Pertussis Update 5/2/2012

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

20. 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

21. 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

22. 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

23. Data

24. Data

25. Data

26. 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

27. 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

28. Billings Area Experience

29. 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%

30. 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

31. 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

32. 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)

33. 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

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

35. 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)

36. 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

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