# Presentation: OSESBZQ42F72AP6HYH7KE4MMALTXLM66

## Addressing an Epidemic: The Clinicians’ Role in Preventing PertussisMark Sawyer, MD. FAAP

**Addressing an Epidemic: ****The Clinicians’ Role in ****Preventing Pertussis****Mark Sawyer, MD. FAAP**

**Presented by:****California Department of Public Health **
**Co-sponsor:**** California Immunization Coalition**
**Joint Sponsorship provided by:**
** ****PAC/LAC**

## Objectives 

- Be able to describe pertussis
- Epidemiology in California during 2010
- Clinical presentation of illness
- Diagnosis
- Treatment
- Immunization recommendations
- Ways to improve current low immunization rates in adults and adolescents to protect Californians, especially vulnerable young infants

## Pertussis (Whooping Cough)

- Highly contagious bacterial respiratory disease
- Spreads easily by aerosols or droplets
- High community immunity level (92+%) needed to stop transmission – US levels far lower
- Affects all ages - young infants most vulnerable
- Highest rates of illness, hospitalization, death
- Exposed to infected close contacts

## First-Hand Video Stories Online

**www.Shot****By****Shot.org**

**Notes:**
on the day of discharge, I asked my doctor and was told that pertussis, wasn’t seen anymore...viral infections are going around... 

So I went home hoping hand washing and breastfeeding would help protect Dylan from getting this “cold.”  .... I eventually tested positive for pertussis... 

Less than 24 hours later my baby was unable to breathe on his own, his immune system was failing, and his heart and kidneys were shutting down.  Dylan died 17 days after he was born.

## All Ages Vulnerable to Pertussis!

- <6 months: too young to be fully immunized
**Most of hospitalizations and deaths occur <3 months  **
**Exposed to infected household contacts**
**Parents , most often mothers, sibs, others**
- 6 months – ~10 years:  protected if immunized
**5 doses of DTaP vaccine given from **_**as early as 6 weeks**_** – 5 years**
**Immunity wears off years after immunization or disease**

## All Ages Vulnerable to Pertussis!

- Preteens – elderly: vulnerable once again
- Disease on average milder – can still debilitate
- Most cases are not recognized or reported
- Since 2005: Tdap booster vaccine available
- Uptake is low: 53% teens**1**, ~6% in adults**2**

**1 ****NIS data for CA, 2009: www.cdc.gov/mmwr/preview/mmwrhtml/mm5932a3.htm**
**2****cdc.confex.com/cdc/nic2010/webprogram/Paper22766.html **

## Cyclical Pattern

- Whooping cough peaks every 2-5 years in California and the U.S.
- Numbers of susceptible people increase,  allowing sustained transmission of disease

## Pertussis cases reported in California, 1950-2010

## CA Pertussis Cases (August 2010) 

**3,311** confirmed, probable and suspect cases,  8**.5 cases/100,000**
**7-fold increase** from reported cases during the same time period in 2009 (**434 **cases)
**8** deaths to date
**7 infants <3 months; no DTaP doses**
**1 premature infant, age 2 months: 1 DTaP **
**Cough illness common in parents or sibs**

## 2010 California Pertussis Cases               as of 8/24/10

| Code | Pertussis Cases |
| --- | --- |
|  |   0 |
|  |   1 - 49 |
|  |  50 - 99 |
|  | 100 - 199 |
|  | 200 - 337 |

**Marin**

**San Luis Obispo**

**Fresno**

**Orange**

**San Diego**

**2010 California Pertussis Cases               as of 8/24/10**

**Riverside**

**Los Angeles**

**Kern**

**Alameda**

**Sonoma**

## CA Pertussis Rates  (8/24/2010)

**Age**
**<6 months **(158/100,000)** **
**7-9 years **(26/100,000)** **
**10-18 years **(20/100,000);** peak @ 10 y**
**Race/ethnicity – highest for**
**All Ages: Whites **(7.7/100,000)
**<6 months: Hispanics**** **(199/100,000)

## Rates of reported pertussis by age -- California, 1 Jan - 24 Aug 2010

## Pertussis Hospitalizations California Jan – Aug 2010

**Incomplete data**
**12% of reported cases hospitalized**
**60% of these <3 months**
**75% <6 months**
**79% Hispanic**
**2005 Medical charges for pertussis >$23 million****1****  **
**1****OSPHD hosp. discharge data**

## Pertussis Symptoms 

- 3-stage illness (catarrhal, paroxysmal, convalescent) lasts 4-12 weeks
- Typical symptoms
**	****paroxysmal cough   **
**	****lack of fever**
**	****no systemic illness**
- Adults
**choking sensation, sweating episodes**

