1. 1 Pertussis (Whooping Cough or Hundred Day Cough) Thein Shwe, MPH, MS, MBBS VPD & IBD Epidemiologist DIDE 4 th Quarter Training 11/18/2009

2. 2 Objectives To describe clinical description, diagnosis and epidemiology of pertussis To describe clinical description, diagnosis and epidemiology of pertussis To understand To understand –Investigation of a case of pertussis and outbreak of pertussis To review U. S. and West Virginia pertussis surveillance data To review U. S. and West Virginia pertussis surveillance data

3. Disease Description Pertussis, a cough illness commonly known as whooping cough (100 Day Cough), is caused by the bacterium Bordetella pertussis. Pertussis, a cough illness commonly known as whooping cough (100 Day Cough), is caused by the bacterium Bordetella pertussis. Prolonged paroxysmal cough often accompanied by an inspiratory whoop. Prolonged paroxysmal cough often accompanied by an inspiratory whoop. Varies with age and history of previous exposure or vaccination. Varies with age and history of previous exposure or vaccination. Neither infection nor immunization provides lifelong immunity Neither infection nor immunization provides lifelong immunity 3

4. Other Bordetella species Three other Bordetella species: Three other Bordetella species: –B. parapertussis, –B. holmesii, and –B. bronchiseptica. B. pertussis and B. parapertussis coinfection is not unusual. B. pertussis and B. parapertussis coinfection is not unusual. Disease with Bordetella species other than B. pertussis is not reportable. Disease with Bordetella species other than B. pertussis is not reportable. 4

5. 5 Clinical Description of Pertussis Stages (6-10 wks.) Catarrhal (1-2 wks.) Paroxysmal Convalescent (up to 3 mths.) Symptoms mild URT symptoms, mild URT symptoms, intermittent dry cough intermittent dry cough coughing spasms coughing spasms inspiratory whoop inspiratory whoop Post-tussive vomiting Post-tussive vomiting Infants <6 mths. Gagging, gasping or apnea No whoop Prolonged

6. HTTP://WWW.SOUNDSOFPE RTUSSIS.COM/SOUND_OF_P ERTUSSIS.CFM HTTP://WWW.SOUNDSOFPE RTUSSIS.COM/SOUND_OF_P ERTUSSIS.CFM SOUND OF PERTUSSIS 6

7. 7 Epidemiology of Pertussis Mode of transmission Person to person via Person to person via –Aerosolized droplets from cough or sneeze –Direct contact with secretions from respiratory tract of infectious person 80% - secondary attack rate 80% - secondary attack rate Older children and adults are important sources of disease for infants and young children Older children and adults are important sources of disease for infants and young children Infants <12 months of age greatest risk for complications and death Infants <12 months of age greatest risk for complications and death

8. 8 Epidemiology of Pertussis cont. Reservoir - Humans Reservoir - Humans Incubation period – 7-10 days (5-21 days). Incubation period – 7-10 days (5-21 days). Infectious period – Most contagious during the catarrhal stage and the first 2 weeks after cough onset Infectious period – Most contagious during the catarrhal stage and the first 2 weeks after cough onset Duration of illness: Duration of illness: –Children: 6-10 wks. –~ ½ of Adolescents: 10 wks or longer

9. Pertussis Complications Syncope (temporary loss of consciousness/faint) Syncope (temporary loss of consciousness/faint) Sleep disturbance Sleep disturbance Incontinence Incontinence Rib fractures Rib fractures Complications among infants Complications among infants –Pneumonia (22%) –Seizures (2%) –Encephalopathy (<0.5%) Death Death –Infants, particularly those who have not received a primary vaccination series, are at risk for complications and mortality. 9

10. Pertussis Laboratory Diagnosis 10

11. Pertussis Laboratory Testing CulturePCRDFASerology SpecimenNP Swabs or aspirates NP SwabBlood Advantages Gold standard 100% Specific Results available quickly Rapid results Disadvantages Relatively insensitive Difficult to isolate Most successful during the catarrhal stage Takes 7-10 days to get the result Sensitivity & specificity varies Calcium alginate swabs cannot be used to collect NP swabs for PCR Not confirmatory No use for surveillance No standardized test available No use for Surveillance CommentsUse with cultureUse with culture and/or PCR NP swab=nasopharyngeal swabs, PCR-Polymerase chain reaction, DFA-direct florescent antibody 11

