Presentation on theme: "Pertussis Awareness And Prevention"— Presentation transcript:
1Pertussis Awareness And Prevention W. Michael Brown, MD, FAAPDirector of PediatricsAssociate Director Family Medicine ResidencyBayfront Medical CenterSt. Petersburg, Florida
2Pertussis Awareness and Prevention: Objectives Increase awareness and prevention of pertussis in the United StatesEducate health care professionals on epidemiology and diagnosis of pertussisDiscuss importance of pertussis immunizationDiscuss important strategies for improving control of pertussisThe objectives of this program, as stated in the above slide, are to:1) Increase awareness and prevention of pertussis in the United States; 2) Educate health care professionals on the epidemiology and diagnosis of pertussis; 3) Discuss the importance of pertussis immunization, and to review efficacy and safety data of pertussis vaccines; and 4) Discuss the implementation of important strategies for improving control of pertussis.
3PERTUSSIS (WHOOPING COUGH) Acute respiratory tract infection by Bordetella pertussishighly communicable80% secondary attack rates among susceptible personsSignificant morbidity and mortality in infantsMilder nonspecific upper respiratory tract infection in adolescents and adultsDifficult to diagnoseReferred to by the Chinese as “the cough of 100 days”Pertussis, or whooping cough, is a highly contagious acute respiratory infection caused by Bordetella pertussis, a gram-negative aerobic bacillus. It is one of the most highly communicable of all infectious diseases, easily transmitted from one person to another via coughed aerosolized droplets.The disease may occur at any age, but it manifests most severely in infants and young children, in whom it is potentially life-threatening. In adults and adolescents, pertussis is relatively mild; the only symptoms may be those of a minor, nonspecific upper respiratory tract infection, or there may be no symptoms whatsoever. Diagnosis is thus difficult in this age group. Infected adults and adolescents with mild disease constitute the reservoir for infection in infants and young children.Edwards KM, Decker MD, Mortimer EA Jr. Pertussis vaccine. In: Plotkin SA, Orenstein WA, eds. Vaccines. Philadelphia, PA: WB Saunders; 1999:Scott PT, Clark JB, Miser WF. Pertussis: an update on primary prevention and outbreak control. Am Fam Physician. 1997;56:
4Prolonged Cough Illness in Adolescents and Adults Due to Bordetella Pertussis SourceLocaleYear(s)% of cough illnessesJackson et alSeattle15%Robertson et alNew S Wales26%Mink et alLos AngelesSchmitt-Grohé et alGermany32%Wright et alNashville21%Wirsing v Köenig et al31%Rosenthal et alChicagoJansen et alSan Diego17%Nennig et alSan Francisco12%Strebel et alMinn-St Paul13%Birbeback et alDenmarkVicent et alKorea50%Gilberg et alParis199952%[Note: New slide provided by S. Barone]
5Pertussis Disease Manifestations Incubation period days (range )StagesCatarrhal: runny nose, sneezing, low-grade fever, mild coughParoxysmal: severe spasms of cough, thick mucus, whoops, vomiting, exhaustionConvalescent: gradual recovery with less frequent & less severe coughingPhotograph courtesy of the WHO
6Why Is Pertussis Increasing? Ascertainment…awareness and better diagnostic testsIncomplete immunization of childrenVariable vaccine efficacyWaning immunity~ 15 years after active disease~ 5-10 years after vaccinationUnder diagnosis, especially in adolescents and adultsLack of an adolescent/adult booster vaccineUNTIL NOW
7DECLINE IN VACCINE-PREVENTABLE DISEASE Disease Maximum Cases %cases in change_____________________________________________________________________________________Diphtheria 296,939 in %Tetanus 1,560 in %Pertussis 265,269 in %Measles 894,134 in %Paralytic polio 21,269 in %3,100 died_______________________ _____________________________________________________________Mumps 152,209 in %Rubella 57,686 in %HIB ,000 prior to %From Centers for Disease Control and Prevention. MMWR 2004
9Efficacy of Acellular Pertussis Vaccines Randomized, Blinded Trials* StudyVaccineEfficacy (%) (Confidence Interval)†(WHO)†StockholmGustafsson L et al. N Engl J Med.1996;334:DAPTACEL™85 (81-89)Connaught DTP48 (37-58)ItalyGreco D et al. N Engl J Med.1996;334(6):Infanrix®84 (76-89)36 (14-52)*Shows results for vaccines available in the United States for 3-dose infant immunization series; effects of any booster dose are not included.†The definition closest to the standard WHO case definition (Edwards KM et al. In: Plotkin SA et al, eds. Vaccines. 1999; ).
