# Presentation: 213822

## Pertussis in Adolescents and AdultsConsideration of Tdap

- National Immunization Program **          **
- Centers for Disease Control and Prevention

**Notes:**
Good Morning
 This morning I will give a brief overview of the epidemiology of the reported cases of pertussis in the United States.

## Whooping Cough -- Pertussis

- Severe, debilitating cough illness lasting weeks to months (“100 day cough”)
- Gram-negative bacillus, *Bordetella pertussis*
- Characterized by paroxysms of cough, vomiting, inspiratory whoop; apnea in young infants
- Worldwide occurrence, affects any age
- Deaths primarily among infants

## Pertussis Challenges 

- Surveillance
- reliance on clinical case definitions; low rate of culture positive cases
- Disease control strategies
- Limited options for antibiotic prophylaxis
- Effective against transmission; less so against disease
- Vaccine
- Targets infants/children
- No vaccine for adolescents and adults

## Pertussis Challenges 

- Education
- Under recognition of pertussis
- Diagnostics
- Obtaining adequate specimen
- Culture backup; PCR no QC, standards
- Individual morbidity
- Symptoms, hospitalizations among adolescents/adults
- High risk groups outside infancy not well characterized (except nosocomial)

## Timeline -- Tdap

- BLA submitted
- GlaxoSmithKline: BoostrixTM, 10-18 years of age (July 7, 2004)
- Aventis-Pasteur: AdacelTM, 11-64 years of age (August 12, 2004)
- FDA Vaccine and Related Biologics Advisory Committee
- March 15, 2005

## ACIP Pertussis (Tdap) Working Group

- Formed June 2004; 11 meetings
- Members: 20 (ACIP, FDA, DoD, HRSA, HIS, NIH and CDC-NIP)
- Consultants: 13 (AAP, AAFP, AAHP, ACOG, ACP, CNACI, HICPAC, IDSA, NMA, state DOHs)
- Presentations: working group, industry, academia, state DOHs,

## Charge to the Working Group

- Consider strategies to improve prevention and control of pertussis in the United States using acellular pertussis vaccines formulated for adolescents and adults ....
- Fully implemented childhood program of vaccination with DTaP

## Stepwise Approach

- Adolescents first
- Replace Td with Tdap
- Then, selective recommendations
- Health care workers (? others)
- Protection of infants through vaccination of adults
- Recommendations for adult populations

## Preference for Initial use of Tdap For Adolescents-- Rationale

- High rates of endemic pertussis among adolescents
- Substantial morbidity among adolescents
- Tdap likely to be cost-effective from societal perspective (perhaps cost saving)
- Potential secondary benefits (reduce total burden of endemic and epidemic pertussis)

## Reported Pertussis in Adolescents Surveillance Data Outside MAAge 10-19 yrs     2000-2004*

| State | High year, n | High year, incidence | Low year, incidence |
| --- | --- | --- | --- |
| MA |    n=1082 |       130 |         41 |
| WI |   n=1573 |       195 |           6 |
| VT |     n=150 |       168 |         32 |
| CO |     n=486 |         75 |         22 |
| WA |     n=271 |         31 |           5 |
| MN |     n=211 |         28 |         12 |

- *NETSS data, 2004 provisional

- Incidence per 100,000 pop

## Pertussis in MA Adolescents
Average Annual Incidence and                    Cumulative Percent , 1996-2003

- Average Annual Incidence and                    Cumulative Percent , 1996-2003

**%**

## Complications in Adolescents Reported with Pertussis 

|  | MA -1
n=314 | MA - 2
n=1679 | Quebec
n=280 |
| --- | --- | --- | --- |
| Cough | Mean 3.4 mo* | 38% > 1 mo @ dx | 47% > 9 wk |
| Pneumonia | 2% | 2% | 2% |
| Rib fracture | 1% |  | 1% |
| Loss of consciousness | 1% |  | 0 |
| Hospitalization  |  | 0.8%
(n=13) | 1% |

- * At interview

## Pertussis in 314 MA AdolescentsMedical Visits/Missed School/Work

- Medical visits ~ 24% _>_ 3 visits
- Mean 2 visits      (range 0-15 visits)
- Student missed school  83%
- Mean 5.5 days        (range 0.4-32 days)
- Parent/caretaker missed work  43%
- Mean 2.4 days        (range 0.1-25 days)
- 2nd parent/caretaker missed work 14%
- Mean 1.8 days        (range 0.1-11 days)

- Lee G. et al CID 2004;39: 1572-1580

**Notes:**
Check age MA all still in school?

## Statewide Pertussis Outbreak Wisconsin 2004

- Aggressive case finding and testing
- PCR available
- 5020 cases overall
- 111 hospitalizations (57 in infants age 0-5m)
- 2028 cases (40%) in 10-19 year olds
- Rate 251/100,000
- 15 adolescents hospitalized
- 33 adolescents with pneumonia

- Data from WI DPH, provisional

## Timeline June-October 2005 ACIP 

- Tdap for adolescents
- Tdap for other age cohorts (including selective high risk settings)
- Reduce morbidity in adults, infants and in selected high risk groups

## Acknowledgements

- Massachusetts Department of Public Health
- Susan Lett, MD, MPH
- Dara S. Friedman, PhD, MPH.
- Arquimedes Areche, MPH
- Stephanie Schauer, PhD
- Fond du Lac County      Health Department
- Diane Cappozzo, RN
- Carol Schmidt, RN
- Warren Post, MD

- Wisconsin Division of Public Health
- Jeffrey P. Davis, MD
- Mark Sotir, PhD, MPH
- Daniel Hopfensperger
- Alexandra Newman, DVM, MPH.
- Wisconsin State Laboratory  of Hygiene
- David Warshauer, PhD
- Tim Monson, MS

## AcknowledgementsCDC-NIP Pertussis Team

- Karen Broder
- Amanda Cohn
- Margaret Cortese
- Katrina Kretsinger
- Christine Miljelski
- John Moran

- Trudy Murphy
- Pekka Nuorti
- Martha Roper
- Barbara Slade
- Pamela Srivastava
- Tej Tiwari