Pertussis Prevention With Tdap Vaccine & Postexposure Prophylaxis and Treatment of Symptomatic Pertussis Doug Montgomery July 1 2010
References CDC / RIPC / CDPH
Prevention of Pertussis, Tetanus, and Diphtheria Among Pregnant and Postpartum Women and Their Infants
MMWR May 30, 2008 / 57 (04);1-47,51
Recommended Antimicrobial Agents for the Treatment and Postexposure Prophylaxis of Pertussis
MMWR December 9, 2005 / 54(RR14);1-16
The guidelines presented today 7/01/2010 are primarily based on CDC/CDPH information
The Goal is to make providers aware of the pertussis epidemic, emphasize the importance of Immunization, and provide basic information re Epidemiology, case definitions, and potential clinical scenarios where antibiotic therapy may be indicated.
More specific indications for PCR testing are in the process of development by Region ( probable Mid July release)
More specific indications for Post Exposure Prophylaxis ( PEP ) & Symptomatic treatment are in the process of development by Region ( probable Mid July release)
Pertussis Epidemic in California
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 Pertussis
Bordetella pertussis is a fastidious gram-negative coccobacillus
Pertussis is primarily a toxin-mediated disease. The bacteria attach to the cilia of the respiratory epithelial cells, produce toxins that paralyze the cilia, and cause inflammation of the respiratory tract, which interferes with the clearing of pulmonary secretions.
Pertussis antigens appear to allow the organism to evade host defenses, in that lymphocytosis is promoted but chemotaxis is impaired. Until recently it was thought that B. pertussis did not invade the tissues. However, recent studies have shown the bacteria to be present in alveolar macrophages.
Pertussis During Pregnancy
Case reports suggest that the morbidity of pertussis is Not increased among pregnant women compared with nonpregnant women.
NO causal relationship with abnormal fetal development, fetal morbidity, or adverse outcome of pregnancy has been confirmed.
Classic pertussis is characterized by three phases :
A typical case of pertussis in children and adults starts with a cough and runny nose for one-to-two weeks, followed by weeks to months of rapid coughing fits that sometimes end with a whooping sound. Fever is rare.
Early phase - Catarrhal phase
Catarrhal phase lasts 1--2 weeks and consists of a watery nasal discharge and frequent cough, frequent sneezing, and injection of the conjunctiva, often with lacrimation. The cough initially suggests tracheal irritation (e.g., a tickle in the throat) and is short, sharp, hacking, and isolated (as distinguished from paroxysmal).
The cough is equally persistent during day and night and rarely croupy or hoarse. Fever is uncommon during any phase unless the illness is complicated by secondary infection or coinfection .
Paroxysmal phase lasts 2--6 weeks.
Bursts of coughing increase in frequency during the first one to two weeks, remain constant for two to three weeks, and then gradually begin to decrease in frequency. Paroxysmal attacks occur more frequently at night, with an average of 15-24 attacks per 24 hours.
Adults may experience greater severity of illness than adolescents, including cough-related incontinence in 28% of cases in women; in up to 5% of cases patients may experience one or more : rib fracture , syncope , or pneumonia , or they require hospitalization.
Approximately one third of adults and adolescents lose weight during the illness. Anecdotal reports of pneumothorax, seizures, and stroke have been reported .
Paroxysmal Coughing Classic Sx Infants
A typical paroxysm in infants is characterized by a succession of coughs that follow each other without inspiration. Paroxysms terminate in typical cases with inspiratory "whoop" and can be followed by posttussive vomiting.
Infants may have coughing fits or “ paroxysms” that last as long as several minutes. The coughing can be so severe that babies vomit, pass out, or even have seizures. In infants, the coughing spell often ends in a “whoop” sound.
Paroxysms can occur more frequently at night
Paroxysmal Coughing Adults & Adolescents Sx
The illness can be milder and the characteristic whoop absent in children, adolescents, and adults who were previously vaccinated.
Adolescents and adults and children partially protected by the vaccine may become infected with B. pertussis but may have milder disease than infants and young children. Pertussis infection in these persons may be asymptomatic, or present as illness ranging from a mild cough illness to classic pertussis with persistent cough. Inspiratory whoop is not common.