10Reported Pertussis Cases by Year United States, 1922 – 2000 300Routine pertussis immunization begins250200Cases (Thousands)15010050192219301940195019601970198019902000YearSource: CDC. Pertussis --- United States, MMWR 2002;51:73-76.
11The Growing Disease Reservoir Increases Exposure to Pertussis 26,00025,82724,00022,00025,827122%20,00018,000All Patients16,000Children 4 yrs. of age14,00011,64711,64712,0009,77110,0007,8675,79580007,58073%5,7953,3555,13760007,2884,57040001,7303,3552000198019901995199920002001200220032004
12Reports of Pertussis in the U.S. Average Number of Cases / Year 3500552%490%30002500Average Number of Cases / Year200015001000500<1 yr1-4 yrs5-9 yrs10-19 yrs20+ yrsCenters for Disease Control and Prevention. MMWR. 2002;51:73-76; Güriş et al. Clin Infect Dis. 1999;28:National Immunization Program, Bacterial Vaccine Preventable Diseases Branch. Pertussis Surveillance Report, August 6, 2004
13…there are between ~800,000 and 3 …there are between ~800,000 and 3.3 million cases per year in the United States.
14Estimated Duration of Immunity After Infection or Vaccination Source of Immunity Duration ReferenceNatural infection years Wirsing Von Konig, 1995Whole-cell vaccineUK years Jenkinson, 1988Finland years He, 1994Germany > 6 years Lugauer, 2002Acellular vaccineItaly years Salmaso, 2001Germany > 6 years Lugauer, 2002Wirsing Von Konig et al. Lancet ID 2002:2:
15Consequences of Waning Immunity Increased transmission of pertussis disease to unimmunized and underimmunized infants and children1Considerable pertussis-related morbidity and economic cost in families2Increased incidence of pertussis disease among adolescents and adults1,3Key Point: Adults and adolescents who are not reimmunized are not onlysusceptible to infection but also pose a significant risk to close contactsof all ages, including infants who are too young to be vaccinated.Notes:Individuals who do become infected can then serve as a reservoir of infection for other susceptible people, including the unimmunized and underimmunized infants most at risk for severe illness.1Pertussis disease is also associated with considerable morbidity and economic cost in families,2 which will undoubtedly increase with the incidence of the disease.Since the immunity afforded by vaccines gradually decreases after vaccination,1 and adolescents and adults in the United States generally do not receive a pertussis booster, it is possible the incidence of pertussis disease in these age groups may continue to increase.1,3References:Edwards KM, Decker MD, Mortimer EA Jr. Pertussis vaccine. In: Plotkin SA, Orenstein WA, eds. Vaccines. Philadelphia, PA; 1999:2. Lee LH, Pichichero ME. Cost of illness due to Bordetella pertussis in families. Arch Fam Med. 2000;9:3. Centers for Disease Control and Prevention. Pertussis—United States, MMWR. 2002;51:73-76.1. Edwards KM et al. In: Plotkin SA et al, eds. Vaccines. 1999;2. Lee LH et al. Arch Fam Med. 2000;9:3. Centers for Disease Control and Prevention. MMWR. 2002;51:73-76.
