Disclosure Slide

1. Disclosure Slide We have no financial relationships with any commercial interest related to the content of this activity

2. Pertussis and Pertussis Vaccination: Why All the Whoop-la? A Summary for South Carolina Medical Providers Riyadh D. Muhammad, MD, MPH – Pediatrician Helen L. Huber, MSN - Pediatric Nurse Practitioner Bureau of Disease Control South Carolina Department of Health and Environmental Control

3. Source: W. Orenstein. An overview of Vaccinology; 2009 Clinical Vaccinology Course, Atlanta.

4. Sounds of Pertussis Whooping Child Whooping Adult

5. Overview • Pertussis Surveillance Data • Clinical Considerations • Background • Clinical Features • Diagnosis • Treatment • Reporting cases to DHEC • Vaccine • Vaccines available • Recommendations • Coverage rates • Safety

6. Reported Pertussis Cases* U.S., 1922-2009† DTaP for all doses (1997) DTaP for doses 4 & 5 (1992) DTP (1949) Tdap (2005) *National Notifiable Diseases Surveillance System (NNDSS) †2009 data provisional Ref: S. Roush, NIC 2010

7. Reported Pertussis Cases* U.S., 1980-2009† Tdap (2005) 1997: PCR included in case definition *National Notifiable Diseases Surveillance System (NNDSS) †2009 data provisional Ref: S. Roush, NIC 2010

8. U.S. Pertussis Cases, 2010 Ref: CDC. Unpublished data.

9. South Carolina Rate

10. S.C. Pertussis Cases, 2010

11. South Carolina, 2010

12. South Carolina

13. Pertussis • Fastidious gram-negative bacillus, Bordetella pertussis • Severe, debilitating cough illness lasting weeks to months (“100 day cough”) • Characterized by paroxysms of cough, inspiratory whoop, vomiting; apnea in young infants

14. Pertussis • Highly contagious • Transmission by contact with secretions, droplets from nose or mouth • Vaccine preventable, but poorly controlled • Despite high childhood vaccine coverage, pertussis remains a problem in S.C. and the U.S.

15. Pertussis • Worldwide occurrence • Affects all ages, even vaccinated persons • Morbidity and mortality complications most common among infants • Transmission from parents, household members • Recommendation for cocooning vaccination approach • Persistent cough itself can cause complications

16. Pertussis Clinical Features • Incubation period 5-10 days (range 4-21 days) • Insidious onset, similar to minor URI with nonspecific cough • Fever minimal or absent • Pertussis presentation varies depending upon age, existing immunity • Classically characterized by • Paroxysms of cough • Inspiratory whoop • Vomiting

17. Timeline of Pertussis Symptoms • Catarrhal stage 1-2 weeks • Mild URI, progresses to cough • Most contagious stage • Paroxysmal 1-6 weekscough stage • Whooping, vomiting • Convalescence Weeks to months • Gradual resolution

18. Pertussis Epidemiology • Reservoir Humans • Transmission Respiratory droplets • Communicability Maximum in catarrhal stage Secondary attack rate up to 80%

19. Pertussis Among Adolescents and Adults • Disease often milder compared to infants and children • Persons with mild disease may transmit the infection • Infection may be asymptomatic, or present as classic pertussis • Pertussis is unrecognized, underreported • Asymptomatic infections are 4 to 22 times more common than symptomatic infections • Symptomatic adolescents and adults are the major source of infection in unvaccinated children

20. Pertussis Among Infants • Most severe disease • Infants under 6 months have an atypical presentation • Short catarrhal stage • Longer period of convalescence • Absence of whoop • Prominent symptoms can be • Gagging • Gasping • Apnea • Can lead to sudden unexplained death

21. Let’s Protect Our Infants!Pertussis Deaths in the U.S., 2004-2006 Age at onset <3 mos 24 32 13 69 (84%) >3 mos 3 7 3 13 (16%) Total 27 39 16 82 2004 2005 2006 Total CDC, unpublished data, 2007

22. Source of Pertussis Among Infants • 616 cases of pertussis in infants • Source identified in 264 (43%) • Parents 47% • Siblings 20% • Grandparents 8% • Other 25% Ref: Bisgard et al. PIDJ 2004;23:985-989.

23. Pertussis Complications Condition Pneumonia SeizuresEncephalopathy Hospitalization Death Percent reported 4.9 0.7 0.1 16 0.2 *Cases reported to CDC 2001-2003 (N=28,998)

24. Pertussis Complications • Seizures • Encephalopathy • Syncope • Rib Fractures • Incontinence Courtesy of T. Schlenker, Children's Hospital of Wisconsin

25. Pertussis Diagnosis • Culture • Polymerase chain reaction (PCR) • Serology • Direct fluorescent antibody (DFA) • DFA and serology might be clinically useful • Cannot be used for case confirmation for reporting

26. Pertussis Diagnosis Is currently complicated by: • Stage of disease (catarrhal, paroxysmal, convalescent) • Antimicrobial administration • Vaccination status • Quality/timely collection of clinical specimen • Transport conditions • Contamination of clinical specimen • Lack of clinically validated and standardized tests

27. Optimal Timing for Pertussis Diagnostic Testing Communicable Period Convalescent Stage Paroxysmal Stage Incubation Period Catarrhal Stage -3 0 2 8 12 Weeks Bacterial Culture Symptom Onset PCR Serology

28. PCR

29. Culture • Isolation drastically declines after: • - 2 weeks of cough • - Antimicrobial or vaccine administration • - Inappropriate collection/transport /growth conditions

