1. Pertussis C. Mary Healy, M.D.
Center for Vaccine Awareness and Research, Texas Children’s Hospital
Ben Taub General Hospital
Baylor College of Medicine, Houston, Texas
C Mary Healy MD, 11/30/ St. David's Medical Center

2. Disclosures Research Grant : Sanofi Pasteur
Advisory Board for Novartis Vaccines

3. Pertussis: The “pernicious” or “100 day” cough
Recognized since the middle ages – “The kink” or “kindhoest”
1640: Clinical description of the 1578 Paris epidemic
1905: Bordetella pertussis isolated
1925: Vaccine protection reported
Incubation Period
7-10 days (4-21)
Catarrhal Stage
“Cold”
Paroxysmal Stage
“Whooping”
Convalescent Stage
“weeks to months”   

4. Dermal necrosis and vasoconstriction
Attach to ciliae; important immunogen; activates cAMP, histamine sensitizing factor, lymphocyte promoting factor and islet-activating protein; stimulates IL-4 and IgE; interferes with phagocytosis; hemolytic; may be neurotoxic
Adhesion and
immunomodulation
Causes fever
Adhesion and
immunogen
Dermal necrosis and vasoconstriction
OMP that mediates adherence
and resists complement
Ciliostasis; inhibits DNA synthesis; kills cilial epithelial cells
Activates cAMP; interferes
with leucocytes; hemolytic
Lancet 2006; 367:

5. Pertussis Vaccination: A Success Story
DTP 
Pre-vaccination
> 180,000 cases
4000 deaths
Vaccination reduced number of cases and deaths by >95%
DTaP 
CDC

6. Incidence of Pertussis, U.S.
DTP 
No. of Cases
CDC

7. Pertussis in Texas
13.5 cases/100,000 pop

8. Pertussis in Texas : not the whole story

9. Pertussis in Texas : not the whole story

10. Why Pertussis is a Problem
Pertussis is highly contagious
Pertussis vaccine protection wears off after age 10 years
There is an epidemic of pertussis in the U.S. in adolescents and adults
Pertussis may be atypical or asymptomatic in adolescents and young adults who then spread the infection widely
Pertussis may be severe and fatal in young infants

11. Pertussis: an evolving story
Rate/100,000
DTP 
No. of Cases
DTaP 
CDC

12. Pertussis Threatens Infants
Infants too young to be immunized (< 6 months) have up to 20 times higher risk of pertussis
Two thirds of these are admitted to hospital
Pneumonia, seizures, brain damage
Pertussis causes ~ 20 deaths per year, almost all in very young infants
Infants of Hispanic ethnicity are at increased risk
Message points:
This photo illustrates the effects of pertussis on infants.
You’ll notice that the lung on the left, the infected infant’s lung, is deflated and not receiving air.
Pertussis causes 40 to 80 infant deaths each year in the U.S.
Since 1990, % of annual pertussis-related deaths occur in infants under six months of age.
Normal Chest x-ray
Baby with Pertussis
C Mary Healy MD, 11/30/ St. David's Medical Center 12

13. Pertussis in Texas 4 deaths in 2008; 3 in 2009
All occurred in infants < 3 mo of age
Haleigh Throgmorton; age 6 weeks
Just how close to home is the threat of pertussis?
Pictured here are two Texas parents, the Throgmortons, whose infant died as a result of pertussis.
This tragic death occurred four years ago, before the pertussis Tdap booster vaccine for adults was available.
Trying to keep other families from a similar tragedy, the Throgmortons share their story to encourage other families to vaccinate against pertussis.
We thank them for letting us share their story today.
Personal Communication: Texas Dept Health 13

14. California 2010
7-fold increase in the pertussis incidence rate compared with 2009
Highest number of cases in 50 years
Highest rate of disease in Hispanic infants < 6 months (172 cases/100,000)
9 deaths
All in infants too young to complete have completed their immunizations
7 of Hispanic ethnicity
Emergency interventions in place
Personal Communication, CDPH

15. Prevention of Infant Pertussis
Treatment and Antimicrobial Prophylaxis
Azithromycin or Erythromycin (all age groups)
Clarithromycin or TMP-SMX (not for young infants)
Tdap vaccine (tetanus, diphtheria, acellular pertussis)
Natural and vaccine induced immunity wanes
One time dose for adolescents and adults
Part of pre-conceptual health
Targeted immunization-cocooning
Postpartum women before hospital discharge
Immunize all contacts of infants < 1 year
Immunize healthcare providers
No outcome data but estimated to have a strong indirect effect:70%  in mo old cases
Red Book: 2009 Report of COID, pp MMWR 2008; 57(RR-4):1-51
Global Pertussis Initiative Vaccine 2007: Vaccine 2007:

16. Who Infects Infants? Household contacts in > 75% of cases
Pediatr Infect Dis J. 2004;23:985-9.
Pediatr Infect Dis J. 2007;26:293-9.