12. Proper Technique for Obtaining a Nasopharyngeal Specimen for Isolation of B pertussis 12

13. http://content.nejm.org/cgi/conte nt/full/NEJMe0903992/DC1 http://content.nejm.org/cgi/conte nt/full/NEJMe0903992/DC1 Nasopharyngeal Swab Collection Procedure 13

14. Why do We do Pertussis Surveillance? To assess burden of disease and guide policy and control strategies To assess burden of disease and guide policy and control strategies –e.g., vaccination of postpartum mothers and adult and adolescent contacts of infants To monitor disease trends and identify populations at risk To monitor disease trends and identify populations at risk To identify clusters of related cases that might indicate an outbreak To identify clusters of related cases that might indicate an outbreak To monitor changes in the B. pertussis organism To monitor changes in the B. pertussis organism 14

15. & Outbreak Investigation Pertussis Case Investigation 15

16. PERTUSSIS CASE DEFINITION CDC/CSTE 16

17. 17 Pertussis Clinical Case Definition 1. A Cough illness lasting at least 2 weeks 2. With one of the following: - paroxysms of coughing, or - paroxysms of coughing, or - inspiratory “whoop,” or - inspiratory “whoop,” or - posttussive vomiting; - posttussive vomiting; And And without other apparent cause (as reported by a healthcare professional)

18. 18 Laboratory Criteria for Diagnosis Isolation of Bordetella pertussis from a clinical specimen (Culture) Isolation of Bordetella pertussis from a clinical specimen (Culture) Positive polymerase chain reaction (PCR) assay for B. pertussis DNA Positive polymerase chain reaction (PCR) assay for B. pertussis DNA

19. 19 Case Classification Probable: Probable: –Meets the clinical case definition, –Not laboratory confirmed, and –Not epidemiologically linked to a laboratory-confirmed case Confirmed: Confirmed: 1. A case of acute cough illness of any duration with a positive culture for B. pertussis 2. A case that meets the clinical case definition and is confirmed by PCR 3. A case that meets the clinical definition and is epidemiologically linked directly to a case confirmed by either culture or PCR

20. EXERCISES Pertussis Case Investigation 20

21. 21 What would you do with this pertussis laboratory report? Exercise 1 - Submitter: Submitter: Patient Name: Smith, James Office of Lab Services Patient Name: Smith, James Office of Lab Services Address: 234 A St 167 11 th Ave. Address: 234 A St 167 11 th Ave. Charleston, WV 25311 S. Charleston, WV25303 Charleston, WV 25311 S. Charleston, WV25303 DOB: 06/12/2005 Attention To: Dr Bloom DOB: 06/12/2005 Attention To: Dr Bloom Age: 4 yrs Age: 4 yrs Sex: Male Sex: Male______________________________________________________ Specimen source: Nasopharyngeal Collection date: 11/7/09 Culture: Bordetella pertussis isolated Reported date: 11/14/09

22. 22 Does it meet the lab criteria? - Check lab criteria for diagnosis - Check lab criteria for diagnosis

23. Exercise 2 Patient Name: Bond, James WVU Hospital Patient Name: Bond, James WVU Hospital Address: Peace Ave. Morgantown, WV Address: Peace Ave. Morgantown, WV Star City, WV 26503 Star City, WV 26503 DOB: 03/1/1985 Attention To: DOB: 03/1/1985 Attention To: Age: 24 yrs Dr Moody Age: 24 yrs Dr Moody Sex: Male Sex: Male_____________________________________________ Specimen source: Nasopharyngeal Specimen date: 11/10/09 Bordetella by Rapid PCR Result - Bordetella pertussis DNA detected Reported date: 11/12/09 23

24. 24 Does it meet the lab criteria? - Check lab criteria for diagnosis - Check lab criteria for diagnosis

25. Exercise 3 Patient Name: A PullmanLab Corp of America Patient Name: A PullmanLab Corp of America DOB: 10/7/1998Dublin, Ohio DOB: 10/7/1998Dublin, Ohio Address: Clarksburg, WV Address: Clarksburg, WV ____________________________________________ ____________________________________________ Test Name – B pertussis IgM Ab, Quantitative Test Name – B pertussis IgM Ab, Quantitative Comment: Positive = >1.1, Negative = 1.1, Negative = <1.0, Borderline = 1.0 -1.1 B pertussis IgM result = 1.7 B pertussis IgM result = 1.7 25

26. 26 Does it meet the lab criteria? - Check lab criteria for diagnosis - Check lab criteria for diagnosis

