Vaccine Preventable Diseases in North Carolina: What’s Happening

1. Vaccine Preventable Diseases in North Carolina: What’s Happening Elizabeth T. Draper RN Nurse Consultant NC Immunization Branch August 2009

2. But….. Haven’t we eliminated vaccine preventable diseases?? • Common myth among those that do not want to immunize their children is that we have eradicated them • Most are at very low levels in the U.S. • Some are still epidemic in other parts of the world—and we live in a small world • If vaccine rates drop in the U.S. old diseases may reappear

3. So what are we seeing in NC? Pertussis Mumps Hepatitis B But you do not want me to try and speak to this—trust me!!!

4. But we also get calls about….. Measles Rubella/CRS Diphtheria And if the need arose we would follow-up on Polio Tetanus

5. AnthraxDiphtheriaHepatitis AHepatitis B, acuteHaemophilus influenzae type b (Hib) – all invasive disease *Human Papillomavirus (HPV)*Influenza (Flu) – only peds deathsJapanese Encephalitis (JE)Lyme Disease Measles Meningococcal Monkeypox Mumps Pertussis (Whooping Cough)*Pneumococcal – other than meningitis Poliomyelitis (Polio)Rabies*Rotavirus Rubella (German Measles) and congenital rubella syndrome*Shingles (Herpes Zoster)SmallpoxTetanus (Lockjaw)Typhoid Fever, acute*Varicella (Chickenpox)Yellow Fever Vaccine Preventable Diseases (* currently not reportable in NC)

6. Measles 2003-2009* *Preliminary data, as of 07/24/09

7. Measles Clinical case definition Measles is an illness characterized by all of the following: · A generalized maculopapular rash lasting 3 days · A temperature 101F° (38.3°C) · Cough, coryza, or conjunctivitis Laboratory criteria for diagnosis · Positive serologic test for measles immunoglobulin M (IgM) antibody · Significant rise in measles antibody level by any standard serologic assay · Isolation of measles virus from a clinical specimen

8. Measles Case classification Probable: A case that meets the clinical case definition, has noncontributory or no serologic or virologic testing, and is not epidemiologically linked to a confirmed case. Confirmed: A case that is laboratory confirmed or that meets the clinical case definition and is epidemiologically linked to a confirmed case. A laboratory confirmed case does not need to meet the clinical case definition.

9. Measles Even though no cases have been reported in NC in the past 19 months we are frequently following up on NC residents that have been exposed to lab confirmed cases at camps and conferences in other states as well as air travel. We have been lucky so far but…………a case of measles for NC could be no more than a plane ride away. MMR vaccine is the best way to prevent this disease Be afraid…be very afraid

10. Mumps 2003-2009* *Preliminary data, as of 07/24/09

11. Mumps Clinical case definition: • An illness with acute onset of unilateral or bilateral tender, self-limited swelling of the parotid and or other salivary gland(s), lasting at least 2 days, and without other apparent cause. Clinically compatible illness: • Infection with mumps virus may present as aseptic meningitis, encephalitis, hearing loss, orchitis, oophoritis, parotitis or other salivary gland swelling, mastitis or pancreatitis., • Laboratory criteria • Isolation of mumps virus from clinical specimen, or●● • Detection of mumps nucleic acid (e.g., standard or real time RT-PCR assays), or●● • Detection of mumps IgM antibody, or●● • Demonstration of specific mumps antibody response in absence of recent vaccination, either ●●a fourfold increase in IgG titer as measured by quantitative assays, or a seroconversion from negative to positive using a standard serologic assay of paired acute and convalescent serum specimens.

12. Mumps Laboratory criteria • Isolation of mumps virus from clinical specimen, or●● • Detection of mumps nucleic acid (e.g., standard or real time RT-PCR assays), or • Detection of mumps IgM antibody, or • Demonstration of specific mumps antibody response in absence of recent vaccination, either ●●a fourfold increase in IgG titer as measured by quantitative assays, or a seroconversion from negative to positive using a standard serologic assay of paired acute and convalescent serum specimens

13. Mumps Case classification Probable: A case that meets the clinical case definition without laboratory confirmation and is epidemiologically linked to a clinically compatible case. Confirmed: A case that 1) meets the clinical case definition or has clinically compatible illness, and 2) is either laboratory confirmed or is epidemiologically linked to a confirmed case.

