1 / 37

Pertussis Update 5/2/2012

Pertussis Update 5/2/2012. Amy.Groom@ihs.gov Twesier@npaihb.org Rita.Harding@ihs.gov. Overview. Epidemiology of pertussis Current outbreaks Diagnosis, treatment and immunization recommendations Resources Outbreak Response Strategies Portland IHS Area Billings IHS Area.

hagen
Download Presentation

Pertussis Update 5/2/2012

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Pertussis Update5/2/2012 Amy.Groom@ihs.gov Twesier@npaihb.org Rita.Harding@ihs.gov

  2. Overview • Epidemiology of pertussis • Current outbreaks • Diagnosis, treatment and immunization recommendations • Resources • Outbreak Response Strategies • Portland IHS Area • Billings IHS Area

  3. Epidemiology of Pertussis • Caused by a bacteria - Bordetella pertussis • Droplet spread (coughing, sneezing) • Endemic in the U.S. • Periodic epidemics every 3 – 5 yrs; frequent outbreaks • 27,550 cases reported in 2010 (last national peak year) • 90% of deaths occur in children < 4 months • Most cases go unreported • Waning vaccine immunity in pre-teens, teens and adults • Childhood vaccination is 80-85% effective • Difficult to detect • Other co-circulating respiratory pathogens • Challenges with PCR test • Adult cases can seem mild

  4. Pertussis Outbreaks • Local outbreaks not uncommon • California • 9,143 cases reported in 2010, 10 infant deaths. • Increased pertussis activity continuing • Washington • As of April 21st, 2012, 1008 cases have been reported for 2012 • 110 cases were reported in 2011 for this same time period • Montana • 90 cases since Jan 1, 2012 • Several infants hospitalized

  5. Signs and Symptoms • Initial signs and symptoms are similar to a cold. • Runny nose • Congestion • Sneezing • Mild cough • Fever • After 1–2 weeks, severe coughing can begin • Can last up to 10 weeks and recur with subsequent respiratory infections • Babies and young children may turn blue while coughing because of a lack of oxygen • Disease in adults is more mild and often goes undiagnosed

  6. Diagnosis • Consider pertussis diagnosis even in immunized patients • Respiratory symptoms of any duration in infants <12 months. • Cough illness that is paroxysmal, accompanied by gagging, post-tussive emesis or inspiratory whoop, or any cough that is > 2 weeks duration (in patients of any age). • Respiratory illness of any duration in patients who have had contact with someone known to have pertussis or who has symptoms consistent with pertussis. • Refer to state department of health for lab testing procedures • Testing appropriate up to 3 weeks after onset of coughing • Nasopharyngeal specimen for pertussis polymerase chain reaction (PCR) or culture • PCR is more sensitive and rapid than culture, but culture is the gold standard • CDC video re: NP specimen collection: • http://www.cdc.gov/pertussis/clinical/diagnostic-testing/specimen-collection.html

  7. Treatment • Antibiotic treatment for cases • Antibiotic prophylaxis for contacts • Erythromycin, clarithromycin, and azithromycin are preferred for the treatment of pertussis in persons ≥1 month of age. • For infants <1 month of age, azithromycin is preferred • Do not wait for lab confirmation to begin antibiotic treatment or prophylaxis • Patient should remain at home until antibiotic prescription is complete

  8. Pertussis Outbreak Control • Primary goal - decrease morbidity and mortality among infants • Secondary – decrease morbidity in persons of all ages • Early detection and treatment can prevent spread • Immunization to prevent cases

  9. Immunization Recommendations • Infants and children • 5 doses of the DTaP vaccine at 2, 4, and 6 months, at 15 through 18 months, and at 4 through 6 years. • Limited immunity after 3 doses • All 5 doses are needed for maximum protection. • Vaccine efficacy 80% - 85% • Children 7-10 years of age who are not fully vaccinated with DTaP should receive a dose of Tdap instead of waiting for the 11-12 year old check up.

  10. Immunization Recommendations Cont. • Adolescents - One dose of Tdap vaccine at age 11 or 12. • Catch up vaccination for unvaccinated 13 – 18 yrs. • Adults - All adults 19 yrs and older should receive a dose of Tdap, regardless of interval since Td vaccination • Adults 65 yrs and older can receive either Tdap product

  11. Immunization Recommendations – Priority Groups • Pregnant Women • Caregivers/household contacts of infants • Healthcare personnel • Priority to those with infant contact

  12. Pregnant Women • All pregnant women who have not been previously vaccinated with Tdap should get one dose of Tdap anytime after 20 weeks gestation. • Maternal pertussis antibodies transfer to the newborn • Protects the mother making her less likely to transmit pertussis to her infant • Women not vaccinated before or during pregnancy should receive Tdap immediately postpartum, before leaving the hospital or birthing center. Link to a story of a mother whose newborn baby contracted and died from pertussis : http://shotbyshot.org/pertussis/kaliahs-story/

  13. IHS 2 year old 4313314* Coverage

  14. FY 2012 Q2 – Age Appropriate DTaP coverage among 3 – 27 month olds

  15. Tdap Coverage among AdolescentsFY 2012 Q2

  16. Immunization Strategies • Review RPMS Immunization Package reports • 3-27 month old, Two year old and Adolescent • Follow up with patients who are not current with their vaccines • Generate lists of patients who are due for Tdap using “Lists and Letters” feature in the RPMS Immunization Package • Conduct Reminder/Recall activities on patients who are due • Expand access to vaccines • Review provider immunization policy • Standing orders for post-partum women • Consider alternative vaccination sites • School based vaccination? • Utilize pharmacists

