Claudia Alvarado RN BSN Public Health Nurse CoordinatorDepartment of Public Health Services

Pertussis OverviewPertussis Overview

First recognized in the 16th CenturyCaused by bacteria Bordetella PertussisPertussis bacteria produces toxins which are responsible for clinical features of illnessPertussis epidemics cyclic every 2-5 yearsEffectively treated with AntibioticClosely related organism: Bordetella para-pertussis

• Incubation period: usually 7-10 days (range 6-21 days)

• Infectious Period: Begins with onset of the catarrhal stage or onset of cough and ends 21 days after cough onset or 5 days of treatment with appropriate antibiotic.

• Mode of transmission: Person-to person through aerosolized droplets or by direct contact with secretions from the respiratory tract

Susceptibility:

Highly contagious with a > 80% secondary attack rate among susceptible persons in a households Pertussis occurs at any age regardless of vaccine

status Vaccine immunity to pertussis wanes in 5-10 years,

may be less with acellular vaccine (data very limited)

Catarrhal stage: Onset often insidious with cold like symptoms usually for 1-2 weeks with gradually increasing coughParoxysmal stage: Paroxysms, inspiratory whoop, vomiting, apnea, cyanosis (often after paroxysms) usually for 1-6 weeks, up to 10 weeksConvalescent stage: Mild cough for weeks to months

• Symptoms in vaccinated persons are milder• Less characteristic symptoms in adolescent and

adults• Infants 6 months and younger have atypical

presentation– Shorter catarrhal stage– Gagging, gasping, apnea, less often paroxysms– Whoop may be absent

Infants <12 months:Hospitalization ( 50%)Apnea (50%)Bacterial Pneumonia (20%)Seizures (1%)Death (1%)Encephalopathy (1%)

•CDC/CSTE Clinical Case Definition (Probable Case)– a cough illness lasting at least 2 weeks with one of the

following: paroxysms of coughing, inspiratory "whoop," or post- tussive vomiting AND

– without other apparent cause (as reported by a health-care professional)

•CDC/CSTE Laboratory/Confirmatory Criteria for Diagnosis – isolation of Bordetella pertussis from a clinical specimen OR– positive polymerase chain reaction (PCR) assay for B.

pertussis OR– Epidemiologic link to laboratory confirmed case

<3 weeks = acute (URI, CHF, PE)3-8 weeks = subacute (persistent URI, lung cancer)>8 weeks = chronic (asthma, reflux disease)Adenoviruses, Mycoplasma pneumoniae,

RSV,Chlamydia pneumoniae

Consider in Pertussis even if patient is immunized

PCR, culture, serology (not accepted, except when done by MA PHL)CDC recommends Nasopharyngeal swabs be tested for PCR and Culture, as PCR prone to false positivesUse Dacron tipped NP swab with flexible wire handleDo not use Cotton or Calcium-Alganate swabs Use Regan-Lowe transport mediaMask and gloves

Azithromycin for 5 days is effective Treatment (all age groups, recommended for infants <1 month)Erythromycin for14 days (not preferred in infants less than one month)Clarithromycin for for 7 days, not recommended for infants <1 month TMP/SMC for 14 days, contraindicated in infants < 6 months

Direct contact with oral, nasal, or respiratory secretions from a symptomatic patient

Direct face to face exposure with a symptomatic case

Sharing the same confined space in close proximity with a symptomatic patient for an hour or more

Performing bronchoscopy, suctioning, exam of mouth, nose or throat and mouth to mouth resuscitation (droplet)

Contact groups: i.e. household, friends, school, car/bus religious groups, sports teams, social events, and…. Healthcare

HIGH RISK CONTACTS: Use more inclusive criteria for definition of close contact

Infants less than one year of age, especially less than six months of agePersons with underlying medical conditions such as chronic lung disease, respiratory insufficiency and cystic fibrosisPersons with immune deficiencies (including HIV)

Protect infants by:

Protecting from known/suspect casesLiberal use of term close contact and PEP for infants and persons around themVaccinating “around” infant

Pregnant women, especially in the third trimester due to the increased risk to a newborn infant, as well as other pregnant women (i.e. in medical setting) Health Care workers providing direct patient care, especially prenatal care, labor and delivery, neonatal and pediatric fieldsBabysitter/daycare worker taking care of infantsParents/Parents to be/Caregivers of infants

For Patient: Exclusion/Isolation until completion of 5 days on ABX or 21 days post cough onset (whichever is sooner) For non-symptomatic contacts: Post Exposure Prophylaxis (PEP) For symptomatic contacts: Evaluation (including NP for PCR and/or CX) and PEP/TX/Exclusion as appropriate

High risk contacts should be started on PEP up to 42 days of exposureHousehold: All should be on PEP or TXHome child care: Treat children as household contactsChildcare center: PEP depending on amount of contact/age

Pregnant Contacts:

Pregnant women and persons close to them should be started on PEP for up to 6 weeks after last exposure to pertussis.