Whooping cough in adults causes coughing fits. In adults you don’t hear the characteristic “whoop” sound toddlers make when they have the disease. But it can cause vomiting, broken ribs, and pneumonia, and coughing can last for months
C onvalescent phase Clinical symptoms
C onvalescent phase of pertussis typically lasts 2--6 weeks. Symptoms can persist for > 6 months. Factors that can lessen the severity of B. pertussis infection include residual immunity from previous infection or vaccination and use of macrolide antimicrobials in the catarrhal (early) phase of the illness.
Epidemiology / Transmission
Studies show that about 75% of pertussis infections among babies are contracted from household members
Pertussis is highly infectious, with attack rates among exposed, nonimmune household contacts as high as 90%. The most infectious periods are the catarrhal and early paroxysmal phases.
Epidemiology / Transmission
Pertussis is transmitted via large respiratory droplets generated by coughing or sneezing or direct contact with respiratory secretions
B. pertussis can be recovered from dried mucus for up to 3 days .
Incubation period is typically 7-10 but may 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 or infection, the infectious period typically is < 21 days .
Untreated infants may remain infectious for 6 weeks or longer .
Surgical mask Ok ( N 95 not necessary)
Gloves / Consider Gown
Frequent hand washing
Transmission risk within ~ 3 feet or less of a cough , sneeze, face to face talking , or medical procedure if droplet precautions not taken
(ie Swab nostril with no mask / gloves)
Not necessary to close hospital room doors or have negative pressure
Treatment of Pertussis Decreases Transmission
Patients are considered to be non-infectious after completing the fifth day of appropriate antimicrobial treatment; however, they should complete a full regimen to avoid bacterial relapse.
Case Classification Clinical 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 premies
4 ) Unimmunized infants and children
5 ) Persons with neuromuscular disease
6 ) Persons who have severe underlying disease such as chronic lung disease or cystic fibrosis or immunocompromised
PCR recommended for Diagnosis (KP Regional Indications Pending)
DNA amplification (e.g., PCR) to detect B. pertussis has increased sensitivity and more rapid turnaround time when compared to culture. Antibiotics and previous vaccination may decrease the sensitivity ; however PCR may still be performed
Perform when symptoms of classic pertussis are present ( > 2 weeks of cough with no other apparent cause )
Not all patients will exhibit paroxysmal cough, or whoop ,or posttussive emesis.
Nasopharyngeal swab collection Validate with PCR kit instructions
1. Put on mask and gloves.
2. Have patient sit with head against a wall as patients have a tendency to pull away during this procedure.
3. Insert swab into one nostril straight back (not upwards ) and continue along the floor of the nasal passage for several centimeters until reaching the nasopharynx (resistance will be met). The distance from the nose to the ear gives an estimate of the distance the swab should be inserted. Do not force swab, if obstruction is encountered before reaching the nasopharynx, remove swab and try the other side.
4. Rotate the swab gently for ~ 10-15 seconds to loosen the
5. Remove swab and immediately inoculate transport media
Postexposure Prophylaxis (PEP) and Treatment of Disease
Antimicrobial treatment administered in the early (catarrhal) phase of the illness can modify the severity of the symptoms.
An antimicrobial generally does not modify the severity or the course of the illness after paroxysmal cough is established but is used to eliminate B. pertussis and halt transmission .
Without use of an effective antimicrobial, B. pertussis can be recovered for 21 days or longer from adult and adolescent patients .
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.).
PEP & Treatment of Disease During Pregnancy
Early recognition of pertussis in a pregnant woman is necessary to ensure the effectiveness of treatment ( review Sx/Sx CDPH Info sheet)
Antimicrobial treatment and prophylaxis are effective in preventing transmission of pertussis to neonates.
A macrolide is administered to a woman with pertussis that is acquired late in pregnancy or shortly before delivery, her household contacts, and 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.
Lack of data confirming the safety and immunogenicity of Tdap in pregnant women
The unknown potential for early protection of the infant against pertussis by transplacental maternal antibodies
Potential adverse effect of maternal antibodies on the ability of the infant to mount an adequate immune response to antigens in pediatric DTaP or conjugate vaccines containing tetanus toxoid or diphtheria toxoid
Because information on the use of Tdap in pregnant women is lacking, Health-care providers are encouraged to report vaccination of pregnant women with Tdap, regardless of trimester, to the appropriate manufacturer's registry.
CDC MMWR May 30, 2008 / 57 (04);1-47,51
Pregnancy and the Tdap Vaccine CDC/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.)