14. National Mumps Outbreak, 2006 • Source of the initial cases unknown • Outbreak peaked in mid-April • Median age of persons reported with mumps was 22 years • Highest incidence was among young adults 18-24 years of age, many of whom were college students • Transmission of mumps virus occurred in many settings, including college dormitories and healthcare facilities

15. Factors Contributing To National Mumps Outbreak, 2006 • College campus environment • Lack of a 2-dose MMR college entry requirement or lack of enforcement of a requirement • Delayed recognition and diagnosis of mumps • Mumps vaccine failure • Vaccine might be less effective in preventing asymptomatic infection or atypical mumps than in preventing parotitis • Waning immunity

16. Updates during the outbreak In a specially convened meeting on May 17, 2006, ACIP redefined evidence of immunity to mumps through vaccination as follows: • One dose of a live mumps virus vaccine for preschool children and adults not at high risk • Two doses for children in grades K–12 and adults at high risk (i.e., persons who work in health-care facilities, international travelers, and students at post-high school educational institutions) Other criteria for evidence of immunity are unchanged: • Birth before 1957 • Documentation of physician-diagnosed mumps • Laboratory evidence of immunity

17. After the outbreak in NC……….. June 2, 2006--Memo “ Effective immediately, providers enrolled in the UCVDP may administer two doses of state-supplied MMR vaccine to all students attending post-high school educational institutions (i.e., colleges, universities, community and technical schools). “ July 1, 2008 - -Memo “This rule change also impacts mumps vaccination. Individuals will now be required to receive a second dose of mumps vaccine before enrolling in school, college or university for the first time on or after July 1, 2008.”

18. Next………….Pertussis

19. Pertussis Clinical Features • Bacterial respiratory illness Bordetella pertussis, gram-negative bacteria • Incubation period 5-10 days (range 4-21 days) • Insidious onset, similar to minor upper respiratory infection with nonspecific cough • Fever usually minimal throughout course of illness • Cough can last for several weeks or months

20. Pertussis disease • Whooping Cough • Cough of 100 days • Highly contagious • Spread by close contact • Infants less than 12 months of age suffer most severe complications • Incidence is increasing

21. Pertussis Epidemiology • Reservoir Human adolescents and adults • Transmission Respiratory droplets • Communicability Maximum in catarrhal stage Secondary attack rate up to 80%

22. Pertussis Clinical Features • Catarrhal stage 1-2 weeks • Paroxysmalcough stage 1-6 weeks • Convalescence Weeks to months

23. Clinical Case Definition Clinical Case Definition A cough illness lasting at least 2 weeks with one of the following: paroxysms of coughing, inspiratory “whoop,” or post-tussive vomiting, and without other apparent cause (as reported by a health professional). Laboratory Criteria for Diagnosis Isolation of B. pertussis from a clinical specimen, or Positive polymerase chain (PCR) reaction assay for B. pertussis.

24. Reportable Classifications Case Classification Confirmed an acute cough illness of any duration associated with B. pertussis isolation, or a case that meets the clinical case definition and is confirmed by PCR, or a case that meets the clinical definition and is epidemiologically-linked directly to a case confirmed by either culture or PCR. Probable Meets the clinical case definition, is not laboratory confirmed, and is not epidemiologically-linked to a laboratory confirmed case.

25. Initial steps for a case • Test • Start antibiotic treatment • Isolate at home for 5 days • Notify the LHD • Identify and recommend chemoprophylaxis to close contacts and high-risk contacts These are not in order and may happen simultaneously

26. Close Contacts Defined A person who had face-to-face exposure within 3 feet of a symptomatic patient. Respiratory droplets are generated during coughing, sneezing, or talking and during the performance of certain procedures such bronchoscopy or suctioning; these particles as propelled through the air for distances of approximately 3 feet. MMWR December 9, 2005 / Vol. 54 / No. RR-14

27. Close Contacts Defined • Close contacts also can include persons who • • have direct contact with respiratory, oral, or nasal secretions from a symptomatic patient (e.g., cough, sneeze, sharing food and eating utensils, • mouth-to-mouth resuscitation, or performing a medical examination of the mouth, nose, and throat) • • shared the same confined space in close proximity with a symptomatic patient for >1 hour MMWR December 9, 2005 / Vol. 54 / No. RR-14

28. Postexposure Prophylaxis (PEP) CDC recommends administration of chemoprophylaxis to all close contacts and all household members of a pertussis case-patient, regardless of age and vaccination status; this might prevent or minimize transmission

29. Recommended Treatment Recommended treatment • Macrolide antibiotic — 5-day course of azithromycin — 7-day course of clarithromycin — 14-day course of erythromycin. • Alternative agent — 14-day course of trimethoprim-sulfamethoxazole. • Treat persons aged >1 year within 3 weeks of cough onset. • Treat infants aged <1 year within 6 weeks of cough onset. Medications and dosages for treatment of a case and PEP of close contacts is the same MMWR December 9, 2005 / Vol. 54 / No. RR-14

30. Pertussis rates in NC *Unofficial Lab confirmed only

31. So are pertussis rates goingor ? Since the 1980s, the number of reported pertussis cases has steadily increased, especially among adolescents and adults

32. Why increase in pertussis ?? • Increased awareness of the disease • Increased use of diagnostic tests for adolescents and adults. • Immunity to pertussis wanes approximately 5–10 years after completion of childhood vaccination, leaving adolescents and adults susceptible to pertussis • Adolescents and adults in turn are reservoirs for pertussis and pass onto younger children and infants

33. Obstacles/Misconceptions • Providers not notifying LHD as soon as pertussis is suspected • Providers ordering serologies instead of NP swab • Providers that refuse to treat contacts because they are up to date on vaccine • Providers that do not want to treat asymptomatic contacts • Providers not acting until lab results are back • Misunderstanding of isolation • Parents believing that this childhood illness no longer occurs • Belief that administration of a Tdap after exposure eliminates need for PEP for close contacts.

