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Responding to the Rise in Pertussis CT AAP CME Program

Responding to the Rise in Pertussis CT AAP CME Program. Kathy Kudish, DVM, MSPH. Immunization Program Connecticut Department of Public Health. Amanda Faulkner, MPH. Meningitis and Vaccine Preventable Diseases Branch Centers for Disease Control and Prevention September 25, 2012.

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Responding to the Rise in Pertussis CT AAP CME Program

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  1. Responding to the Rise in PertussisCT AAP CME Program Kathy Kudish, DVM, MSPH Immunization Program Connecticut Department of Public Health Amanda Faulkner, MPH Meningitis and Vaccine Preventable Diseases Branch Centers for Disease Control and Prevention September 25, 2012 National Center for Immunization and Respiratory Diseases Division of Bacterial Diseases

  2. Pertussis (Whooping Cough) • Highly contagious respiratory disease • Severe, debilitating cough illness (“100 day cough”) in persons of all ages • Highest morbidity and mortality among infants • Estimated worldwide deaths > 300,000/yr • Vaccine-preventable • Poorly controlled, despite high vaccine coverage • First U.S. pertussis vaccines for adolescents and adults (Tdap)† licensed in 2005 †Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine 2

  3. Clinical Course (in weeks) Communicable period (onset to 3 weeks after start of paroxysmal cough) Incubation period (typically 5-10 days; max 21 days) Convalescent stage (weeks to months) Catarrhal stage (1-2 weeks) -3 0 2 8 12 Paroxysmal stage (1-6 weeks) Onset 3

  4. Clinical Stages • Catarrhal • Watery eyes, low-grade fever, malaise, mild eye inflammation, runny nose, late-phase nonproductive cough • Paroxysmal • Paroxysms (bursts of coughing during a single exhalation) followed by an inspiratory "whooping" sound, post-tussive cyanosis, and vomiting • In infants younger than six months (especially those younger than four weeks): apnea, bradycardia, prolonged cough, poor feeding, no paroxysms • Convalescent • Paroxysms gradually improve but recur with respiratory infections www.aafp.prg 4

  5. Young infants at highest risk of disease and complications Atypical symptoms: Catarrhal stage and cough may be minimal or absent Apnea (sometimes with seizures) Sneezing Gagging, choking, vomiting Whoop infrequent Cough illness among close contacts Presumptive treatment should begin immediately Infant Pertussis Source: Shot of Prevention, Brady passed away at just 2 months from pertussis 5

  6. Pertussis among Adolescents and Adults • Wide spectrum of presentation • Disease often milder than in infants and children • May be asymptomatic • Can be quite severe and with classic presentation • Clinically difficult to distinguish from other causes of cough illness • Persons with mild disease can transmit infection

  7. Pertussis Treatment • When to treat • Adults, adolescents, children • Antimicrobials may modify course if given early (reduce duration and severity of symptoms and lessen communicability) • Treatment >3 weeks after cough onset limited benefit • Infants and pregnant women near term • Treatment up to 6 weeks after cough onset should be considered • Recommended treatment • Macrolide / azolide antimicrobial • 5 day course azithromycin • 7 day course clarithromycin • 14 day course erythromycin • Alternative agent: • 14 day course trimethoprim-sulfamethoxazole (Bactrim)

  8. Laboratory Testing

  9. Diagnostic Challenges • Stage of disease • Quality/timely collection of clinical specimen (s) • Antimicrobial administration • Vaccination status • Transport conditions • Contamination of clinical specimen • Lack of clinically validated/ standardized tests

  10. Diagnostic NeedsClinical vs. Public Health • Clinical setting • Optimizes sensitivity • Rapid turnover • Public health setting • Optimizes specificity • Confirmation of etiology • Prevention and control measures

  11. Pertussis Diagnostics at CDC • Culture • 100% specific • Low sensitivity • Incubation time 4-10 days • Multi-target real-time PCR • 4 targets • Speciate 3 Bordetella spp. • Co-infections • IgG anti-PT ELISA • Quantitative/qualitative • Adolescents and adults • Late phase of disease

  12. Commercial Pertussis Serologic Assays • Commercial assays are not standardized and clinical accuracy is unknown • CDC is conducting a study to better understand the usefulness of commercially available assays for clinical diagnosis • Not included in CDC/CSTE pertussis case definition • CDC ELISA is not commercially available • Tech transfer is ongoing in collaboration with APHL and state public health laboratories

