Lessons Learned in Implementing a Cocoon Program to Prevent Infant Pertussis at Four

Kansas Hospitals

Elizabeth Lawlor, MSEpidemiologist

Coauthor: Martha Siemsen, ARNP-BC, Medical InvestigatorBureau of Epidemiology and Public Health Informatics

Kansas Department of Health and Environment

What is pertussis?

• Caused by bacterium Bordetella pertussis• Known as whooping cough• Highly contagious• Symptoms: uncontrollable, violent coughing –

can result in difficulty breathing• Can be fatal• Immunization can be used to protect against

pertussis

Number diagnosed with Pertussisby age group, United States 1997-2000

<6 months

6-11 months

1-4 years 5-9 years 10-19 years

≥20 years0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Age Group

Num

ber d

iagn

osed

with

per

tuss

is

Centers for Disease Control and Prevention. Pertussis – United States, 1997-2000. MMWR 2002; 51: 73-76.

Hospitalizations due to Pertussisby age group, United States 1997-2000

<6 months

6-11 months

1-4 years 5-9 years 10-19 years

≥20 years0

1000

2000

3000

4000

5000

6000

7000

8000

9000

0

10

20

30

40

50

60

70

80

90

Age Group

Num

ber d

iagn

osed

with

per

tuss

is

Perc

ent

hosp

italiz

ed

Centers for Disease Control and Prevention. Pertussis – United States, 1997-2000. MMWR 2002; 51: 73-76.

Pneumonia Secondary to Pertussis by age group, United States 1997-2000

<6 months

6-11 months

1-4 years 5-9 years 10-19 years

≥20 years0

1000

2000

3000

4000

5000

6000

7000

8000

9000

0

2

4

6

8

10

12

14

16

18

Age Group

Num

ber d

iagn

osed

with

per

tuss

is

Perc

ent d

iagn

osed

with

pne

umon

ia

Centers for Disease Control and Prevention. Pertussis – United States, 1997-2000. MMWR 2002; 51: 73-76.

Mortality due to Pertussis by age group, United States 1997-2000

<6 months

6-11 months

1-4 years 5-9 years 10-19 years

≥20 years0

1000

2000

3000

4000

5000

6000

7000

8000

9000

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Age Group

Num

ber d

iagn

osed

with

per

tuss

is

Perc

ent

mor

talit

y

Centers for Disease Control and Prevention. Pertussis – United States, 1997-2000. MMWR 2002; 51: 73-76.

Rise of Pertussis Cases Reported to the CDC

Centers for Disease Control and Prevention. Summary of Notifiable Diseases, 1994-2004. http://www.cdc.gov/osels/ph_surveillance/nndss/annsum/index.htm

1994 2000 2003 20040

5000

10000

15000

20000

25000

30000Pertussis in all patientsPertussis in children < 4years of age

Year

Num

ber o

f Con

firm

ed a

nd P

roba

ble

Case

s

Who Was the Source?

47%

20%

8%

25%

2004 Study

56%16%

6%

22%

2007 Study

Parent OtherGrandparentSibling

Bisgard et al. Infant pertussis: who was the source? Pediatr Infect Dis J. 2004; 23: 985-9.

Wendelboe et al. Transmission of Bordetella pertussis to Young Infants. Pediatr Infect Dis J. 2007; 26:293-299.

Cocooning

• 2001 - The Global Pertussis Initiative (GPI) recommended cocooning: – Immunization of family members and close contacts of the

newborn

• 2006 - ACIP recommended Tdap booster immunization

• Two groups are targeted:– Postpartum women before hospital discharge– Contacts of infants age < 1 year

Objectives of Pilot Program

• Increase pertussis awareness through education– Health care providers– Families of newborns

• To immunize 80% of postpartum women delivering at project hospitals

• To immunize 1 primary caregiver designated by the new mother

The chosen ones

• Number of births• Vaccines for Children

(VFC) enrollment • Location• Willingness to

participate

Initial Implementation

• January 2010: Presentations to hospitals and local health departments

• Goals:– Mom • Standing orders for postpartum Tdap• Tdap administered on hospital discharge