**coryza; no pharyngitis**
**Post-tussive vomiting**
**Post-tussive whoop**

## Clinical Course (in weeks)

**-3**

**0**

**2**

**12**

**8**

**Onset**

**Incubation period**
**(max 21 days)**

**Catarrhal stage**
**(1-2 weeks)**

**Paroxysmal stage**
**(1-6 weeks)**

**Convalescent stage**
**(weeks to months)**

**Communicable period (onset to 3 weeks after start of paroxysmal cough)**

## Adolescent and Adult Morbidity

**Morbidity**
**Cough: 97% ******** 3 weeks, 52% ******** 9 weeks; **
**Paroxysms: ******** 3 weeks in 73%**
**Whoop; Post-tussive emesis not all **
**Disrupted sleep 14 days avg**
**Complications: pneumonia, cyanosis**
**Average missed days**
**School 5 days ; Work 9 days**

**Notes:**
Special follow-up with adolescents and adults who contracted pertussis in Quebec during 1998 revealed that morbidity is substantial in these age groups:
extended cough;
paroxysms;
whooping;
post-tussive emesis;
missed school and work;
disrupted sleep.1

Complications are also common, including pneumonia, cyanosis and hospitalization. 

Reference:
1. De Serres et al. J Infect Dis. 2000;182:174–9.

## Pertussis in Infants

**Initially infant looks deceptively well; coryza, no fever, mild cough**
**Leukocytosis with lymphocytosis**
**Apneic episodes**
**Seizures**
**Respiratory distress**
**Pneumonia**
**Adenovirus or RSV co-infection can confuse picture **

##  Pertussis: Sounds of the Cough

- www.SoundsofPertussis.com

**One place to hear the cough:**
**            ****SoundsOfPertussis.com**

## Common pertussis misdiagnoses

- Bronchitis
- Asthma
- Gastroesophageal reflux
- Postviral bronchospasm
- Chronic sinusitis
- Tuberculosis
- Chlamydia/mycoplasma infection

**Notes:**
Read slide

## Pertussis Diagnosis

| Test method | Sensitivity | Specificity |
| --- | --- | --- |
| Culture | 36% | 100% |
| PCR | 95% | 98% |
| DFA (polyclonal) | 11% | 94% |
| DFA (monoclonal) | 8% | 98% |

**Tilley PAG, Diag Micro and Infect Dis 2000; 17-23**

## Pertussis Diagnostic Tests

**Culture**
**Still important to send**
**Requires special handling, lab notification**
**Most likely positive in first weeks of cough**
**PCR**
**More sensitive **
**Available in more labs**
**DFA-*****not***** recommended**

**Notes:**

DFA: 
Not part of CSTE case definition
Poor sensitivity (18-78%)
Requires large numbers of organisms    (>104 /ml)
Best when test early in course of illness
Requires skilled and experienced microscopist
Antibiotic therapy can affect binding of DFA reagent to cell wall

## Culture Sensitivity

- < 50% sensitive
- Factors effecting sensitivity:
**Type and quality of specimen**
**Time specimen obtained in the course of illness**
**Appropriate transport**
**Choice of culture media**
**Length of time cultures incubate**

## Pertussis PCR

**No commercial FDA-approved kits**
**No universal quality assurance criteria**
**Potential for false positives**
**Still affected by disease phase and antibiotic treatment**
**More expensive than culture**
**Labs often have not had opportunity to do adequate clinical validation of their test**

**Notes:**
Not standardized across US

## Specimen Collection

**Nasopharyngeal specimen**
- ciliated epithelial cells
**NO throat, sputum, or mouth specimens**
- Normal flora overgrow B. pertussis
**NP aspirates, washes, or swabs**
- Commercial syringe/bulb aspiration/wash kit
**Dacron or rayon swabs**
- NO cotton or calcium alginate swabs

## Specimen Collection

-  Nasopharyngeal swab
- Leave it in 30 seconds
-  NP aspirate
- Use 0.5-1 cc sterile saline & bulb or syringe w/butterfly tubing

- Can be used for:
- Culture
- Nucleic acid detection (PCR)

## Nasopharyngeal aspirate Syringe or bulb kits

## Limited Role for Pertussis Serology 

- Not used for Public Health reporting
- No universal serologic correlate for protection
- Vaccination confounds serology testing
- Serology often unhelpful in making diagnosis
- 4-fold rise in IgG titer can be diagnostic

**Notes:**
What do you want to say about serology?

## Where can I send samples for diagnostic testing?

**Commercial labs**
**Large hospital labs**
**Public Health labs**

**Notes:**
We need a list of commercial labs and a clear statement about whether the local Public Health lab is an option for testing.

