Pertussis Pertussis UpdateUpdate

Linda Bethel, RN, MPHLinda Bethel, RN, MPHEpidemiology and Immunization Epidemiology and Immunization

Services BranchServices Branch

PertussisPertussisMost poorly controlled vaccine-preventable Most poorly controlled vaccine-preventable diseasedisease– Cyclical: Peaks every 2-5 yearsCyclical: Peaks every 2-5 years

Adults are vulnerableAdults are vulnerable– 27% of reported cases in 2004 were adults27% of reported cases in 2004 were adults– Immunity is not lifelong, wanes 4-12 years after DTaP Immunity is not lifelong, wanes 4-12 years after DTaP

series and 4-20 years after natural infectionseries and 4-20 years after natural infection

Tdap (for adolescents and adults) licensed in Tdap (for adolescents and adults) licensed in 20052005– In 2008 ~40% of adolescents and ~6% of adults had In 2008 ~40% of adolescents and ~6% of adults had

been vaccinatedbeen vaccinated*Wendleboe et al. Infect Dis J 2005;24 (Suppl 5):S58-61.

Pertussis, continuedPertussis, continuedTransmission occurs by close contact via Transmission occurs by close contact via dropletsdroplets

Very contagious: approximately 90% of Very contagious: approximately 90% of susceptible household contacts become susceptible household contacts become infectedinfected

92-95% of population must be immune to 92-95% of population must be immune to eliminate transmission. eliminate transmission.

* Weiss and Hewlett. Ann Rev Microbiol. 1986;40:661-86

SymptomsSymptoms

Three stages (catarrhal, paroxysmal, and Three stages (catarrhal, paroxysmal, and convalescent) lasting 4-12 weeksconvalescent) lasting 4-12 weeks

Typical symptoms:Typical symptoms:– Paroxysmal coughParoxysmal cough– Lack of feverLack of fever– No systemic illnessNo systemic illness– Post-tussive vomitingPost-tussive vomiting– Inspiratory (post-tussive) whoopInspiratory (post-tussive) whoop

Pertussis in Young InfantsPertussis in Young Infants

Initially mild cough, no fever, runny noseInitially mild cough, no fever, runny nose

Develops into serious symptoms:Develops into serious symptoms:– Gagging, gaspingGagging, gasping– Apneic episodes (face may turn red or purple)Apneic episodes (face may turn red or purple)– Post-tussive vomitingPost-tussive vomiting– SeizuresSeizures– Respiratory distressRespiratory distress– PneumoniaPneumonia

Pertussis Transmission to InfantsPertussis Transmission to InfantsAdults transmit pertussis to infantsAdults transmit pertussis to infants– Among 264 known source-cases:Among 264 known source-cases:

Almost 50% were parents, most often mothersAlmost 50% were parents, most often mothers

51% were adults >19 years of age51% were adults >19 years of age

Bisgard KM, et al. Infant pertussis: who was the source? Pediatr Infect Dis J 2004; 23(11):985-989.

Wendelboe AM, et al. Transmission of Bordetella pertussis to young infants. Pediatr Infect Dis J 2007; 26(4):293-299.

Pertussis Cases - 2010Pertussis Cases - 2010

California (as of 9/7/10):California (as of 9/7/10):– 3,834 cases3,834 cases– 9.8 cases/100,0009.8 cases/100,000– Most cases since 1958, highest incidence Most cases since 1958, highest incidence

since 1962since 1962– 9 infant deaths, all <2 months old9 infant deaths, all <2 months old

San Diego (as of 9/13/10):San Diego (as of 9/13/10):– 514 cases514 cases– 1 infant death1 infant death

Number of reported cases by year of onset – California 1950-2010*

0

1000

2000

3000

4000

5000

6000

7000

1950

1952

1954

1956

1958

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

*

year

case

s

0

10

20

30

40

50

60

70

case

s p

er 1

00,0

00

Cases

Rate per 100,000

* As of 9/7/2010. California Department of Public Health, Immunization Branch

San Diego County Pertussis Annual Total Cases by Year of San Diego County Pertussis Annual Total Cases by Year of Report, 1999 – 2010 YTD (as of 9/13/2010)Report, 1999 – 2010 YTD (as of 9/13/2010)

