1. A New Way of Thinking: Pertussis Outbreak Management and Control Help Us Shape the Future of CDC’s Pertussis Outbreak Guidelines Jennifer L. Liang, DVM, MPVM Meningitis and Vaccine Preventable Diseases Branch National Center for Immunization and Respiratory Diseases

2. Motivation for Today’s Discussion Current guidelines created in 2000 Based on stakeholder feedback, revision needed Considerations –New adolescent and adult vaccine –Changes in diagnostics –Need for judicious use of antibiotics –Limited resources

3. Workshop “Rules of Engagement” We want to hear from YOU! –Audience participation will be rewarded Panel members –Share their experiences –Help facilitate an open dialogue with you Slides for discussion Session is being recorded Most importantly…have fun!

4. Panel Members California –Kathleen Harriman, PhD, MPH, RN Illinois (Village of Skokie) –Catherine Counard, MD, MPH Oregon –Juventila Liko, MD, MPH Texas –Rita Espinoza, MPH Wisconsin –Jerry Gabor, MS

5. Topics for Today’s Discussion Format of the new CDC Pertussis Outbreak Prevention and Control Guidelines (20 minutes) Core principles of pertussis outbreak control and prevention (20 minutes) –Data driven vs. expert opinion

6. Current Guidelines Thoughts about the current guidelines? –Format –Level of detail Background material useful or TMI? Data vs. expert opinion –Ease of use –Likes/Dislikes

7. Format of New Guidelines: Prix fixe menu versus a la carte Type of FormatProsCons “a la carte” options Empowering; Flexibility; Can be customized to the situation May requires more data for decision making; Inconsistency in response Prix fixe menu / set algorithm Clear guidance; Consistency in approach Lack of flexibility; One size doesn’t fit all

8. Core Principles- A Paradigm Shift?

9. Chemoprophylaxis- Core Principles What should be the overarching goals of chemoprophylaxis guidelines? –Stop transmission/prevent all cases Is this possible? –Focus on protecting high-risk individuals including infants < 1 yr Re-evaluate chemoprophylaxis in the era of Tdap

10. Chemoprophylaxis Options OptionProsCons Wide - all close contacts Potential to interrupt transmission quickly Resource intensive; Overuse of antibiotics; Difficult to operationalize close contact definition; Unknown effectiveness; Adherence to recommendations Targeted - household members and “high risk” Better able to define and focus high-risk contacts; Avoids overuse of antibiotics; Less resource intensive Risk of continued transmission and new cases; Unknown effectiveness; Adherence to recommendations Restricted - close contacts with infants, pregnant women

11. Chemoprophylaxis- Other considerations Close contact –Defining Influenced by setting (community, school, hospital)? –Operationalizing

12. Chemoprophylaxis- Other considerations Communication and education as alternatives –Notification of area doctors (blastfax, email, media) Identify cases and provide early treatment –Communication to close contacts and larger community Educate to monitor for signs and symptoms of pertussis

13. Acknowledgements Tom Clark Tami Skoff Stacey Martin Amanda Cohn Tej Tiwari Rita Espinoza Juventila Liko Kathleen Harriman Jerry Gabor Catherine Counard

14. Additional ideas or comments you have about the Guidelines for the Control of Pertussis Outbreaks? Please fill in the feedback form! Leave in box by door or Fax 404-639-3059 or e-mail JLiang@cdc.gov

15. Thank you

17. CDC Outbreak Definition Household –Two or more cases Institutions (e.g., school, day care, health care settings) –Two or more cases clustered in time (within 42 days of each other) and space where transmission is suspected to have occurred in that setting Communities –When the number of reported cases is: Higher than what is expected on the basis of previous reports during a non-endemic period For a given population In a defined time period

18. CaliforniaThe CDC outbreak definition is used. Institutions: Two or more cases clustered in time (e.g., cases occurring within 42 days of each other) and space (e.g., in one building) where transmission is suspected to have occurred in that setting (e.g., nosocomial transmission in a hospital) Communities: When the number of reported cases is higher than what is expected on the basis of previous reports during a nonepidemic period; for a given population; in a defined time period (i.e., historical disease patterns). OregonTwo or more cases from different households clustered in time (e.g., cases that occur within 42 days of each other) and space (e.g., in one child care center or classroom). IllinoisTwo or more cases clustered in time (e.g., cases occurring within 42 days of each other) and space (e.g., in one child care center or class) [Published CDC guidelines] TexasTwo or more cases involving clustered in time (e.g., occurring within 42 days of each other) and either epi-linked or sharing a common space where transmission is suspected to have occurred. One case in an outbreak must be lab confirmed (PCR+ and meets case definition, or culture +). In an outbreak setting, a case may be defined as an acute cough illness lasting ≥ 2 weeks without other symptoms. WisconsinIn a school or daycare 2 or more cases in a 30 day period. Mandatory exclusion is not routinely applied to asymptomatic contacts. Pertussis Outbreak Definition