16Reported Pertussis Cases Are the Tip of the Iceberg Nationwide, an estimated 12% of pertussis cases are actually reportedUnderreporting may be greatest among adolescents and adultsReportedAtypical formsNot ReportedKey Point: Pertussis is highly underreported—only 12% of cases areactually reported. It is likely that underreporting may be greatest amongadults and adolescents.Notes:One study estimated that nationwide, only 12% of pertussis cases are actually reported. [Güriş 1999, pg 1235, col 2, para 1, line 1]Due to a lack of typical pertussis symptoms such as whoop, underreporting may be higher among adolescents and adults than for young children. [Güriş 1999, pg 1235, col 2, para 1, lines 2-4]Therefore, the reported cases form the tip of the iceberg. The majority of cases are not reported due to various reasons, such as atypical forms, wide disease variability, underconsultation, underdiagnosis, low physician awareness, and inconsistency in case definitions.Reference:Güriş D et al. Changing epidemiology of pertussis in the United States: increasing reportedincidence among adolescents and adults, Clin Infect Dis. 1999;28:1230.Wide disease variabilityUnder- reportingUnderconsultationUnderdiagnosisLow physician awarenessInconsistent case definitionsGüriş et al. Clin Infect Dis. 1999;28:1230.16
17Pertussis Cases Reported in 2002 Each Dot Represents One Case The total number of cases and incidence rate for each state represent provisional numbers, which may change as states report more cases for 2002Source: Bacterial Vaccine Preventable Diseases Branch, National Immunization Program, CDC.Sharp demarcation at state borders illustrates inconsistent reporting.
1875% Of Suspected Sources For Infant Pertussis Cases Were Family Members Other25%Mom32%20% Other AdultsGrandparent8%Dad15%Sibling20%47% Mom or Dad33% Other ChildrenBisgard, K. et al. Ped Infect Dis J. 2004;23:
19The Cycle of Pertussis Susceptibility Promotes Transmission & Disease Unvaccinated or partially vaccinated infants: SusceptibleBreak the Pertussis Cycle: VaccinateReduce morbidity in all age groupsReduce reservoir of Pertussis diseasePrevent transmission of Pertussis disease between adolescents and adults, and from adolescents and adults to infantsPrimary vaccination: ProtectedSusceptible adolescents and adults:Reservoir of B pertussisBooster vaccination: Prolonged protectionNo additional booster: Immunity wanesSupported by multiple publications. See notes
21Severe vs Mild Pertussis More common in infantsOccurs in nonimmune individualsParoxysmal cough (>21 days’ duration) with heavy inspiration (whoops) accompanied by vomiting and gaggingCharacteristic symptoms (eg, whoop) often absent1An important mechanism of transmission to infantsEstimated to represent 21% to 26% of acute cough illness in adults2,3Often unrecognized, underdiagnosed1. Scott PT et al. Am Fam Physician. 1997;56:2. Strebel P. Infect Med. 1996;13:S33-S41.3. Edwards KM et al. In: Plotkin SA et al, eds. Vaccines. 1999;* World Health Organization (WHO) definition.
22Common Clinical Manifestations of Adolescent-Adult Pertussis Cough 97% 3 weeks, 52% 9 weeksParoxysms 3 weeks in 73%Whoop in 69%Post-tussive emesis in 65%Teens missed average 5 days of school; Adults missed average 7 days of workAverage 14 days of disrupted sleepDe Serres et al. J Infect Dis. 2000;182:174–9.
23PERTUSSIS DEATHS BY AGE, UNITED STATES (1980-1999)
25Diagnostic Laboratory Findings In Pertussis Marked lymphocytosis with leukocyte counts often exceeding 50,000 cells/mm3Generally afebrile with no elevation of ESR or other acute phase reactionsCXR with a “shaggy heart” produced by bilateral perihilar infiltrates, edema, and atelectasisCulture of posterior NP swab may take 2 weeks, but negative cultures are common especially after 4 weeks of illnessDirect immunofluorescent assay of NP secretions had variable sensitivity and low specificitySerologic tests to measure immunglobin antibody to pertusis toxin (IgG, IgM, IgA).DNA by PCR of NP secretions is the most sensitive and rapid test but may not always be available*Most cases of Pertussis are diagnosed clinically!