118 12494

230

101117

371

173

50 54

143

514

0

100

200

300

400

500

6001

99

9

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

(Y

TD

)

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 9/13/2010

Epidemic curve of reported pertussis cases Epidemic curve of reported pertussis cases and deaths by month of onset -- California, and deaths by month of onset -- California,

2005, 2009-2010*2005, 2009-2010*

0

200

400

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1200

Janu

ary

Febru

ary

Mar

ch April

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June Ju

ly

Augus

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Septe

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Octobe

r

Novem

ber

Decem

ber

month of onset

case

s

2005

2009

2010

X 2005 death

X 2009 death

X 2010 death

X

X

X

XX

X

X

X

XX

X

X

XX

XX

X

X

X

XX

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 9/7/2010

County of San Diego Pertussis Cases by Month Reported, 2009 and 2010 (as of 9/13/2010, N=514)

020406080

100120140160180200

Jan

Fe

b

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Se

p

Oct

No

v

De

c

Month of Report

Nu

mb

er

of C

ase

s

2009 2010 (YTD)

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 9/7/2010

San Diego County Incidence Rates for Pertussis Cases by Age and Race / Ethnicity, 2010 YTD (as of 9/13/2010, N=514)

3.3 1.4

43.1

71.0

47.6

214.0

0

50

100

150

200

250

300

<6MOS 6M-6Y 7-9Y 10-18Y 19-64Y 65+YAge Group

Nu

mb

er

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0 P

op

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tion

Asian/Non-Hispanic African/American Black/Non-HWhite/Non-Hispanic Hispanic/LatinoAll race/ethnicities

San Diego County Number of Pertussis Cases Reported by Race/Ethnicity and Age Group, 2010 (as of 9/13/2010, N=514)

141

50

87

165

5

66

0

20

40

60

80

100

120

140

160

180

<6MOS 6M-6Y 7-9Y 10-18Y 19-64Y 65+Y

Age Group

Nu

mb

er o

f C

ases

All race/ethnicities White/Non-Hispanic Hispanic/Latino

African/American Black/Non-H Asian/Non-Hispanic Other/Unknown

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 9/13/2010

Pertussis MitigationPertussis MitigationPromote the use of Tdap - particularly in those who have Promote the use of Tdap - particularly in those who have contact with infantscontact with infants– Free vaccine through 12/31/2010 for birth hospitals with Free vaccine through 12/31/2010 for birth hospitals with

postpartum Tdap policies; encourage ED use of Tdap postpartum Tdap policies; encourage ED use of Tdap – Work with payers re: Tdap reimbursementWork with payers re: Tdap reimbursement– CDPH expanded Tdap recommendationsCDPH expanded Tdap recommendations

Clinician educationClinician education– CDPH Tdap recommendationsCDPH Tdap recommendations– Pertussis signs and symptomsPertussis signs and symptoms– Treatment recommendations for infants with severe pertussisTreatment recommendations for infants with severe pertussis– Accelerated DTaP schedule for infantsAccelerated DTaP schedule for infants

Public educationPublic education– Vaccination/cocooningVaccination/cocooning– Pertussis signs and symptomsPertussis signs and symptoms– Keep ill people away from infantsKeep ill people away from infants

California Department of Public Health, Immunization Branch

New CDPH Tdap RecommendationsNew CDPH Tdap Recommendations

Immunize pre-teens and adults with TdapImmunize pre-teens and adults with Tdap– 7-9 years old who are underimmunized7-9 years old who are underimmunized– Those Those >> 10 years of age who have not yet 10 years of age who have not yet

received Tdap, especially:received Tdap, especially:Women of childbearing age, preferably before, or Women of childbearing age, preferably before, or else during or immediately after pregnancyelse during or immediately after pregnancyOthers with close contact with young infantsOthers with close contact with young infantsHealth Care personnelHealth Care personnelIncludes persons > 64 years of ageIncludes persons > 64 years of age

