Prevention of pertussis

Pertussis Pertussis Prevention WithPrevention With Tdap Vaccine Tdap Vaccine

&&Postexposure Postexposure

Prophylaxis and Prophylaxis and Treatment of Treatment of SymptomaticSymptomatic

PertussisPertussisDoug Montgomery July 1 Doug Montgomery July 1 20102010

References References CDC / RIPC / CDPHCDC / RIPC / CDPH

CDPH WEBSITECDPH WEBSITE RIPC INFORMATIONRIPC INFORMATION

Prevention of Pertussis, Tetanus, and Diphtheria Prevention of Pertussis, Tetanus, and Diphtheria Among Pregnant and Postpartum Women and Among Pregnant and Postpartum Women and Their InfantsTheir Infants

MMWRMMWR May 30, 2008 / 57 (04);1-47,51May 30, 2008 / 57 (04);1-47,51

Recommended Antimicrobial Agents for the Recommended Antimicrobial Agents for the Treatment and Postexposure Prophylaxis of Treatment and Postexposure Prophylaxis of PertussisPertussis

MMWR December 9, 2005 / 54(RR14);1-MMWR December 9, 2005 / 54(RR14);1-1616

Pertussis Guidelines Pertussis Guidelines The guidelines presented today 7/01/2010 The guidelines presented today 7/01/2010

are primarily based on CDC/CDPH are primarily based on CDC/CDPH informationinformation

The Goal is to make providers aware of the The Goal is to make providers aware of the pertussis epidemic, emphasize the pertussis epidemic, emphasize the importance of Immunization, and provide importance of Immunization, and provide basic information re Epidemiology, case basic information re Epidemiology, case definitions, and potential clinical scenarios definitions, and potential clinical scenarios where antibiotic therapy may be indicated.where antibiotic therapy may be indicated.

More specific indications for PCR testing More specific indications for PCR testing are in the process of development by are in the process of development by Region ( probable Mid July release)Region ( probable Mid July release)

More specific indications for Post Exposure More specific indications for Post Exposure Prophylaxis ( PEP ) & Symptomatic Prophylaxis ( PEP ) & Symptomatic treatment are in the process of treatment are in the process of development by Region ( probable Mid July development by Region ( probable Mid July release)release)

Pertussis Epidemic in Pertussis Epidemic in CaliforniaCalifornia

ACOG E mail 6/28/2010 Pertussis is Epidemic in California

New Moms Need Tdap Protection

CDPH-----WHOOPING COUGH EPIDEMIC MAY BE WORST IN 50 YEARS Date: 6/23/2010

As of June 15, California had recorded 910 cases of pertussis, a four-fold increase from the same period last year when 219 cases were recorded. Five infants — all under three months of age — have died from the disease this year. In addition, 600 more possible cases of pertussis are being investigated by local health departments

Pertussis is Epidemic in California

New Moms Need Tdap Protection

ACOG E mail In 2010, California is on pace to have the highest number of

pertussis (whooping cough) cases in 50 years. The number of whooping cough cases so far this year is more than four times the number for the same period last year. Young infants are most vulnerable to the devastating effects of pertussis.

Thousands of infant hospitalizations are anticipated. Already several newborns have died. In most cases, infants

catch pertussis from a family member or household contact. So, it is important to make sure that everyone is protected

from pertussis by vaccination – children, adolescents, and adults, especially those with close contact with infants. Neither vaccination or illness from whooping cough provides lifetime immunity.

Pathogenesis of Pathogenesis of Pertussis Pertussis

Bordetella pertussis is a fastidious Bordetella pertussis is a fastidious gram-negative coccobacillusgram-negative coccobacillus

Pertussis is primarily a toxin-mediated disease. The Pertussis is primarily a toxin-mediated disease. The bacteria attach to the cilia of the respiratory bacteria attach to the cilia of the respiratory epithelial cells, produce toxins that paralyze the epithelial cells, produce toxins that paralyze the cilia, and cause inflammation of the respiratory cilia, and cause inflammation of the respiratory tract, which interferes with the clearing of tract, which interferes with the clearing of pulmonary secretions. pulmonary secretions.