27. REGARDLESS OF TYPE OF TEST AND RESULT, ALL PERTUSSIS REPORTS SHOULD BE INVESTIGATED IMMEDIATELY PERTUSSIS CASE INVESTIGATION 27

28. Importance of Rapid Case Identification Early diagnosis and treatment to limit disease spread Early diagnosis and treatment to limit disease spread Identify and provide prophylaxis to close contacts pending laboratory confirmation Identify and provide prophylaxis to close contacts pending laboratory confirmation When suspicion of pertussis is low, investigation can be delayed pending laboratory confirmation When suspicion of pertussis is low, investigation can be delayed pending laboratory confirmation –Exception: prophylaxis of infants and their household contacts should NOT be delayed 28

29. 29 What is the next step in a case investigation? Refer to Pertussis Protocol Refer to Pertussis Protocol Use Pertussis WVEDSS form Use Pertussis WVEDSS form Begin your case ascertainment Begin your case ascertainment

30. Pertussis Surveillance Protocol http://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/PERTUSSIS%20Protocol%20Sep t2007.pdf 30

31. Pertussis WVEDSS Form 31

32. 32 How do you ascertain a case? Three pieces of information needed to determine if you have a pertussis case Three pieces of information needed to determine if you have a pertussis case 1. Clinical information 2. Additional laboratory report(s) 3. Epidemiological information

33. 33 What information would you obtain from a provider?

34. 34 What information would you obtain from a provider? cont’d

35. 35 What would you obtain from the patient/parent?

36. 36 What Epidemiological information do you need to obtain?

37. 37 Contact Tracing of a Pertussis Case

38. Management for Exposed persons Type of Contact Evaluate & Lab VaccinateProphylaxis/treatment Asymptomatic Within 3 weeks NoYesYes Asymptomatic > 3 weeks NoYes Consider for households with high- risk contacts (infants, pregnant women, people who have contact with infants) SymptomaticYes Collect NP swab YesYes

39. Postexposure Prophylaxis for Pertussis in Infants, Children, Adolescents, and Adults Source: Red Book 2009 AAP – pg. 507 AgeAzithromycin (Recommended) Erythromycin Recommended Clarithromycin (Recommended) TMP-SMX (alternative) <1mo10mg/kg/day as a single dose for 5 days 40mg/kg/day in 4 divided dosesx14days Not recommendedCI at <2 mo of age 1-5 moSee above 15mg/kg/day in 2 divided doses x 7 days ≥2mo of age:TMP,8mg/kg/da y;SMX,40mg/kg/day in 2 doses x 14 days ≥6 mo or older & children 10mg/kg/day as a single dose on day 1(maximum 500 mg); then 5 mg/kg/day as a single dose on days 2- 5(maximum 250 mg/day) 40 mg/kg/day in 4 divided doses for 14 days (maximum 2g/day) 15mg/kg/day in 2 divided doses x 7 days (maximum 1 g/day) See above Adolesce nts & adults 500 mg as a single dose on day 1, then 250 mg as a single dose on days 2-5 2g/day in 4 divided doses for 14 days 1g/day in 2 divided doses for 7 days TMP, 200 mg/day; SMX,1600 mg/day in 2 divided doses x 14 days TMP- trimethoprin; SMX-sulfamethoxazole; CI - contraindication 39

40. 40 Once the investigation is completed: Document public health action Document public health action Check case classification Check case classification Print the report for your files or per your Print the report for your files or per your LHD policy & procedure LHD policy & procedure Send lab report(s) to DIDE Send lab report(s) to DIDE Submit completed WVEDSS report electronically to your regional epidemiologist and DIDE Submit completed WVEDSS report electronically to your regional epidemiologist and DIDE

41. 41 Pertussis Outbreak Case Definition Outbreak is defined as : Outbreak is defined as : –Two or more cases –Involving two or more households –Clustered in time & space AND –One case must be confirmed by positive culture

42. Pertussis Outbreak Line List Form http://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/Pertussis%20Outbreak%20Linelisting%20Form. pdf 42

43. 43 Outbreak Notification and Control Notify your regional epidemiologist & DIDE Notify your regional epidemiologist & DIDE immediately immediately Evaluate case status & manage close contacts Evaluate case status & manage close contacts Obtain nasopharyngeal swabs for culture (confirmation) and PCR Obtain nasopharyngeal swabs for culture (confirmation) and PCR

