Pertussis Investigation (Whooping Cough) in First 24-48 Hours

1. Pertussis Investigation(Whooping Cough) in First 24-48 Hours Thein Shwe, MPH, MS, MBBS VPD & IBD Epidemiologist Hot Topics Training 11/17/2010 Division of Infectious Disease Epidemiology Office of Epidemiology & Prevention Services Bureau for Public Health West Virginia Dept. of Health & Human Resources

2. Objectives • To describe clinical description, diagnosis and epidemiology of pertussis • To understand • Investigation of a case of pertussis and outbreak of pertussis • To review a pertussis case study

3. Disease Description • Pertussis, a cough illness commonly known as whooping cough (100 Day Cough), is caused by the bacterium Bordetella pertussis. • Prolonged paroxysmal cough often accompanied by an inspiratory whoop. • Varies with age and history of previous exposure or vaccination. • Neither infection nor immunization provides lifelong immunity

4. Other Bordetella species • Three other Bordetella species: • B. parapertussis, • B. holmesii, and • B. bronchiseptica. • B. pertussis and B. parapertussis coinfection is not unusual. • Disease with Bordetella species other than B. pertussis is not reportable.

5. Clinical Description of Pertussis

6. http://children.webmd.com/pertussis-whooping-cough-10/coughing-soundshttp://children.webmd.com/pertussis-whooping-cough-10/coughing-sounds SOUND OF PERTUSSIS

7. Epidemiology of Pertussis Mode of transmission • Person to person via • Aerosolized droplets from cough or sneeze • Direct contact with secretions from respiratory tract of infectious person • 80% - secondary attack rate • Older children and adults are important sources of disease for infants and young children • Infants <12 months of age greatest risk for complications and death

8. Epidemiology of Pertussis cont. • Reservoir - Humans • Incubation period: 7-10 days (5-21 days). • Infectious period: Most contagious during the catarrhal stage (3 weeks before cough) and the first 2 weeks after cough onset • Duration of illness: • Children: 6-10 wks. • ~ ½ of Adolescents: 10 wks or longer

9. Pertussis Complications • Syncope (temporary loss of consciousness/faint) • Sleep disturbance • Incontinence • Rib fractures • Complications among infants • Pneumonia (22%) • Seizures (2%) • Encephalopathy (<0.5%) • Death • Infants, particularly those who have not received a primary vaccination series, are at risk for complications and mortality.

10. Pertussis Laboratory Diagnosis WV OLS offers pertussis PCR and Culture for free of charge 304-558-3530

11. Pertussis Laboratory Testing

12. Proper Technique for Obtaining a Nasopharyngeal Specimen for Isolation of B pertussis

13. Nasopharyngeal Swab Collection Procedure http://www.nejm.org/doi/full/10.1056/NEJMe0903992

14. Pertussis Case Investigation & Outbreak Investigation

15. PERTUSSIS CASE DEFINITION CDC/CSTE (2010) http://www.cdc.gov/ncphi/disss/nndss/casedef/pertussis_current.htm

16. Pertussis Probable Case Definition • - In the absence of a more likely diagnosis, a cough illness lasting ≥2 weeks, with at least one of the following symptoms: • paroxysms of coughing; OR • inspiratory "whoop”; OR • post-tussive vomiting; AND • absence of laboratory confirmation; AND • no epidemiologic linkage to a laboratory-confirmed (PCR or culture) case of pertussis

17. Pertussis Confirmed Case Definition Option 1 • Acute cough illness of any duration with isolation (culture) of B. pertussis from a clinical specimen

18. Pertussis Confirmed Case Definition Option 2 Cough illness lasting ≥2 weeks, with at least one of the following symptoms: • paroxysms of coughing; • inspiratory "whoop"; or • post-tussive vomiting AND polymerase chain reaction (PCR) positive for pertussis;

19. Pertussis Confirmed Case Definition Option 3 • Illness lasting ≥2 weeks, with at least one of the following symptoms: • paroxysms of coughing; • inspiratory "whoop"; or • post-tussive vomiting; AND, contact with a laboratory-confirmed (PCR or culture) case of pertussis.

20. PERTUSSIS CASE INVESTIGATION

21. Importance of Rapid Case Identification • Early diagnosis and treatment to limit disease spread • Identify and provide prophylaxis to close contacts pending laboratory confirmation • When suspicion of pertussis is low, investigation can be delayed pending laboratory confirmation • Exception: prophylaxis of infants and their household contacts should NOT be delayed

22. What is the next step in a case investigation? • Refer to Pertussis Protocol • Use Pertussis WVEDSS form • Begin your case ascertainment

23. Resources Needed for Case Investigation

24. Resources Needed for Case Investigation cont.

25. Resources Needed for Case Investigation cont.

26. Resources Needed for Case Investigation cont.

27. How do you ascertain a case? • Three pieces of information needed to determine if you have a pertussis case • Clinical information • Laboratory report(s) • Epidemiological information

