northern California: untangling the web of transmission.

63 : Role of migratory birds in introduction and range expansion of Ixodes scapularis ticks and of Borrelia burgdorferi and Anaplasma phagocytophilum in Canada.

64 : Blackbirds and song thrushes constitute a key reservoir of Borrelia garinii, the causative agent of borreliosis in Central Europe.

65 : Role of deer in the epizootiology of Babesia microti in Massachusetts, USA.

66 : Bacteriolytic activity of selected vertebrate sera for Borrelia burgdorferi sensu stricto and Borrelia bissettii.

67 : Transmission dynamics of Borrelia burgdorferi s.s. during the key third day of feeding by nymphal Ixodes scapularis (Acari: Ixodidae).