## Conclusions on Diagnostic Tests

**No one test is adequate**
**PCR and culture are 2 best available**
**The longer you wait after onset of symptoms, the harder to diagnose **
**Lack of good diagnostic tests and specific clinical presentation leads one to conclude that immunization is the best strategy to control pertussis in adults.**

## Pertussis Treatment

**Macrolide drugs, first choice**
**Azithromycin for 5 days**
**Erythromycin for 14 days**
**Clarithromycin for 7 days**
**(TMP-SMX for 14 days for macrolide-allergic patients)**
**Limited impact on illness but decreases transmission**
**Therapy not useful after 21 days of cough**

## Post-exposure prophylaxis

**Same drugs and doses as for treatment**
**Recommended for**
**Household contacts**
**Daycare contacts**
**Other close exposures (health care workers, sports teams)**
**Not recommended for most school contacts**

**Notes:**
What groups do you want to emphasize for PEP?

## Pertussis Prevention

- Cover coughs, sneezes
- Wash hands often and thoroughly with soap and warm water
- Protect newborns, restrict contacts
- Seek medical care for prolonged cough illness
- IMMUNIZE

## Tdap vaccines

- Two FDA-licensed vaccines
- Boostrix (GlaxoSmithKline) - 10-64 years
- Adacel (Sanofi Pasteur) for 11-64 years
- Replacement for Td
**= Td + reduced dose of acellular pertussis**
- Available through the VFC program

## Tdap Recommendations CDC/AAP/AAFP/ACOG/ACP

**Routine use at 11-12 years of age**
**Replace Td for all ages 11-64**
**Special focus on adults in contact with young infants**
**Health care workers**
**Parents and siblings**
**Grandparents**
**No defined minimum interval**

## New CDPH Tdap RecommendationsJuly 2010

- Immunize pre-teens, teens & adults with Tdap
**7-9 year olds who are underimmunized**
_**>**_**10 years**** who have not yet received Tdap, especially**
**women of childbearing age, ****preferably before, or else during**** or immediately after pregnancy**
**others with close contact with young infants**
**includes persons ****>64 years**** of age**
- No minimum interval between Td and Tdap
- Reminder to promptly immunize young children with DTaP – can start as early as 6 weeks

## Tdap in Pregnant Women

**No reports of problems with Td or Tdap during pregnancy**
**Immunization during pregnancy with a preference for the 2****nd**** and 3****rd**** trimester recommended by AAP and ACOG**

## Tdap in the Elderly

**Not currently FDA-approved above age 64 because of lack of large studies**
**Main concern would be decreased efficacy, not increased adverse events**

## Tdap Coverage Rates

**Adolescents 13-17 years****	****	****53%****1**
**Adults 18-64 years****	****	****	****6%****2**
**Proportion of tetanus vaccines              given to adults as Tdap ****	****	****20.7%**

**2009 NIS Data for CA: **
**www.cdc.gov/mmwr/preview/mmwrhtml/mm5932a3.htm** ** **
**2) 2008 data:  cdc.confex.com/cdc/nic2010/ webprogram/Paper22766.html **

**Notes:**
Need updated rates from 2010 NIS Teen and updated adult rates

## Vaccines: A Community Endeavor

**Herd immunity important**
**Pertussis is very contagious**
**Newborns can’t be protected by vaccines**
**Immunize those around newborns “cocooning”**

## Effect of Postpartum Tdap Policy?

**Preliminary CDPH data suggest - a lower incidence of pertussis in infants born at hospitals that offer Tdap to their close contacts.**

## CA Tdap Expansion Program

- Free Tdap to birth hospitals to immunize women post-partum AND their family members
- Extended! Order vaccine by December 31
- Requires a plan for sustaining the program once State supplied vaccine runs out

**Notes:**
Do we want to say anything about this program since it will already be September?

## Summary

**Record pertussis cases in 2010**
**Physicians need to raise their awareness of pertussis clinical presentation**
**Immunization is the most important intervention to prevent pertussis**
**Immunization rates poor for adolescents and adults**
**Household contacts of young infants a prime target for immunization**

## Educate Yourselves, Your Patients

**EZIZ.org **up-to-date pertussis materials for clinical practice
**ShotByShot.org ** video stories of people touched by vaccine-preventable diseases
**Vaccine Safety Fact Sheets** on **ImmunizeCA.org** for providers, MAs, and patients.
**CDPH Immunization Branch**, Pertussis page **GetImmunizedCA.org**