26Period Of Communicability Of Pertussis -2-1123456789101112Weeks of coughCatarrhal stageParoxysmal stageConvalescent stageCough onsetPeriod of communicabilityPersons with pertussis are most infectious during the catarrhal period starting as early as one day of coughSome individuals, such as infants who remain culture-positive for several weeks, may be infectious for a longer period
27Diagnostic Laboratory Findings in Pertussis Positive CultureCatarrhalParoxysmal StageConvalescent50Lymphocyte Count (thousands)30101-22-55-12+Time After Onset of Symptoms (weeks)Adapted from Mortimer EA. In: Krugman’s Infectious Diseases of Children. 10th ed. Mosby Year Book, Inc; 1998:
28The best site to obtain an appropriate clinical specimen is the posterior nasopharynx, either by aspiration of nasopharyngeal secretions or by insertion of a swab applicator into the posterior nasopharynx.1Samples taken from nasal discharge or by swabbing the throat and tonsils are inadequate.2Polymerase chain reaction (PCR) is emerging as the diagnostic method of choice on the basis of studies showing it to be more specific and sensitive than culture.3,4Serologic testing is not standardized and because of a lack of association between antibody levels and immunity to pertussis, results are difficult to interpret.3,4Direct fluorescent antibody (DFA) can yield rapid results but has disadvantages of variable sensitivity and specificity.1References:1. CDC. Epidemiology and prevention of vaccine-preventable diseases (The Pink Book), 7th ed. USDepartment of Health and Human Services. 2002: Available atAccessed March 13, 2005.2. Murphy T, Bisgard K, Sanden G. VPD Surveillance Manual, Chapter 2. Diagnosis andlaboratory methods. June 2000;3. Chia JH, Su LH, Lin PY, et al. Comparison of multiplex polymerase chain reaction, culture, andserology for the diagnosis of Bordetella pertussis infection [abstract]. Chang Gung Med J.2004;27(6):4. Wright SW. Pertussis infection in adults. South Med J. 1998;91(8):
29Serology 3 weeks or longer IFA never DiagnosisCulture weeks coughPCRSerology weeks or longerIFA never
30TREAMENT OF PERTUSSISInfants younger than 6 months generally require hospitalizationAntibiotic Therapy:Erythromycin 40 to 50 mg/kg/day given QID x 14 daysAzythromycin 10 to 12 mg/kg/day given Qday X 5 daysClarithromycin 15 to 20 mg/kg/day given BID X 7 daysBactrim or Septra 8 mg TMP/ 40 mg SMX per kg per day in two divided doses for 14 days if allergic to macrolides*Treatment with antibiotics does not effect duration or severity of clinical courseCough suppressantsMMWR Jan. 2005Pertussis is most common among infants less than a year old, but anyone can get this disease. Pertussis can be hard to diagnose in very young infants, teens and adults because their symptoms often look like a cold with a nagging cough. However many different forums provide an avenue for transmission:Adolescents acquiring pertussis from community and household contactsSchool age or daycare children transmitting pertussis back to adultsThe disease ranges from asymptomatic to severe however adolescents and adults with pertussis are more likely to have milder illness (I.e. and illness resembling and upper respiratory infection or acute cough illness without paroxysms, whoop, or post-tussive vomiting).1 Adults and adolescents can then transmit pertussis to their young infants who are at the highest risk of morbidity and mortality.1 Cherry JD. Epidemiological, clinical, and laboratory aspects of pertussis in adults. Clin Inf Dis 1999; 28 (Suppl 2): S112-7.
31Antigenic Components of B pertussis FIMPertussis toxin (PT), also known as “lymphocytosis-promoting factor” (systemic action)Filamentous hemagglutinin (FHA)Pertactin (PRN) or 69 kD* proteinFimbrial agglutinogens (FIM) (1-4 serotypes)FHAPTPRN*kD = kilodalton.Edwards KM et al. In: Plotkin SA et al, eds. Vaccines. 1999;
32Diphtheria, Tetanus, and Acellular Pertussis Vaccines Currently licensed in USTripedia®Infanrix®*Daptacel™Boostrix™Adacel®Indicated Age GroupInfants/ Children†Adolescents‡ (10-18 years)Adults/ Adolescents‡ (11-64 years)AntigenicComponents§ PT (µg) FHA (µg) PRN (µg) FIM (µg) D (Lf) T (Lf)— — 6.7 5— 25 10— 2.5 5
34The Adacel Program in Newfoundland Replaced Td in 1999 school yearAdacel delivered in a Grade 9 (14 year olds) school-based programApproximately 25,000 doses given by June 2004
35Incidence of Pertussis in Newfoundland, 1993-2003 7060Introduction of adolescent dTaP55040Incidence per 100,000 Population30**** Pertussis outbreak confined to persons not immunized with dTaP52010****Time PeriodsCCDR Notifiable Disease Annual Summaries
36Pertussis Incidence and Vaccine Use, 1993 – 2004 Canada’s Northwest Territories Switch to PentacelAdacel begun12108Average Yearly Cases / 10,000642Time PeriodsKandola, K. Abstract in Can J Infect Dis Med Microbiol. 2004;15:351. Manuscript in preparation.