Pertussis antigens appear to allow the organism to Pertussis antigens appear to allow the organism to evade host defenses, in that evade host defenses, in that lymphocytosis lymphocytosis is is promoted but chemotaxis is impaired. Until recently promoted but chemotaxis is impaired. Until recently it was thought that B. pertussis did not invade the it was thought that B. pertussis did not invade the tissues. However, recent studies have shown the tissues. However, recent studies have shown the bacteria to be present in alveolar macrophages.bacteria to be present in alveolar macrophages.

Pertussis During Pertussis During Pregnancy Pregnancy

Case reports suggest that the morbidity Case reports suggest that the morbidity

of pertussis is of pertussis is Not increasedNot increased among pregnant women compared with among pregnant women compared with nonpregnant women. nonpregnant women.

NONO causal relationshipcausal relationship with with abnormal fetal development, fetal abnormal fetal development, fetal morbidity, or adverse outcome of morbidity, or adverse outcome of pregnancy has been confirmed.pregnancy has been confirmed.

Clinical symptomsClinical symptoms Classic pertussis is characterized by Classic pertussis is characterized by

three phasesthree phases: :

1) catarrhal1) catarrhal

2) paroxysmal 2) paroxysmal

3) convalescent3) convalescent A typical case of pertussis in children A typical case of pertussis in children

and adults starts with a cough and and adults starts with a cough and runny nose for one-to-two weeks, runny nose for one-to-two weeks, followed by weeks to months of rapid followed by weeks to months of rapid coughing fits that sometimes end with coughing fits that sometimes end with a whooping sound. Fever is rare. a whooping sound. Fever is rare.

Early phase - Early phase - Catarrhal Catarrhal phasephase

Catarrhal phaseCatarrhal phase lasts 1--2 weeks and lasts 1--2 weeks and consists of a watery nasal discharge and consists of a watery nasal discharge and frequent cough, frequent sneezing, and injection frequent cough, frequent sneezing, and injection of the conjunctiva, often with lacrimation. The of the conjunctiva, often with lacrimation. The cough initially suggests tracheal irritation (e.g., cough initially suggests tracheal irritation (e.g., a tickle in the throat) and is short, sharp, a tickle in the throat) and is short, sharp, hacking, and isolated (as distinguished from hacking, and isolated (as distinguished from paroxysmal). paroxysmal).

The cough is equally persistent during day and The cough is equally persistent during day and night and rarely croupy or hoarse. Fever is night and rarely croupy or hoarse. Fever is uncommon during any phase uncommon during any phase unless the illness unless the illness is complicated by secondary infection or is complicated by secondary infection or coinfectioncoinfection. .

Paroxysmal phaseParoxysmal phase Paroxysmal phaseParoxysmal phase lasts 2--6 weeks. lasts 2--6 weeks. Bursts of coughing increase in frequency during the Bursts of coughing increase in frequency during the

first one to two weeks, remain constant for two to three first one to two weeks, remain constant for two to three weeks, and then gradually begin to decrease in weeks, and then gradually begin to decrease in frequency. Paroxysmal attacks occur more frequently at frequency. Paroxysmal attacks occur more frequently at night, with an average of 15-24 attacks per 24 hours. night, with an average of 15-24 attacks per 24 hours.

Adults may experience greater severity of illnessAdults may experience greater severity of illness than adolescents, including cough-related than adolescents, including cough-related incontinenceincontinence in 28% of cases in women; in up to 5% of in 28% of cases in women; in up to 5% of cases patients may experience one or more : cases patients may experience one or more : rib rib fracturefracture,, syncope syncope, or , or pneumoniapneumonia, or they require , or they require hospitalization. hospitalization.

Approximately one third of adults and adolescents Approximately one third of adults and adolescents lose lose weightweight during the illness. Anecdotal reports of during the illness. Anecdotal reports of pneumothorax, seizures, and stroke have been pneumothorax, seizures, and stroke have been reportedreported..

Paroxysmal CoughingParoxysmal CoughingClassic Sx InfantsClassic Sx Infants

A typical paroxysm in infants is characterized A typical paroxysm in infants is characterized by a succession of coughs that follow each by a succession of coughs that follow each other without inspiration. Paroxysms terminate other without inspiration. Paroxysms terminate in typical cases with inspiratory "whoop" and in typical cases with inspiratory "whoop" and can be followed by posttussive vomiting.can be followed by posttussive vomiting.