Especially important during the last trimester due to increased risk for a infant, if exposed.

Droplet precautions (if mom and infant on ABX rooming together and breastfeeding encouraged)

Clinical/Outpatient settings: Most individuals in waiting rooms etc. with a Pertussis case should not be considered close contacts. Persons who had direct contact with respiratory secretions from the case or intense close contact may be considered for PEP

Facilities/Institutions: (i.e. Nursing Homes and institutions for developmentally disabled):Residents have multiple sources of exposure and increased risk of complicationsMore inclusive interpretation of “close” contacts may be indicated.

Hospital setting: Determination of close contact should be more inclusive in settings such as a neonatal intensive care unit, newborn nursery, or infant ward, because infants are at risk for developing severe disease

Health Care Workers (HCWs) and Patients should be considered exposed only if the source is a confirmed case, or a suspect case during an outbreak.HCWs should wear a mask for respiratory protection. Patients and HCWs exposed to pertussis, should be questioned about symptoms of cough illness, and be instructed to report the development of symptoms within 42 days of exposure to infection control staff.

If symptomatic, Health Care Worker (HCW) should be cultured for pertussis, treated and excluded for the first 5 days of a full course of appropriate antibiotic treatment.If a symptomatic HCW cannot take or refuses antimicrobial therapy, the HCW should be excluded for 21 days after the onset of cough. The use of a mask by the HCW does not provide adequate protection during this time.Active surveillance in health care settings should continue for 42 days after the onset of cough of the last case of pertussis.

http://www.cdc.gov/pertussis/images/pertussis-graph-2012-lg.jpg

Year Reported Cases*2000 7,8672001 7,5802002 9,7712003 11,6472004 25,8272005 25,6162006 15,6322007 10,4542008 13,2782009 16,8582010 27,5502011* 18,719*Total reported cases include those with unknown age

http://www.cdc.gov/pertussis/surv-reporting.html

Wisconsin 87.6 Utah 33.6 Arizona 12.2

Minnesota 72.6* New Mexico 27 Idaho 12

Washington 62.3 Alaska 23.5 Pennsylvania 11.7Vermont 51.9 Oregon 21.9 Missouri 11.6Montana 44.7 Kansas 17.2 Colorado 11

Maine 42.6 New Hampshire 14.9 Kentucky 10.7

Iowa 42.1 New York 13.8 Wyoming 10.3

North Dakota 41.9Illinois 12.3Nebraska 8.8

Year 2007 2008 2009 2010 2011 2012

Cases 79 44 79 22 171 184

Incidence per 100.000

6 3 6 2 12 15

In Household: Two or more cases, with at least one case being confirmed. This definition may be used to count cases/surveillance purposes.

Other settings (i.e. School, Daycare, Health Care):Two or more cases clustered in a setting and time (within 42days of each other), one of which has been confirmed.

Community Outbreak: A higher than expected number of reported cases in a population in a defined time period on the basis of previously reported disease numbers during a non epidemic time period (historical disease patterns)

Institution of droplet precautions in addition to standard precautions for suspect and known casesCohort exposed patientsPEP for exposed employees and patientsEvaluate all symptomatic exposed employees, treat and exclude until on TX x 5 days or 21 days post cough onsetActive surveillance x 42 days after onset of cough of last case of pertussis

Education of high risk units via in-serviceEducation of other staff via fact sheets, other communications Evaluation of staff with respiratory illnessCohort patients with cough illnessRestriction of patients to affected floor, masking when leaving floorConsideration of requirement for visitors to wear surgical mask while in facilityConsideration of vaccination for exposed staff

Immunization of Health-Care Immunization of Health-Care PersonnelPersonnelRecommendations of the Advisory Recommendations of the Advisory Committee on Immunization Committee on Immunization Practices (ACIP)Practices (ACIP)

http://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf

Recommended Adult Immunization Recommended Adult Immunization ScheduleSchedule——United States - 2012United States - 2012

http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf

Report on Pertussis Epidemic –Washington 20122,520 confirmed and probable cases of pertussis (83.4% confirmed) between January 01 and June 16 2012 Review done with attention to Immunization status of patients

Vaccinate HCP regardless of age with a single dose of Tdap as soon as feasible if no prior doseNo minimal interval between last Td and Tdap for HCWHospitals and ambulatory-care facilities should provide Tdap for HCWs and maximize immunization rates

THANK YOU!