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Pertussis C. Mary Healy, M.D. Center for Vaccine Awareness and Research, Texas Childrens Hospital Ben Taub General Hospital Baylor College of Medicine,

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Presentation on theme: "Pertussis C. Mary Healy, M.D. Center for Vaccine Awareness and Research, Texas Childrens Hospital Ben Taub General Hospital Baylor College of Medicine,"— Presentation transcript:

1 Pertussis C. Mary Healy, M.D. Center for Vaccine Awareness and Research, Texas Childrens Hospital Ben Taub General Hospital Baylor College of Medicine, Houston, Texas

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 Lancet 2006; 367: 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 Dermal necrosis and vasoconstriction Ciliostasis; inhibits DNA synthesis; kills cilial epithelial cells Activates cAMP; interferes with leucocytes; hemolytic Causes feverAdhesion and immunomodulation OMP that mediates adherence and resists complement Adhesion and immunogen

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

6 DTP Incidence of Pertussis, U.S. 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 DTP DTaP No. of Cases Rate/100,000 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 Normal Chest x-rayBaby with Pertussis

13 Pertussis in Texas 4 deaths in 2008; 3 in 2009 All occurred in infants < 3 mo of age Haleigh Throgmorton; age 6 weeks Personal Communication: Texas Dept Health

14 California 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? Pediatr Infect Dis J. 2004;23: Pediatr Infect Dis J. 2007;26: Household contacts in > 75% of cases

17 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 Doctors 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 Phase 1: 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 7 th, 2008 through Sept 20th, 2010, 10,450 postpartum women received Tdap prior to discharge Well-accepted No adverse events reported June Jan % 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 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) Phase 2: Household Contacts

25 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

26 Contact Relationship to Infant 87% lived in the infants 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 Educational initiatives Immunization Partnership Adopted promotion of pertussis cocooning as a goal for current year

29 For the Future Maternal Immunization Anecdotal evidence from pre-vaccine era Anecdotal evidence from pre-vaccine era Studies in the 1940s s demonstrated infant protection Studies in the 1940s s demonstrated infant protection High levels of maternal antibody did not interfere with infant response to DTaP High levels of maternal antibody did not interfere with infant response to DTaP Transfer of pertussis antibodies from mother to infants occursand antibody persist 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: 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

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