Infants may have coughing fits or “ paroxysms” Infants may have coughing fits or “ paroxysms” that last as long as several minutes. The that last as long as several minutes. The coughing can be so severe that babies vomit, coughing can be so severe that babies vomit, pass out, or even have seizures. In infants, the pass out, or even have seizures. In infants, the coughing spell often ends in a “whoop” sound. coughing spell often ends in a “whoop” sound.

Paroxysms can occur more frequently at night Paroxysms can occur more frequently at night

Paroxysmal CoughingParoxysmal CoughingAdults & Adolescents SxAdults & Adolescents Sx

The illness can be milder and the The illness can be milder and the characteristic whoop characteristic whoop absentabsent in children, adolescents, and adults who in children, adolescents, and adults who were were previously vaccinated.previously vaccinated.

Adolescents and adults and children partially protected by Adolescents and adults and children partially protected by the vaccine may become infected with B. pertussis but may the vaccine may become infected with B. pertussis but may have milder disease than infants and young children. have milder disease than infants and young children. Pertussis infection in these persons may be asymptomatic, Pertussis infection in these persons may be asymptomatic, or present as illness ranging from a mild cough illness to or present as illness ranging from a mild cough illness to classic pertussis with persistent cough. Inspiratory whoop is classic pertussis with persistent cough. Inspiratory whoop is not common. not common.

Whooping cough in adults causes coughing fits. In adults Whooping cough in adults causes coughing fits. In adults you don’t hear the characteristic “whoop” sound toddlers you don’t hear the characteristic “whoop” sound toddlers make when they have the disease. But it can cause vomiting, make when they have the disease. But it can cause vomiting, broken ribs, and pneumonia, and coughing can last for broken ribs, and pneumonia, and coughing can last for monthsmonths

CConvalescent phaseonvalescent phase Clinical symptomsClinical symptoms

CConvalescent phaseonvalescent phase of pertussis of pertussis typically lasts 2--6 weeks. Symptoms typically lasts 2--6 weeks. Symptoms can persist for can persist for >>6 months. Factors 6 months. Factors that can lessen the severity of that can lessen the severity of B. pertussisB. pertussis infection include infection include residual immunity from previous residual immunity from previous infection or vaccination and use of infection or vaccination and use of macrolide antimicrobials in the macrolide antimicrobials in the catarrhal (early) phase of the illness. catarrhal (early) phase of the illness.

Epidemiology / Epidemiology / TransmissionTransmission

Studies show that about 75% of Studies show that about 75% of pertussis infections among babies are pertussis infections among babies are contracted from household members contracted from household members

Pertussis is highly infectious, with Pertussis is highly infectious, with attack rates among exposed, attack rates among exposed, nonimmune nonimmune household contacts as household contacts as high as 90%.high as 90%. The most infectious The most infectious periods are the periods are the catarrhal and early catarrhal and early paroxysmalparoxysmal phases. phases.

Epidemiology / Epidemiology / TransmissionTransmission

Pertussis is transmitted via Pertussis is transmitted via large respiratory large respiratory droplets generated by coughing or sneezing droplets generated by coughing or sneezing or direct contact with respiratory secretionsor direct contact with respiratory secretions

B. pertussisB. pertussis can be recovered from can be recovered from dried mucus dried mucus for up to 3 daysfor up to 3 days. .

Incubation period is typically 7-10 but may Incubation period is typically 7-10 but may range from 5-21 days and as long as 41 days.range from 5-21 days and as long as 41 days.

Symptomatic Adults & Adolescents are infectious until 21 days after onset of paroxysmal cough if no (or partial) treatment is given

Adolescents and Adults with previous vaccination Adolescents and Adults with previous vaccination or infection, the or infection, the infectious period typicallyinfectious period typically is is <<21 days21 days. .

Untreated infants may remain Untreated infants may remain infectious for 6 infectious for 6 weeks or longerweeks or longer. .

Droplet PrecautionsDroplet Precautions Surgical mask Ok ( N 95 not necessary)Surgical mask Ok ( N 95 not necessary) Gloves / Consider Gown Gloves / Consider Gown Frequent hand washingFrequent hand washing Transmission risk within ~ 3 feet or less Transmission risk within ~ 3 feet or less

of a cough , sneeze, face to face talking , of a cough , sneeze, face to face talking , or medical procedure if droplet or medical procedure if droplet precautions not taken precautions not taken

(ie Swab nostril with no mask / gloves)(ie Swab nostril with no mask / gloves) Not necessary to close hospital room Not necessary to close hospital room

doors or have negative pressuredoors or have negative pressure

Treatment of Pertussis Treatment of Pertussis Decreases TransmissionDecreases Transmission

Patients are considered to be non-Patients are considered to be non-infectious after completing the fifth day infectious after completing the fifth day of appropriate antimicrobial treatment; of appropriate antimicrobial treatment; however, they should complete a full however, they should complete a full regimen to avoid bacterial relapse. regimen to avoid bacterial relapse.

