Pertussis Whooping cough is back Adapted for BugLine from presentation by: Cassandra D. Youmans, MD, MPH, MS-HCM, FAAP District Health Director East Central Health District VI Objectives Enhance East Central Public Health District VI’s ability to recognize and respond appropriately to pertussis Refresh University Hospital healthcare personnel to allow appropriate treatment and reporting of pertussis Give Tdap* vaccine to healthcare personnel to protect our: Highest risk patients by surrounding them immunity A circle of immunity made up of vaccinated caregivers Healthcare personnel from “catching” pertussis * Tdap, Tetanus, diphtheria and pertussis Two Pupils Treated for Pertussis Saturday, April 15, 2006 Columbia County School officials confirmed that at least one pupil tested positive for whooping cough, and the two siblings are being treated. One attended Evans High School, and the other Evans Middle School…highly contagious, spread through the air by cough and begins with cold symptoms and a cough… The case was not properly reported to the public health department, allowing for the above Augusta Chronicle And the article included a warning to parents Resurgence of Pertussis Mutation Waning vaccine-induced immunity 5 to 7 years after vaccination, leaving adolescents and adults unprotected Waning disease-induced immunity doesn’t last much longer than that of vaccination Enhanced identification: Public health awareness, surveillance, diagnostic programs Bordetella pertussis, the germ Gram-negative rod Humans are the only host Incubation period 6-to-21 days (usually 7-to-10 days) Duration of illness 6-to-10 weeks (usually 6 weeks) Expected occurrence 3-to-5 year cycles of increased disease Pertussis is under reported, 40-160 fold less than actual illness Asymptomatic infections are 4–22 times more common than symptomatic infections Spread Close person to person contact via aerosolized droplets from respiratory secretions of patients with disease 90% of nonimmune household contacts acquire the disease Adolescents and adults (27% of reported cases in 2004) are the major source of infection in unvaccinated children Infants and young children are infected by older siblings who have mild to asymptomatic disease (43% of reported cases) Clinical Symptoms Initially mild upper respiratory tract symptoms (catarrhal stage,1-2wks), most contagious period progressive paroxysms of cough (paroxysmal stage 2-4 wks) Inspiratory whoop, followed by vomiting Fever minimal to absent Symptoms subside gradually over months (convalescent stage1-2 wks) Clinical Symptoms in Infants Most severe in infants <6 Infant Complications months Seizures (3%) Atypical presentation Pneumonia (22%) Apnea most common symptom Encephalopathy (1%) Whoop is absent Death Hospitalization often needed Case fatality rate: Lymphocyte predominant, 1.3% in infants <1 month increased white count can match severity of the cough 0.3% in infants 2-11 months Diagnosis Increase of pertussis antibody IgA antibody titer to pertussis is becoming the method of choice IgG antibody to pertussis toxin indicative of recent infection Single serum test for significantly high pertussis specific antibody can confirm the diagnosis Adolescents and adults with B. pertussis cough illness don’t seek care until the week 3-4 of illness Organism most frequently recovered in catarrhal or early paroxysmal stage PCR on nasopharyngeal secretions obtained with Dacron swab, put on special media, with 10 to 14 day incubation Alert the Lab when pertussis is suspected - the culture media is not readily available Negative cultures are common Treatment Aim is to eradicate nasopharyngeal carriage Treatment duration usually 14 days with erythromycin sulfate (EES), newer Macrolides 5-7 days Macrolides-erythromycin, azithromycin, and clarithromycin Azithromycin eradicates naso-pharyngeal carriage the fastest Hypertrophic pyloric stenosis has been reported with oral EES in infants younger than 6 weeks Trimethoprim-sulfamethoxazole is an alternative to erythromycin-resistant strain, or for intolerance to macrolides Penicillins, first and second generation cephalosporins are not effective Supportive Care Hospitalized patients need to be on Droplet Isolation for 5 days after therapy Monitor exposed children for respiratory symptoms for 20 days Laboratory confirmation is difficult, so diagnosis often based on characteristic clinical manifestations Children may return to school after 5 days of appropriate antibiotic therapy Prevention - Terms Tetanus Diphtheria (Td) Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed (Tdap) Prevention = Immunization Universal immunization of all children <7 years of age is recommended by the AAP U.S. pertussis is an acellular vaccine in combination with diphtheria and tetanus toxoids Acellular vaccines contain one or more immunogens from B pertussis Acellular vaccines are absorbed on aluminum salt and must be given intramuscularly 3 DTaP, and 1 combined vaccine that includes DTaP and Haemophilus influenzae type b conjugate vaccine is given at 15-18 months Recommendations of the Advisory Committee on Adult Immunization Practices (ACIP) One dose of Tdap for adults 19– 64 years of age to replace the next booster does of tetanus and diphtheria toxoids vaccine (Td) Tdap for adults who have close contact with infants <12 months of age May give Tdap within 2 year intervals to protect against pertussis Tdap is not licensed for adults >65 years Contraindications and Precautions Contraindications to Tdap History of serious allergic reaction (anaphylaxis) to vaccine components History of encephalopathy not attributable to an identifiable cause within 7 days of vaccination with pertussis vaccine Precautions to Tdap Guillain-Barre Syndrome, 6 weeks after a dose of tetanus toxoid Moderate to severe acute illness Unstable neurological condition References ACIP Votes to Recommend Use of Combined Tetanus Diphtheria and Pertussis (Tdap) Vaccine for Adults. Advisory Committee on Immunization Practices. 2006 Cherry, JD. MD, MSc. The epidemiology of pertussis, Pediatric Infectious Disease Journal. 2006; 25:4:361-362 Pickering, LK. Pertussis.The Red Book. 2003; 26:472-486 Gilbert, D.N. The Sanford Guide to Antimicrobial Therapy. 2005; 35:24 Questions?
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