No minimum interval between Td and No minimum interval between Td and TdapTdap

Why here, why now?Why here, why now?A sufficient number of susceptible people have accumulated in the A sufficient number of susceptible people have accumulated in the population via birth cohorts of unvaccinated infants, waning population via birth cohorts of unvaccinated infants, waning population immunity from vaccine or disease (and less chance for population immunity from vaccine or disease (and less chance for boosting opportunities), parental choice not to vaccinate children, boosting opportunities), parental choice not to vaccinate children, etc.etc.

The 2005 epidemic was nationwide, but although other states have The 2005 epidemic was nationwide, but although other states have reported pertussis increases this year, none have reported reported pertussis increases this year, none have reported increases like those seen in Californiaincreases like those seen in California

Some have speculated that California may have less population Some have speculated that California may have less population immunity than other states because it is one of only 11 states that immunity than other states because it is one of only 11 states that does not have a Tdap requirement for middle school students, does not have a Tdap requirement for middle school students, however, 2009 National Immunization Survey data indicates that however, 2009 National Immunization Survey data indicates that estimated Tdap rates in California adolescents (53.1%) are not estimated Tdap rates in California adolescents (53.1%) are not much lower than the national estimate (55.6%)much lower than the national estimate (55.6%)

California Department of Public Health, Immunization Branch

Pertussis Booster RequirementPertussis Booster Requirement

Pertussis Cases in children and adolescents Pertussis Cases in children and adolescents aged 0-18 years, by vaccine history – aged 0-18 years, by vaccine history –

California, 9/7/2010California, 9/7/2010

0

50

100

150

200

250

300

350

<1m 1m 2m 3m 4m 5m

6-11

m1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18

age (years)

cas

es

Unk vaccine history

6 doses

5 doses

1-4 doses

0 doses

*As of 9/7/2010

DTaP

DTaP DTaP

DTaP

DTaP

Tdap

California Department of Public Health, Immunization Branch

Countering Vaccine MythsCountering Vaccine Myths

The majority of people who get disease have been The majority of people who get disease have been vaccinatedvaccinated

This is explained by two factors: This is explained by two factors: – no vaccine is 100% effective (most childhood no vaccine is 100% effective (most childhood

vaccines are effective for 85% to 95% of recipients); vaccines are effective for 85% to 95% of recipients); and and

– most people in the U.S. are vaccinatedmost people in the U.S. are vaccinated

When most people have been vaccinated, most cases of When most people have been vaccinated, most cases of disease will occur in vaccinated people. Those who are disease will occur in vaccinated people. Those who are vaccinated and did not respond to the vaccine often vaccinated and did not respond to the vaccine often outnumber those who are not vaccinatedoutnumber those who are not vaccinated

California Department of Public Health, Immunization Branch

PertussisPertussis

ResourcesResources

Updated Updated FlyerFlyerFor For ProvidersProviders

For the Public in English & For the Public in English & SpanishSpanish

For Schools

Link to Pertussis MaterialsLink to Pertussis Materialswww.eziz.orgwww.eziz.org

ResourcesResourcesCalifornia Department of Public Health California Department of Public Health Immunization Branch (CDPH)Immunization Branch (CDPH)– www.eziz.orgwww.eziz.org– http://www.cdph.ca.gov/programs/immunize/Pages/dehttp://www.cdph.ca.gov/programs/immunize/Pages/de

fault.aspxfault.aspx

County of San Diego Immunization ProgramCounty of San Diego Immunization Program– www.sdiz.orgwww.sdiz.org– Linda Bethel, RN, MPHLinda Bethel, RN, MPH

(619) 692-5607(619) 692-5607

Linda.bethel@sdcounty.ca.govLinda.bethel@sdcounty.ca.gov

Questions?Questions?