DR HASNI IBRAHIM

FMS

KK SELISING

Jadual Imunisasi IMUNISASI UMUR ( BULAN )

0 1 2 3 4 5 6 12 18

BCG

Hepatitis B

DTaP

Hib

Polio

Measles

MMR

Dos Primer Dos Tambahan Sabah sahaja

Vaksin kombinasi

5 dalam 1

Difteria

Hib

Pertussis (aP)

Tetanus

Polio (IPV)

DTaP-IPV/Hib – Komposisi

OUTLINE INTRODUCTION

CLINICAL PRESENTATION

COMPLICATION

LAB INVESTIGATION

TREATMENT AND PROPHYLAXIS

DISEASE SURVEILLANCE

PERTUSSIS Respiratory infection caused by Bordetella

Pertussis

Highly contagious

Spread through

1)respiratory droplets

11) direct contacts with fluids from

nose or mouth of infected people

100 day’s cough or cough of 100 days

I.P of the disease is 5-10 days (max is up to 21 days)

The infectious period is at the beginning of catarrhal period which is prior to cough onset and up to 21 days after the cough started.

Antibiotics shorten the period of infectivity/lessen severity

Predominantly illness of infants under 2 years of age

Infant within the first week of life are susceptible, when mortality from whooping cough is the highest

In adolescent & adult pertussis often present as chronic bronchitis.

CLINICAL PRESENTATION Illness is characterised by 3 stages

a) catarrhal stage

b) paroxysmal

c) convalescent

Classic symptoms are paroxysmal cough, inspiratory whoop and vomiting after coughing

Catarrhal

Runny nose ( coryza)

Sneezing

Low grade fever ,malaise

Conjunctival inflammation

Occasional cough,similar to common cold. Cough becomes more severe but non productive

Duration

Insidious

Gradually worsening symptoms, lasted 1-2weeks

Paroxysmal Coughing spells with

inspiratory whoop. Whoop is absent under

6/12 of age, teenage & adult.

Post tussive gagging/ vomiting /cyanosis.

Convalescent Gradual resolution of

symptoms.

Duration 2-4 weeks Weight loss,

leucocytosis, and lymphocytosis are common

Several weeks - months

Pertussive cough

Stages of pertussis inf and period of communicability

P---- P = period of communicability

cough onset

----P----l--------P------------------------------

-2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12

(weeks of cough)

/Catharral/ paroxysmal / convalescent /

complication Asphyxia

Hypoxia

Encephalopathy

Convulsion

Cerebral hemorrhage

Pulmonary complication-atelectasis,pneumonia, pneumothorax

Death

Laboratory diagnosis Detection of B Pertussis- Culture, Polymerase chain

reaction (PCR), direct immunofluorescence (DFA) and serological methods

Culture special media – Regan Lowe charcoal agar media/Bordet –

Gengou media Gold standard Sensitivity 15 - 80 %, specificity 100 % Isolation during catarrhal stage is most succesful (first 1-2

weeks of cough) Culture requires 7-12 days Affected by antibioticis

Specimen collection and transport

A) Pernasal swab or posterior nasopharynx specimen must be obtained.Throat swab should not be taken.

B) A dacron or calcium alginate (not cotton swab)on a soft flexible wire is passed through the nostrils and along floor of the nasal cavity into the posterior nasopharynx, rotate the swab and withdraw it, orlet it be there for 15 to 30 sec or until a cough is produced

C) Inoculate sample into special media and incubate for 7 days

PCR assay for B pertussis

Recommended to detect B Pertussis

Better than culture as it is not affected by antibiotic

Specimen from health is sent to Sungai Buloh

Serial number (16) KKM – 171/BKP/09/43/0640)

Treatment and Prophylaxis Tx reduces transmission The spread can be limited by decrease infectivity and

protecting close contact. Infectious starts from catarrhal stage thro third week

after onset of paroxysms or until 5days after starting antibiotic

If begins in catarrhal stage , b4 paroxysmal cough- lessen severity.

If tx begins later it reduce period of infectivity not the severity

Recommended doses for tx and chemoprophylaxis is the same.

Prophylaxis Significant exposure to a confirmed case In day care centre or school children Check pattern of exposure/ exposure time other coughing persons in the class any other reported pertussis case presence of high risk individuals

The need for prophylaxis in high risk group is imp Infants Non Immunized children Immunocompromised individual Pregnant women Individuals with chronic respiratory illness,inc asthmatics

DRUG

ERYTHRO

MYCIN

INFANT

<7 d 20mg/kg /d into bd dose – 14/7

8-28 d – 30 mg/kg/d into3 doses -14/7

CHILD

40-50mg/kg/d

Into 4 doses/d

14/7

Max 2 gm /d

ADULT

1-2 g/d into 4x/d-14/7

CLARITHRO

MYCIN

X in pregnant

AZITHRO

MYCIN

5/7 course

TRIMETOPRIM

SULFAMETHO

XAZOLE

X in pregnant

Not recommended infant < 6/12

Preferred use in < 6/12

Not recommended

Infant <2/12

15mg/kg/dinto 2 doses- 1/52 (max 1 g/d)

10mg/kg/d on 1st d then 5mg/kg/d once daily for next 5d (max250mg/d)

8mgTMP/40mg SMXinto bd dose -14/7 (max320mgTMP/1600mg SMX /d)

1 g orally into bd/d

-min 1/52

500 mg on 1st d

250 mg OD -5/7

320mgTMP/1600mg

SMX

Into bd -14/7

Case Definition; Clinical case definition:

A person with a cough lasting at least two weeks with at least With one of the following: 1. Paroxysms (i.e. fits) of coughing 2. Inspiratory "whooping" 3. Post-tussive vomiting (i.e. vomiting immediately after fits of coughing)

And without other apparent cause. ·

Disease Surveillance

Case Definition Laboratory criteria for diagnosis

Isolation of Bordetella pertussis from clinical specimen,

OR

Positive polymerase chain reaction (PCR) assay for B.pertussis.