28. Verify the diagnosis Clinical information • Cough (yes/no) • Duration of cough • Paroxysmal cough • Post-tussive vomiting • Whoop Laboratory information • Is laboratory testing done? • Type of test • Culture • PCR • Serology

29. Epidemiologic Information • Vaccination history • Received any pertussis-containing vaccine • No. of doses • Vaccine date • Manufacturer • Lot no. • Epi-linked (Yes/No) • Transmission setting • Secondary transmission • Contact tracing

30. Management of Close Contact(s) • Identify close contacts • Prevent secondary transmission • Collect nasopharyngeal swab (if not done so) for PCR and culture testing at OLS • Treat the patient with recommended antibiotics • Isolate the patient for 5 days (after the beginning of antibiotics) or 21 days (if no A/b treatment received)

31. Contact TracingClose contact definition • Direct face-to-face contact for a period (not defined) with a case-patient who is symptomatic during the catarrhal and early paroxysmal stages of infection. • All residents of the same household; • Daycare and baby-sitting contacts; and • Close friends, regardless of immunization status.

32. Contact TracingClose contact definition (cont.) • Shared confined space in close proximity for a prolonged period of time, such as >1 hours, with a symptomatic case-patient: or

33. Contact TracingClose contact definition (cont.) • Direct contact with respiratory, oral, or nasal secretions from a symptomatic case-patient – example: • an explosive cough or sneeze in the face, • sharing food, sharing eating utensils during a meal, • kissing, • mouth-to mouth resuscitation, or • performing s full medical exam including examination of the nose and throat.

34. Contact Tracing of a Pertussis Case

35. Management for Exposed persons

36. Postexposure Prophylaxis for Pertussis in Infants, Children, Adolescents, and AdultsSource: Red Book 2009 AAP – pg. 507

37. Once the investigation is completed.. • Document public health action • Check case classification • Print the report for your files or per your LHD policy & procedure • Send lab report(s) to DIDE • Submit completed WVEDSS report electronically to your regional epidemiologist and DIDE

38. Pertussis Outbreak Case Definition • Outbreak is defined as: • Two or more cases • Involving two or more households • Clustered in time & spaceAND • One case must be confirmed by positive culture

39. Pertussis Outbreak Line List Formhttp://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/Pertussis%20Outbreak%20Linelisting%20Form.pdf

40. Outbreak Notification and Control • Notify your regional epidemiologist & DIDE immediately • Evaluate case status & manage close contacts • Obtain nasopharyngeal swabs for culture (confirmation) and PCR

41. Outbreak Control in Any Settings • Treat/Prophylax with recommended antibiotic • Isolate 5 days after starting antibiotic treatment or 21 days from cough onset if no treatment • Bring immunizations up-to-date • Accelerated vaccination if cases are occurring young infants

42. Alert your providers and notify the parents… • Healthcare Providers • Send Health alert letter • Provider information sheet • Parent/Guardian • Send notification letter • Public information sheet

43. Exposures in Child Care • Exposed Children (especially incompletely immunized) and childcare providers should be • Observed for respiratory tract symptoms for 21 days after contact with an infectious person has been terminated • Administer vaccine and antibiotics • Exclude: • Symptomatic or confirmed pertussis until completion of 5 days of the recommended course of antimicrobial therapy or 21 days if untreated

44. Follow up & Report • Check the status of the outbreak control • Document and update your regional epidemiologist and DIDE when the outbreak is controlled completely • Forward report with lab results to DIDE

45. Case Study • On November 1, 2010, an Infection Preventionist (IP) of CAMC called your health department to notify you about two 6-month old twins who presented to the ED with • cough for 10 days since 10/22/10, • apnea and paroxysmal cough, • the labs are pending at this time, • the ER doctor had high suspicion of pertussis, • both babies were admitted to CAMC, and • treated with Azithromycin 10mg/kg/day for 5 days.

46. Question 1. What would you do as soon as you receive a call like this?

47. QUESTION 2. What Information would you collect for contact tracing?

48. Contact Tracing Information • Six household members and a baby sitter were exposed to these twins during the infectious period. • A baby sitter and 5 of 6 household members have been coughing: • Amy, mother, 30 yo, cough started on 10/23, no vaccine • Bob, father, 32 yo, cough started on 10/24, vaccine yes, # of dose -UK • Ann, grandma, 67 yo, cough started on 10/16, no vaccine • John, brother, 9 yo, no cough, had 4 doses of PCV • Julie, sister, 6 yo, cough started on 10/22, had 4 doses of PCV • Brad, brother, 4 yo, cough started on 10/24, had 4 doses of PCV • Katie, baby sitter, 19 yo, cough started on 10/10, had 3 doses of PCV • 3 siblings attend the same elementary school and have been attending school while coughing. • No lab done yet on any symptomatic cases as of 11/1/10 • None of them has received PEP yet as of 11/1/10

50. Question 3 What is your next step at this time?