Pertussis Update5/2/2012

Amy.Groom@ihs.govTwesier@npaihb.orgRita.Harding@ihs.gov

Overview

• Epidemiology of pertussis• Current outbreaks• Diagnosis, treatment and immunization

recommendations• Resources• Outbreak Response Strategies

– Portland IHS Area– Billings IHS Area

Epidemiology of Pertussis• Caused by a bacteria - Bordetella pertussis • Droplet spread (coughing, sneezing) • Endemic in the U.S.

– Periodic epidemics every 3 – 5 yrs; frequent outbreaks– 27,550 cases reported in 2010 (last national peak year)– 90% of deaths occur in children < 4 months– Most cases go unreported

• Waning vaccine immunity in pre-teens, teens and adults– Childhood vaccination is 80-85% effective

• Difficult to detect– Other co-circulating respiratory pathogens– Challenges with PCR test– Adult cases can seem mild

Pertussis Outbreaks• Local outbreaks not uncommon

• California – 9,143 cases reported in 2010, 10 infant deaths. – Increased pertussis activity continuing

• Washington– As of April 21st, 2012, 1008 cases have been reported for 2012

• 110 cases were reported in 2011 for this same time period

• Montana– 90 cases since Jan 1, 2012– Several infants hospitalized

Signs and Symptoms

• Initial signs and symptoms are similar to a cold. – Runny nose– Congestion– Sneezing– Mild cough– Fever

• After 1–2 weeks, severe coughing can begin– Can last up to 10 weeks and recur with subsequent respiratory

infections– Babies and young children may turn blue while coughing because

of a lack of oxygen– Disease in adults is more mild and often goes undiagnosed

Diagnosis• Consider pertussis diagnosis even in immunized patients

– Respiratory symptoms of any duration in infants <12 months. – Cough illness that is paroxysmal, accompanied by gagging, post-tussive emesis

or inspiratory whoop, or any cough that is > 2 weeks duration (in patients of any age).

– Respiratory illness of any duration in patients who have had contact with someone known to have pertussis or who has symptoms consistent with pertussis.

• Refer to state department of health for lab testing procedures– Testing appropriate up to 3 weeks after onset of coughing

• Nasopharyngeal specimen for pertussis polymerase chain reaction (PCR) or culture– PCR is more sensitive and rapid than culture, but culture is the gold standard

• CDC video re: NP specimen collection: • http://

www.cdc.gov/pertussis/clinical/diagnostic-testing/specimen-collection.html

Treatment

• Antibiotic treatment for cases• Antibiotic prophylaxis for contacts

– Erythromycin, clarithromycin, and azithromycin are preferred for the treatment of pertussis in persons ≥1 month of age.

– For infants <1 month of age, azithromycin is preferred• Do not wait for lab confirmation to begin antibiotic

treatment or prophylaxis• Patient should remain at home until antibiotic

prescription is complete

Pertussis Outbreak Control

• Primary goal - decrease morbidity and mortality among infants

• Secondary – decrease morbidity in persons of all ages

• Early detection and treatment can prevent spread

• Immunization to prevent cases

Immunization Recommendations

• Infants and children – 5 doses of the DTaP vaccine at 2, 4, and 6 months,

at 15 through 18 months, and at 4 through 6 years. • Limited immunity after 3 doses• All 5 doses are needed for maximum protection. • Vaccine efficacy 80% - 85%

• Children 7-10 years of age who are not fully vaccinated with DTaP should receive a dose of Tdap instead of waiting for the 11-12 year old check up.

Immunization Recommendations Cont.

• Adolescents - One dose of Tdap vaccine at age 11 or 12.– Catch up vaccination for unvaccinated 13 – 18 yrs.

• Adults - All adults 19 yrs and older should receive a dose of Tdap, regardless of interval since Td vaccination– Adults 65 yrs and older can receive either Tdap

product

Immunization Recommendations – Priority Groups

• Pregnant Women• Caregivers/household contacts of infants• Healthcare personnel

– Priority to those with infant contact

Pregnant Women• All pregnant women who have not been previously

vaccinated with Tdap should get one dose of Tdap anytime after 20 weeks gestation.– Maternal pertussis antibodies transfer to the newborn– Protects the mother making her less likely to transmit

pertussis to her infant• Women not vaccinated before or during pregnancy

should receive Tdap immediately postpartum, before leaving the hospital or birthing center.

