CASE TEACHING NOTES
"Is It a Lemon or a Lyme?
A Case Study on the Decision
to Vaccinate or Not"
Biotechnical and Clinical Laboratory Sciences
University at Buffalo, State University of New York
This multi-part dilemma case was designed for a junior level immunology course. It could also be used
in a microbiology or bacteriology course where the emphasis is on treatment as well as disease.
Although the case revolves around a particular microbe that causes Lyme disease, the central question is
"Should a person get vaccinated given the associated risks and the benefits?"
At the University at Buffalo, our program is accredited to teach Clinical Laboratory Science by the
National Accrediting Agency for Clinical Laboratory Sciences. This accreditation requires that a list of
objectives for each lecture in the program be provided for the students. This serves as an aid to the
students in understanding which concepts in the material are of primary importance, and is also helpful
to the teacher when preparing the tests. These objectives are categorized as in the affective domain (how
the student relates to the subject), the cognitive domain (how the student understands the subject), and
the psychomotor domain (how the student performs the task).
There are many objectives for this case study. In the affective domain, I expect that by working through
this case, students will:
realize that health care decisions are their own and should be made after obtaining the knowledge
needed to make an informed decision;
learn that in order to decide whether or not to be vaccinated, an individual should assess their
individual risk and determine if the disease pathology is potentially serious, the effectiveness and
side effects of therapy for the disease, and the effectiveness and possible side effects of the
learn to share their ideas and participate in groups since group work is an increasing part of
operating in the scientific world, both in industry and academia;
gain insight into the need to evaluate the quality of the information that they obtain from different
In the cognitive domain, I expect that after this exercise students should have learned something from
each group. They should be able to:
judge the relative risk for development of Lyme disease in various regions of the country and the
world (with information from the epidemiology group);
judge the relative risks at different times of the year and with different activities (from the
epidemiology and etiology/pathology groups);
discuss the pathologies caused by the bacteria in Lyme disease (from the etiology/pathology
compare the signs and symptoms of the various stages, or manifestations, of Lyme disease (from
the etiology/pathology group);
describe the etiology of Lyme disease (again, from the etiology/pathology group);
evaluate the appropriate treatment for patients with each stage of the disease, for penicillin allergic
individuals, and for pregnant patients as well as be able to describe the potential adverse side
effects of these treatments (from the prevention/treatment group);
discuss the efficacy of antibiotic treatment of the different stages of the disease (again, from the
describe laboratory assays, including PCR, Western blotting, enzyme immunoassays, and
immunofluorescent assays, for the Borrelia or for the anti-Borrelia burgdorferi antibody or the
Borrelia antigens; for the different laboratory assays, they should be able to describe the
specificity and sensitivity of each (from the laboratory diagnosis group).
describe the vaccine protocol and be able to describe the risks, costs, and benefits of the Lyme
disease vaccine as well as the vaccine's efficacy (from the vaccine group);
analyze case studies involving Lyme disease (all groups).
In the psychomotor domain, I expect that the students will:
gain experience in performing web searches for information.
I hand out the case assignment two weeks before I expect to have the in-class presentations in order to
give the students time to meet and prepare their presentations together. The students are expected to read
the associated chapter in the textbook, Christine Stevens Clinical Immunology and Serology, A
Laboratory Perspective (1996). The students are also each expected to read their assigned material
(summary sheets) and as a group assign each member certain of the associated links from which to
gather information. Members of each group should also be given the take of finding additional sources
of information not listed and summarizing the information from these sources.
Most students in my immunology lecture class take either a Monday laboratory session or a Wednesday
laboratory session. I assign project groups based on the laboratory assignments. In the laboratory class,
there is a tendency for friends to sit next to one another, so my group assignments involve splitting each
lab into two groups, alternating placement in each of the two groups as I walk by the seated students.
The groups contain four to five students each. The fifth group is formed from the students that elected
not to take the laboratory component. This case study is the second of two group projects in my
classroom, and the groups contain the same individuals for both projects. The advantage of selecting
students in the same laboratory session is that there are incubation times during the laboratory procedure
in which the students have time to interact and begin work on these assignments and to divide the work
appropriately. There is an in-class and an out-of-class component to the projects. Since these projects are
not too labor-intensive, approximately one-third of the work can be completed in the laboratory. The
total amount of time that the students should spend on this project is four to five hours.
This project is worth one-eighth of their grade. The two projects each have equal weight as the four tests
and the final exam has double weight. I give each group a grade based on a total of 10 points, and the
individual student grade is determined by the peer evaluation technique suggested by Herreid (see
Herreid 2001). The students in the groups of five were given 40 points to distribute, not grading
themselves. They could not give 10 points to each other student, and some grading fluctuation had to
occur. The students received their peer score times their group score as their final grade. For example, if
a student's peer score average was a 9 and their group score a 9, their grade would be 9 x 9 = 81.
The presentation phase is run as follows: Each group presents its findings and their recommendation to
the class about whether, based on their group's information only, they would recommend use of the
vaccine. The order of the presentations is: (1) epidemiology, (2) etiology and pathology, (3) prevention
and treatment, (4) laboratory diagnosis, and (5) vaccine.
The summary begins with a brief discussion on what, if any, part of the presentations surprised us. Next
I have the students write on an index card which group they were in and the personal decision they
would make after hearing all the information presented concerning whether or not they would get
vaccinated with the Lyme vaccine. I tally this information in front of the students on the blackboard, and
this concludes the lesson.
Variations for Teaching the Case
Using more of a problem-based learning (PBL) format, the students could be placed in groups of five
and told to "brainstorm" about what they need to know in order to make a decision about being
vaccinated. In this scenario, they would not be told at the outset what factors would be involved in the
decision. The class then would have a discussion led by the instructor about what these factors are. Each
student in each group could then research and present a different factor. The students would report to
each other within their groups, discuss vaccination from this greater knowledge base, and then prepare a
written report as a group that is an analysis of the issues and their group's decision about whether or not
to be vaccinated. The instructor would lead a group discussion summarizing the thoughts of each group.
CDC Lyme Disease Home Page- CDC Division Vector-Borne Diseases. Available at:
Edlow, J.A. 1999. "Lyme Disease and Related Tick-borne Illnesses." Annals of Emergency
Medicine 33(6): 680-693.
Herreid, C.F. 2001. "When Justice Peeks: Evaluating Students in Case Method Teaching."
Journal of College Science Teaching 30(7):430-433. Available at:
Modlin, J.F. et al. 1999. "Recommendations for the Use of Lyme Disease Vaccine,
Recommendations of the Advisory Committee on Immunization Practices (ACIP)," Morbidity and
Mortality Weekly Report, June 4, 48 (RR07): 1-17. Available at:
Murray, P. 1996. The Widening Circle: A Lyme Disease Pioneer Tells Her Story. New York: St.
The National Academies Institute of Medicine. 2001. "Immunization Safety Review: Measles-
Mumps-Rubella Vaccine and Autism." Available at:
Stevens, C. 1996. Clinical Immunology and Serology, A Laboratory Perspective. Philadelphia:
Acknowledgments: This case was developed with support from The Pew Charitable Trusts as part of
the Case Studies in Science Workshop held at the University at Buffalo, State University of New York,
on June 12-16, 2000. The author wishes to thank Tucker Crum, Janet MacDonough, and LeLeng To for
their contributions to the development of this case.
Date Posted: 04/19/02 nas