OCCUPATIONAL EXPOSURE TO PERTUSSIS IN THE OUTPATIENT PRIMARY CARE NETWORK

Adrienne Smallwood, Harvard Class of 2013

Special thanks to

Dr. Kristen Feemster M.D., MPH, MSHP

Assistant Professor, Perelman School of Medicine

Department of Infectious Diseases, Children’s Hospital of Philadelphia

Maria Middleton, Research Assistant Julie Fierro, MD/MPH student Joanne Levy and the SUMR Program!

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Outline of Talk

1. Background on Pertussis 2. Epidemiology 3. Research Question 4. Methodology 5. Analysis 6. Future Steps and takeaways

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Background 4

What is Pertussis?

Pertussis (Whooping cough) is a contagious respiratory infection

Spread by droplets within 3 feet Symptoms:

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o Symptoms of common cold o Prolonged, violent coughing

with whooping sound o Vomiting

Source: Center for Disease Control and Prevention

Treated with Antibiotics

Background 6

Highly contagious ~90% susceptible household contacts who are

exposed to a case will become infected High transmissibility during catarrhal stage

when symptoms are nonspecific

Remain contagious for ~3 weeks after developing symptoms

Vaccination is the most effective prevention measure but immunity wanes over time and those at highest risk for severe disease are too young to be vaccinated

Background

Serious in children/infants

75% of infants develop complications > 50% of infants hospitalized, 1% die

Adolescent and adult contacts with unrecognized disease often the reservoir for infection Less severe in adults Previously vaccinated individuals can have

atypical symptoms

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Source: Center for Disease Control and Prevention

Pertussis Commercial 8

https://www.youtube.com/watch?v=Aq9mkRr_E7c

Epidemiology 9

Epidemiology

1010

11647

27000

0

5000

10000

15000

20000

25000

30000

1976 2003 2010

Cases of Pertussis in the US

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232% increase in pertussis cases in the past 7 years

Source: Centers for Disease Control and Prevention

Background: Occupational Exposures 11

Healthcare workers at increased risk of exposure and subsequent transmission to susceptible patients Very important in pediatrics

CDC recommends Tdap booster to all HCWs in

2006 Exposed vaccinated HCW to receive post-exposure

prophylaxis or daily symptom monitoring

Occupational Exposures: 2002 -2011 12

Pertussis: What Happened? 13

Pertussis: Current Situation 14

Epidemic in several communities throughout the country including metropolitan Philadelphia

450 cases over 10 years and now100 cases at CHOP in the past 6 months Many cases in fully vaccinated children

Increasing number of cases in community increased number of occupational exposures (and uncountable potential patient exposures)

Data suggests that we may be missing many cases

Pertussis: Are we Missing Exposures? 15

Pertussis in the Media 16

So why is there a Whooping Cough outbreak?

Change from whole-cell to acellular vaccine Waning immunity in adults and adolescents

Atypical presentation when infected unrecognized disease

Refusal to vaccinate

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Research Question and Aims 18

Research Question

Goal: Understand the knowledge, attitudes, and beliefs of healthcare workers develop more effective infection control policies

Question: What barriers exist in using appropriate infection control measures in primary care outpatient pediatric offices? Behaviors: Physician mask use, offering patient a mask,

Tdap booster use

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Methodology 20

Overview of our Approach 21

To assess the barriers to the appropriate use of PPE in clinics with the highest and lowest rates of occupational exposure to pertussis Clinical survey: 25 questions including 2 vignettes Nonclinical survey: 22 questions

To observe and inventory the presence of specific

infection control measures at each clinic site Inventory Checklist

Survey Methodology 22

Questionnaire adapted from previously validated instruments

Based upon an integrated behavior model

Clinical vignettes to determine impact of different scenarios related to the use of PPE

Compare results between clinics with the highest and lowest rates of occupational exposure to pertussis to assess the barriers to the appropriate use of PPE

Survey Design: Integrated Behavioral Model 23

Survey Methodology 24

Example Statements

Knowledge: Adults can get whooping cough even if they had whooping cough as children.

Personal Agency: Wearing PPE interferes with my ability to do my job due to difficulty breathing with a mask on

Attitude: It is convenient to provide patients with a cough a mask when they come to the office

Clinical Survey Vignettes

Version A: In an attempt to improve quality of care, the nurse manager of your practice will be rearranging office supplies. The masks (personal protective equipment) required for use when entering the examination room of a child suspected of having pertussis will be located in bins outside of the examination rooms. All supplies will be fully in stock in sufficient quantities at all times. Based on this information, what action(s), if any, would you take?

Version B: In an attempt to improve quality of care, the nurse manager of your practice will be rearranging office supplies. The masks (personal protective equipment) required for use when entering the examination room of a child suspected of having pertussis will be located in a common room at the end of the hall. All supplies will be fully in stock in sufficient quantities at all times. Based on this information, what action(s), if any, would you take?

Randomized Control Trial

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Study Sample

29 primary care sites in the CHOP network

445 clinical staff (169 physicians, 22 nurse

practitioners, 254 nurses)

216 non-clinical staff

Anticipate a 75% response rate.

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Inventory

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My Roles 28

Develop the survey database in RedCap Implement the surveys to staff members at each site Conduct the inventory and direct observation Enter survey responses into the database

8 site visits,133 surveyed 66% clinical 34% non-clinical

Analysis 29

Analysis: Example Data 30

Non-clinical Staff: “It is convenient to provide patients with a cough a mask when they come to the office”

Strongly Agree 69%

Somewhat Agree 18%

Neutral 10%

Somewhat Disagree 3%

Strongly Disagree 0%

Analysis: Example Data 31

Clinical Staff: “Using recommended pertussis PPE interferes with patient care”

Strongly Agree 1%

Somewhat Agree 21%

Neutral 12%

Somewhat Disagree 23%

Strongly Disagree 43%

Analysis: More Findings 32

30% of clinical staff don’t think they could get

pertussis if they had it as a child 44% of non-clinical staff don’t know that infants can

get pertussis from adults. 58% of non-clinical staff believe that they could

improve the frequency with which they provide masks to patients with a cough

Analysis: Feedback 33

High number of patients coming in with a cough Older kids do not want to wear masks Requests (barriers at front desk, kid sized masks)

Future Steps and Takeaways 34

Future Steps

Finish site visits & data analysis Health alert Change in practice at CHOP and other places

Down the line:

Intervention for adult vaccinations

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What I learned from my SUMR Experience

Infectious diseases as a public health concern Survey methodology Research: Recognizing a problem, understanding

the underlying reasons, and finding a logical solution

Career path options!

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Thank you!

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