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Pertussis Pertussis (Whooping Cough or (Whooping Cough or Hundred Day Cough)Hundred Day Cough)

Thein Shwe, MPH, MS, MBBSThein Shwe, MPH, MS, MBBSVPD & IBD EpidemiologistVPD & IBD EpidemiologistDIDE 4DIDE 4thth Quarter Training Quarter Training

11/18/200911/18/2009

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ObjectivesObjectives To describe clinical description, diagnosis and To describe clinical description, diagnosis and

epidemiology of pertussisepidemiology of pertussis

To understand To understand – Investigation of a case of pertussis and outbreak of pertussis Investigation of a case of pertussis and outbreak of pertussis

To review U. S. and West Virginia pertussis surveillance To review U. S. and West Virginia pertussis surveillance datadata

Disease DescriptionDisease Description Pertussis, a cough illness commonly known as Pertussis, a cough illness commonly known as

whooping cough (100 Day Cough), is caused by the whooping cough (100 Day Cough), is caused by the bacterium bacterium Bordetella pertussisBordetella pertussis. .

Prolonged paroxysmal cough often accompanied by Prolonged paroxysmal cough often accompanied by an inspiratory whoop. an inspiratory whoop.

Varies with age and history of previous exposure or Varies with age and history of previous exposure or vaccination. vaccination.

Neither infection nor immunization provides lifelong Neither infection nor immunization provides lifelong immunityimmunity

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Other Bordetella speciesOther Bordetella species

Three other Three other BordetellaBordetella species: species: – B. parapertussisB. parapertussis, , – B. holmesiiB. holmesii, and , and – B. bronchiseptica. B. bronchiseptica.

B. pertussisB. pertussis and and B. parapertussisB. parapertussis coinfection is coinfection is not unusual. not unusual.

Disease with Disease with BordetellaBordetella species other than species other than B. B. pertussispertussis is not reportable. is not reportable.

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Clinical Description of PertussisClinical Description of Pertussis

StagesStages

(6-10 wks.)(6-10 wks.)

CatarrhalCatarrhal

(1-2 wks.)(1-2 wks.)

ParoxysmalParoxysmal

(1-2 wks.)(1-2 wks.)

ConvalescentConvalescent

(up to 3 mths.)(up to 3 mths.)

SymptomsSymptoms mild URT mild URT symptoms, symptoms, intermittent intermittent dry coughdry cough

coughing coughing spasmsspasmsinspiratory inspiratory whoop whoop Post-tussive Post-tussive vomitingvomiting

Infants <6 Infants <6 mths. mths.

Gagging, Gagging, gasping or gasping or apneaapnea

No whoopNo whoop ProlongedProlonged

HTTP://WWW.SOUNDSOFPERTUSSIS.COM/SOUND_OF_PERTUSSIS.CFM

SOUND OF PERTUSSISSOUND OF PERTUSSIS

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Epidemiology of PertussisEpidemiology of PertussisMode of transmissionMode of transmission Person to person viaPerson to person via

– Aerosolized droplets from cough or sneezeAerosolized droplets from cough or sneeze– Direct contact with secretions from respiratory tract of infectious personDirect contact with secretions from respiratory tract of infectious person

80% - secondary attack rate 80% - secondary attack rate

Older children and adults are important sources of disease for Older children and adults are important sources of disease for infants and young childreninfants and young children

Infants <12 months of age greatest risk for complications and Infants <12 months of age greatest risk for complications and deathdeath

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Epidemiology of Pertussis cont.Epidemiology of Pertussis cont.

ReservoirReservoir - Humans - Humans Incubation period Incubation period – 7-10 days (5-21 days).– 7-10 days (5-21 days). Infectious period Infectious period – Most contagious during the – Most contagious during the

catarrhal stage and the first 2 weeks after catarrhal stage and the first 2 weeks after cough onsetcough onset

Duration of illnessDuration of illness::– Children: 6-10 wks.Children: 6-10 wks.– ~ ½ of Adolescents: 10 wks or longer~ ½ of Adolescents: 10 wks or longer

Pertussis ComplicationsPertussis Complications Syncope (temporary loss of consciousness/faint)Syncope (temporary loss of consciousness/faint) Sleep disturbanceSleep disturbance IncontinenceIncontinence Rib fracturesRib fractures Complications among infantsComplications among infants

– Pneumonia (22%)Pneumonia (22%)– Seizures (2%)Seizures (2%)– Encephalopathy (<0.5%)Encephalopathy (<0.5%)

DeathDeath– Infants, particularly those who have not received a Infants, particularly those who have not received a

primary vaccination series, are at risk for complications primary vaccination series, are at risk for complications and mortality. and mortality.