Link to a story of a mother whose newborn baby contracted and died from pertussis : http://shotbyshot.org/pertussis/kaliahs-story/

IHS 2 year old 4313314* Coverage

FY09 Q

2

FY09 Q

3

FY09 Q

4

FY10 Q

1

FY10 Q

2

FY10 Q

3

FY10 Q

4

FY11 Q

1

FY11 Q

2

FY11 Q

3

FY11 Q

4

FY12 Q

1

FY12 Q

20%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4313314 COVERAGEFY 2009 - FY 2012

FY 2012 Q2 – Age Appropriate DTaP coverage among 3 – 27 month olds

3-4 mnths 5-6 mnths 7-15 mnths

16-18 mnths

19-23 mnths

24-27 mnths

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

DTaP

DTaP

Tdap Coverage among AdolescentsFY 2012 Q2

ABRALA ABQ

BEM BIL CANAS

NAV OKPHX

PORTUC

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

13 yrs olds13-17 yrs olds

Immunization Strategies

• Review RPMS Immunization Package reports– 3-27 month old, Two year old and Adolescent– Follow up with patients who are not current with their vaccines

• Generate lists of patients who are due for Tdap using “Lists and Letters” feature in the RPMS Immunization Package

• Conduct Reminder/Recall activities on patients who are due• Expand access to vaccines

– Review provider immunization policy– Standing orders for post-partum women– Consider alternative vaccination sites

• School based vaccination?

– Utilize pharmacists

Resources

• CDC pertussis site: http://www.cdc.gov/vaccines/vpd-vac/pertussis/default.htm#clinical

• CDC guidelines for control of pertussis outbreaks: http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm

• Northwest Portland Area Indian Health Board site: http://www.npaihb.org/

• State health department websites

Portland Area Pertussis Update

• Background– Increased cases in 2010, again in 2nd half of 2011– Potential exposures from First Nations visitors,

January, Lummi– Steady increases throughout Jan-Mar– April- WA DOH announces Pertussis Epidemic,

cases surpass 1000

Portland Area Pertussis Response

• Following potential exposures at Lummi, assisted WA DOH in developing clinical guidance- sent to Area Clinical Directors 2/7/12

• Promed reports continued increase in pertussis cases- article distributed to clinic directors and immunizations coodrinators– "I think it ended up just being our time," Person [County Health

Officer] said. "It ends up being everybody's time at some point."

• 4/10/2010- Distributed another email to immunization coordinators and American Indian Health Commission members detailing WA epidemic and requesting sites prepare a pertussis response plan

Portland Area Pertussis Response

• Developed slides for Area Director’s report to the NPAIHB Quarterly Board Meeting.

• Attended meeting on 4/18/2012 and responded to questions by delegates

• Distributed vaccine coverage data by state, example Pertussis Response Plan and latest guidance by WA DOH 4/24

• Completed updates to NPAIHB website 4/26

Portland Area Pertussis Response

• Contacted by WA DOH to assist in distribution of Tdap vaccine for un/underinsured adults– Contacted sites by email with phone follow-up– Completed final requests by 5/1

• Attended American Indian Health Commission Immunization Workgroup meeting, 4/27

DataUS National Immunization Survey, Q1/2010-Q4/2010†

  3+DTaP¥ 4+DTaP‡ 4:3:1:3:3:1:4**

US National 95.0±0.6 84.4±1.0 70.2±1.3

Idaho 90.8±4.5 77.9±5.7 57.4±6.8

Oregon 96.3±2.5 83.7±5.0 67.0±6.4

Washington 93.2±3.0 81.9±4.9 70.9±5.5

WA-Eastern WA 93.3±3.7 83.5±5.8 73.7±6.7

WA-Western WA 93.1±3.7 81.3±6.2 70.0±6.9* Estimate=NA (Not Available) if the unweighted sample size for the denominator was <30 or (CI half width)/Estimate > 0.588 or (CI half width) >10. Estimates presented as point estimate (%) ± 95% Confidence Interval.

† Children in the Q1/2010-Q4/2010 National Immunization Survey were born from January 2007 through July 2009.

¥ 3 or more doses of any diphtheria and tetanus toxoids and pertussis vaccines including diphtheria and tetanus toxoids, and any acellular pertussis vaccine (DTaP/DTP/DT).

‡ 4 or more doses of DTaP.

** 4 or more doses of DTaP, 3 or more doses of poliovirus vaccine, and 1 or more doses of any MMR vaccine, ≥3 doses of Hib vaccine of any type, 3 or more doses of HepB, 1 or more doses of varicella vaccine, and 4 or more doses of PCV.