Case ClassificationCase ClassificationClinical Factors to ConsiderClinical Factors to Consider Is there an epidemiologic link to a

confirmed pertussis case , with cough >/= 2 weeks (with no other apparent cause)

An epidemiologic link = exposure to a case confirmed by either culture or PCR

Cough Characteristics and timing are key —Date of cough onset, duration of cough —Paroxysms, whoop, posttussive

vomiting Increase the specificity for Pertussis

Dx therefore high suspicion for + case.

Close contact definition

Those who have had direct contact with respiratory, oral or nasal secretions from a symptomatic case (catarrhal or paroxysmal stages), e.g., a cough or sneeze in the face, sharing food/eating utensils, kissing

Performing a medical examination of the nose and throat ( without mask / gloves )

Sharing a confined space in close proximity for a prolonged period of time (≥1 hour) with a symptomatic case.

High risk (for severe pertussis disease )

Contact Definition

Contacts at high risk for severe pertussis disease and adverse outcomes include:

1 ) Contacts who may transmit pertussis to a high risk person (healthcare or childcare workers)

2 ) Pregnant or recently post-partum women 3 ) Infants <6 months of age, especially premies4 ) Unimmunized infants and children5 ) Persons with neuromuscular disease 6 ) Persons who have severe underlying disease

such as chronic lung disease or cystic fibrosis or immunocompromised

PCR recommended for PCR recommended for DiagnosisDiagnosis

(KP Regional Indications (KP Regional Indications Pending)Pending) DNA amplification (e.g., PCR) to detect DNA amplification (e.g., PCR) to detect

B. pertussisB. pertussis has increased sensitivity and has increased sensitivity and more rapid turnaround time when more rapid turnaround time when compared to culture. Antibiotics and compared to culture. Antibiotics and previous vaccination may decrease the previous vaccination may decrease the sensitivity ; however PCR may still be sensitivity ; however PCR may still be performedperformed

Perform when symptoms of classic pertussis Perform when symptoms of classic pertussis are present ( are present ( >>2 weeks of cough with no 2 weeks of cough with no other apparent cause )other apparent cause )

Not all patients will exhibit paroxysmal Not all patients will exhibit paroxysmal cough, or whoop ,or posttussive emesis.cough, or whoop ,or posttussive emesis.

Nasopharyngeal swab Nasopharyngeal swab collectioncollection

Validate with PCR kit Validate with PCR kit instructionsinstructions

1. Put on mask and gloves.1. Put on mask and gloves. 2. Have patient sit with head against a wall as patients have 2. Have patient sit with head against a wall as patients have

a tendency to pull away during this procedure.a tendency to pull away during this procedure. 3. Insert swab into one nostril 3. Insert swab into one nostril straight back (not straight back (not

upwardsupwards) and continue along the floor of the nasal passage ) and continue along the floor of the nasal passage for several centimeters until reaching the nasopharynx for several centimeters until reaching the nasopharynx (resistance will be met). The distance from the nose to the (resistance will be met). The distance from the nose to the ear gives an estimate of the distance the swab should be ear gives an estimate of the distance the swab should be inserted. Do not force swab, if obstruction is encountered inserted. Do not force swab, if obstruction is encountered before reaching the nasopharynx, remove swab and try the before reaching the nasopharynx, remove swab and try the other side.other side.

4. Rotate the swab gently for ~ 10-15 seconds to loosen the4. Rotate the swab gently for ~ 10-15 seconds to loosen the

epithelial cells.epithelial cells. 5. Remove swab and immediately inoculate transport media5. Remove swab and immediately inoculate transport media

Postexposure Prophylaxis Postexposure Prophylaxis (PEP)(PEP)

and Treatment of Disease and Treatment of Disease Antimicrobial treatment administered in the Antimicrobial treatment administered in the

early (catarrhal)early (catarrhal) phase of the illness can phase of the illness can modify the severitymodify the severity of the symptoms. of the symptoms.