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Pertussis Laboratory Pertussis Laboratory DiagnosisDiagnosis

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Pertussis Laboratory TestingPertussis Laboratory TestingCulture PCR DFA Serology

Specimen NP Swabs or aspirates

NP Swabs or aspirates

NP Swab Blood

Advantages •Gold standard•100% Specific

Results available quickly

Rapid results

Disadvantages

•Relatively insensitive•Difficult to isolate•Most successful during the catarrhal stage•Takes 7-10 days to get the result

•Sensitivity & specificity varies

•Calcium alginate swabs cannot be used to collect NP swabs for PCR

•Not confirmatory

•No use for surveillance

•No standardized test available

•No use for Surveillance

Comments Use with culture

Use with culture and/or PCR

Use with culture and/or PCR

NP swab=nasopharyngeal swabs, PCR-Polymerase chain reaction, DFA-direct florescent antibody

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Proper Technique for Obtaining a Proper Technique for Obtaining a Nasopharyngeal Specimen for Isolation of Nasopharyngeal Specimen for Isolation of B B

pertussispertussis

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http://content.nejm.org/cgi/content/full/NEJMe0903992/DC1

Nasopharyngeal Nasopharyngeal Swab Collection Swab Collection

ProcedureProcedure

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Why do We do Pertussis Why do We do Pertussis Surveillance?Surveillance?

To assess burden of disease and guide policy and To assess burden of disease and guide policy and control strategiescontrol strategies– e.g., vaccination of postpartum mothers and adult and e.g., vaccination of postpartum mothers and adult and

adolescent contacts of infantsadolescent contacts of infants

To monitor disease trends and identify populations To monitor disease trends and identify populations at riskat risk

To identify clusters of related cases that might To identify clusters of related cases that might indicate an outbreakindicate an outbreak

To monitor changes in the To monitor changes in the B. pertussisB. pertussis organism organism1414

& &

Outbreak Outbreak InvestigationInvestigation

Pertussis Case Pertussis Case InvestigationInvestigation

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PERTUSSIS CASE PERTUSSIS CASE DEFINITIONDEFINITION

CDC/CSTECDC/CSTE

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Pertussis Clinical Case Pertussis Clinical Case DefinitionDefinition

1.1. A Cough illnessA Cough illness lasting at least lasting at least 2 2 weeksweeks

2.2. With With oneone of the following: of the following:

- - paroxysms of coughing, orparoxysms of coughing, or

- - inspiratory “whoop,” inspiratory “whoop,” oror

- - posttussive vomiting;posttussive vomiting; And And

without other apparent cause (as reported without other apparent cause (as reported by a healthcare professional)by a healthcare professional)

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Laboratory Criteria for Laboratory Criteria for DiagnosisDiagnosis

Isolation of Isolation of Bordetella pertussis Bordetella pertussis from from a clinical specimen a clinical specimen (Culture)(Culture)

Positive polymerase chain reaction Positive polymerase chain reaction

(PCR) (PCR) assay for assay for B. pertussis B. pertussis DNADNA

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Case ClassificationCase Classification ProbableProbable::

– Meets the clinical case definition,Meets the clinical case definition,– Not laboratory confirmed, andNot laboratory confirmed, and– Not epidemiologically linked to a laboratory-confirmed Not epidemiologically linked to a laboratory-confirmed

case case

ConfirmedConfirmed::1.1. A case of acute cough illness of A case of acute cough illness of any duration any duration

with a positive culture for with a positive culture for B. pertussis B. pertussis 2.2. A case that meets the clinical case definition A case that meets the clinical case definition

and is confirmed by PCR and is confirmed by PCR 3.3. A case that meets the clinical definition and is A case that meets the clinical definition and is

epidemiologically linked directly to a case epidemiologically linked directly to a case confirmed by either culture or PCRconfirmed by either culture or PCR

EXERCISESEXERCISES

Pertussis Case InvestigationPertussis Case Investigation

2020

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What would you do with this What would you do with this pertussis laboratory report?pertussis laboratory report?