Tdap recommended in the 3 rd trimester due to current Epidemic RIPC /KP Peds ID / KP Adult ID UCLA/Loma Linda
Lack of Information is Class C
Long safety history for Td in pregnancy
History of Safety & Efficacy of whole cell pertussis immunization in 1930’s & 1940’s regarding pertussis prevention for Mom and Baby ( MMWR May 30, 2008 / 57 (04);1-47,51)
Adult ID / Pediatric ID / RIPC / UCLA / Loma Linda
Tdap during the 2 nd or 3 rd trimester
Specific language/consent addressing Tdap administration during pregnancy may be forthcoming from the RIPC
CDC Special situations in which Tdap might be used (during pregnancy) include…
… instances when a pregnant woman is at increased risk for pertussis which might include
1 ) Women living in a community in which a pertussis outbreak is occurring.
(ie Current Epidemic in California)
2) Women employed in institutions in which a pertussis outbreak is occurring
MMWR May 30, 2008 / 57 (04);1-47,51
Special Situation which may help with acceptance of Tdap immunization in 3 rd trimester
A woman should consider receiving Tdap as an alternative to antenatal Td if she
1) does not have sufficient tetanus immunity to protect against maternal and neonatal tetanus
2) requires urgent booster protection against diphtheria (e.g., for travel to an area in which diphtheria is endemic).
Be a Champion for Antenatal Maternal Immunization
Numerous personal testimonials and excellent patient information flyers on CDPH/pertussis website that will facilitate the acceptance of antenatal Tdap immunization.
Just Google … “CDPH and Pertussis”
And you can access all the above information
Tdap in Pregnant Women Refusing Antenatal Immunization
If a Mom refuses Tdap in the 3 rd trimester make 100% sure that Tdap is strongly recommended after delivery of the baby and before Mom is discharged home.
Remember the family and all other close contacts as well.
Breastfeeding & Tdap is OK
Existing data do not provide evidence that human colostral pertussis antibodies contribute to infant protection, although pertussis-specific antibodies present in the mother are found in colostral milk
No data to suggest that postpartum maternal vaccination interferes with subsequent pediatric vaccine efficacy.
Who else should get Tdap Vaccine
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 Validate and Recommend for all Close baby Contacts
VALIDATE that all siblings up until age 6yo are receiving scheduled DTaP immunizations completed as early as 12 months or as late as age 6 years
(encourage early completion)
Tdap is recommended at age 10 -12 years even though the recommended childhood DTP/DTaP vaccination series has been completed
Adolescents/Siblings from ~ 13 -18 should receive “catch-up” Tdap vaccine if not previously given @ 10-12 yo
All Adults 18- 64 that will be close contacts
All Adults > 64 if they are a baby caregiver / close contact
Close contacts younger than 7 years of age who have not completed the four-dose primary series should complete the series with the minimal intervals.
Close contacts who are 4–6 years of age and who have not yet received the second booster dose (usually the fifth dose of DTaP) should be vaccinated.
The administration of Tdap to persons 10 through 64 years of age who have been exposed to a person with pertussis is not contraindicated , but the efficacy of postexposure use of Tdap is unknown.
All healthcare workers( Peds/Ob) recommended to receive Tdap Vaccine
Health care workers are nearly twice as likely to get whooping cough (pertussis) as other adults. Protect Your Patients, Protect Your Family , Protect Yourself
CDC recommendation. Health-care personnel who work in hospitals or ambulatory care settings should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap. An interval as short as 2 years or less from the last dose of Td is recommended in epidemic situations
Timing with Previous Td
If the patient has recently received the Td vaccine >/= to 2 years prior Tdap is OK
Tdap can be given sooner than 2 years in special circumstances (such as the epidemic currently in California)
If given < 2 years make sure the patient has not had a previous moderate or severe adverse reaction to Td or tetanus toxoid-- or diphtheria toxoid--containing vaccine .
Contraindications to Tdap
An anaphylactic reaction, neurological reaction or encephalopathy within 7 days after a prior Td
Consider a more specific Informed Consent
-Temperature = 40.5 C within 48h of a prior Td
-Shock-like state within 48h of a prior Td
-Seizure within three days of a prior Td
What are the side effects from Tdap vaccines
(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)
What are the side effects from Tdap vaccines
(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)
(1 in 300)
• Nausea, vomiting, diarrhea , stomach ache
(up to 3 in 100 adolescents and 1 in 100 adults)
What are the side effects from Tdap vaccines
(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.