An antimicrobial generally An antimicrobial generally does not modify does not modify the severitythe severity or the course of the illness or the course of the illness after paroxysmal coughafter paroxysmal cough is established is established but is used to but is used to eliminate eliminate B. pertussisB. pertussis and and halt transmissionhalt transmission..

Without Without use of an effective antimicrobial, use of an effective antimicrobial, B. pertussisB. pertussis can be recovered can be recovered for 21 days or for 21 days or longer from adult and adolescent longer from adult and adolescent patientspatients. .

Post-exposure chemoprophylaxis (PEP)

People with the highest priority for PEP include:

1)close contacts in household, childcare, and healthcare settings;

2)close contacts at high risk for severe disease and adverse outcomes;

3)close contacts who may transmit disease to persons at high risk for severe disease;

4)and close contacts in group settings where close interactions occur (e.g., after-school care groups, playgroups, groups of close friends, teammates, etc.).

PEPPEP&&

Treatment of DiseaseTreatment of DiseaseDuring PregnancyDuring Pregnancy

Early recognition of pertussis in a pregnant Early recognition of pertussis in a pregnant woman is necessary to ensure the effectiveness woman is necessary to ensure the effectiveness of treatmentof treatment ( review Sx/Sx CDPH Info sheet) ( review Sx/Sx CDPH Info sheet)

Antimicrobial treatment and prophylaxis are Antimicrobial treatment and prophylaxis are effective in preventing transmission of pertussis to effective in preventing transmission of pertussis to neonates. neonates.

A macrolide is administered to a woman with A macrolide is administered to a woman with pertussis that is acquired late in pregnancy or pertussis that is acquired late in pregnancy or shortly before delivery, her household contacts, and shortly before delivery, her household contacts, and the neonate. the neonate.

Post-exposure chemoprophylaxis (PEP)

INDICATIONS

CDC and AAP recommend PEP for all close contacts (of confirmed cases) , regardless of age or immunization status.

Starting PEP ≥3 weeks after exposure to an infectious case is probably of no benefit to the contact.

Postexposure Prophylaxis Postexposure Prophylaxis (Regional guidelines (Regional guidelines

Pending)Pending)

Administration of postexposure prophylaxis to Administration of postexposure prophylaxis to asymptomatic household contacts asymptomatic household contacts within 21 within 21 days of onset of coughdays of onset of cough in the index in the index patient ,can prevent symptomatic infection. patient ,can prevent symptomatic infection.

PEP recommended for all household close PEP recommended for all household close contacts of contacts of confirmed casesconfirmed cases

Coughing (symptomatic) household members of a Coughing (symptomatic) household members of a pertussis patient should be treated as if they pertussis patient should be treated as if they have pertussis. have pertussis.

Low Threshold for PEP in exposure settings that Low Threshold for PEP in exposure settings that include infants aged <12 months or women in include infants aged <12 months or women in the third trimester of pregnancy the third trimester of pregnancy

Tx is the same for Tx is the same for Symptomatic Pertussis & PEPSymptomatic Pertussis & PEP

Azithromycin.Azithromycin. Adults: 500 mg on day 1, Adults: 500 mg on day 1, followed by 250 mg per day on days 2--5.followed by 250 mg per day on days 2--5.

ClarithromycinClarithromycin. Adults: 500 mg po bid for . Adults: 500 mg po bid for 7 days.7 days.

ErythromycinErythromycin. Erythromycin estolate 500 . Erythromycin estolate 500

mg po qid x 14 daysmg po qid x 14 days

Alternate agent (TMP--SMZ).Alternate agent (TMP--SMZ). Bactrim Bactrim DS 1tab po bid x 14 days DS 1tab po bid x 14 days

Specific Regional W/U Specific Regional W/U PendingPending

Draft 7/1/2010Draft 7/1/2010 Symptomatic Patient meets case definitionSymptomatic Patient meets case definition PCR performed on Symptomatic patientPCR performed on Symptomatic patient Start Zithromax Tx of Symptomatic patientStart Zithromax Tx of Symptomatic patient Timing is Critical - Start PEP ASAP & within 21 Timing is Critical - Start PEP ASAP & within 21

days of exposure for close contacts of confirmed days of exposure for close contacts of confirmed casecase