34. Talking points for media calls • Pertussis is endemic in the US • Clusters happen on a seasonal basis • The vaccine is not 100% effective • Immunity wanes after time with the primary series • NC mandated Tdap in 2008 for 6th graders and college entry but it will take several years for this to have an effect on the population • Adults <65 need 1 Tdap as well; no mandate for this • Control measures involve PEP for close contacts with antibiotics and to isolate and treat the ill • The goal is to prevent severe illness and save lives particularly in infants

35. What can we do ???? Most recent tool we have is………… Tdap

36. Tdap ACIP Recommended February 2006 • Available in NC March 2006 • Two Formulations: • Adacel (licensed for 11 through 64 years of age) • Boostrix (licensed for 10 through 18 years of age) until recently; 12/8/08 FDA approved for Boostrix to cover through age 64; NCIR will be updated soon so providers that administer adult Tdap can begin using in this manner.

37. Tdap • The primary objective of replacing a dose of Td with Tdap is to protect the vaccinated adult against pertussis. • The secondary objective of adult Tdap vaccination is to reduce the reservoir of pertussis in the population at large, AND thereby potentially decrease exposure of persons at increased risk for complicatedinfection (e.g., infants), and reduce the cost and disruption of pertussis in health-care facilities and other institutional settings.

38. New Tdap Requirement Effective January 1, 2008, the administrative rule, 10A NCAC 41A.0401, has been changed, adding requirements for one booster dose of Tdap (tetanus/diphtheria/pertussis) vaccine to be given to the following age groups: • All individuals attending public school who are entering the 6th grade on or after August 1, 2008, if five years or more have passed since the last dose of tetanus/diphtheria toxoid • All individuals not attending public schools (i.e., private, home-school, non-traditional schools) who are 12 years of age on or after August 1, 2008, if five years or more have passed since the last dose of tetanus/diphtheria toxoid. • Individuals enrolling in college or university for the first time on or after July 1, 2008, if a tetanus/diphtheria toxoid or tetanus/diphtheria/pertussis vaccine has not been administered within the past 10 years.

39. Tdap & Adolescents • Adolescents aged 11-18 should receive a single dose of Tdap instead of Td for booster • Tdap can be administered at the same visit as any other age indicated vaccine • Recommended interval between last dose of DTaP and Tdap is 5 years

40. Tdap & Adults • Adults aged 19–64 years should receive a single dose of Tdap to replace a single dose of Td for active booster vaccination against tetanus, diphtheria, and pertussis if they received their last dose of Td >10 years earlier. • Replacing 1 dose of Td with Tdap will reduce the morbidity associated with pertussis in adults and might reduce the risk for transmitting pertussis to persons at increased risk for pertussis and its complications.

41. Interval exceptions • Tdap may be administered at any time after Td if the benefit of protection against pertussis outweighs the risk of a local reaction. Some situations might be: • HCW that has direct patient contact • Adolescent or adult that has close contact with children < 12 months of age • During a pertussis outbreak

42. Tdap & Adolescents • Adolescents aged 11-18 should receive a single dose of Tdap instead of Td for booster • Tdap can be administered at the same visit as any other age indicated vaccine

43. Tdap & Adults • Adults aged 19–64 years should receive a single dose of Tdap to replace a single dose of Td for active booster vaccination against tetanus, diphtheria, and pertussis if they received their last dose of Td >10 years earlier. • Replacing 1 dose of Td with Tdap will reduce the morbidity associated with pertussis in adults and might reduce the risk for transmitting pertussis to persons at increased risk for pertussis and its complications.

44. Any questions ????

45. Resources • Guidelines for the Control of Pertussis Outbreaks"The Pertussis Guide", 2000-- some chapters updated in 2006http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm • Epidemiology and Prevention of Vaccine-Preventable Diseases("The Pink Book", 10th edition; Mar. 2008) http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm • MMWR Recommendations and Reports December 9, 2005 / 54(RR14) Recommended Antimicrobial Agents for the Treatment and Postexposure Prophylaxis of Pertussis 2005 CDC Guidelines http://www.cdc.gov/mmwr/PDF/rr/rr5414.pdf • Surveillance of Vaccine-Preventable Diseases (4th edition, 2008) http://www.cdc.gov/vaccines/pubs/surv-manual/default.htm