Exercise 1 -Exercise 1 -

Submitter:Submitter: Patient Name: Smith, James Office of Lab ServicesPatient Name: Smith, James Office of Lab Services Address: 234 A St 167 11Address: 234 A St 167 11thth Ave. Ave. Charleston, WV 25311 S. Charleston, Charleston, WV 25311 S. Charleston,

WV25303WV25303 DOB: 06/12/2005 Attention To: Dr DOB: 06/12/2005 Attention To: Dr

BloomBloom Age: 4 yrs Age: 4 yrs Sex: MaleSex: Male____________________________________________________________________________________________________________

Specimen source: Nasopharyngeal Collection date: 11/7/09Specimen source: Nasopharyngeal Collection date: 11/7/09

Culture: Culture: Bordetella pertussis Bordetella pertussis isolated isolated Reported date: 11/14/09Reported date: 11/14/09

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Does it meet the lab Does it meet the lab criteria?criteria?

- Check lab criteria for diagnosis- Check lab criteria for diagnosis

Exercise 2Exercise 2 Patient Name: Bond, James WVU HospitalPatient Name: Bond, James WVU Hospital Address: Peace Ave. Morgantown, Address: Peace Ave. Morgantown,

WV WV Star City, WV 26503 Star City, WV 26503 DOB: 03/1/1985 Attention To:DOB: 03/1/1985 Attention To: Age: 24 yrs Dr MoodyAge: 24 yrs Dr Moody Sex: MaleSex: Male__________________________________________________________________________________________

Specimen source: Nasopharyngeal Specimen date: 11/10/09Specimen source: Nasopharyngeal Specimen date: 11/10/09

Bordetella by Rapid PCRBordetella by Rapid PCR

Result - Result - Bordetella pertussis Bordetella pertussis DNA detected DNA detected

Reported date: 11/12/09Reported date: 11/12/09

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Does it meet the lab Does it meet the lab criteria?criteria?

- Check lab criteria for diagnosis- Check lab criteria for diagnosis

Exercise 3Exercise 3

Patient Name: A PullmanPatient Name: A Pullman Lab Corp of AmericaLab Corp of America DOB: 10/7/1998DOB: 10/7/1998 Dublin, OhioDublin, Ohio Address: Clarksburg, WVAddress: Clarksburg, WV ________________________________________________________________________________________

Test Name – B pertussis IgM Ab, Quantitative Test Name – B pertussis IgM Ab, Quantitative Comment: Positive = >1.1, Negative = <1.0, Comment: Positive = >1.1, Negative = <1.0,

Borderline = 1.0 -1.1 Borderline = 1.0 -1.1 B pertussis IgM result = 1.7 B pertussis IgM result = 1.7

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Does it meet the lab Does it meet the lab criteria?criteria?

- Check lab criteria for diagnosis- Check lab criteria for diagnosis

REGARDLESS OF TYPE OF TEST REGARDLESS OF TYPE OF TEST AND RESULT,AND RESULT,

ALL PERTUSSIS REPORTS ALL PERTUSSIS REPORTS SHOULD BE INVESTIGATED SHOULD BE INVESTIGATED

IMMEDIATELY IMMEDIATELY

PERTUSSIS CASE PERTUSSIS CASE INVESTIGATIONINVESTIGATION

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Importance of Rapid Case Importance of Rapid Case IdentificationIdentification

Early diagnosis and treatment to limit disease Early diagnosis and treatment to limit disease spreadspread

Identify and provide prophylaxis to close Identify and provide prophylaxis to close contacts pending laboratory confirmationcontacts pending laboratory confirmation

When suspicion of pertussis is low, When suspicion of pertussis is low,

investigation can be delayed pending investigation can be delayed pending laboratory confirmation laboratory confirmation – Exception: prophylaxis of infants and their Exception: prophylaxis of infants and their

household contacts should NOT be delayedhousehold contacts should NOT be delayed2828

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What is the next step in a What is the next step in a case investigation?case investigation?

Refer to Pertussis Protocol Refer to Pertussis Protocol

Use Pertussis WVEDSS form Use Pertussis WVEDSS form

Begin your case ascertainmentBegin your case ascertainment

Pertussis Surveillance Pertussis Surveillance ProtocolProtocol

http://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/PERTUSSIS%20Protocolhttp://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/PERTUSSIS%20Protocol%20Sept2007.pdf%20Sept2007.pdf

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Pertussis WVEDSS FormPertussis WVEDSS Form

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How do you ascertain a How do you ascertain a case?case?

