PertussisWhooping cough is back
Adapted for BugLine from presentation by:
Cassandra D. Youmans, MD, MPH, MS-HCM, FAAP
District Health Director
East Central Health District VI
Objectives
Enhance East Central Public Health District VI’s ability to recognize and respond appropriately to pertussis Refresh University Hospital healthcare personnel to allow
appropriate treatment and reporting of pertussis
Give Tdap* vaccine to healthcare personnel to protect our: Highest risk patients by surrounding them immunity
A circle of immunity made up of vaccinated caregivers
Healthcare personnel from “catching” pertussis
* Tdap, Tetanus, diphtheria and pertussis
Two Pupils Treated for Pertussis
Saturday, April 15, 2006
Columbia County School officials confirmed that at least one pupil tested positive for whooping cough, and the two siblings are being treated. One attended Evans High School, and the other Evans Middle School…highly contagious, spread through the air by cough and begins with cold symptoms and a cough…
The case was not properly reported to the public health department, allowing for the above
And the article included a warning to parents
Augusta Chronicle
Resurgence of Pertussis
Mutation
Waning vaccine-induced immunity 5 to 7 years after vaccination, leaving adolescents and adults unprotected
Waning disease-induced immunity doesn’t last much longer than that of vaccination
Enhanced identification: Public health awareness, surveillance, diagnostic programs
Bordetella pertussis, the germ
Gram-negative rod Humans are the only host Incubation period 6-to-21 days (usually
7-to-10 days) Duration of illness 6-to-10 weeks
(usually 6 weeks) Expected occurrence 3-to-5 year cycles
of increased disease Pertussis is under reported, 40-160 fold
less than actual illness Asymptomatic infections are 4–22
times more common than symptomatic infections
Spread
Close person to person contact via aerosolized droplets from respiratory secretions of patients with disease
90% of nonimmune household contacts acquire the disease
Adolescents and adults (27% of reported cases in 2004) are the major source of infection in unvaccinated children
Infants and young children are infected by older siblings who have mild to asymptomatic disease (43% of reported cases)
Clinical Symptoms
Initially mild upper respiratory tract symptoms (catarrhal stage,1-2wks), most contagious period progressive paroxysms of cough (paroxysmal stage 2-4 wks)
Inspiratory whoop, followed by vomiting
Fever minimal to absent Symptoms subside gradually over
months (convalescent stage1-2 wks)
Clinical Symptoms in Infants
Most severe in infants <6 months
Atypical presentation Apnea most common symptom Whoop is absent Hospitalization often needed Lymphocyte predominant,
increased white count can match severity of the cough
Infant Complications Seizures (3%) Pneumonia (22%) Encephalopathy (1%) Death Case fatality rate: 1.3% in infants <1 month
0.3% in infants 2-11 months
Diagnosis Increase of pertussis antibody
IgA antibody titer to pertussis is becoming the method of choice IgG antibody to pertussis toxin indicative of recent infection Single serum test for significantly high pertussis specific antibody can
confirm the diagnosis
Adolescents and adults with B. pertussis cough illness don’t seek care until the week 3-4 of illness Organism most frequently recovered in catarrhal or early paroxysmal
stage
PCR on nasopharyngeal secretions obtained with Dacron swab, put on special media, with 10 to 14 day incubation Alert the Lab when pertussis is suspected - the culture media is not
readily available Negative cultures are common
Treatment
Aim is to eradicate nasopharyngeal carriage
Treatment duration usually 14 days with erythromycin sulfate (EES), newer Macrolides 5-7 days
Macrolides-erythromycin, azithromycin, and clarithromycin
Azithromycin eradicates naso-pharyngeal carriage the fastest
Hypertrophic pyloric stenosis has been reported with oral EES in infants younger than 6 weeks
Trimethoprim-sulfamethoxazole is an alternative to erythromycin-resistant strain, or for intolerance to macrolides
Penicillins, first and second generation cephalosporins are not effective
Supportive Care
Hospitalized patients need to be on Droplet Isolation for 5 days after therapy
Monitor exposed children for respiratory symptoms for 20 days
Laboratory confirmation is difficult, so diagnosis often based on characteristic clinical manifestations
Children may return to school after 5 days of appropriate antibiotic therapy
Prevention - Terms
Tetanus Diphtheria (Td)
Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed (Tdap)
Prevention = Immunization
Universal immunization of all children <7 years of age is recommended by the AAP
U.S. pertussis is an acellular vaccine in combination with diphtheria and tetanus toxoids
Acellular vaccines contain one or more immunogens from B pertussis
Acellular vaccines are absorbed on aluminum salt and must be given intramuscularly
3 DTaP, and 1 combined vaccine that includes DTaP and Haemophilus influenzae type b conjugate vaccine is given at 15-18 months
Recommendations of the Advisory Committee on Adult Immunization Practices (ACIP)
One dose of Tdap for adults 19– 64 years of age to replace the next booster does of tetanus and diphtheria toxoids vaccine (Td)
Tdap for adults who have close contact with infants <12 months of age
May give Tdap within 2 year intervals to protect against pertussis
Tdap is not licensed for adults >65 years
Contraindications and Precautions
Contraindications to Tdap History of serious allergic reaction
(anaphylaxis) to vaccine components
History of encephalopathy not attributableto an identifiable cause within 7 days of vaccination
with pertussis vaccine
Precautions to Tdap Guillain-Barre Syndrome, 6 weeks
after a dose of tetanus toxoid
Moderate to severe acute illness Unstable neurological condition
References
ACIP Votes to Recommend Use of Combined Tetanus Diphtheria and Pertussis (Tdap) Vaccine for Adults. Advisory Committee on Immunization Practices. 2006
Cherry, JD. MD, MSc. The epidemiology of pertussis, Pediatric Infectious Disease Journal. 2006; 25:4:361-362
Pickering, LK. Pertussis.The Red Book. 2003; 26:472-486
Gilbert, D.N. The Sanford Guide to Antimicrobial Therapy. 2005; 35:24
Questions?
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