pertussis: illness and prevention€¦ · interval since last td < 2 yrs last td n = 97 ≥ 2...
TRANSCRIPT
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Pertussis: Resurgence, Prevention
and Role of the Ob/Gyn
Kimberly B. Fortner, MD
Vanderbilt University Department OB/Gyn
Division Maternal-Fetal Medicine
Vanderbilt Vaccine Research Program
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Learning Objectives
At the conclusion of this activity, participants
should understand:
• The epidemiology of pertussis and its
recent resurgence in the United States
• How to diagnose and treat active pertussis
infection in an Ob/Gyn population
• How to prevent pertussis infection in an
Ob/Gyn population
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Case Study
28yo G5 P0040 uncomplicated pregnancy
• Received influenza vaccine antenatally
• Preterm labor at 34 weeks EGA
Baby Callie
• 2 week NICU stay
• Day of life 36, developed cough
Baby Callie with parents
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Case Study
• Parents reassured
• Day of life 38, returned
to pediatrician’s office
• Callie had respiratory
arrest
• Infant died on Day 38
• Tdap - “Nobody
mentioned it...nobody
brought it up, nobody
talked about it.” Rod shaped bacteria
(green) lodge in cilia of
respiratory tract
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Pertussis
Highly contagious respiratory infection
Outbreaks first described in 16th century
1906 - Bordetella pertussis isolated
1930s - First pertussis vaccine developed
1940s - ~ 200,000 cases/year prior to
vaccination
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Pertussis Vaccines
DTP Vaccine
• Whole cell Pertussis
• Diphtheria and Tetanus toxoids
– Prevents illness in 70-90% children
– Reactogenic1
– No longer available in US
DTaP Vaccine
• Acellular Pertussis
• Diphtheria and Tetanus toxoids
– Acellular vaccine
• Licensed 1991
Tdap Vaccine
• Acellular pertussis vaccine
• Little “d” and little “p” – Lower
quantities of diphtheria and pertussis antigens
• Adult booster
• Licensed 2008
1Edwards KM, Decker MD, Vaccines, 6th Edition
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Pertussis: United States, 1940-
2006
0
50000
100000
150000
200000
250000
1940 1950 1960 1970 1980 1990 2000
Cas
es
1940s – widespread
DTP vaccination
1991 – DTaP
licensed in US
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Pertussis: United States, 1980-
2006
0
5000
10000
15000
20000
25000
30000
1980 1985 1990 1995 2000 2005
Cas
es
1991 – DTaP
licensed in US
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Routine DTaP
Vaccination Schedule
Dose
# 1
# 2
# 3
# 4
# 5
Age
2 months
4 months
6 months
12-18 months
4-5 years
Minimum Interval
---
4 wks
4 wks
6 mos
At school entry
So, why are we discussing Pertussis?
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Pertussis Epidemic: 2012
Substantial rise in pertussis cases
Declared pertussis epidemic
– Reported cases 2,520 (1300% increase)
– Highest number cases since 1942
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0
50,000
100,000
150,000
200,000
250,000
300,000
1922 1930 1940 1950 1960 1970 1980 1990 2000 2011*
Nu
mb
er
of
case
s
Year
Reported NNDSS Pertussis Cases 1922-
2011*
DTP
0
5,000
10,000
15,000
20,000
25,000
30,000
1990 1995 2000 2005 2011*
Tdap
DTaP
SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the
Public Health Service
*2011 data have not been finalized and are subject to change. 2011 data were accessed on July 5, 2012.
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0
5000
10000
15000
20000
25000
30000
1990 1993 1996 1999 2002 2005
Year
Ca
se
s
<11 11-18 >18
Reported Pertussis by Age Group
1990-2006 4 – 5 fold
increase in
adolescents &adults
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Why is there a resurgence?
Waning immunity
Decreased vaccine coverage
Better diagnosis
Changes in organism
Pertussis: Known Villain
Aliases: Bordatella;
whooping cough
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Waning Vaccine-Induced Immunity
Infect Med. 1996;13:S33-S41.
0
20
40
60
80
100
0 1 2 3 4 5 6
Time Since Last Dose (Years)
1951
1978
1988
1979
1988
Observational
Studies
Randomized
Clinical Trials Wh
ole
-Ce
ll P
ert
ussis
Va
ccin
e E
ffic
acy (
%)
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Why Immunity Wanes
Natural Infection
Prevaccine era = natural boost
Postvaccine era = rare boost
Large poor of susceptible hosts
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Estimated Duration of Immunity
Source of
Immunity Duration Reference
Natural Infection 15 years Wirsing von Konig,
1995
Whole-cell Vaccine
UK 6 years Jenkinson, 1988
Finland 6 years He, 1994
Germany 6+ years Lagauer, 2002
Acellular Vaccine
Italy 6 years Salmaso et al,
2001
Germany 6+ years Lagauer et al, 2002 Lancet Infect Dis 2002; 2: 744–50
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Cycle of Pertussis Susceptibility in
Vaccinated Populations
Primary Vaccination:
Protected
Booster Vaccination: Prolonged Protection
No additional booster: Immunity
wanes
Susceptible Adults and Adolescents:
Reservoir of Pertussis
Unvaccinated or Partially Vaccinated Infants: Susceptible
Lancet Infect Dis. 2002;2(12):774.