37United States Licensure Trial: Summary of Immunogenicity Key point: Seroprotection rates for diphtheria and tetanus were comparable withthe Tdap and Td vaccines.Notes:This slide presents seroprotection achieved one month post vaccination with the Tdap and Td vaccines in adolescents and adults in a pivotal US trial.Td 506 was a Phase 3, multicenter, randomized, double-blind trial conducted in the United States in adolescents (11-17 years) and adults (18-64 years) comparing the safety and immunogenicity of Tdap (Adacel™) and Td.In adolescents, the diphtheria seroprotection rates were equal99.8% with Tdap and Td; as were the tetanus seroprotection rates which were 100%.In adults, the diphtheria seroprotection rates were 94.1% and 95.1% with Tdap and Td, respectively. The tetanus seroprotection rates were 100% and 99.8% with Tdap and Td, respectively.For diphtheria, the seroprotection rates among adults increased equally by 50% with both vaccines. Among adolescents they increased by 38% and 41% with Tdap and Td, respectively.For tetanus, the seroprotection rates among adults increased by 2.7% and 4.1% with Tdap and Td, respectively. Among adolescents they increased by 0.4% and 0.8% with Tdap and Td, respectively.Reference:Data on file, Td 506 Aventis Pasteur Limited, Toronto, Canada.PrePostDiphtheriaTetanusData reported for sera collected one month after vaccination.Data on file, Td 506, Aventis Pasteur Limited, Toronto, Canada.
38United States Licensure Trial: Summary of Solicited Systemic Reactions Key Point: The incidence of systemic adverse reactions was comparablefollowing Tdap and Td vaccine administration. For both Tdap and Tdvaccines, headache is the most common reaction reported among adultsand adolescents.Notes:This slide presents the most common systemic adverse events observed after Tdap and Td vaccine administration in adolescents and adults in a large scale US safety and immunogenicity trial (Td506).This trial was a Phase 3, multicenter, randomized, double-blind trial conducted in the United States in adolescents (11-17 years) and adults (18-64 years) comparing the safety and immunogenicity of Tdap (Adacel™) vs Td.The adverse events observed with Tdap were comparable to those observed with Td vaccine.The most common systemic reaction, among both adolescents and adults was headache, with an incidence of 44% for Tdap and 40% for Td in adolescents.Other common systemic reactions included fever, body ache/weakness, tiredness, sore/swollen joint, and chills.Severe systemic reactions were uncommon: the most common, headache, was reported in 1.96% of adolescents and 2.77% of adults in Tdap vaccine recipients.Severe occurrences of all other systemic reactions occurred in <2.00% of adolescents and <2.37% of adults in Tdap recipients.Reference:Data on file, Td 506, Aventis Pasteur Limited, Toronto, Canada.FeverHeadacheGeneralizedBody AcheTirednessSore JointsChillsData collected from days 0-14.Data on file, Td 506, Aventis Pasteur Limited, Toronto, Canada.
