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Pertussis Investigation (Whooping Cough) in First 24-48 Hours. Thein Shwe, MPH, MS, MBBS VPD & IBD Epidemiologist Hot Topics Training 11/17/2010 Division of Infectious Disease Epidemiology Office of Epidemiology & Prevention Services Bureau for Public Health

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pertussis investigation whooping cough in first 24 48 hours

Pertussis Investigation(Whooping Cough) in First 24-48 Hours

Thein Shwe, MPH, MS, MBBS

VPD & IBD Epidemiologist

Hot Topics Training

11/17/2010

Division of Infectious Disease Epidemiology

Office of Epidemiology & Prevention Services

Bureau for Public Health

West Virginia Dept. of Health & Human Resources

objectives
Objectives
  • To describe clinical description, diagnosis and epidemiology of pertussis
  • To understand
    • Investigation of a case of pertussis and outbreak of pertussis
  • To review a pertussis case study
disease description
Disease Description
  • Pertussis, a cough illness commonly known as whooping cough (100 Day Cough), is caused by the bacterium Bordetella pertussis.
  • Prolonged paroxysmal cough often accompanied by an inspiratory whoop.
  • Varies with age and history of previous exposure or vaccination.
  • Neither infection nor immunization provides lifelong immunity
other bordetella species
Other Bordetella species
  • Three other Bordetella species:
    • B. parapertussis,
    • B. holmesii, and
    • B. bronchiseptica.
  • B. pertussis and B. parapertussis coinfection is not unusual.
  • Disease with Bordetella species other than B. pertussis is not reportable.
http children webmd com pertussis whooping cough 10 coughing sounds
http://children.webmd.com/pertussis-whooping-cough-10/coughing-soundshttp://children.webmd.com/pertussis-whooping-cough-10/coughing-sounds

SOUND OF PERTUSSIS

epidemiology of pertussis
Epidemiology of Pertussis

Mode of transmission

  • Person to person via
    • Aerosolized droplets from cough or sneeze
    • Direct contact with secretions from respiratory tract of infectious person
  • 80% - secondary attack rate
  • Older children and adults are important sources of disease for infants and young children
  • Infants <12 months of age greatest risk for complications and death
epidemiology of pertussis cont
Epidemiology of Pertussis cont.
  • Reservoir - Humans
  • Incubation period: 7-10 days (5-21 days).
  • Infectious period: Most contagious during the catarrhal stage (3 weeks before cough) and the first 2 weeks after cough onset
  • Duration of illness:
    • Children: 6-10 wks.
    • ~ ½ of Adolescents: 10 wks or longer
pertussis complications
Pertussis Complications
  • Syncope (temporary loss of consciousness/faint)
  • Sleep disturbance
  • Incontinence
  • Rib fractures
  • Complications among infants
    • Pneumonia (22%)
    • Seizures (2%)
    • Encephalopathy (<0.5%)
  • Death
    • Infants, particularly those who have not received a primary vaccination series, are at risk for complications and mortality.
slide10
Pertussis Laboratory Diagnosis

WV OLS offers pertussis PCR and Culture for free of charge

304-558-3530

nasopharyngeal swab collection procedure

Nasopharyngeal Swab Collection Procedure

http://www.nejm.org/doi/full/10.1056/NEJMe0903992

pertussis case investigation

Pertussis Case Investigation

&

Outbreak Investigation

pertussis case definition
PERTUSSIS CASE DEFINITION

CDC/CSTE (2010)

http://www.cdc.gov/ncphi/disss/nndss/casedef/pertussis_current.htm

pertussis probable case definition
Pertussis Probable Case Definition
  • - In the absence of a more likely diagnosis, a cough illness lasting ≥2 weeks, with at least one of the following symptoms:
    • paroxysms of coughing; OR
    • inspiratory "whoop”; OR
    • post-tussive vomiting; AND
  • absence of laboratory confirmation; AND
  • no epidemiologic linkage to a laboratory-confirmed (PCR or culture) case of pertussis
pertussis confirmed case definition
Pertussis Confirmed Case Definition

Option 1

  • Acute cough illness of any duration with isolation (culture) of B. pertussis from a clinical specimen
pertussis confirmed case definition18
Pertussis Confirmed Case Definition