Booster Vaccination: Prolonged Protection
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Cycle of Pertussis Susceptibility in
Vaccinated Populations
Primary Vaccination:
Protected
Booster Vaccination: Prolonged Protection
No additional booster: Immunity
wanes
Susceptible Adults and Adolescents:
Reservoir of Pertussis
Unvaccinated or Partially Vaccinated Infants: Susceptible
Lancet Infect Dis. 2002;2(12):774.
Susceptible Adults and Adolescents:
Reservoir of Pertussis
Unvaccinated or Partially Vaccinated Infants: Susceptible
Booster Vaccination: Prolonged Protection
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Reported Pertussis Outbreaks
Adults in the workplace (MMWR 2004; 53(10:216-219)
Nursing homes/Long-term care facilities (J Inf Dis, 1991/ 164:704-709, JPed 1989; 114:934-939)
Students & staff in schools (MMWR, 2003; 52(1)1-4)
Health-care workers and hospital patients (Infect Control Hosp Epid 1995; 16:556-563, 2006; 27:546-552, 541-545)
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Who is at High Risk for Infection?
Unvaccinated Infants
Health-care workers
Daycare workers
Adolescents & adults
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Pertussis Incidence Among Infants
2001-2009
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Pertussis Incidence by Age Group,
2011
AGE GROUP
<6 mo 6-12mo 13-18 mo 18-23 mo 2-5 yr 6-9 yr >10 yr
Incid
ence p
er
100,0
00 p
opula
tion 300
150
Source: CDC, National Pertussis Surveillance System and Supplemental Pertussis
Surveillance System (2012)
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Pertussis Deaths in US, 2004-
2006
2004
2005
2006
Total
CDC, unpublished data, 2007
<3 mos
24
32
13
69
(84%)
>3 mos
3
7
3
13
(16%)
Total
27
39
16
82
Age at onset
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Unvaccinated Infants with
Pertussis: Who is the Source?
Infants with documented pertussis infection in GA, IL, MA, MN (PedInfDisJ 2004;23:985-989)
Identification of infectious source
Mother 32%
Father 15%
Sibling 20%
Grandparent 8%
Other 25%
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0
10
20
30
40
50
60
0-4 5-9 10-19 20+
Age of Source (Years)
% o
f In
fan
t C
ase
s
Ped Inf DisJ 2004;23:985-989
Unvaccinated Infant with Pertussis:
Age of the Source
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Clinical Features
Respiratory Spread
Highly infectious
Incubation period 7-10 days
Insidious onset, similar to minor URI – Runny nose
– Non-specific cough
– Low-grade fever
– No sore throat
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Classic “Whooping Cough” Phases
Phase 1 “Catarrhal”
– Rhinorrhea
– Conjunctival injection
– Malaise
– Low grade fever
– Lasts 1-2 weeks
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Classic “Whooping Cough” Phases
Phase 2 “Paroxysmal”
– Bursts of rapid cough
with long inspiratory
gasp = “whoop”
– Lasts 1-6 weeks, as
long as 10 weeks1
1Hewlett EL Edwards KM. NEJM 2005
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Classic “Whooping Cough” Phases
Phase 3 “Convalescent”
– Gradual resolution of
cough
– Irritants lead to recurrent
coughing
– Secondary complications
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Clinical Picture of Pertussis
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Common Clinical Manifestations of
Adolescent-Adult Pertussis
Cough 3 weeks (97%), cough 9 weeks (52%)
Paroxysms 3 weeks (73%)
Whoop (69%)
Post-tussive emesis (65%)
Average missed days of school = 5
Average missed days of work = 7
Average days disrupted sleep = 14 J Infect Dis. 2000;182:174–9.
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Johnston CID 1986; Grant CC, Pediatrics 1998; Mikelova J Pediatr 2003
Common Clinical Manifestations of
Infants with Pertussis
Minor Complications
– Subconjunctival hemorrhages, epistaxis,
otitis media
Major Complications (24%)
– Pulmonary
– Neurologic
– Nutritional
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Diagnosis of Pertussis
Nasopharyngeal swab
within 2-3 wks of onset
Culture
– Sensitivity 20-80%;
Specificity 100%
– Positive for ~ 2 wks of
infection
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Diagnosis of Pertussis
PCR
– Limited availability
– Sensitivity 93.5%; Specificity 97.1%
– Remains positive for 3-4 wks of infection
Serology – anti-PT IgG
– 3-4 weeks after cough
– Not uniformly available
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Treatment of Pertussis
Active infection
– May not decrease symptoms but clears carriage
– Erythromycin 500mg qid x 14d
– TMP-SMX DS bid x 14 d
– Azithromycin 500mg x 1d. 250mg qd x 4d
Post-exposure prophylaxis
– Within 3 weeks if close contact = within 3 feet or in close space
– Same as treatment regimen
MMWR 2008; 57(RR4): 10
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Pertussis is . . .