17. Interrupt Transmission to Infants
“Cocooning” Infants
Interrupt Transmission to Infants
In 2006, CDC recommended Tdap booster vaccine for contacts of young infants:
All postpartum women before hospital discharge
All contacts of infants < 1 year
Healthcare providers for infants < 1 year
N Engl J Med 2005;352:
MMWR 2008; 57:1-51; Vaccine 2007:

18. Challenges with Cocooning
Pertussis awareness
Healthcare providers
Population at large
New immunization platform
No infrastructure in place
Need to target two populations
Postpartum women
Families
New immunization providers
Reimbursement

19. Implementation of Cocooning
Parents of infants in NICU (N=598)
Immunized 72% of all parents
86.9% of parents who had been screened
Uptake higher in infants with stays > 3 days
No adverse reactions observed
Doctor’s Office, North Carolina (N=200)
Approached parents attending for routine neonatal care
51.2% of parents immunized
40% of those immunized consented to Tdap on the second visit
Dylag et al. Pediatrics 2008;122:e;550-5
Walter et al. Acad Pediatr 2009; 9:344-7

20. The Cocoon Strategy:
Aim: the phased implementation of pertussis cocooning at Ben Taub General Hospital (BTGH), Houston, Texas
Phase 1: postpartum immunization
Phase 2: immunization of household contacts
Ben Taub General Hospital
One of two public, tax-supported hospitals in Harris County Hospital District
~5000 deliveries per year
Predominantly Hispanic (>90%), medically underserved and underinsured population
High risk for pertussis illness
No infrastructure for cocooning in place

21. Raising Awareness
Healthcare Providers (HCP) educated by Grand Rounds and small group in-services
Obstetricians, Family Practitioners
Midwives, Nursing Personnel
Translators
Posters and literature in antenatal and postnatal areas
Pertussis information packets for families
Information on other means to access low or no-cost vaccines
Available to answer questions

22. Phase 1: Postpartum Women
Starting January 2008, standing order for postpartum Tdap unless maternal contraindication is present*
Tdap administered on hospital discharge concurrent with rubella vaccine (if needed)
* 2 year minimum interval since prior tetanus-containing vaccine observed Jan 2008-May 2009; no minimum interval required June 2009-Jan 2010

23. Phase 1: Postpartum women
150 HCPs completed pertussis in-service
Since Jan 7th, 2008 through Sept 20th, 2010, 10,450 postpartum women received Tdap prior to discharge
Well-accepted
No adverse events reported
June Jan 2010
92% of postpartum women are protected
86% immunized by us
6% previously had Tdap
87% of those by our program with a prior baby
Healy et al. National Immunization Conference, 2010

24. Phase 2: Household Contacts
Starting June 2009, contacts of newborn infants offered Tdap
Where possible, postpartum women were interviewed to ascertain the number of additional contacts eligible and recommended to receive Tdap
Pertussis education was provided
Consenting eligible contacts were immunized on-site in the “Tdap Cocoon Clinic” (Mon-Fri; 10am-7pm)

25. Phase 2: Household Contacts
Two Thirds of Mothers Interviewed
Average of 3 contacts per infant eligible for Tdap (range 1-11)
Average of 2 contacts per infant received Tdap (range 0-10)
58% of families had ≥ 1 contact immunized
1860 contacts immunized
Timing of immunization
91% before or the day of infant discharge
8% day 1-7 post infant discharge
Healy et al. National Immunization Conference, 2010
C Mary Healy MD, 11/30/ St. David's Medical Center

26. Contact Relationship to Infant
87% lived in the infant’s household
98% would be in daily contact with infant
Healy et al. National Immunization Conference, 2010

27. Challenges Identified
Education
Start early and often
Takes time and effort, different groups have different perceptions
Convenient, out of hours service
Readily accessible immunization records
Financial constraints
Vaccine costs
Requires multiple personnel
Multi-disciplinary approach
Prepare for the unexpected !

28. Other Texas Initiatives
Texas Medical Association
Postpartum immunization program in Williamson County hospitals
Strongly encourage contacts to avail of vaccines at a variety of locations
Educational initiatives
Pamphlets, Webinar
Texas Pediatric Society
Immunization Partnership
Adopted promotion of pertussis cocooning as a goal for current year

29. For the Future Maternal Immunization Neonatal Immunization
Anecdotal evidence from pre-vaccine era
Studies in the 1940s s demonstrated infant protection
High levels of maternal antibody did not interfere with infant response to DTaP
Transfer of pertussis antibodies from mother to infants occurs and antibody persist
Neonatal Immunization
Variable results
Interfered with response to other vaccines
Disease may precede immune response

30. In Summary:
The disease burden from pertussis is considerable and very young infants are at high risk of life-threatening illness
Pertussis immunity wears off within 10 years of vaccination and booster Tdap vaccine is required
Targeted immunization strategies such as cocooning are recommended to prevent infants becoming infected with pertussis by family and household contacts

31. In Summary: Finally, let us remember why this is important ……….
Cocooning needs initial and sustained educational efforts and novel initiatives to build this new immunization platform
All immunization providers in a variety of settings should work together to form the “protective cocoon” around the vulnerable infants
Finally, let us remember why this is important ……….

32. Protect Our Infants

33. Acknowledgements Center for Vaccine
Awareness and Research Carol J. Baker, MD
Julie A. Boom, MD
Amy B. Middleman, MD
Betsy H. Mayes, RN
Baylor College of Medicine
Marcia A. Rench, RN
Baylor Methodist
Community Health Fund
Harris County Hospital
District Foundation
Williamson County Health
Dept.
Ben Taub General Hospital
Kenneth Mattox, MD
Harold Miller, MD
Amy Young, MD
Joseph Garcia Prats, MD
Francis Kelly, RN
Sara Ruppelt, PharmD
City of Houston Health Dept.
Immunization Partnership
Sanofi Pasteur
Texas Dept of Health
All HCPs who care for pregnant women and their newborn infants
Finally I’d like to acknowledge our associates and funding sources for this study. 33 33