PEP household close contactsPEP household close contacts PEP close contacts out of household ( work , PEP close contacts out of household ( work ,

school)school) PEP consider for high risk contacts PEP consider for high risk contacts Contacts not receiving PEP Contacts not receiving PEP notified SxSx notified SxSx

PertussisPertussis ““Household Isolation” until 5 days of Tx completed Household Isolation” until 5 days of Tx completed

Tdap Tdap VaccineVaccineTetanus, DiphtheriaTetanus, DiphtheriaAcellular PertussisAcellular Pertussis

Adacel® Adacel® Thimerosol freeThimerosol free

RIPC / CDPH / CDCRIPC / CDPH / CDCMay 30, 2008 / 57 (04);1-47,51May 30, 2008 / 57 (04);1-47,51

Lack of information Lack of information Regarding Tdap in Regarding Tdap in

PregnancyPregnancy Lack of data confirming the safety and Lack of data confirming the safety and

immunogenicity of Tdap in pregnant womenimmunogenicity of Tdap in pregnant women The unknown potential for early protection of the The unknown potential for early protection of the

infant against pertussis by transplacental maternal infant against pertussis by transplacental maternal antibodiesantibodies

Potential adverse effect of maternal antibodies on Potential adverse effect of maternal antibodies on the ability of the infant to mount an adequate the ability of the infant to mount an adequate immune response to antigens in pediatric DTaP or immune response to antigens in pediatric DTaP or conjugate vaccines containing tetanus toxoid or conjugate vaccines containing tetanus toxoid or diphtheria toxoiddiphtheria toxoid

Because information on the use of Tdap in pregnant Because information on the use of Tdap in pregnant women is lacking, Health-care providers are women is lacking, Health-care providers are encouraged to report vaccination of pregnant encouraged to report vaccination of pregnant women with Tdap, regardless of trimester, to the women with Tdap, regardless of trimester, to the appropriate manufacturer's registry.appropriate manufacturer's registry.

CDC MMWR May 30, 2008 / 57 CDC MMWR May 30, 2008 / 57 (04);1-47,51(04);1-47,51

Pregnancy and the Tdap Pregnancy and the Tdap VaccineVaccine

CDC/CDPH / ACOGCDC/CDPH / ACOG Tdap can be given:

·Before pregnancy (ideal)

·During pregnancy in the 2nd or 3rd trimester

·After pregnancy (even while breastfeeding) (Any new mother who is not up-to-date, should be given Tdap vaccine post-partum before discharge from the hospital or birthing center.)

TdapTdap recommended in the recommended in the 3 rd 3 rd trimestertrimester

due to current Epidemicdue to current EpidemicRIPC /KP Peds ID / KP Adult IDRIPC /KP Peds ID / KP Adult ID

UCLA/Loma LindaUCLA/Loma Linda Lack of Information is Class C Lack of Information is Class C Long safety history for Td in pregnancyLong safety history for Td in pregnancy History of History of Safety & EfficacySafety & Efficacy of whole cell pertussis of whole cell pertussis

immunization in 1930’s & 1940’s regarding pertussis immunization in 1930’s & 1940’s regarding pertussis prevention for prevention for MomMom and Baby (and Baby (MMWRMMWR May 30, 2008 / May 30, 2008 / 57 (04);1-47,51)57 (04);1-47,51)

Adult ID / Pediatric ID / RIPC / UCLA / Loma LindaAdult ID / Pediatric ID / RIPC / UCLA / Loma Linda

Tdap during the 2Tdap during the 2ndnd or 3 rd or 3 rd trimestertrimester

Specific language/consent addressing Tdap Specific language/consent addressing Tdap administration during pregnancy may be forthcoming administration during pregnancy may be forthcoming from the RIPCfrom the RIPC

CDC Special situations in CDC Special situations in which Tdap might be used which Tdap might be used

(during pregnancy) include…(during pregnancy) include………instances when instances when a pregnant woman is at increased risk for a pregnant woman is at increased risk for

pertussis which might includepertussis which might include

11) Women living in a community in ) Women living in a community in which a pertussis outbreak is which a pertussis outbreak is occurring. occurring.