44. 44 Outbreak Control in Any Settings Treat/Prophylax with recommended antibiotic Treat/Prophylax with recommended antibiotic Isolate 5 days after starting antibiotic treatment Isolate 5 days after starting antibiotic treatment or 21 days from cough onset if no treatment or 21 days from cough onset if no treatment Bring immunizations up-to-date Bring immunizations up-to-date –Accelerated vaccination if cases are occurring young infants

45. 45 Alert your providers and notify the parents… Healthcare Providers Healthcare Providers –Send Health alert letter –Provider information sheet Parent/Guardian Parent/Guardian –Send notification letter –Public information sheet

46. 46 Exposures in Child Care Exposed Children (especially incompletely immunized) and childcare providers should be Exposed Children (especially incompletely immunized) and childcare providers should be –Observed for respiratory tract symptoms for 21 days after contact with an infectious person has been terminated Administer vaccine and antibiotics Administer vaccine and antibiotics Exclude: Exclude: –Symptomatic or confirmed pertussis until completion of 5 days of the recommended course of antimicrobial therapy or 21 days if untreated

47. 47 Follow up & Reporting Check for the status of the outbreak control Check for the status of the outbreak control Document and update your regional epidemiologist and DIDE when the outbreak is controlled completely Document and update your regional epidemiologist and DIDE when the outbreak is controlled completely Forward report with lab results to DIDE Forward report with lab results to DIDE

48. WEST VIRGINIA &U.S.A PERTUSSIS SURVEILLANCE DATA 48

49. Number of Reported Pertussis Cases, by Year, United States, 1922-2005 Source: MMWR December 15, 2006 / 55(RR17);1-33 49

50. Number of Reported Pertussis Cases, by Year, United States, 1922-2006 Source: MMWR May 30, 2008 / 57 (04);1-47,51 50

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54. Summary Discussed Discussed –Disease description including clinical characteristics, laboratory diagnosis and epidemiology –Pertussis case investigation and outbreak investigation –National and state surveillance data 54

55. 55 Resources IDEP Pertussis site: IDEP Pertussis site: http://www.wvdhhr.org/idep/a-z/a-z- pertussis.asp http://www.wvdhhr.org/idep/a-z/a-z- pertussis.asp http://www.wvdhhr.org/idep/a-z/a-z- pertussis.asp http://www.wvdhhr.org/idep/a-z/a-z- pertussis.asp CDC Pertussis Surveillance Investigation: CDC Pertussis Surveillance Investigation: http://www.cdc.gov/nip/publications/sur- manual/chpt08_pertussis.pdf http://www.cdc.gov/nip/publications/sur- manual/chpt08_pertussis.pdfhttp://www.cdc.gov/nip/publications/sur- manual/chpt08_pertussis.pdfhttp://www.cdc.gov/nip/publications/sur- manual/chpt08_pertussis.pdf Guideline for Control of Pertussis Outbreak: Guideline for Control of Pertussis Outbreak: http://www.cdc.gov/nip/publications/pertussis/g uide.htm http://www.cdc.gov/nip/publications/pertussis/g uide.htm http://www.cdc.gov/nip/publications/pertussis/g uide.htm http://www.cdc.gov/nip/publications/pertussis/g uide.htm

56. References CDC VPD Surveillance Manual, 4 th Edition, 2008 Pertussis: Chapter 10 CDC VPD Surveillance Manual, 4 th Edition, 2008 Pertussis: Chapter 10 Pertussis (Whooping Cough) Pg. 504-519, Red Book, 2009 Report of the Committee on Infectious Diseases – American Academy of Pediatrics, 28 th Edition Pertussis (Whooping Cough) Pg. 504-519, Red Book, 2009 Report of the Committee on Infectious Diseases – American Academy of Pediatrics, 28 th Edition http://www.cdc.gov/vaccines/recs/schedules/adult- schedule.htm http://www.cdc.gov/vaccines/recs/schedules/adult- schedule.htm http://www.cdc.gov/vaccines/recs/schedules/adult- schedule.htm http://www.cdc.gov/vaccines/recs/schedules/adult- schedule.htm Pertussis Pg. 455-461, Control of Communicable Diseases Manual, APHA & WHO, 19 th Edition, David Heymann, MD, Editor Pertussis Pg. 455-461, Control of Communicable Diseases Manual, APHA & WHO, 19 th Edition, David Heymann, MD, Editor 56

57. Questions? Thank you! 57

58. VACCINATION SCHEDULES Appendices 58

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