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Modified two-tier testing (MTTT): a faster Lyme disease diagnosis

Lyme disease is a growing health issue; in fact, according to the Centers of Disease Control and Prevention (CDC), recent estimates suggest that approximately 300,000 people may get Lyme disease each year in the United States.1

Treatment is more effective if begun early, and an updated recommendation from the CDC paves the way for earlier detection and diagnosis of the disease using modified two-tier testing (MTTT) which utilizes immunoassays rather than immunoblots in the second tier of the algorithm.

Updated CDC recommendation for serologic diagnosis of Lyme disease: 2-step testing process

  • Test serum in an immunoassay measuring combined IgG and IgM antibodies to specific borrelial proteins.
  • Verify the results using a second FDA-cleared IgG and IgM immunoassays in place of a Western blot (immunoblot) test. This is an acceptable alternative for the serologic diagnosis of Lyme disease.

According to published data,2,3 the sensitivity of MTTT is improved over the STTT algorithm with comparable specificity in early stage of Lyme disease (localized and disseminated). The CDC has recommended that clinicians and laboratories consider serologic assays that utilize a second EIA in place of western immunoblot assay as acceptable alternatives for the serologic diagnosis of Lyme disease.4

How the lab can help

The new test from Quest utilizes immunoassays rather than immunoblots in the second tier of the algorithm, which may be able to assist in the identification of early Lyme disease within the first 30 days of infection.

For more information, visit Quest Diagnostics or these helpful websites:



  1. Centers for Disease Control and Prevention, Data and Surveillance. Page last reviewed: November 22, 2019,state%20health%20departments%20and%20the%20District%20of%20Columbia. Accessed July 23, 2020
  2. Porwancher RB, Hagerty CG, Fan J, Landsberg L, Johnson BJ, Kopnitsky M, Steere AC, Kulas K, Wong SJ. Multiplex immunoassay for Lyme disease using VlsE1-IgG and pepC10-IgM antibodies: improving test performance through bioinformatics. Clin Vaccine Immunol. 2011 May;18(5):851-9. doi: 10.1128/CVI.00409-10. Epub 2011 Mar 2.
  3. Branda JA, Linskey K, Kim Y, Steere AC, Ferrano MJ. Two-Tiered Antibody Testing for Lyme Disease With Use of 2 Enzyme Immunoassays, a Whole-Cell Sonicate Enzyme Immunoassay Followed by a VlsE C6 Peptide Enzyme Immunoassay. Clin Infect Dis 2011; 53:541–5474Centers for Disease Control and Prevention. Updated CDC Recommendation for Serologic Diagnosis of Lyme Disease. Page last reviewed: August 15, 2019. . Accessed July 23, 2020