Pertussis Overview
Claudia Alvarado RN BSN
Public Health Nurse Coordinator
Department of Public Health Services
First recognized in the 16th Century
Caused by bacteria Bordetella Pertussis
Pertussis bacteria produces toxins which are
responsible for clinical features of illness
Pertussis epidemics cyclic every 2-5 years
Effectively treated with Antibiotic
Closely related organism: Bordetella para-pertussis
• Incubation period: usually 7-10 days (range 6-21 days)
• Infectious Period: Begins with onset of the catarrhal
stage or onset of cough and ends 21 days after cough
onset or 5 days of treatment with appropriate
antibiotic.
• Mode of transmission: Person-to person through
aerosolized droplets or by direct contact with
secretions from the respiratory tract
Susceptibility:
Highly contagious with a > 80% secondary attack
rate among susceptible persons in a households
Pertussis occurs at any age regardless of vaccine
status
Vaccine immunity to pertussis wanes in 5-10 years,
may be less with acellular vaccine (data very
limited)
Catarrhal stage: Onset often insidious with cold
like symptoms usually for 1-2 weeks with gradually
increasing cough
Paroxysmal stage: Paroxysms, inspiratory whoop,
vomiting, apnea, cyanosis (often after paroxysms)
usually for 1-6 weeks, up to 10 weeks
Convalescent stage: Mild cough for weeks to
months
• Symptoms in vaccinated persons are milder
• Less characteristic symptoms in adolescent and
adults
• Infants 6 months and younger have atypical
presentation
– Shorter catarrhal stage
– Gagging, gasping, apnea, less often paroxysms
– Whoop may be absent
Infants <12 months:
Hospitalization ( 50%)
Apnea (50%)
Bacterial Pneumonia (20%)
Seizures (1%)
Death (1%)
Encephalopathy (1%)
• CDC/CSTE Clinical Case Definition (Probable Case)
– a cough illness lasting at least 2 weeks with one of the
following: paroxysms of coughing, inspiratory "whoop," or
post- tussive vomiting AND
– without other apparent cause (as reported by a health-care
professional)
• CDC/CSTE Laboratory/Confirmatory Criteria for Diagnosis
– isolation of Bordetella pertussis from a clinical specimen OR
– positive polymerase chain reaction (PCR) assay for B.
pertussis OR
– Epidemiologic link to laboratory confirmed case
<3 weeks = acute (URI, CHF, PE)
3-8 weeks = subacute (persistent URI, lung
cancer)
>8 weeks = chronic (asthma, reflux disease)
Adenoviruses, Mycoplasma pneumoniae,
RSV,Chlamydia pneumoniae
Consider in Pertussis even if patient is immunized
PCR, culture, serology (not accepted, except when
done by MA PHL)
CDC recommends Nasopharyngeal swabs be tested for
PCR and Culture, as PCR prone to false positives
Use Dacron tipped NP swab with flexible wire handle
Do not use Cotton or Calcium-Alganate swabs
Use Regan-Lowe transport media
Mask and gloves
Azithromycin for 5 days is effective Treatment (all
age groups, recommended for infants <1 month)
Erythromycin for14 days (not preferred in infants
less than one month)
Clarithromycin for for 7 days, not recommended for
infants <1 month
TMP/SMC for 14 days, contraindicated in infants < 6
months
Direct contact with oral, nasal, or respiratory
secretions from a symptomatic patient
Direct face to face exposure with a symptomatic
case
Sharing the same confined space in close proximity
with a symptomatic patient for an hour or more
Performing bronchoscopy, suctioning, exam of
mouth, nose or throat and mouth to mouth
resuscitation (droplet)
Contact groups: i.e. household, friends, school, car/bus religious
groups, sports teams, social events, and…. Healthcare
HIGH RISK CONTACTS: Use more inclusive criteria for definition of
close contact
Infants less than one year of age, especially less
than six months of age
Persons with underlying medical conditions such as
chronic lung disease, respiratory insufficiency and
cystic fibrosis
Persons with immune deficiencies (including HIV)
Protect infants by:
Protecting from known/suspect cases
Liberal use of term close contact and PEP for
infants and persons around them
Vaccinating “around” infant
Pregnant women, especially in the third trimester
due to the increased risk to a newborn infant, as
well as other pregnant women (i.e. in medical
setting)
Health Care workers providing direct patient care,
especially prenatal care, labor and delivery,
neonatal and pediatric fields
Babysitter/daycare worker taking care of infants
Parents/Parents to be/Caregivers of infants
For Patient: Exclusion/Isolation until completion of
5 days on ABX or 21 days post cough onset
(whichever is sooner)
For non-symptomatic contacts: Post Exposure
Prophylaxis (PEP)
For symptomatic contacts: Evaluation (including
NP for PCR and/or CX) and PEP/TX/Exclusion as
appropriate
High risk contacts should be started on PEP up
to 42 days of exposure
Household: All should be on PEP or TX
Home child care: Treat children as household
contacts
Childcare center: PEP depending on amount of
contact/age
Pregnant Contacts:
Pregnant women and persons close to them
should be started on PEP for up to 6 weeks after
last exposure to pertussis.