Three pieces of information needed Three pieces of information needed to determine if you have a pertussis to determine if you have a pertussis casecase

1.1. Clinical informationClinical information

2.2. Additional laboratory report(s)Additional laboratory report(s)

3.3. Epidemiological informationEpidemiological information

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What information would you obtainWhat information would you obtain from a provider? from a provider?

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What information would you What information would you obtain from a provider? obtain from a provider?

cont’dcont’d

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What would you obtain from What would you obtain from the patient/parent?the patient/parent?

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What Epidemiological What Epidemiological information do you need to information do you need to

obtain? obtain?

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Contact Tracing of a Contact Tracing of a Pertussis CasePertussis Case

Management for Exposed personsManagement for Exposed persons

Type of ContactType of Contact Evaluate Evaluate & Lab & Lab

VaccinateVaccinate Prophylaxis/Prophylaxis/

treatmenttreatment

AsymptomaticAsymptomatic

Within 3 weeksWithin 3 weeks

NoNo YesYes YesYes

AsymptomaticAsymptomatic

> 3 weeks> 3 weeks

NoNo YesYes Consider for Consider for households with high-households with high-risk contacts (infants, risk contacts (infants, pregnant women, pregnant women, people who have people who have contact with infants)contact with infants)

SymptomaticSymptomatic YesYes

Collect Collect NP NP swabswab

YesYes YesYes

Postexposure Prophylaxis for Pertussis in Postexposure Prophylaxis for Pertussis in Infants, Children, Adolescents, and AdultsInfants, Children, Adolescents, and Adults

Source: Red Book 2009 AAP – pg. 507Source: Red Book 2009 AAP – pg. 507

Age Azithromycin(Recommended)

ErythromycinRecommended

Clarithromycin(Recommended)

TMP-SMX(alternative)

<1mo 10mg/kg/day as a single dose for 5 days

40mg/kg/day in 4 divided dosesx14days

Not recommended CI at <2 mo of age

1-5 mo See above See above 15mg/kg/day in 2 divided doses x 7 days

≥2mo of age:TMP,8mg/kg/day;SMX,40mg/kg/day in 2 doses x 14 days

≥6 mo or older & children

10mg/kg/day as a single dose on day 1(maximum 500 mg); then 5 mg/kg/day as a single dose on days 2-5(maximum 250 mg/day)

40 mg/kg/day in 4 divided doses for 14 days (maximum 2g/day)

15mg/kg/day in 2 divided doses x 7 days(maximum 1 g/day)

See above

Adolescents & adults

500 mg as a single dose on day 1, then 250 mg as a single dose on days 2-5

2g/day in 4 divided doses for 14 days

1g/day in 2 divided doses for 7 days

TMP, 200 mg/day; SMX,1600 mg/day in 2 divided doses x 14 days

TMP- trimethoprin; SMX-sulfamethoxazole; CI - contraindication

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Once the investigation is Once the investigation is completed:completed:

Document public health actionDocument public health action Check case classificationCheck case classification Print the report for your files or per your Print the report for your files or per your

LHD policy & procedureLHD policy & procedure Send lab report(s) to DIDE Send lab report(s) to DIDE Submit completed WVEDSS report Submit completed WVEDSS report

electronically to your regional electronically to your regional epidemiologist and DIDEepidemiologist and DIDE

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Pertussis Outbreak Case Pertussis Outbreak Case DefinitionDefinition

Outbreak is defined asOutbreak is defined as::– Two or more casesTwo or more cases – Involving Involving two or more householdstwo or more households– Clustered in Clustered in time & spacetime & space ANDAND– OneOne case must be case must be confirmed by confirmed by

positive culturepositive culture

Pertussis Outbreak Line List FormPertussis Outbreak Line List Formhttp://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/Pertussis%20Outbreakhttp://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/Pertussis%20Outbreak

%20Linelisting%20Form.pdf%20Linelisting%20Form.pdf

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Outbreak Notification and Outbreak Notification and ControlControl

Notify your regional epidemiologist & Notify your regional epidemiologist & DIDEDIDE

immediatelyimmediately

Evaluate case status & manage close Evaluate case status & manage close contactscontacts

Obtain Obtain nasopharyngeal swabs for culture nasopharyngeal swabs for culture (confirmation) and PCR(confirmation) and PCR