Option 2

Cough illness lasting ≥2 weeks, with at least one of the following symptoms:

  • paroxysms of coughing;
  • inspiratory "whoop"; or
  • post-tussive vomiting

AND

polymerase chain reaction (PCR) positive for pertussis;

pertussis confirmed case definition19
Pertussis Confirmed Case Definition

Option 3

  • Illness lasting ≥2 weeks, with at least one of the following symptoms:
    • paroxysms of coughing;
    • inspiratory "whoop"; or
    • post-tussive vomiting; AND, contact with a laboratory-confirmed (PCR or culture) case of pertussis.
slide20
PERTUSSIS

CASE INVESTIGATION

importance of rapid case identification
Importance of Rapid Case Identification
  • Early diagnosis and treatment to limit disease spread
  • Identify and provide prophylaxis to close contacts pending laboratory confirmation
  • When suspicion of pertussis is low, investigation can be delayed pending laboratory confirmation
    • Exception: prophylaxis of infants and their household contacts should NOT be delayed
what is the next step in a case investigation
What is the next step in a case investigation?
  • Refer to Pertussis Protocol
  • Use Pertussis WVEDSS form
  • Begin your case ascertainment
how do you ascertain a case
How do you ascertain a case?
  • Three pieces of information needed to determine if you have a pertussis case
  • Clinical information
  • Laboratory report(s)
  • Epidemiological information
verify the diagnosis
Verify the diagnosis

Clinical information

  • Cough (yes/no)
  • Duration of cough
  • Paroxysmal cough
  • Post-tussive vomiting
  • Whoop

Laboratory information

  • Is laboratory testing done?
  • Type of test
    • Culture
    • PCR
    • Serology
epidemiologic information
Epidemiologic Information
  • Vaccination history
    • Received any pertussis-containing vaccine
    • No. of doses
    • Vaccine date
    • Manufacturer
    • Lot no.
  • Epi-linked (Yes/No)
  • Transmission setting
  • Secondary transmission
  • Contact tracing
management of close contact s
Management of Close Contact(s)
  • Identify close contacts
  • Prevent secondary transmission
  • Collect nasopharyngeal swab (if not done so) for PCR and culture testing at OLS
  • Treat the patient with recommended antibiotics
  • Isolate the patient for 5 days (after the beginning of antibiotics) or 21 days (if no A/b treatment received)
contact tracing close contact definition
Contact TracingClose contact definition
  • Direct face-to-face contact for a period (not defined) with a case-patient who is symptomatic during the catarrhal and early paroxysmal stages of infection.
    • All residents of the same household;
    • Daycare and baby-sitting contacts; and
    • Close friends, regardless of immunization status.
contact tracing close contact definition cont
Contact TracingClose contact definition (cont.)
  • Shared confined space in close proximity for a prolonged period of time, such as >1 hours, with a symptomatic case-patient: or
contact tracing close contact definition cont33
Contact TracingClose contact definition (cont.)
  • Direct contact with respiratory, oral, or nasal secretions from a symptomatic case-patient – example:
    • an explosive cough or sneeze in the face,
    • sharing food, sharing eating utensils during a meal,
    • kissing,
    • mouth-to mouth resuscitation, or
    • performing s full medical exam including examination of the nose and throat.
slide36
Postexposure Prophylaxis for Pertussis in Infants, Children, Adolescents, and AdultsSource: Red Book 2009 AAP – pg. 507
once the investigation is completed
Once the investigation is completed..
  • Document public health action
  • Check case classification
  • Print the report for your files or per your

LHD policy & procedure

  • Send lab report(s) to DIDE
  • Submit completed WVEDSS report electronically to your regional epidemiologist and DIDE
pertussis outbreak case definition
Pertussis Outbreak Case Definition
  • Outbreak is defined as:
    • Two or more cases
    • Involving two or more households
    • Clustered in time & spaceAND
    • One case must be confirmed by positive culture
slide39
Pertussis Outbreak Line List Formhttp://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/Pertussis%20Outbreak%20Linelisting%20Form.pdf
outbreak notification and control
Outbreak Notification and Control
  • Notify your regional epidemiologist & DIDE