OR

Positive paired sera for B.pertussis.

Case Classification; Pertussis Suspected: A case that meets the clinical case definition.

Confirmed:

i. A clinical compatible case with B.pertussis isolation,OR

ii. A case that meet the clinical case definition and is confirmed by PCR, OR

iii. A case that meet the clinical case definition and is confirmed serology test with 4 fold rise of antibody in paired sera, OR

iv. A case that meet the clinical case definition and is epidemiologically linked directly to a confirmed case (first generation contact) by either culture or PCR.

In an outbreak settings with two or more cases epidemiologically linked, a case may be defined as a case with cough illness lasting more than 14 days.

Reporting & case Investigation 1. Purpose of reporting & investigation

2. Reporting & follow-up

Any case of suspected pertussis must be notified to the nearest District Health Office

within 7 days from the date of diagnosis

3. Case Investigation

4. Outbreak Mx

5. Identify Contact

Purpose of reporting & investigation i. To investigate case, identify and evaluate contacts

and recommend appropriate preventive measures, including exclusion, antibiotic prophylaxis and/or immunization.

ii. To assist in the diagnosis of cases.

iii. To educate exposed persons regarding signs and symptoms of the disease, thereby facilitating early diagnosis.

iv. To identify situations of under vaccination or vaccine failure.

Reporting & Follow-up Any case of suspected pertussis must be notified to the

nearest District Health Office

within 7 days from the date of diagnosis

Case Investigation a.In order to assess the likelihood a suspected case is a true

case prior to laboratory testing, public health staff should collect necessary information using Pertussis Case Investigation Form including the contact worksheet.

b. Investigate all contacts and possible source of infection. A

search for early and missed atypical cases is indicated where a non-immune infant or young child is or might be at risk.

c. It is important that information on the duration of cough

be obtained, especially if the first interview is conducted within 14 days of cough onset and cough is still present. In these circumstances, a follow-up interview after 14days of onset must be conducted to identify persons with 14 days cough duration.

Outbreak investigation Definition of an outbreak

• Two or more cases clustered in time (occurring within 42 days of each other) and space (in one child care center / class). The outbreak case definition may be used to count cases if one case has been confirmed.

• Investigate cases and their contacts as stated above.

• Develop a line listing of the cases and their contacts for easy reference.

Identify Contact Identify close contacts that had significant exposure to

the case during the infectious period. “Close Contact “ is defined as:

- Direct face-face

- Shared confined space; household,family

members,classmate

- Direct contact (medical staff)

Examine all high risk contact

Treat & give prophylaxis

Control of Patient & Contacts Isolation

Suspected cases not received antibiotics-isolated for 3 weeks esp from young child & un-immunized infant.

Isolation of contact:

- symptomatic-3 week

- asymptomatic h/care worker not

receiving a/b- ? 5 day- 3 week

Quarantine

- excluded from school/daycare/public gatherings for 3 weeks

Treatment & Prophylaxis Tx- recommended antimicrobial agents

The need for prophylaxis in the following high risk groups is particularly important:

i. infants

ii.non-immunized children

iii.immunocompromised individuals

iv.pregnant women

v.individuals with chronic respiratory illness,

including asthmatics

Control in Healthcare settings Control measure should be Implemented when one or

more cases are recognized in hospital, institution, OPD or other health care setting

Apply the control measures to all patient,

families & staff in close contact with confirm cases

Treat & given prophylaxis accordingly

HCW who used surgical mask during treating cases do not required prophylaxis.

Infectious control

Asses the immunization status of close contact under age 7 Contacts who are less than 7 years of age and are non-immunised or

have received fewer than 4 dose of DPT or DTaP should, in addition to receiving antibiotic prophylaxis, have pertussis immunisation initiated or continued according following guidelines, as soon as possible after exposure :

Give 1 st dose at ≥ 6 weeks of age ; doses 1,2 and 3 must be separated by at least 4 weeks

Children who receive their 3rd dose of DPT or DTaP ≥ 6 month before exposure should receive the 4th dose at this time.

Children who have received four doses of DTP /DTaP should get a booster of DTP /DTaP, unless a dose has been given within the last three years.

Preventive Measures Educate the public, particularly parents of infants, about

the dangers of whooping cough and on the advantages of initiating immunization at 2 months of age and adhering to the immunization schedule.

Evaluate the immunization coverage of the locality. Do mop-up if the coverage is less than 90%.

Active primary immunization against B. pertussis infection is recommended with 3 doses of pertussis vaccine consisting of a suspension of killed bacteria.

Routine childhood vaccination and post – exposure antimicrobial prophylaxis is the best preventive measures against Pertussis.

THANK YOU FOR YOUR

ATTENTION