39United States Licensure Trial: Summary of Solicited Local Reactions Adolescents = years. Adults = years.Key point: The incidence of local adverse events in the first 3 days after vaccination issimilar between Tdap and Td vaccines for both adults and adolescents, and thesereactions were well-tolerated.Notes:This trial was a Phase 3, multicenter, randomized, double-blind trial conducted in the United States in adolescents (11-17 years) and adults (18-64 years), comparing the safety and immunogenicity of Tdap (Adacel) vs Td.Localized reactions of pain, swelling, and redness or erythema are common adverse reactions observed at the injection site for both Tdap and Td vaccine recipients and were comparable with both vaccines.For both age groups, local pain was the most common reaction.The incidence of any pain was slightly higher in adolescents receiving Tdap than Td (78% vs 71%); this difference is due to a slight increase in reports of mild pain among Tdap recipients. Comparable rates of local pain were reported in adults receiving Tdap and Td vaccines.Overall Tdap vaccine was well-tolerated in both adolescents and adults; injection site erythema, swelling, and pain were brief in duration and tended to be of mild or moderate intensity.Reports of severe local reactions were uncommon.The severity data is as follows:Severe erythema in adolescents: Tdap vs Td (6.04% vs 5.34%); in adults: Tdap vs Td ( 6.18% vs 4.81%).Severe swelling in adolescents: Tdap vs Td (6.38% vs 5.46%); in adults: Tdap vs Td (5.77% vs 5.53%).Severe pain in Adolescents: Tdap vs Td (1.45% vs 0.64%), in adults: Tdap vs Td (1.12% vs 0.89%).Reference:Data on file, Td 506, Aventis Pasteur Limited, Toronto, Canada.Severe Erythema*ErythemaSevere Swelling*SwellingSevere Local Pain†Local PainNo significant difference was observed between Tdap and Td recipients for any safety parameters measured with the exception of pain in adolescents which was marginally more frequent in Tdap recipients.Data collected from days 0-3.*≥35 mm; †Severe local pain: incapacitating, unable to perform usual activities, may have/or required medical care or absenteeism.Data on file, Td 506, Aventis Pasteur Limited, Toronto, Canada.
40Adequacy, Efficacy, & Safety Data for Tdap Vaccines Age Indications: Adacel years, Boostrix yearsBoth vaccines met all agreed non-inferiority criteriaFor Diphtheria and Tetanus antigens, at least as immunogenic as US – licensed Td vaccinesPertussis booster response induced an immune response at least as immunogenic as Daptacel and InfanrixCan be used concomitantly with other vaccinesSafety profile comparable to US-licensed Td Vaccine
41FDA Vaccine Advisory Committee Unanimous vote March 2005Adacel safe and effective age years of ageBoostrix safe and effective years of ageLicensure… May, June 2005CDC ACIPJuly yr Universal Immunization, catch up 5 yrs from last Td Oct Universal Adult Immunization,10 yrs from Td
42Rationale for Vaccinating Adolescents and Adults: Bordetella Pertussis Reservoirs Adolescents and Adults Are Primary Sources for Infant TransmissionHealth Care ProvidersMost hospital outbreaks of pertussis disease involve transmission from health care workers to pediatric patients1Adults/ParentsIn Chicago, young mothers with a cough >7 days were shown to be a significant source of pertussis disease transmission to their young infants2GrandparentsIn 15% of families, an adult patient was identified as the source of infection for other household members. Fifteen percent of these adults were grandparents or great-grandparents of an affected child3Adolescents/SiblingsFor 27% of infants hospitalized with pertussis disease in London between 1998 and 2000, an older, fully vaccinated sibling was the source of infection4Key Point: Identification and vaccination of the adult B pertussis reservoirs, such ashealthcare providers, parents, grandparents, and siblings are essential to preventingthe transmission of the disease to infants.Young infants are at highest risk for severe complications from pertussis as they are too young to be immunized. Certain adolescent and adult population groups who serve as pertussis reservoirs should be vaccinated.Health care workers: Most hospital outbreaks of pertussis disease involve transmission from health care workers to pediatric patients.1 [Sheretz 2001, pg 1, col 1, para 3, lines 6-10]Adults/parents: A study assessing risk factors for pertussis among young infants during a pertussis outbreak in Chicago in 1993 found that young mothers with cough >7 days were shown to be a significant source of pertussis disease transmission to their young children.2 [Izurieta 1996, pg 503, abstract, lines 11-13]Grandparents: A 2-year study assessing the symptoms and complications of pertussis