– Caregiver• Voucher given during pre-registration or during

hospital stay

Voucher

Pertussis Vaccine VoucherMom’s Initials: ____________ Date: ___________

Relationship to newborn: Parent Grandparent Other _________

Franklin County Health Department1418 South Main St, Ottawa, KS (785) 229-3530M, T, R, F 7 – 4:30, W 7 – 6:15

Results (January – June 2010)

Total number of births: 248

Post Partum Women

Number Vaccinated

Percent Vaccinated

208 83.9%

Results (January – June 2010)

Total number of births: 248

Post Partum Women

Number Vaccinated

Percent Vaccinated

208 83.9%

Results (January – June 2010)

Total number of births: 248

Primary Caregivers

Number Vaccinated

Percent Vaccinated

42 16.9%

Post Partum Women

Number Vaccinated

Percent Vaccinated

208 83.9%

Results (January – June 2010)

Total number of births: 248

Primary Caregivers

Number Vaccinated

Percent Vaccinated

42 16.9%

Post Partum Women

Number Vaccinated

Percent Vaccinated

208 83.9%

Time for a Change

• Postpartum vaccination on target• Primary caregiver vaccination rate lower than

expected• Barriers identified:– Fear of Needles– Time– Lost voucher

Local Health Department Differences

County 1 County 2

Appointment Needed? No Yes

Administration Fee Charged? No Yes

Local health department resources used

Healthy start nurses

Packets sent to new parents

Proximity to hospital Across the street Across the street

Caregiver Immunization Rates, January – June 27.9% 14.3%

Local Health Department Differences

County 1 County 2

Appointment Needed? No Yes

Administration Fee Charged? No Yes

Local health department resources used

Healthy start nurses

Packets sent to new parents

Proximity to hospital Across the street Across the street

Caregiver Immunization Rates, January – June 27.9% 14.3%

Process Enhancements

• Standing order for family member vaccination prior to mother and infant discharge

• Involve stake holders– Medical Records, Nursing staff, Pharmacists,

Pediatricians, OB/GYN, Local Health Departments

Stumbling Blocks

• Admission to the hospital versus no admission for designated family member– Liability concerns– Tracking methods– Cost

• Hospital conglomerates

Ransom Memorial

Feb-10

Mar-1

0

Apr-10

May-1

0

Jun-10

Jul-1

0

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-1

10%

20%

40%

60%

80%

100%

Perc

ent o

f Car

egiv

ers

Vacc

inat

ed

(Bas

ed o

n nu

mbe

r of b

irth

s)

Began vaccinating caregiver at hospital

Lessons Learned

• The best laid plans• There’s more than one way to skin a cat• Get them while they’re hot• Don’t throw the baby out with the bath water• It takes a village

Current Activities

• Local health departments offered Tdap to vaccinate new parents

• Tdap offered to hospitals to vaccinate mom and caregiver

Needed Actions

• Continued education of hospitals and OB/Gyns about importance of vaccinating – New recommendations by ACIP

• Educate new moms on pertussis– Brochures, etc.

• Work with hospitals to overcome barriers to vaccinating caregivers

Acknowledgements• KDHE Staff

– Martha Siemsen, ARNP-BC– Sue Bowden, RN, BS– Immunization Staff

• Franklin County Health Department– Midge Ransom – Administrator– Rebecca Hastings – Immunizations

• Montgomery County Health Department– Ruth Bardwell – Administrator– Carolyn Mueller – Immunizations

• Dickinson County Health Department– Linda Davies – Administrator– Brenda Weaver – Immunizations

• All HCP’s who care for pregnant women and their newborn infants

• Ransom Memorial Hospital– Larry Felix – Administrator– Justine Fine – OB Nurse Manager

• Coffeyville Memorial Hospital– Jerry Marquette – Administrator– Carla Robson – OB Nurse Manager

• Memorial Hospital-Abilene– Mark A Miller – Administrator– Teresa Hudson – OB Nurse Manager

• Mercy Hospital Independence– Eric Ammons - Administrator– Jenn Wintjen – OB Nurse Manager

Elizabeth Lawlor, MSEpidemiologist

Bureau of Epidemiology and Public Health InformaticsKansas Department of Health and Environment

785-368-8208 elawlor@kdheks.gov