pertussis update linda bethel, rn, mph epidemiology and immunization services branch
TRANSCRIPT
Pertussis Pertussis UpdateUpdate
Linda Bethel, RN, MPHLinda Bethel, RN, MPHEpidemiology and Immunization Epidemiology and Immunization
Services BranchServices Branch
PertussisPertussisMost poorly controlled vaccine-preventable Most poorly controlled vaccine-preventable diseasedisease– Cyclical: Peaks every 2-5 yearsCyclical: Peaks every 2-5 years
Adults are vulnerableAdults are vulnerable– 27% of reported cases in 2004 were adults27% of reported cases in 2004 were adults– Immunity is not lifelong, wanes 4-12 years after DTaP Immunity is not lifelong, wanes 4-12 years after DTaP
series and 4-20 years after natural infectionseries and 4-20 years after natural infection
Tdap (for adolescents and adults) licensed in Tdap (for adolescents and adults) licensed in 20052005– In 2008 ~40% of adolescents and ~6% of adults had In 2008 ~40% of adolescents and ~6% of adults had
been vaccinatedbeen vaccinated*Wendleboe et al. Infect Dis J 2005;24 (Suppl 5):S58-61.
Pertussis, continuedPertussis, continuedTransmission occurs by close contact via Transmission occurs by close contact via dropletsdroplets
Very contagious: approximately 90% of Very contagious: approximately 90% of susceptible household contacts become susceptible household contacts become infectedinfected
92-95% of population must be immune to 92-95% of population must be immune to eliminate transmission. eliminate transmission.
* Weiss and Hewlett. Ann Rev Microbiol. 1986;40:661-86
SymptomsSymptoms
Three stages (catarrhal, paroxysmal, and Three stages (catarrhal, paroxysmal, and convalescent) lasting 4-12 weeksconvalescent) lasting 4-12 weeks
Typical symptoms:Typical symptoms:– Paroxysmal coughParoxysmal cough– Lack of feverLack of fever– No systemic illnessNo systemic illness– Post-tussive vomitingPost-tussive vomiting– Inspiratory (post-tussive) whoopInspiratory (post-tussive) whoop
Pertussis in Young InfantsPertussis in Young Infants
Initially mild cough, no fever, runny noseInitially mild cough, no fever, runny nose
Develops into serious symptoms:Develops into serious symptoms:– Gagging, gaspingGagging, gasping– Apneic episodes (face may turn red or purple)Apneic episodes (face may turn red or purple)– Post-tussive vomitingPost-tussive vomiting– SeizuresSeizures– Respiratory distressRespiratory distress– PneumoniaPneumonia
Pertussis Transmission to InfantsPertussis Transmission to InfantsAdults transmit pertussis to infantsAdults transmit pertussis to infants– Among 264 known source-cases:Among 264 known source-cases:
Almost 50% were parents, most often mothersAlmost 50% were parents, most often mothers
51% were adults >19 years of age51% were adults >19 years of age
Bisgard KM, et al. Infant pertussis: who was the source? Pediatr Infect Dis J 2004; 23(11):985-989.
Wendelboe AM, et al. Transmission of Bordetella pertussis to young infants. Pediatr Infect Dis J 2007; 26(4):293-299.