in adults showed that in 15% of cases, an adult was the source of infection for other household members. Fifteen percent of these adults were grandparents or great-grandparents of the affected child.3 [Postels-Multani 1995, pg 140, col 2, para 5, lines 5-6; pg 141, col 1, para 1, lines 5-7]Adolescents/siblings: For 27% of infants hospitalized with pertussis disease in London between 1998 to 2000, an older, fully vaccinated sibling was the source of infection.4 [Crowcroft 2003, pg 802, abstract, para 3, lines 8-9]References:1. Sherertz RJ, Bassetti S, Bassetti-Wyss B. “Cloud” health-care workers. Emerg Infect Dis. 2001;7:2. Izurieta HS, Kenyon TA, Strebel PM et al. Risk factors for pertussis in young infants during an outbreak in Chicago in Clin Infect Dis. 1996;22:3. Postels-Multani S, Schmitt HJ, Wirsing von Konig CH, et al. Symptoms and complications of pertussis in adults. Infection. 1995;23:4. Crowcroft NS, Booy T, Harrison T et al. Arch Dis Child. 2003;88:1. Sheretz et al. Emerg Infect Dis. 2001;7:2. Izurieta et al. Clin Infect Dis. 1996;22:3. Postels-Multani et al. Infection. 1995;23:4. Crowcroft et al. Arch Dis Child. 2003;88:
43Recommendations of the ACIP (CDC) for the use of Tdap vaccines: Advisory Committee On Immunization Practices (ACIP) Recommendations For Tdap Vaccine In AdolescentsRecommendations of the ACIP (CDC) for the use of Tdap vaccines:Adolescents 11 to 12 years of age be given Tdap in place of the Td booster currently being usedTdap vaccine should be given to adolescents 13 to 18 years who missed the 11 to 12 year dose of TdAdolescents 11 to 18 years of age who have already been vaccinated with Td are encouraged to receive a dose of Tdap to further protect against pertussisAdolescents can and should receive Tdap and the meningococcal conjugate vaccine (menactra) at the same visit
44ACIP Recommendations for Tdap Vaccine Use in Adults Adults who have not received a Td immunization during the last 10 years should receive a single dose of Tdap VaccineThose not previously given Tdap vaccine may be given Tdap vaccine at shorter intervals (< 10 years) following last Td immunizations in settings of wound management and increased risk (including pertussis outbreaks and contact with infantsAdults who anticipate having close contact with infants (ie: parents, healthcare workers and daycare workers) should receive a single dose of Tdap vaccine to protect against pertussis if they have not received Tdap vaccine. Ideally these adults should receive Tdap vaccine at least one month before beginning close contact with infants
45Other ACIP Recommendations for Adult Tdap Use Women should receive Tdap vaccine immediately post partum if not previously immunizedWomen are encouraged to receive Tdap vaccine before conceptionTdap vaccine is encouraged over Td vaccine in the wound care setting for those who have not previously received Tdap vaccinePregnancy is not a contraindication to Tdap and may be considered in the 2nd and 3rd trimester
46ACIP Recommendations for Tdap Use In Healthcare Workers There are 8-10 million workers employed in hospital and ambulatory settings.The risk of contracting pertussis from healthcare workers is nearly 2 times greater than the general population.For each decade the immunization of healthcare workers could prevent as many as 100, 000 cases of pertussis and save up to $151 million in direct and indirect costs.Therefore it is recommended that all healthcare workers and anyone who works in a healthcare setting receive Tdap.
47Strategies to Control Pertussis… Improve immunization coverageEnsure immunization of all appropriate infantsPrevent mild diseaseImprove surveillance and reportingImplement Tdap vaccines for adolescents and adultsEliminate reservoirs of infection in general populationReduce transmission to vulnerable infants
48SUMMARYEpidemiology of pertussis disease has changed with the spectrum of illness shifting to a milder form in all age groupsB. pertussis infections in the adolescent and adult populations are common and endemic accounting for more of the disease seen todayImmunity after natural infection or vaccinations is not life long and wanes rapidly after 5 – 8 yearsPertussis acounts for up to 25% of acute cough illnesses in the adolescent and adult populationsThe adolescent and adult populations serve as a major resevoir of disease transmission to the young infant populationImmunizing the infant population on time and implementing a booster vaccine program in the adolescent and adult populations will have the greatest impact on decreasing the amount of disease seen
49…a universal program of adolescent and adult boosters would decrease the circulation of B pertussis… and possibly could lead to the elimination of the organism…