  13. R-PCR Assay IS481 • Present in three Bordetella spp. • 50 to >200 copies in B. pertussis • 8 to 10 copies in B. holmesii • 0 to 7 copies in B. bronchiseptica • High Ct value could indicate • Positive test for B. pertussis • False positive • Positive for • B. holmesii • B. bronchiseptica Real-Time PCR Amplification Plot

  14. Falsely-positive PCR Results during Outbreak Investigations • Hospital: NH, 2006 • Community: CO, 2009 • Community: NY, 2010 14

  15. Falsely-positive PCR Results • Use of IS481 as a single target assay • High Ct values interpreted as positive results • Contamination of clinical specimens during collection • B. pertussis DNA present in some vaccines • Confirmed by environmental sampling of clinics • Key factors likely ungloved hands and use of liquid transport media + + + + False Positives 15

  16. CDC Best Practices Guidance for Healthcare Professionals on the Use of PCR for Diagnosing Pertussis • Target clinicians to optimize the use of PCR • Testing patients with signs and symptoms of pertussis • Optimal timing and specimen collection for PCR testing • Avoiding contamination of clinical specimens with B. pertussis DNA • Understanding and interpreting PCR results • Available at: http://www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-pcr-bestpractices.html

  17. Specimen Collection for Pertussis PCR • Acceptable samples: • Nasopharyngeal swabs • Nasopharyngeal aspirates • Nasal swabs are not acceptable • Visit www.cdc.gov/pertussis for instructions on specimen collection

  18. Optimal Timing in Weeks for Diagnostic Testing Cough Onset 0 2 4 6 8 10 12 Culture PCR Serology

  19. Epidemiology and Vaccination

  20. Pertussis Surveillance and Reporting • Nationally notifiable • Clinical (Probable) case • Cough ≥2 weeks AND • One among paroxysms, whoop, post-tussive vomiting • Confirmed case • Culture OR • Clinical case and PCR positive OR • Clinical case and epi-linked to confirmed case

  21. Reported Pertussis Cases by Diagnosis±, 1990-2010 ±Data collection for PCR and Epi-Link began in 1995 Source: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System, 2010

  22. Pertussis Immunization in the US • Infants/children • Widely used since 1940s • Transitioned from DTP to DTaP throughout the 1990s • DTaP at 2, 4, 6 months; 15-18 months; 4-6 years • Children 7 through 10 years not fully immunized against pertussis should receive a single dose of Tdap • Adolescents/adults • Licensed in 2005, recommended in 2006 • Single Tdap, preferred at 11-12 years • All adolescents/adults who did not receive at 11-12 years should receive a single dose as soon as feasible (includes those 65 yr and older) • Tdap can be administered regardless of interval since the previous Td dose

  23. Reported NNDSS pertussis cases: 1922-2011 DTaP Tdap DTP SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the Public Health Service

  24. DTaP Coverage among Children Aged 19 through 35 months — 2004-2011 24 CDC National Immunization Survey

  25. Reported pertussis incidence by age group: 1990-2011 SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System

  26. Annual Incidence by State, 2010 2010 incidence 9.0 (n=27,550) Incidence 1.1-3.6 3.7-6.5 6.6-10.2 10.3-23.2 Incidence is per 100,000 population Source : CDC National Notifiable Disease Surveillance System, *2010 data accessed July 22, 2011 CDC Wonder Population Estimates (Vintage 2009)

  27. Annual incidence by State, 2011 2011 incidence 6.1 (n=18,719) Incidence 0.7-2.8 2.9-5.1 5.2-9.3 9.4-23.3 Incidence is per 100,000 population Source : CDC National Notifiable Disease Surveillance System, 2011 2010 Census data used for population estimates

  28. tdap implementation and impact

  29. Tdap Vaccine Effectiveness • Bridging studies of ADACEL and BOOSTRIX1 • 85-89% • APERT study2 • 92% (95% CI: 32.0-99.0) • Australia3 – screening method • 78.0% (95% CI: 60.7-87.6) • St. Croix outbreak4 • 65.6% (95% CI: -35.8-91.3) • MN case-control study • 72.3% (95% CI: 38.8-87.4) 1 Schmitt HJ et al. JAMA 1996;275:37-41; Gustafsson LH et al. NEJM 1996;334:349-355 2 Ward JI et al. N Engl J Med. 2005 Oct 13;353(15):1555-63. 3 Rank C, et al. Pediatr Infect Dis J. 2009 Feb;28(2):152-3. 4 Wei SC, et al. CID 2010; 51(3):315-321.