30. ‘Pseudo’ Outbreaks of Pertussis: Pitfalls of PCR

31. Problems Identified in Pseudo Pertussis Outbreaks • Over reliance on PCR • Single, non-specific DNA targets • Few cultures were performed • Testing ill persons without typical pertussis symptoms • Viruses, parapertussis, Chlamydia, Mycoplasma, etc • Contamination of PCR tests via • Specimens from true cases • Pertussis vaccines • Inappropriate specimen handling

32. Obtain PCR and Culture • CDC and DHEC recommend culture along with your PCR • PCR should be used in conjunction with and not in place of culture • Pertussis culture is • Cheap • Facilitates validation of PCR results • Keeps PCR ‘honest’ • False positives • Contamination • None are FDA approved

33. Collecting Pertussis Specimens • Nasopharyngeal (NP) wash or swab • Use for culture, PCR • Throat swabs, cotton-tipped swabs not acceptable and inhibit growth of B. pertussis *A video of NP swab collection is available at: http://video.cdc.gov/asxgen/nip/isd/swabdemo.wmv

34. Collecting NP Swabs for Pertussis Testing • Requires 2 Dacron tipped swabs with flexible shafts per patient • One placed in Regan Lowe Transport Media at bedside (used for culturing) • One placed in a sterile tube without media (used for PCR) • Avoid contamination • Failure to follow these procedures can cause • False negatives • False positives

35. Antibiotic Treatment • Macrolide antibiotics first-line • 5-day course of azithromycin, or • 7-day course of clarithromycin, or • 14-day course of erythromycin • Alternative is a14-day course of TMP/SMX • Treat persons >1 year within 3 weeks of cough onset (up to 90% clear infection in 3-4 weeks) • Treat persons <1 year within 6 weeks of cough onset (infectious longer) • Postexposure antibiotics to case contacts within 3 weeks of exposure

36. Fairfield, Lexington, Newberry, Richland 803-576-2749 Chester, Lancaster, York 803-286-9948

37. Reporting Pertussis to DHEC • Providers required to report • Not the sole responsibility of laboratories • Report suspected or confirmed cases • No need to wait for lab confirmation • DHEC assists providers • Diagnostic testing • Outbreak investigation and control • Identification of source cases • Contact tracing for antibiotic prophylaxis • Vaccine resources

38. Pertussis Case Investigation • Suspect pertussis infection • Infant with: initially URI symptoms*, coughing, apnea, gagging, gasping, hypoxia, seizures; contact with a coughing individual • Older child or adult with: cough illness, paroxyms, whooping, post-tussive vomiting, prolonged cough; cases may be diagnosed with ‘bronchitis’ • Inform local DHEC county • Collect specimens • Culture and PCR (use recommended methods, materials) • Begin treatment (do not wait for lab confirmation)

39. Pertussis Case Investigation • Identify contacts during infectious period • Most infectious at cough onset through 21 days after cough onset • Close contacts should receive antibiotic prophylaxis, regardless of vaccination • Pertussis is highly infectious • Use standard and droplet precautions • Consider face masks to all patients with URI (flu, pertussis, etc) • Cases must stay home until completion of 5 days of antibiotics

40. Clinicians and Pertussis • Use recommended methods to diagnose and treat suspected cases • Early diagnosis and treatment will prevent infant cases and deaths • Use postpartum cocooning strategies to vaccinate parents, families of newborns before mother is discharge • Ensure patients are appropriately vaccinated with DTaP and Tdap

41. Pertussis Vaccines:Got Tdap?

42. Pertussis Vaccines • DTaP • Infant/childhood vaccine • Ages 6 weeks to 6 years • Tdap • Adolescent/Adult vaccine • Ages 10 to 64 years • Group in whom studies were done • No licensed vaccine for those 7-9 years of age • Some off label use reported for >64 year olds

43. Pertussis Vaccines Ref: Sandora et al. Clin Microbiol Rev. 2008:21(3);426-434.

44. DTaP Adverse Reactions • Local reactions • Temp of 101° or higher • More severe adverse reactions not common • Local reactions and fever more common following 4th and 5th doses (swelling involving entire thigh or upper arm has been reported—NOT a contraindication to 5th dose)

45. DTaP Precautions • Moderate or severe acute illness • Temperature 105° (40.5° C.) or higher within 48 hours with no other identifiable cause • Collapse or shock-like state (hypotonic hyporesponsive episode) within 48 hours • Persistent, inconsolable crying lasting 3 hours or longer, occurring within 48 hours • Convulsions with or without fever occurring within 3 days

46. DTaP/Tdap Contraindications • Severe allergic reaction (anaphylaxis) to vaccine component or following a prior dose • Encephalopathy not due to another identifiable cause occurring within 7 days after vaccination with a pertussis-containing vaccine

47. Tdap in Persons with Adverse Events after DTaP • Occurrence of adverse reactions (precaution) following DTaP vaccine in childhood is NOT a contraindication or precaution to administration of Tdap to an adolescent or adult

48. Tdap Precautions • History of a severe local reaction (Arthus reaction) following a prior dose of a tetanus and/or diphtheria toxoid-containing vaccine • Progressive neurologic disorder until the condition has stabilized • History of Guillain-Barré syndrome within 6 weeks after a prior dose of tetanus toxoid-containing vaccine • Moderate or severe acute illness

49. Tdap Adverse Reactions • Local reactions 21%-75% (pain, redness, swelling) • Temp of 100.4oF 3%-5% or higher • Adverse reactions occur at approximately the same rate as Td alone

50. Tdap Recommendations • Approved as a single booster to replace Td in persons fully vaccinated with pediatric DTaP or DTP • Routine administration at 11-12 year well visit. • Adolescents and adults <65 years of age who have not received a dose of Tdap, or for whom vaccine status is unknown, should be immunized as soon as feasible. • Priority groups • Health care personnel (HCP) • Any individual with infant contact (<1 year of age) • Use Tdap for wound prophylaxis, not Td, if not already received Tdap