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Thomas Clark, MD, MPHCenters for Disease Control and Prevention
Immunization Program Managers MeetingNovember 16, 2010
Pertussis Epidemiology in the United States
National Center for Immunization & Respiratory Diseases
Meningitis and Vaccine Preventable Diseases Branch/Division of Bacterial Diseases
BACKGROUND AND OVERVIEW
Impact of Vaccines in the United States
Vaccine-Preventable Disease
Number of Reported Cases
20th Century Annual
Morbidity*
2008**
Smallpox 48,164 0
Diphtheria 175,885 0
Pertussis 147,271 13,278†
Tetanus 1,314 19
Polio (paralytic) 16,316 0
Measles 503,282 140
Mumps 152,209 454
Rubella 47,745 16
Congenital rubella 823 0
H. influenza (invasive <5 yrs)
20,000 30* CDC, MMWR, April 2, 1999. 48(12); :242-264** CDC, MMWR, January 8, 2010. 58(51 & 52); 1460-1468† National Notifiable Diseases Surveillance System, CDC, 2008
Pertussis Immunization in the US
• Infants (1997)– DTaP at 2, 4, 6 months
• Toddler (1992)– DTaP at 15-18 months
• Pre-school (1992)– DTaP at4-6 years
• Adolescent/adult (2005)– Single Tdap preferred at 11-12 years
DTaP coverage among children aged 19 through 35 months
2004 2005 2006 2007 2008 200978
80
82
84
86
88
90
92
94
96
98
3+4+
CDC National Immunization Survey
1922
1930
1940
1950
1960
1970
1980
1990
2000
2009
0
50,000
100,000
150,000
200,000
250,000
300,000
Year
Nu
mb
er
of
ca
se
s
Reported pertussis cases – 1922-2009
DTP
1990
1995
2000
2005
2009
0
5,000
10,000
15,000
20,000
25,000
30,000
Tdap
DTaP
SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the Public Health Service
Annual incidence (per 100,000) by state - 2009
Source: CDC National Notifiable Disease Surveillance System, 2009CDC Wonder Population Estimates (Vintage 2009)
0-2.7
2.8-4.6
4.7-6.6
6.7-21.5
Incidence
2009 incidence 5.5
Annual incidence by State (per 100,000) by state - preliminary 2010*
Source : CDC National Notifiable Disease Surveillance System , *Provisional data, cumulative to week
ending September 25, 2010 (MMWR Week 38) CDC Wonder Population Estimates (Vintage 2009)
0.0-1.8
1.9-3.2
3.2-5.0
5.1-10.0
Incidence
Reported pertussis incidence by age group - 1990-2009
1990
1995
2000
2005
2009
0
20
40
60
80
100
<1 yr
1-6 yrs
7-10 yrs
11-19
20+ yrs
Year
Inc
ide
nc
e r
ate
(p
er
10
0,0
00
)
SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System
TDAP IMPLEMENTATION AND EVALUATION
Proportion of reported pertussis cases by age group - 1990-2009
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
0.00
20.00
40.00
60.00
80.00
100.00
all other ages20+ years11-19 years
Year
Perc
en
t
Source: CDC National Notifiable Disease Surveillance System, 2009CDC Wonder Population Estimates (Vintage 2009)
Tdap coverage among adolescents aged 13-17 years – 2006-2009
Series10
10
20
30
40
50
60
70
80
90
100
10.8
30.4
40.8
55.6
CDC. National, State, and Local Area Vaccination Coverage Among Adolescents Aged 33-17 Years - United States, 2008. MMWR 2008;58(36);997-1001.CDC. Vaccination Coverage Among Adolescents Aged 13-17 Years – United States, 2007. MMWR 2008;57(40)1100-1103.CDC. Vaccination Coverage Among Adolescents Aged 13-17 Years– United States, 2006. MMWR 2007;56(34) 885-888. CDC. National, State, and Local Area Vaccination Coverage among Adolescents Aged 13-17 Years - United States, 2009 MMWR 2010 ;59(32);1018-1023.
