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Pertussis

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					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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