immediately

  • Evaluate case status & manage close contacts
  • Obtain nasopharyngeal swabs for culture (confirmation) and PCR
outbreak control in any settings
Outbreak Control in Any Settings
  • Treat/Prophylax with recommended antibiotic
  • Isolate 5 days after starting antibiotic treatment

or 21 days from cough onset if no treatment

  • Bring immunizations up-to-date
    • Accelerated vaccination if cases are occurring young infants
alert your providers and notify the parents
Alert your providers and notify the parents…
  • Healthcare Providers
    • Send Health alert letter
    • Provider information sheet
  • Parent/Guardian
    • Send notification letter
    • Public information sheet
exposures in child care
Exposures in Child Care
  • Exposed Children (especially incompletely immunized) and childcare providers should be
    • Observed for respiratory tract symptoms for 21 days after contact with an infectious person has been terminated
  • Administer vaccine and antibiotics
  • Exclude:
    • Symptomatic or confirmed pertussis until completion of 5 days of the recommended course of antimicrobial therapy or 21 days if untreated
follow up report
Follow up & Report
  • Check the status of the outbreak control
  • Document and update your regional epidemiologist and DIDE when the outbreak is controlled completely
  • Forward report with lab results to DIDE
case study
Case Study
  • On November 1, 2010, an Infection Preventionist (IP) of CAMC called your health department to notify you about two 6-month old twins who presented to the ED with
    • cough for 10 days since 10/22/10,
    • apnea and paroxysmal cough,
    • the labs are pending at this time,
    • the ER doctor had high suspicion of pertussis,
    • both babies were admitted to CAMC, and
    • treated with Azithromycin 10mg/kg/day for 5 days.
question 1

Question 1.

What would you do as soon as you receive a call like this?

question 2
QUESTION 2.

What Information would you collect for contact tracing?

contact tracing information
Contact Tracing Information
  • Six household members and a baby sitter were exposed to these twins during the infectious period.
  • A baby sitter and 5 of 6 household members have been coughing:
    • Amy, mother, 30 yo, cough started on 10/23, no vaccine
    • Bob, father, 32 yo, cough started on 10/24, vaccine yes, # of dose -UK
    • Ann, grandma, 67 yo, cough started on 10/16, no vaccine
    • John, brother, 9 yo, no cough, had 4 doses of PCV
    • Julie, sister, 6 yo, cough started on 10/22, had 4 doses of PCV
    • Brad, brother, 4 yo, cough started on 10/24, had 4 doses of PCV
    • Katie, baby sitter, 19 yo, cough started on 10/10, had 3 doses of PCV
  • 3 siblings attend the same elementary school and have been attending school while coughing.
  • No lab done yet on any symptomatic cases as of 11/1/10
  • None of them has received PEP yet as of 11/1/10
question 3

Question 3

What is your next step at this time?

question 4

Question 4

Do you have an outbreak at this time and why?

information about close contacts
Information about Close Contacts
  • All close contacts received PEP.
  • Nasopharyngeal swabs have been taken from all symptomatic contacts for lab confirmation and all were negative for B. pertussis for PCR and culture.
  • All symptomatic contacts had at least two weeks of cough.
question 5

Question 5

Do you have an outbreak at this time and why?

question 6

Question 6

What is your next step at this time?

summary
Summary
  • Disease description including clinical characteristics, laboratory diagnosis and epidemiology
  • Pertussis case investigation and outbreak investigation
    • Case study
resources
Resources
  • IDEP Pertussis site:
  • http://www.wvdhhr.org/idep/a-z/a-z-pertussis.asp
  • CDC Pertussis Surveillance Investigation:
  • http://www.cdc.gov/nip/publications/sur-manual/chpt08_pertussis.pdf
  • Guideline for Control of Pertussis Outbreak:
  • http://www.cdc.gov/nip/publications/pertussis/guide.htm
references
References
  • CDC VPD Surveillance Manual, 4th Edition, 2008 Pertussis: Chapter 10
  • Pertussis (Whooping Cough) Pg. 504-519, Red Book, 2009 Report of the Committee on Infectious Diseases – American Academy of Pediatrics, 28th Edition
  • http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm
  • Pertussis Pg. 455-461, Control of Communicable Diseases Manual, APHA & WHO, 19th Edition, David Heymann, MD, Editor
thank you

Thank you!

Questions?