(ie Current Epidemic in California)(ie Current Epidemic in California)

2)2) Women employed in institutions in which a Women employed in institutions in which a pertussis outbreak is occurringpertussis outbreak is occurring

MMWRMMWR May 30, 2008 / 57 (04);1-47,51May 30, 2008 / 57 (04);1-47,51

Special Situation which Special Situation which may help with acceptance may help with acceptance of Tdap immunization in 3 of Tdap immunization in 3

rd trimesterrd trimester A woman should consider receiving Tdap A woman should consider receiving Tdap

as an alternative to antenatal Td if she as an alternative to antenatal Td if she

1)1)does not have sufficient tetanus does not have sufficient tetanus immunity to protect against maternal immunity to protect against maternal and neonatal tetanus and neonatal tetanus

2)2)requires urgent booster protection requires urgent booster protection against diphtheria (e.g., for travel to an against diphtheria (e.g., for travel to an area in which diphtheria is endemic). area in which diphtheria is endemic).

Be a Champion for Be a Champion for Antenatal Maternal Antenatal Maternal

ImmunizationImmunization

Numerous personal testimonials and Numerous personal testimonials and excellent patient information flyers on excellent patient information flyers on CDPH/pertussis website that will CDPH/pertussis website that will facilitate the acceptance of antenatal facilitate the acceptance of antenatal Tdap immunization.Tdap immunization.

Just Google … “CDPH and Pertussis”Just Google … “CDPH and Pertussis”

And you can access all the above And you can access all the above informationinformation

Tdap in Pregnant Women Tdap in Pregnant Women Refusing Antenatal Refusing Antenatal

ImmunizationImmunization

If a Mom refuses Tdap in the 3 rd If a Mom refuses Tdap in the 3 rd trimester make 100% sure that trimester make 100% sure that Tdap is strongly recommended Tdap is strongly recommended after delivery of the baby and after delivery of the baby and before Mom is discharged home.before Mom is discharged home.

Remember the family and all other Remember the family and all other close contacts as well. close contacts as well.

Breastfeeding & Tdap is Breastfeeding & Tdap is OKOK

Existing data do not provide evidence Existing data do not provide evidence that human colostral pertussis that human colostral pertussis antibodies contribute to infant antibodies contribute to infant protection, although pertussis-protection, although pertussis-specific antibodies present in the specific antibodies present in the mother are found in colostral milk mother are found in colostral milk

No data to suggest that postpartum No data to suggest that postpartum maternal vaccination interferes with maternal vaccination interferes with subsequent pediatric vaccine efficacy.subsequent pediatric vaccine efficacy.

Who else should get Tdap Who else should get Tdap VaccineVaccine

Prevent pertussis with Tdap To "cocoon" new babies with protection, the following

people need pertussis vaccine at least 2 weeks before OR Ideally months before contact with an infant:

All close contacts of the infant AGES 11->64 (Grandparents, Father of baby, Siblings, Relatives, Child care providers, etc)

Immunity from the disease and the vaccine wanes, so Tdap booster shots are necessary for Adolescents & Adults

All close contacts should be immunized with Tdap when indicated as soon as feasible with the Dx of Pregnancy

Pertussis Immunization Pertussis Immunization Validate and Recommend for Validate and Recommend for

all Close baby Contactsall Close baby Contacts VALIDATE that all siblings up until age 6yo are VALIDATE that all siblings up until age 6yo are

receiving scheduled DTaP immunizations receiving scheduled DTaP immunizations completed as early as 12 months or as late as age completed as early as 12 months or as late as age 6 years 6 years

(encourage early completion)(encourage early completion) Tdap is recommended at age Tdap is recommended at age 10 -1210 -12 years years even even

though the recommended childhood DTP/DTaP though the recommended childhood DTP/DTaP vaccination series has been completedvaccination series has been completed

Adolescents/Siblings from ~ Adolescents/Siblings from ~ 13 -1813 -18 should should receive “catch-up” Tdap vaccine if not previously receive “catch-up” Tdap vaccine if not previously given @ 10-12 yogiven @ 10-12 yo

All Adults All Adults 18- 6418- 64 that will be close contacts that will be close contacts All Adults All Adults > 64 > 64 if they are a baby caregiver / if they are a baby caregiver /

close contact close contact ( Special Informed consent required )( Special Informed consent required )

Pertussis ImmunizationPertussis Immunization( Regional guidelines pending regarding Tdap in ( Regional guidelines pending regarding Tdap in

exposed patients)exposed patients)

Close contacts younger than 7 years of age who Close contacts younger than 7 years of age who have not completed the four-dose primary have not completed the four-dose primary series should complete the series with the series should complete the series with the minimal intervals.minimal intervals.