  30. Tdap Coverage among Adolescents Aged 13–17 years — 2006–2010 Percentage(%) 2010 2007 2008 2009 2006 CDC. National, State, and Local Area Vaccination Coverage Among Adolescents Aged 33-17 Years - United States, 2008. MMWR 2008;58(36);997-1001. CDC. Vaccination Coverage Among Adolescents Aged 13-17 Years – United States, 2007. MMWR 2008;57(40)1100-1103. CDC. Vaccination Coverage Among Adolescents Aged 13-17 Years– United States, 2006. MMWR 2007;56(34) 885-888. CDC. National, State, and Local Area Vaccination Coverage among Adolescents Aged 13-17 Years - United States, 2009 MMWR 2010 ;59(32);1018-1023. 30

  31. Tdap Incidence of Reported Pertussis — 1990–2010 CDC unpublished data 31

  32. Accelerated Decline of PertussisRate ratios of pertussis incidence among adolescents 11-18 years, 1990-2009 Slope = -0.4752, p<.0001 Slope = +0.2225, p<.0001 Skoff et al. Arch Pediatr Adolesc Med. 2012 Jan 11. [ePub ahead of print] 32

  33. Absence of Indirect Effects of TdapMean incidence of reported pertussis among infants Skoff et al. Arch Pediatr Adolesc Med. 2012 Jan 11. [ePub ahead of print] 33

  34. Emergence of disease among children aged 7 – 10 years

  35. 35

  36. Pertussis Cases by Age – 2002-2005

  37. Pertussis Cases by Age – 2006-2009

  38. Evaluation of dtap vaccine effectiveness (VE) and duration of protection

  39. California VE Study • Cases & controls 4-10 yrs at illness onset or enrollment • Reported pertussis cases in 15 CA counties • Unmatched controls from case-patient providers (3:1) • Vaccine histories collected by in-person visits to providers • Logistic regression, accounting for clustering • 250 provider offices, 4,000 charts abstracted

  40. Pertussis Disease among Unvaccinated compared to Vaccinated Children * Accounting for clustering by county and provider

  41. Overall VE & Duration of Protection Estimates * Accounting for clustering by county and provider

  42. Overall VE & Duration of Protection Estimates * Accounting for clustering by county and provider

  43. Tdap and DTaP StudiesSummary and Conclusions • Tdap program has reduced the burden of pertussis in adolescents • No evidence for “herd immunity” • Excellent initial DTaP vaccine effectiveness • Modest but immediate waning of immunity from DTaP • Pertussis burden in children aged under 10 years appears to be a “cohort effect” from change to all aP vaccines • i.e. a problem of susceptibility despite vaccination

  44. 2012 U.S. Pertussis Activity

  45. Reported NNDSS pertussis cases: 1922-2012* DTaP Tdap DTP SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the Public Health Service

  46. Changes in Pertussis Reporting by State from 2011 to 2012*† Decrease/No change < 2-fold increase 2 to 3-fold increase > 3-fold increase *Data for 2012 are provisional and subject to change. †Cases reported through Week 37 in 2011 were compared with cases reported through Week 37 in 2012; fold-changes were calculated for each state.

  47. Pertussis cases by age — United States, 2012 47

  48. Prevention and Control guidelines

  49. Revised CDC Guidelines for the Prevention and Control of Pertussis: Objectives • Primary: Preventing death and serious complications in individuals at increased risk of severe and/or complicated disease, including infants <12 months • Secondary: • Limit transmission in outbreak setting • Limit further spread and duration of transmission within closed communities • Decrease morbidity in affected populations • Lower risk of dissemination to unaffected groups within an outbreak

  50. Revised CDC Pertussis Outbreak and Control Guidelines: Overview • Emphasis on those at highest risk • Lack of evidence of broad-scale prophylaxis • Tiered approach offers flexibility but encourages judicious use of antibiotics • Alternatives to prophylaxis • Cough exclusion and “watchful waiting” • Opportunity to increase pertussis vaccine coverage

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