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Pertussis Outbreak in an Undervaccinated Community Martha Siemsen, APRN-BC Medical Investigator Kansas Department of Health & Environment Bureau of Surveillance and Epidemiology Our Vision - Healthy Kansans living in safe and sustainable environments

Disease Investigations in Kansas Case investigations are responsibility of 99 local health departments (LHD) Each LHD has a health officer Administrator Medical Consultant I’d like to begin by giving you a brief overview of disease investigation as it is performed in Kansas and the law related to immunization exemption. Kansas is a decentralized state, meaning that the counties have control and the state can only make recommendations. The state of Kansas is divided into 105 counties. There are currently 99 local health departments as several of the counties share disease investigation responsibilities within their boundaries and for enforcing Kansas isolation/quarantine laws. Each county health department has a health officer. In the smaller counties, in many instances, the administrator of the health department assumes the duties of the health officer. Where this occurs, medical consultants are utilized. Physicians, laboratories, schools, health departments, hospitals, among others are required to report suspected and confirmed cases of infectious/contagious diseases. The immunization law allows for 2 exemptions, religious and medical.

Investigation Tools Disease Investigation Guidelines http://www.kdheks.gov/epi/disease_protocols.htm Contact/Interview of cases/parents Onset and Disease Characteristics Vaccination Status Household/Community Transmission Understanding of treatment/prophylaxis Understanding of control measures The local health department staff perform interviews using published Disease Investigation Guidelines or DIGs as a resource prepared by the KDHE for their use and was available to the health department investigators during the outbreak. The DIGs contain a rapid assessment form (1 page) for gathering information. Our Vision - Healthy Kansans living in safe and sustainable environments

Welcome to the Unknown Physician Contact Lacking Demographics Medical Conditions Lacking Clinical Symptoms Unknown Vaccination Status Unknown Treatment/Prophylaxis of Household Unknown Education Provided to Case/parent The majority of cases were found through laboratory reporting The only information available was the name, birth date and physician last name The physician had to be contacted initially for the additional information needed to follow up with families. On occasion, the physician office had limited clinical and vaccination information and incorrect demographics. Our Vision - Healthy Kansans living in safe and sustainable environments

Continuation of the Unknown School Contact Determine is case was in school Identify close contacts Vaccination status of case/contacts Ensure unvaccinated contacts were excluded For cases with limited demographic information, the school was able to provide this, in most cases. The vaccination status was not always available At times, the case was continuing to attend class. Our Vision - Healthy Kansans living in safe and sustainable environments

The Outbreak June 2009 Community Educational Setting Identified through disease reporting Community Large families Strict religious belief system Objection to vaccination Male-centric Educational Setting In setting the stage…. In June 2009, KDHE identified this outbreak through passive surveillance in a religious community in the North East portion of Kansas. This community is distrustful of government The children attend one school, which has Kindergarten through college. There is also a boarding school with students from other states and countries. Our Vision - Healthy Kansans living in safe and sustainable environments

The Outbreak This outbreak was concentrated in Pottawatomie county. It also involved cases in the surrounding counties of Jackson, Shawnee (in which Topeka, the state capitol is) and Wabaunsee Our Vision - Healthy Kansans living in safe and sustainable environments

Patient Demographics 94 patients met the case definition for suspect, probable, or confirmed case of pertussis Median age 9 years (range 1 month – 83 years) 54 (57%) were female Predominantly white, non-Hispanic community 2 hospitalized and 1 death Median age of 9 – school age But as young as 1 month up to 83 years of age Predominately white, non Hispanic community The one death occurred in the 82 year old, epi-linked post death to grand daughter. Initial report was from a positive PCR. Physician wrote the presumptive cause of death was either an acute Myocardial Infarction or Pulmonary Embolus Our Vision - Healthy Kansans living in safe and sustainable environments

The Outbreak School setting accounted for 40% of the cases. The 48% of our Other category were infants, adults and those that were unaccounted. Of the 47% with a vaccination history, not all had received the full series of DTap. Even though 54% of our cases were confirmed by positive PCR, no culture was obtained to confirm the outbreak, according to CDC definition. Our Vision - Healthy Kansans living in safe and sustainable environments

Epidemic Curve (n=94) From the graph you can see that the initial case occurred in June 2009 transmission continued to the surrounding counties over several months. The peak occurred during October and cases are continuing to be reported in 2010 in this community Our Vision - Healthy Kansans living in safe and sustainable environments

The Outbreak A majority of the cases occurred in the elementary grades and a review of the vaccination records revealed that 75% of the kindergarten students and 50% of the first graders had religious exemptions The upper grades had fewer exemptions (around 10%) and fewer cases of pertussis