Common Morbid Difficult to diagnose Contagious Very bad for infants
A vaccine-preventable disease!
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Vaccines aren’t just
for kids anymore!
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2009 ACIP/AAP Recommendations
Adolescents age 11-18 = single booster
dose of Tdap instead of Td (June 2005)
Adults age 19-64 = Tdap in place of their
next decennial Td (October 2005)
MMWR 2009; 57(53)
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2009 ACIP: Pregnant & Postpartum Women
Women of childbearing age should receive Tdap in
place of their next decennial Td but ideally during
preconception wellness
Pregnant women should receive Tdap postpartum
before leaving hospital if last Td > 2 yrs
Non-pregnant adolescents and adults having direct
contact with an infant (< 1 yr) should receive Tdap at
least 2 wks before contact if last Td > 2 yrs
MMWR 57 (04); 1-47, 51
MMWR 2009; 57(53)
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Cocooning Immunization Strategy
2008-2011, CDC-ACIP recommended
strategy of “cocooning vaccination”
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Issues with Cocooning Strategy
Limited recall last Td
Ob/Gyns, L&D RNs, and Hospitals not prepared
Inability vaccinate household contacts
Postpartum vaccination fails to leverage potential for passive immunity
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Interval since last Td
Mass vaccination campaign of healthcare
workers
4524 vaccinated, 2221 (49.1%) completed
survey
Comparison of adverse events/reactogenicity
Vaccine 28 (2010) 8001–8007
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Vaccine 28 (2010) 8001–8007
Interval since last Td
< 2 yrs last Td
n = 97
≥ 2 yrs last Td
n = 578
Pain 67.9% 73.5%
Redness* 23.5% 19.6%
Swelling* 37.8% 33.4%
Subjective fever* 15.2% 11.4%
No difference in moderate to severe symptoms
No difference in serious adverse events
16 pregnant women vaccinated – all normal
outcomes
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Gall SA, Am J Obstet Gynecol 2011;204:334.e1-5.
Tdap during pregnancy
104 women
– 52 received Tdap prior or during pregnancy
– 52 received Tdap postpartum
Maternal and cord blood collected
Findings:
– Higher cord blood antibodies if vaccinated in pregnancy
– High correlation between maternal and cord blood antibody levels
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Safety of Tdap in Pregnancy
Tdap vs Td vaccine during pregnancy
440 pregnant women and their infants
Compared antibody levels: birth, 2, 4, 6, 7,
12, and 13 months of age
Safety of Tdap in pregnancy: obstetric
outcomes and developmental assessment
at 1 year
Halperin SA, NCT00553228
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Pertussis Vaccine in Healthy
Pregnant Women
Double-blind, crossover RCT
Pregnant women randomized 2:1 to Tdap
during pregnancy vs. postpartum
– Antibody levels at birth, 2, 7, and 13 months
– Developmental assessment at 13 months
NCT00707148 - NIAID
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Updated and Provisional ACIP
Recommendations
Tdap can be administered regardless of interval since last Td
Tdap should be given in 2nd or 3rd trimester in women without prior Tdap
Continue Tdap vaccination for household contacts of infants
ACIP Meeting June 22, 2011
http://www.cdc.gov/vaccines/recs/provisional/default.htm
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Tdap Vaccination Summary
As of August 2011, Tdap Vaccination is
recommended for pregnant women in the
late second (>20 weeks) or third trimester
who have not previously received Tdap. If
not given during pregnancy, Tdap should be
given postpartum.
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Newest ACIP Guidelines
October 2012
Vaccination with EACH Pregnancy
Review of Available Data
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Pertussis
Who should advocate for patients to be
vaccinated?
ALL OF US!
1Jamieson DJ et al. Lancet 2009;374:451-8.
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Ob/Gyn’s Role in Immunization
Often first medical contact for young women
Provide 1/3 of medical visits for women ages
17 – 21
Function as primary care practitioners
Caring for pregnant women
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Ob/Gyn’s Role in Immunization
Pediatricians & Ob/Gyns -near eradication
of congenital rubella
Remarkable achievement = Rh
Isoimmunization (1968)
– 1973 – over 50,000 babies’ lives saved
– Time magazine –Top Ten Medical
Achievements of the 1960’s
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Who benefits from maternal
immunization?
Pregnant woman
Family/Household contacts
Fetus/Infant
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NIH’s Network of Vaccine and
Treatment Evaluation Units (VTEUs)
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How does Vanderbilt Help me?
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We have seen the Enemy…
Pertussis
VTEU Study Objectives
– To evaluate longevity of
vaccination protection
– To understand pertussis
antibody levels in human
breast milk Pertussis: Known Villain
Aliases: Bordatella;
whooping cough
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Ongoing studies
Enrolling 55 women
– Post partum
– Healthy
– Full term delivery
– No Tdap in 2 years prior
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Thank you!