Especially important during the last trimester
due to increased risk for a infant, if exposed.
Droplet precautions (if mom and infant on ABX
rooming together and breastfeeding
encouraged)
Clinical/Outpatient settings: Most individuals in waiting
rooms etc. with a Pertussis case should not be considered
close contacts. Persons who had direct contact with
respiratory secretions from the case or intense close
contact may be considered for PEP
Facilities/Institutions: (i.e. Nursing Homes and institutions
for developmentally disabled):
Residents have multiple sources of exposure and increased
risk of complications
More inclusive interpretation of “close” contacts may be
indicated.
Hospital setting: Determination of close contact
should be more inclusive in settings such as a
neonatal intensive care unit, newborn nursery, or
infant ward, because infants are at risk for developing
severe disease
Health Care Workers (HCWs) and Patients should
be considered exposed only if the source is a
confirmed case, or a suspect case during an
outbreak.
HCWs should wear a mask for respiratory
protection. Patients and HCWs exposed to
pertussis, should be questioned about symptoms
of cough illness, and be instructed to report the
development of symptoms within 42 days of
exposure to infection control staff.
If symptomatic, Health Care Worker (HCW) should be
cultured for pertussis, treated and excluded for the first 5
days of a full course of appropriate antibiotic treatment.
If a symptomatic HCW cannot take or refuses
antimicrobial therapy, the HCW should be excluded for
21 days after the onset of cough. The use of a mask by
the HCW does not provide adequate protection during
this time.
Active surveillance in health care settings should
continue for 42 days after the onset of cough of the last
case of pertussis.
Year
Reported Cases*
2000
7,867
2001
7,580
2002
9,771
2003
11,647
2004
25,827
2005
25,616
2006
15,632
2007
10,454
2008
13,278
2009
16,858
2010
27,550
2011* 18,719
*Total reported cases include those with unknown age
http://www.cdc.gov/pertussis/survreporting.html
Wisconsin
87.6 Utah
33.6
27
Arizona
Idaho
12.2
Minnesota
72.6* New Mexico
12
Washington
Vermont
Montana
23.5
21.9
17.2
Pennsylvania
Missouri
Colorado
11.7
11.6
11
Maine
Iowa
62.3 Alaska
51.9 Oregon
44.7 Kansas
New
42.6 Hampshire
42.1 New York
14.9
13.8
Kentucky
Wyoming
10.7
10.3
North Dakota
41.9 Illinois
12.3 Nebraska
8.8
Year
2007
2008 2009
2010
2011
2012
Cases
79
44
79
22
171
184
Incidence
per
100.000
6
3
6
2
12
15
In Household: Two or more cases, with at least one case
being confirmed. This definition may be used to count
cases/surveillance purposes.
Other settings (i.e. School, Daycare, Health Care):Two or
more cases clustered in a setting and time (within 42days of
each other), one of which has been confirmed.
Community Outbreak: A higher than expected number of
reported cases in a population in a defined time period on
the basis of previously reported disease numbers during a
non epidemic time period (historical disease patterns)
Institution of droplet precautions in addition to
standard precautions for suspect and known cases
Cohort exposed patients
PEP for exposed employees and patients
Evaluate all symptomatic exposed employees, treat
and exclude until on TX x 5 days or 21 days post cough
onset
Active surveillance x 42 days after onset of cough of
last case of pertussis
Education of high risk units via in-service
Education of other staff via fact sheets, other
communications
Evaluation of staff with respiratory illness
Cohort patients with cough illness
Restriction of patients to affected floor, masking
when leaving floor
Consideration of requirement for visitors to wear
surgical mask while in facility
Consideration of vaccination for exposed staff
Immunization of Health-Care Personnel
Recommendations of the Advisory Committee
on Immunization Practices (ACIP)
http://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf
Recommended Adult Immunization Schedule—
United States - 2012
http://www.cdc.gov/vacc
ines/schedules/downloa
ds/adult/adultschedule.pdf
Report on Pertussis Epidemic –Washington 2012
2,520 confirmed and probable cases of pertussis
(83.4% confirmed) between January 01 and June 16
2012
Review done with attention to Immunization status of
patients
Vaccinate HCP regardless of age with a single dose
of Tdap as soon as feasible if no prior dose
No minimal interval between last Td and Tdap for
HCW
Hospitals and ambulatory-care facilities should
provide Tdap for HCWs and maximize immunization
rates
THANK YOU!