Pertussis Cases - 2010Pertussis Cases - 2010
California (as of 9/7/10):California (as of 9/7/10):– 3,834 cases3,834 cases– 9.8 cases/100,0009.8 cases/100,000– Most cases since 1958, highest incidence Most cases since 1958, highest incidence
since 1962since 1962– 9 infant deaths, all <2 months old9 infant deaths, all <2 months old
San Diego (as of 9/13/10):San Diego (as of 9/13/10):– 514 cases514 cases– 1 infant death1 infant death
Number of reported cases by year of onset – California 1950-2010*
0
1000
2000
3000
4000
5000
6000
7000
1950
1952
1954
1956
1958
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
*
year
case
s
0
10
20
30
40
50
60
70
case
s p
er 1
00,0
00
Cases
Rate per 100,000
* As of 9/7/2010. California Department of Public Health, Immunization Branch
San Diego County Pertussis Annual Total Cases by Year of San Diego County Pertussis Annual Total Cases by Year of Report, 1999 – 2010 YTD (as of 9/13/2010)Report, 1999 – 2010 YTD (as of 9/13/2010)
118 12494
230
101117
371
173
50 54
143
514
0
100
200
300
400
500
6001
99
9
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
(Y
TD
)
Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 9/13/2010
Epidemic curve of reported pertussis cases Epidemic curve of reported pertussis cases and deaths by month of onset -- California, and deaths by month of onset -- California,
2005, 2009-2010*2005, 2009-2010*
0
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Janu
ary
Febru
ary
Mar
ch April
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June Ju
ly
Augus
t
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mbe
r
Octobe
r
Novem
ber
Decem
ber
month of onset
case
s
2005
2009
2010
X 2005 death
X 2009 death
X 2010 death
X
X
X
XX
X
X
X
XX
X
X
XX
XX
X
X
X
XX
Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 9/7/2010
County of San Diego Pertussis Cases by Month Reported, 2009 and 2010 (as of 9/13/2010, N=514)
020406080
100120140160180200
Jan
Fe
b
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Se
p
Oct
No
v
De
c
Month of Report
Nu
mb
er
of C
ase
s
2009 2010 (YTD)
Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 9/7/2010
San Diego County Incidence Rates for Pertussis Cases by Age and Race / Ethnicity, 2010 YTD (as of 9/13/2010, N=514)
3.3 1.4
43.1
71.0
47.6
214.0
0
50
100
150
200
250
300
<6MOS 6M-6Y 7-9Y 10-18Y 19-64Y 65+YAge Group
Nu
mb
er
Ca
ses
pe
r 1
00
,00
0 P
op
ula
tion
Asian/Non-Hispanic African/American Black/Non-HWhite/Non-Hispanic Hispanic/LatinoAll race/ethnicities
San Diego County Number of Pertussis Cases Reported by Race/Ethnicity and Age Group, 2010 (as of 9/13/2010, N=514)
141
50
87
165
5
66
0
20
40
60
80
100
120
140
160
180
<6MOS 6M-6Y 7-9Y 10-18Y 19-64Y 65+Y
Age Group
Nu
mb
er o
f C
ases
All race/ethnicities White/Non-Hispanic Hispanic/Latino
African/American Black/Non-H Asian/Non-Hispanic Other/Unknown
Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 9/13/2010
Pertussis MitigationPertussis MitigationPromote the use of Tdap - particularly in those who have Promote the use of Tdap - particularly in those who have contact with infantscontact with infants– Free vaccine through 12/31/2010 for birth hospitals with Free vaccine through 12/31/2010 for birth hospitals with
postpartum Tdap policies; encourage ED use of Tdap postpartum Tdap policies; encourage ED use of Tdap – Work with payers re: Tdap reimbursementWork with payers re: Tdap reimbursement– CDPH expanded Tdap recommendationsCDPH expanded Tdap recommendations
Clinician educationClinician education– CDPH Tdap recommendationsCDPH Tdap recommendations– Pertussis signs and symptomsPertussis signs and symptoms– Treatment recommendations for infants with severe pertussisTreatment recommendations for infants with severe pertussis– Accelerated DTaP schedule for infantsAccelerated DTaP schedule for infants
Public educationPublic education– Vaccination/cocooningVaccination/cocooning– Pertussis signs and symptomsPertussis signs and symptoms– Keep ill people away from infantsKeep ill people away from infants
California Department of Public Health, Immunization Branch
New CDPH Tdap RecommendationsNew CDPH Tdap Recommendations
Immunize pre-teens and adults with TdapImmunize pre-teens and adults with Tdap– 7-9 years old who are underimmunized7-9 years old who are underimmunized– Those Those >> 10 years of age who have not yet 10 years of age who have not yet
received Tdap, especially:received Tdap, especially:Women of childbearing age, preferably before, or Women of childbearing age, preferably before, or else during or immediately after pregnancyelse during or immediately after pregnancyOthers with close contact with young infantsOthers with close contact with young infantsHealth Care personnelHealth Care personnelIncludes persons > 64 years of ageIncludes persons > 64 years of age
No minimum interval between Td and No minimum interval between Td and TdapTdap
Why here, why now?Why here, why now?A sufficient number of susceptible people have accumulated in the A sufficient number of susceptible people have accumulated in the population via birth cohorts of unvaccinated infants, waning population via birth cohorts of unvaccinated infants, waning population immunity from vaccine or disease (and less chance for population immunity from vaccine or disease (and less chance for boosting opportunities), parental choice not to vaccinate children, boosting opportunities), parental choice not to vaccinate children, etc.etc.