School Outbreak Control Measures Increase awareness of outbreak Educate school staff to refer students with cough Maintain surveillance log Vaccination/Exclusion of susceptible students Assessment of vaccination status and referral Prior to the beginning of the school year, local health department staff met with the school liaison to advise of the outbreak and to discuss disease containment activities that were needed to be taken by the school Educational information was given at that time to be shared with school personnel and to educate school staff to refer coughing students. LHD and KDHE staff recommended the school keep a surveillance log to track coughing students, vaccination status, and exclusion of contacts. This was not done. The school did allow a representative from KDHE and the local health department to review the vaccination records of students K-12, both in the day school and the boarding school to assess vaccination status and to identify those students for exclusion. However, the invitation did not occur until we were well into the outbreak in October. Our Vision - Healthy Kansans living in safe and sustainable environments

Community Outbreak Control Measures Sent blast faxes to Health Care Providers Issued press releases to educate community Notified hospitals, daycares and schools Community Awareness activities included: Blast Faxes sent x 2 to the medical community advising of the outbreak and asking the physician to consider pertussis when examining patients with a cough illness, information on Best Practices for testing (culture), treatment, prophylaxis, prevention, clinical symptoms and disease reporting requirements. The physician who was performing the majority of the testing also received these blast faxes. The last fax was cosigned by the medical consultants of the health departments affected and the Director of Health, KDHE. Grand rounds with local physicians was conducted by the health department medical consultant emphasizing Best Practices for testing, treatment/prophylaxis, prevention, clinical symptoms and disease reporting requirements Press releases were issued through the local paper Daycare providers, hospitals and other schools were notified of the outbreak and were encouraged to report coughing illnesses. Our Vision - Healthy Kansans living in safe and sustainable environments

Challenges Limited staff resources Large Families Cultural communication Timely /Under-Reporting Adherence to prevention efforts Case confirmation Exclusion of cases Limited staff resources both at the LHD and at KDHE Several positions were vacated at the LHD and those positions went unfilled, due to budget constraints. A nurse, working part time, was reassigned to be the lead on this investigator at the health department. The KDHE lab could accept very few specimens for PCR testing due to budgetary and staff constraints due to H1N1. The size of the families involved proved to be a detriment for testing, prophylaxis and or treatment. Even though community organizations exist, financial information is required before funds can be released. Because of distrust of government, families were unwilling to provide this information which led to late prophylaxis and lack of testing. Reporting and Prevention: The physician, who cared for the majority of the cases is a member of this religious community. A one on one meeting was held with this physician by a representative of the health department to discuss Best Practices for testing (culture), reporting and prevention. In spite of this, PCR testing continued to be the test of choice, reporting occurred only with positive PCR’s which could have led to underreporting of cases and vaccination activity remained unchanged, unless a parent asked for the vaccine to be administered. The church minister decided against bringing the matter to the congregation for fear of decreased attendance to church services and activities. (the cry room at this church was given as a place of contact with others with pertussis on occasion) Case Confirmation: Because the community has lack of trust in the government, and is male centric, information was not easy to obtain. Names and birthdates or ages of contacts, demographic information, places of contact and clinical information was arduous; thus leading to difficulty in confirming cases. Since we did not have a positive culture, we had to use the CDC definition of a confirmed case. The use of prepaid phones added to the challenge of follow up because the LHD was unable to contact the families. Due to the demands of the vaccination effort during the H1N1 pandemic, local health department staff were unable to make home visits to those families who did not return follow up calls. Exclusion of cases: School often did not exclude susceptible students or those diagnosed with pertussis. Due to miscommunication between the KDHE and the local health department, exclusion of susceptible classmates (those without any history of vaccination) did not occur. Our Vision - Healthy Kansans living in safe and sustainable environments

Lessons Learned Presence of male authority More involvement of county commissioner Direct communication community leaders Promote vaccination using culturally appropriate strategies Strengthen interview skills Would we do anything differently? You bet’cha!! Staff performing the investigations were all female. Perhaps male authority figures from the county and state in this male centric religious community would have made a difference. Therefore should this occur again, the following strategies will be implemented: The involvement of the male county commissioner in the delivery of culturally appropriate messages to church and school leadership in the community will be requested. The services of a male KDHE Disease Investigation Specialist will be obtained, not only to participate in actual interviews, but also to coach the local investigator(s) in successful interviewing techniques used when dealing with persons who are mistrustful of government/hesitant to provide information. The KDHE Director of Health will be asked to take a more active role in the education of physicians in this community. The KDHE will defer to the local health authority The CDC/CSTE to reconsider recommendations during an outbreak when it becomes apparent that a culture is not forthcoming and the community is resistant to prevention efforts such as vaccination. Our Vision - Healthy Kansans living in safe and sustainable environments

Our Vision - Healthy Kansans living in safe and sustainable environments