2006
2007
2008
Perc
en
tage (
%)
2009
Tdap Vaccine Effectiveness
• Bridging studies of ADACEL and BOOSTRIX1
– 85-89%
• APERT study2
– 92% (95% CI: 32.0-99.0)
• Australia3 – screening method– 78.0% (95% CI: 60.7-87.6)
• St. Croix outbreak4 – case-control study– 65.6% (95% CI: -35.8-91.3)
• MN case-control study – 72.3% (95% CI: 38.8-87.4)
1 Schmitt HJ et al. JAMA 1996;275:37-41; Gustafsson LH et al. NEJM 1996;334:349-3552 Ward JI et al. N Engl J Med. 2005 Oct 13;353(15):1555-63.3 Rank C, et al. Pediatr Infect Dis J. 2009 Feb;28(2):152-3. 4 Wei SC, et al. CID 2010; 51(3):315-321.
Incidence of reported pertussis - 1990-2008
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
0
2
4
6
8
10
Overall
Year
Cas
es/1
00,0
00 P
op
ula
tio
n
Tdap
CDC unpublished data
Accelerated decline of pertussis Rate ratios of pertussis incidence among
adolescents 11-18 years, 1990-2008
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
00.5
11.5
22.5
33.5
44.5
11-18 years of age vs. all other age groups combined
Year
Ra
te R
ati
o (
Inc
ide
nc
e)
CDC unpublished data
EMERGENCE OF DISEASE IN CHILDREN AGED 7-10 YEARS
Pertussis incidence by age group - 1990-2009
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
0
5
10
15
20
25
30
35
40
1-6 years7-10 years11-14 years15-19 years
Year
Incid
en
ce (
per
10
0,0
00
)
Source: CDC National Notifiable Disease Surveillance System, 2009CDC Wonder Population Estimates (Vintage 2009)
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
0
5
10
15
20
25
Proportion of all pertussis cases con-tributed by children aged 7-10 years
Year
Perc
en
t
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180
200400600800
10001200140016001800
2004
Age (years)
Cases
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180
200
400
600
800
1000
1200
1400
1600
2005
Age (years)
Cases
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180
50100150200250300350400450
2002
Age (years)
Cases
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180
100200300400
500600700800
2003
Age (years)
Cases
Pertussis cases by age – 2002-2005
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180
200
400
600
800
1000
1200
2008
Age (years)
Cases
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180
200
400
600
800
1000
1200
1400
1600
2009
Age (years)
Cases
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180
100200300400500600700800
2006
Age (years)
Cases
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180
50100150200250300350400450
2007
Age (years)
Cases
Pertussis cases by age – 2006-2009
Incidence rate ratios of pertussis among children aged 7-10 years – 1990-
200919
9019
9119
9219
9319
9419
9519
9619
9719
9819
9920
0020
0120
0220
0320
0420
0520
0620
0720
0820
09
01234567
7-10 years of age vs. all other ages combined
Year
Rate
Rati
o
Source: CDC National Notifiable Disease Surveillance System, 2009CDC Wonder Population Estimates (Vintage 2009)
In 2005, 7-10 year old cohort includes aP vaccine recipients
1 2 3 4 5 6 7 8 9 10111213141516171819200
100
200
300
400
500
600
700
Pertussis Cases by Birth Cohort
1980-19911992-19992000-2008
Age (years)
Ca
se
s/#
of
Bir
th C
oh
ort
s i
n E
ach
Ag
e
Ye
ar
Waning Immunity by Vaccine Type
Priority Analytic Questions
• Comparative vaccine effectiveness using immunization registries
• Case-control study of effectiveness of 5th DTaP dose in California
• Modeling impact of waning immunity and changes to vaccination schedule
• Impact of changing strain diversity on disease occurrence
Additional Activities
• ACIP • Clinical Validation Study• Laboratory training and tech
transfer• External review of vaccinology
activities
For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Thank You
National Center for Immunization & Respiratory Diseases
Meningitis and Vaccine Preventable Diseases/Division of Bacterial Diseases