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Outbreak Control in Any SettingsOutbreak Control in Any Settings

Treat/Prophylax with recommended Treat/Prophylax with recommended antibiotic antibiotic

Isolate 5 days after starting antibiotic Isolate 5 days after starting antibiotic treatmenttreatment

oror 21 days from cough onset if no 21 days from cough onset if no treatmenttreatment

Bring immunizations up-to-dateBring immunizations up-to-date– Accelerated vaccination if cases are occurring Accelerated vaccination if cases are occurring

young infantsyoung infants

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Alert your providers and notify the Alert your providers and notify the parents…parents…

Healthcare ProvidersHealthcare Providers– Send Health alert letterSend Health alert letter– Provider information sheet Provider information sheet

Parent/GuardianParent/Guardian– Send notification letterSend notification letter– Public information sheet Public information sheet

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Exposures in Child CareExposures in Child Care

Exposed Children (especially incompletely Exposed Children (especially incompletely immunized) and childcare providers should beimmunized) and childcare providers should be– Observed for respiratory tract symptoms for 21 days Observed for respiratory tract symptoms for 21 days

after contact with an infectious person has been after contact with an infectious person has been terminatedterminated

Administer vaccine and antibiotics Administer vaccine and antibiotics Exclude: Exclude:

– Symptomatic or confirmed pertussis until Symptomatic or confirmed pertussis until completion of 5 days of the recommended completion of 5 days of the recommended course of antimicrobial therapy or 21 days if course of antimicrobial therapy or 21 days if untreated untreated

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Follow up & ReportingFollow up & Reporting

Check for the status of the outbreak controlCheck for the status of the outbreak control

Document and update your regional Document and update your regional epidemiologist and DIDE when the outbreak is epidemiologist and DIDE when the outbreak is controlled completelycontrolled completely

Forward report with lab results to DIDEForward report with lab results to DIDE

WEST VIRGINIAWEST VIRGINIA

&&

U.S.AU.S.A

PERTUSSIS PERTUSSIS SURVEILLANCE DATASURVEILLANCE DATA

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Number of Reported Pertussis Cases, by Year, Number of Reported Pertussis Cases, by Year, United States, 1922-2005United States, 1922-2005

Source: MMWRSource: MMWR December 15, 2006 / 55(RR17);1-33 December 15, 2006 / 55(RR17);1-33

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Number of Reported Pertussis Cases, Number of Reported Pertussis Cases, by Year, United States, 1922-2006by Year, United States, 1922-2006

Source: MMWR May 30, 2008 / 57 (04);1-47,51Source: MMWR May 30, 2008 / 57 (04);1-47,51

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SummarySummary

DiscussedDiscussed– Disease description including clinical Disease description including clinical

characteristics, laboratory diagnosis and characteristics, laboratory diagnosis and epidemiologyepidemiology

– Pertussis case investigation and Pertussis case investigation and outbreak investigationoutbreak investigation

– National and state surveillance dataNational and state surveillance data

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ResourcesResources

IDEP Pertussis site:IDEP Pertussis site: http://www.wvdhhr.org/idep/a-z/a-z-pertus

sis.asp CDC Pertussis Surveillance Investigation:CDC Pertussis Surveillance Investigation:

http://www.cdc.gov/nip/publications/sur-manual/chpt08_pertussis.pdf

Guideline for Control of Pertussis Guideline for Control of Pertussis Outbreak:Outbreak:

http://www.cdc.gov/nip/publications/pertussis/guide.htm

ReferencesReferences

CDC VPD Surveillance Manual, 4CDC VPD Surveillance Manual, 4thth Edition, 2008 Edition, 2008 Pertussis: Chapter 10Pertussis: Chapter 10

Pertussis (Whooping Cough) Pg. 504-519, Red Pertussis (Whooping Cough) Pg. 504-519, Red Book, 2009 Report of the Committee on Infectious Book, 2009 Report of the Committee on Infectious Diseases – American Academy of Pediatrics, 28Diseases – American Academy of Pediatrics, 28thth Edition Edition

http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Pertussis Pg. 455-461, Control of Communicable Pertussis Pg. 455-461, Control of Communicable Diseases Manual, APHA & WHO, 19Diseases Manual, APHA & WHO, 19thth Edition, Edition, David Heymann, MD, Editor David Heymann, MD, Editor

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QuestionsQuestions??

Thank you!Thank you!

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