The 2005 epidemic was nationwide, but although other states have The 2005 epidemic was nationwide, but although other states have reported pertussis increases this year, none have reported reported pertussis increases this year, none have reported increases like those seen in Californiaincreases like those seen in California
Some have speculated that California may have less population Some have speculated that California may have less population immunity than other states because it is one of only 11 states that immunity than other states because it is one of only 11 states that does not have a Tdap requirement for middle school students, does not have a Tdap requirement for middle school students, however, 2009 National Immunization Survey data indicates that however, 2009 National Immunization Survey data indicates that estimated Tdap rates in California adolescents (53.1%) are not estimated Tdap rates in California adolescents (53.1%) are not much lower than the national estimate (55.6%)much lower than the national estimate (55.6%)
California Department of Public Health, Immunization Branch
Pertussis Booster RequirementPertussis Booster Requirement
Pertussis Cases in children and adolescents Pertussis Cases in children and adolescents aged 0-18 years, by vaccine history – aged 0-18 years, by vaccine history –
California, 9/7/2010California, 9/7/2010
0
50
100
150
200
250
300
350
<1m 1m 2m 3m 4m 5m
6-11
m1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18
age (years)
cas
es
Unk vaccine history
6 doses
5 doses
1-4 doses
0 doses
*As of 9/7/2010
DTaP
DTaP DTaP
DTaP
DTaP
Tdap
California Department of Public Health, Immunization Branch
Countering Vaccine MythsCountering Vaccine Myths
The majority of people who get disease have been The majority of people who get disease have been vaccinatedvaccinated
This is explained by two factors: This is explained by two factors: – no vaccine is 100% effective (most childhood no vaccine is 100% effective (most childhood
vaccines are effective for 85% to 95% of recipients); vaccines are effective for 85% to 95% of recipients); and and
– most people in the U.S. are vaccinatedmost people in the U.S. are vaccinated
When most people have been vaccinated, most cases of When most people have been vaccinated, most cases of disease will occur in vaccinated people. Those who are disease will occur in vaccinated people. Those who are vaccinated and did not respond to the vaccine often vaccinated and did not respond to the vaccine often outnumber those who are not vaccinatedoutnumber those who are not vaccinated
California Department of Public Health, Immunization Branch
PertussisPertussis
ResourcesResources
Updated Updated FlyerFlyerFor For ProvidersProviders
For the Public in English & For the Public in English & SpanishSpanish
For Schools
Link to Pertussis MaterialsLink to Pertussis Materialswww.eziz.orgwww.eziz.org
ResourcesResourcesCalifornia Department of Public Health California Department of Public Health Immunization Branch (CDPH)Immunization Branch (CDPH)– www.eziz.orgwww.eziz.org– http://www.cdph.ca.gov/programs/immunize/Pages/dehttp://www.cdph.ca.gov/programs/immunize/Pages/de
fault.aspxfault.aspx
County of San Diego Immunization ProgramCounty of San Diego Immunization Program– www.sdiz.orgwww.sdiz.org– Linda Bethel, RN, MPHLinda Bethel, RN, MPH
(619) 692-5607(619) 692-5607
[email protected]@sdcounty.ca.gov
Questions?Questions?