19. CDC Definition of Close Contact Specific definitions of a contact are problematic and will vary according to the situation. Transmission can be expected with: –Direct face-to-face contact for a period (not defined) with a case-patient who is symptomatic (e.g., in the catarrhal or paroxysmal period of illness); –Shared confined space in close proximity for a prolonged period of time, such as ≥1 hour, with symptomatic case- patient; or –Direct contact with respiratory, oral, or nasal secretions from a symptomatic case-patient (e.g., an explosive cough or sneeze in the face, sharing food, sharing eating utensils during a meal, kissing, mouth-to-mouth resuscitation, or performing a full medical exam including examination of the nose and throat. CDC. Guidelines for the Control of Pertussis Outbreaks. 2000.

20. CaliforniaDirect contact with respiratory, oral or nasal secretions from a symptomatic case (catarrhal or paroxysmal stages). OregonImmediate family members (spend many hours together or sleep under the same roof) and anyone who had direct contact with respiratory secretions. Although obviously these are somewhat arbitrary distinctions, “ close contacts ” should also include those who shared confined space (within ~6 feet) for >1 hour during the communicable period. Schoolchildren sitting within ~3 feet of a case (i.e., adjacent seating) can also be included. IllinoisHousehold contacts and very close friends (typically have >1 hour of face-to- face contact )*. * IDPH data from previous outbreaks indicated that as little as 10 minutes of face-to-face contact (exam rooms, cars) could lead to infection. One hour seemed judicious. TexasDirect face-to-face contact; sharing space of 2 hours or longer; direct contact with respiratory, oral, or nasal secretions from an infectious pertussis case; household members WisconsinFollow CDC guidelines. In schools this means a students table/pod within a 3 ft radius, car pools and best friends, etc. Definition of Close Contact

21. CDC Guidelines for Chemoprophylaxis If pertussis is highly suspected in patient, chemoprophylaxis of all household and close contacts...recommended regardless of their age or vaccination status. Initiating chemoprophylaxis ≥3 wks after exposure has limited benefit for the contacts. However…considered for high-risk contacts (e.g., infants) up to 6 wks after exposure. (2000 Pertussis Guidelines) Administered to close contacts of patients and to persons who are at high risk for having severe or complicated pertussis. (2005 CDC guidelines. MMWR)

22. CaliforniaHighest priority include: household and child care settings; hospital setting; at high risk for severe disease and adverse outcomes; may transmit disease to persons at high risk for severe disease; and in group settings where close interactions occur.  Reasonable for contacts other than those listed above on a case-by-case basis.  Contacts not receive chemoprophylaxis during a school or community outbreak monitored closely for 21 days after the last exposure so that antimicrobial treatment/exclusion can be implemented immediately if catarrhal symptoms occur. OregonClose contacts of confirmed, presumptive, and suspect cases who are:  Infants  Pregnant women in 3rd trimester (since they will soon have contact with an infant)  All household contacts of a case if there is an infant or a pregnant woman in 3rd trimester in the household, even if the infant in the household is the case  All those attending or working in a childcare setting (i.e., same room) of a case if there is an infant or one of those same third trimester women in the setting  Other contacts at the discretion of the local health department IllinoisReserved for household contacts and very close friends (typically have >1 hour of face-to-face contact )*. Recommended for all close contacts regardless of vaccination status. * IDPH data - as little as 10 minutes of face-to-face contact could lead to infection. One hour seemed judicious. TexasIf within 21 days, prophylax all close contacts. WisconsinFollows 2005 CDC guidelines. Guidelines for Chemoprophylaxis

23. State mandate for Tdap in adolescents Tdap mandate?Year CaliforniaNo OregonYes2008 IllinoisNo TexasYesSY 2009-2010 WisconsinYesSY 2008-2009