  17. Resources • CDC pertussis site: http://www.cdc.gov/vaccines/vpd-vac/pertussis/default.htm#clinical • CDC guidelines for control of pertussis outbreaks: http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm • Northwest Portland Area Indian Health Board site: http://www.npaihb.org/ • State health department websites

  18. Portland Area Pertussis Update • Background • Increased cases in 2010, again in 2nd half of 2011 • Potential exposures from First Nations visitors, January, Lummi • Steady increases throughout Jan-Mar • April- WA DOH announces Pertussis Epidemic, cases surpass 1000

  19. Portland Area Pertussis Response • Following potential exposures at Lummi, assisted WA DOH in developing clinical guidance- sent to Area Clinical Directors 2/7/12 • Promed reports continued increase in pertussis cases- article distributed to clinic directors and immunizations coodrinators • "I think it ended up just being our time," Person [County Health Officer] said. "It ends up being everybody's time at some point." • 4/10/2010- Distributed another email to immunization coordinators and American Indian Health Commission members detailing WA epidemic and requesting sites prepare a pertussis response plan

  20. Portland Area Pertussis Response • Developed slides for Area Director’s report to the NPAIHB Quarterly Board Meeting. • Attended meeting on 4/18/2012 and responded to questions by delegates • Distributed vaccine coverage data by state, example Pertussis Response Plan and latest guidance by WA DOH 4/24 • Completed updates to NPAIHB website 4/26

  21. Portland Area Pertussis Response • Contacted by WA DOH to assist in distribution of Tdap vaccine for un/underinsured adults • Contacted sites by email with phone follow-up • Completed final requests by 5/1 • Attended American Indian Health Commission Immunization Workgroup meeting, 4/27

  22. Data

  23. Data

  24. Data

  25. Recommendations • ACIP recommendations for DTaP series for those 0 to 6 years, Tdap for adolescents and adults. • Pregnant woman 20 weeks or greater gestation • Provisional guidelines for adults over 64 • HCP- all HCP should receive Tdap vaccine • Diagnose, treat, report according to State/CDC guidelines

  26. Next Steps • Patient/community education • Produce digital stories for PSAs, clinic video displays • Develop key points for distribution to area Tribal newspapers, clinic newsletters • Maintain NPAIHB website with up to date information • Develop RPMS queries for surveillance to track cases/contacts • Encourage alternative vaccine sites • Engage Clinic Directors at upcoming CD meeting, 5/10 • Participate in panel discussion at Cross Border Public Health Meeting, 5/15 • Contact: CAPT Thomas Weiser, MD, MPH Medical Epidemiologist tweiser@npaihb.org

  27. Billings Area Experience

  28. Pertussis “Exposing” Indian Communities in MT One Reservation = Current Cluster • 3 (maybe 4) cases • 3 Indian children, 1 Non-Indian school teacher • Time potential for contacts to still become cases Two Reservations = Possible Cases Early 2012 Immunization Rates 3 to 27 Month Old • Service Unit Range = 91% to 40%

  29. Process Challenges • How to educate key players • Without burying them in emails • How to “positively” present facts that impact vaccine acceptance and disease spread • Vaccine efficacy only 80% - “you still need those shots” • Stay home until all Rx taken – “not just till you feel better” • How to leverage outbreak to improve immunization • Without scaring everyone into stampeding clinic • How to persuade (require) employees to get Tdap • National policy? • How to prioritize and deal with other pressing issues • New TB cases & oil boom STI impacts still happen

  30. Relationship Challenges - State Health • Limited understanding of Indian country and vaccine/care seeking behaviors (eg multiple locations) • False sense of security – stay calm, it is only one case – not sure why Washington is imploding – just investigate and vaccinate • Emphasis on case “jurisdiction” which makes impact of outbreak seem less until you start asking questions • Initial misunderstanding in use of state lab as “fail safe” systems to avoid missing cases

  31. Immunization Challenges • Low immunization protection rates • 40% (equals 32% if factor in 80% vaccine efficacy) • Transition to new MT “opt-in” registry • Majority Indian children records blocked to view • Clinic nurses can get parent permissions when child is in clinic but do not have registry edit capability for immediate access • PHNs cannot update recall lists to identify patients needing outreach visits (probably most vulnerable group)

  32. A good public health threat is exciting!!! • Mobilize team response – we’re all in this together - everyone has a role – how can I help you??? • Empower (challenge) staff to play CSI when assessing symptoms or doing contact investigations • Keep staff updated with tidbits of new information, changing disease patterns, whatever - make everyone feel vital to the response effort

  33. Success – Strategy Model GAME PLAN – KEY STRATIGIES Immunize Immunize Immunize Recognize Diagnosis Treat Evaluate Contacts Refer for Further Investigation and Reporting

  34. Success – Staff Resources • Empowered Pediatricians • Enthusiastic Public Health Nurses • Trained Pharmacists to Immunize • Laboratory to Monitor Lab Results • Hard Working Clinic Staff • Health Promotion for Digital Storytelling • Everyone as a TEAM (the dream)

  35. Current Tasks • Alert locum staff (walk-in & ER) to think (not miss) pertussis • Reach pregnant women • Coordinate closely with State and orient new State staff to Indian Country • Gain immediate public health emergency access to immunization registry • WHATEVER ELSE POPS UP

  36. Future Issue We have not been tested yet . . . what happens next???

More Related