Close contacts who are 4–6 years of age and Close contacts who are 4–6 years of age and who have not yet received the second booster who have not yet received the second booster dose (usually the fifth dose of DTaP) should be dose (usually the fifth dose of DTaP) should be vaccinated. vaccinated.

The administration of Tdap to persons 10 The administration of Tdap to persons 10 through 64 years of age who have been through 64 years of age who have been exposed to a person with pertussis is not exposed to a person with pertussis is not contraindicatedcontraindicated, but the efficacy of , but the efficacy of postexposure use of Tdap is unknown. postexposure use of Tdap is unknown.

All healthcare All healthcare workers( Peds/Ob) workers( Peds/Ob)

recommended to receive recommended to receive Tdap VaccineTdap Vaccine

Health care workers are nearly twice as likely to get Health care workers are nearly twice as likely to get whooping cough (pertussis) as other adults. whooping cough (pertussis) as other adults. Protect Protect Your Patients, Protect Your Family , Protect Your Patients, Protect Your Family , Protect YourselfYourself

CDC recommendation. Health-care personnel who CDC recommendation. Health-care personnel who work in hospitals or ambulatory care settings should work in hospitals or ambulatory care settings should receive a single dose of Tdap as soon as feasible if receive a single dose of Tdap as soon as feasible if they have not previously received Tdap. An interval they have not previously received Tdap. An interval as short as 2 years or less from the last dose of Td is as short as 2 years or less from the last dose of Td is recommended in epidemic situationsrecommended in epidemic situations

Timing with Previous TdTiming with Previous Tdo If the patient has recently received the If the patient has recently received the

Td vaccine >/= to 2 years prior Tdap is Td vaccine >/= to 2 years prior Tdap is OK OK

o Tdap can be given sooner than 2 years Tdap can be given sooner than 2 years in special circumstances (such as the in special circumstances (such as the epidemic currently in California)epidemic currently in California)

o If given < 2 years make sure the patient If given < 2 years make sure the patient has not had a previous moderate or has not had a previous moderate or severe adverse reaction to Td or severe adverse reaction to Td or tetanus tetanus toxoid-- or diphtheria toxoid--containing toxoid-- or diphtheria toxoid--containing vaccine vaccine ..

Tdap Vaccination Tdap Vaccination

Contraindications to TdapContraindications to Tdap

An anaphylactic reaction, neurological An anaphylactic reaction, neurological reaction or encephalopathy within 7 days reaction or encephalopathy within 7 days after a prior Tdafter a prior Td

Consider a more specific Informed Consider a more specific Informed Consent Consent

-Temperature = 40.5 C within 48h of a -Temperature = 40.5 C within 48h of a prior Tdprior Td

-Shock-like state within 48h of a prior Td-Shock-like state within 48h of a prior Td -Seizure within three days of a prior Td-Seizure within three days of a prior Td

What are the side effects from Tdap vaccines

Mild Problems (Noticeable, but did not interfere with

activities)

• Pain (about 3 in 4 adolescents and 2 in 3 adults) • Redness or swelling (about 1 in 5) • Mild fever of at least 100.4°F (up to about 1 in 25 adolescents and 1 in 100

adults) • Headache (about 4 in 10 adolescents and 3 in 10

adults) • Tiredness (about 1 in 3 adolescents and 1 in 4 adults) • Nausea, vomiting, diarrhea, stomach ache (up to 1 in 4 adolescents and 1 in 10 adults) • Chills, body aches, sore joints, rash, swollen glands

(uncommon)


Moderate Problems (Interfered with activities, but did not require medical

attention)

Pain at the injection site (about 1 in 20 adolescents and 1 in 100 adults) • Redness or swelling (up to about 1 in 16 adolescents and 1 in 25

adults) • Fever over 102°F (about 1 in 100 adolescents and 1 in 250 adults) • Headache (1 in 300) • Nausea, vomiting, diarrhea, stomach ache (up to 3 in 100 adolescents and 1 in 100 adults)


Severe Problems (Unable to perform usual activities; required medical

attention)

Two adults had nervous system problems after getting the vaccine during clinical trials. These may or may not have been caused by the vaccine. These problems went away on their own and did not cause any permanent harm.

Figure 3

Education

Prevention of pertussis