DataPercent Up to Date with Recommended Number of DTAP Doses by Age Group

3 to 4 months

5 to 6 months

7 to 15 months

16 to 18 months

19 to 23 months

24 to 27 months

19 to 35 months

State 1 DTAP 2 DTAP 3 DTAP 3 DTAP 4 DTAP 4 DTAP 4 DTAP

WA 67.1 60.3 65.7 77.1 67.3 72.3 73.1

OR 63.3 63.6 52.0 69.6 47.3 59.0 60.0

ID 72.7 33.3 50.0 64.3 59.5 75.9 78.2

DataPercent Up to Date for All Recommended Immunizations by Age Group

State3 to 4

months5 to 6

months7 to 15

months16 to 18 months

19 to 23 months

24 to 27 months

19 to 35 months*

Refusals (all ages)

WA 65.8 53.4 63.2 47.6 55.6 57.4 59.3 3.5

OR 63.3 57.6 48.7 30.4 36.3 52.5 48.1 1.9

ID 72.7 33.3 48.5 21.4 50.0 72.4 67.7 8.4

Recommendations

• ACIP recommendations for DTaP series for those 0 to 6 years, Tdap for adolescents and adults.– Pregnant woman 20 weeks or greater gestation – Provisional guidelines for adults over 64– HCP- all HCP should receive Tdap vaccine

• Diagnose, treat, report according to State/CDC guidelines

Next Steps• Patient/community education

– Produce digital stories for PSAs, clinic video displays– Develop key points for distribution to area Tribal newspapers,

clinic newsletters– Maintain NPAIHB website with up to date information

• Develop RPMS queries for surveillance to track cases/contacts• Encourage alternative vaccine sites• Engage Clinic Directors at upcoming CD meeting, 5/10• Participate in panel discussion at Cross Border Public Health Meeting,

5/15• Contact: CAPT Thomas Weiser, MD, MPH

Medical Epidemiologist tweiser@npaihb.org

Billings Area Experience

Pertussis “Exposing” Indian Communities in MT

One Reservation = Current Cluster– 3 (maybe 4) cases

• 3 Indian children, 1 Non-Indian school teacher• Time potential for contacts to still become cases

Two Reservations = Possible Cases Early 2012

Immunization Rates 3 to 27 Month Old – Service Unit Range = 91% to 40%

Process Challenges• How to educate key players

– Without burying them in emails • How to “positively” present facts that impact vaccine acceptance

and disease spread– Vaccine efficacy only 80% - “you still need those shots”– Stay home until all Rx taken – “not just till you feel better”

• How to leverage outbreak to improve immunization– Without scaring everyone into stampeding clinic

• How to persuade (require) employees to get Tdap– National policy?

• How to prioritize and deal with other pressing issues – New TB cases & oil boom STI impacts still happen

Relationship Challenges - State Health

• Limited understanding of Indian country and vaccine/care seeking behaviors (eg multiple locations)

• False sense of security – stay calm, it is only one case – not sure why Washington is imploding – just investigate and vaccinate

• Emphasis on case “jurisdiction” which makes impact of outbreak seem less until you start asking questions

• Initial misunderstanding in use of state lab as “fail safe” systems to avoid missing cases

Immunization Challenges

• Low immunization protection rates – 40% (equals 32% if factor in 80% vaccine efficacy)

• Transition to new MT “opt-in” registry– Majority Indian children records blocked to view– Clinic nurses can get parent permissions when child

is in clinic but do not have registry edit capability for immediate access

– PHNs cannot update recall lists to identify patients needing outreach visits (probably most vulnerable group)

A good public health threat is exciting!!!

• Mobilize team response – we’re all in this together - everyone has a role – how can I help you???

• Empower (challenge) staff to play CSI when assessing symptoms or doing contact investigations

• Keep staff updated with tidbits of new information, changing disease patterns, whatever - make everyone feel vital to the response effort

Success – Strategy Model

GAME PLAN – KEY STRATIGIES

Immunize Immunize Immunize

Recognize Diagnosis Treat

Evaluate Contacts

Refer for Further Investigation and Reporting

Success – Staff Resources

• Empowered Pediatricians • Enthusiastic Public Health Nurses• Trained Pharmacists to Immunize • Laboratory to Monitor Lab Results• Hard Working Clinic Staff• Health Promotion for Digital Storytelling

• Everyone as a TEAM (the dream)

Current Tasks

• Alert locum staff (walk-in & ER) to think (not miss) pertussis

• Reach pregnant women• Coordinate closely with State and orient new

State staff to Indian Country• Gain immediate public health emergency

access to immunization registry• WHATEVER ELSE POPS UP

Future Issue

We have not been tested yet . . . what happens next???