PROTOCOL FOR THE MANAGEMENT OF CLOSE CONTACTS OF PERTUSSIS INFECTION

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1 PROTOCOL FOR THE MANAGEMENT OF CLOSE CONTACTS OF PERTUSSIS INFECTION Printed copies must not be considered the definitive version DOCUMENT CONTROL PROTOCOL NO Policy Group Infection Control Committee Author Version no. 3.0 Dr David Breen Reviewer Implementation July 2013 Mrs. Mary Waugh date Scope NHS Dumfries and Galloway Board wide (Applicability) Status Approved Next review date July 2015 Approved by HPT/ICT Last review date: April 2008 [Type text]

2 PROTOCOL FOR THE MANAGEMENT OF CLOSE CONTACTS OF PERTUSSIS INFECTION CONTENTS Page 1. Introduction 3 2. Rational for Public Health Action 3 3. Surveillance 3 4. Case Definitions Suspected case of pertussis Confirmed cases of pertussis 4.3 Epidemiologically linked case of pertussis Laboratory Confirmation 4 5. Case management Exclusion Antibiotic therapy TABLE 1: Recommended antibiotic treatment and post exposure prophylaxis by age group Immunisation Contact Management Definition of close contacts Definition of contacts considered as priority groups for public health Action Chemoprophylaxis Immunisation 6 6. Outbreaks Nursery and School Settings 6 References 8 Appendix 1: Recommended antibiotic treatment and post exposure prophylaxis for Pertussis by age group 9 Appendix 2: Algorithm for Management of Cases and Close contacts 10 2

3 1. Introduction This protocol is based on the Health Protection Agency Guidelines for the Public Health management of Pertussis (1) published in February 2011and updated in October Rationale for public health action Outbreaks of Pertussis can occur in households, schools, healthcare settings and in the community. If outbreaks are detected at an early stage, prompt action including chemoprophylaxis and vaccination can limit the spread (2, 3). Chemoprophylaxis and vaccination of close contacts may also be of benefit in reducing transmission to those who are most at risk of severe or complicated infection and is therefore recommended in settings where there is a vulnerable person or an individual who may facilitate ongoing transmission to vulnerable groups. This has been divided into two groups: Group a) At increased risk of severe or complicated pertussis ( Vulnerable ) Young infants (particularly those under three months of age [4]) are at greatest risk of severe complications, hospitalisation and death following B. pertussis infection. Although most cases of severe illness occur amongst those too young to have received any immunisations, partially immunised infants also remain at increased risk (5). Group b) At increased risk of transmitting infection to individuals in Group 1. Pregnant women Although Pertussis in pregnant women is not thought to be more severe than in other adults, and no obstetric or foetal adverse outcomes have been described (6) mother to infant transmission at the time of, or shortly after, birth has been described (7,8) and is often associated with severe neonatal illness (9-11). Healthcare workers If necessary refer to Public Health management of Pertussis HPA Guidelines for the public health management (12) 3. Surveillance Health Protection Scotland request Pertussis surveillance, to be completed for infants under one year only. For all other cases surveillance will be completed by the Health Protection Team and kept within the Active Case file with filenote. 3

4 4. Case Definitions 4.1 Suspected case of Pertussis AND a. Any person in whom a clinician suspects pertussis infection or b. Any person with an acute cough lasting for 14 days or more, without an apparent cause plus one or more of the following:- - Paroxysms of coughing - Post-tussive vomiting - Inspiratory whoop -Absence of laboratory confirmation -No epidemiologic link to a laboratory confirmed case. 4.2 Confirmed case of Pertussis Any person with signs and symptoms consistent with pertussis with: B. pertussis isolated from nasopharyngeal aspirate or pernasal swab or Anti- Pertussis toxin IgG titre >70 IU/ml13 (in the absence of vaccination within the past year) or Confirmed B. pertussis PCR positive on any clinical specimen. 4.3 Epidemiologically linked case of Pertussis A suspected case with signs and symptoms consistent with pertussis, but no laboratory confirmation, who was in contact with a laboratory confirmed case of pertussis in the 21 days before the onset of symptoms. 4.4 Laboratory confirmation Appropriate Public Health action should not wait for laboratory results as negative results cannot exclude Pertussis infection. 5. Case management 5.1 Exclusion Children with suspected, epidemiologically linked or confirmed pertussis should be excluded from schools or nurseries for five days from commencing appropriate/ recommended antibiotic therapy or for 21 days from onset of symptoms ( in those who are not treated). See Appendix 1. If case is healthcare worker or patient in healthcare setting see HPA Guidelines for management of Pertussis incidents in healthcare settings for further details go to: (12) For cases working in other settings, contact with vulnerable individuals ( as defined in Section 2) should be avoided for five days from commencing appropriate /recommended antibiotic therapy or for 21 days from onset of symptoms (in those who are not treated). Exclusion for asymptomatic contacts is NOT required. 4

5 5.2 Antibiotic Therapy For suspected, epidemiologically linked or confirmed cases, recommended antibiotic regimes are summarised in Appendix 1: Recommended antibiotic treatment and post exposure prophylaxis for Pertussis by age group. 5.3 Immunisation Ensure unvaccinated and partially immunised cases up to 10 years of age complete their primary immunisation and booster vaccine once they have recovered from their acute illness, according to the PHE guidance Vaccination of individuals with uncertain or incomplete immunisation status. Pregnant women who have been diagnosed with Pertussis (at any stage of pregnancy) should still be offered a dose of Pertussis-containing vaccine from 28 weeks of pregnancy in line with current temporary Pertussis vaccination programme for pregnant women (13, 14). 5.4 Contact Management Management of contacts should proceed for all clinically suspected epidemiologically linked and laboratory confirmed cases see Appendix Definition of close contacts Family members or people living within a single house would qualify as close 'household contacts'. Contacts in institutions with overnight stay in the same room e.g. boarding schools dormitories should also be considered close contacts Other type of contact (e.g. contact at work, in school or casual contact) would not be considered close contact but each situation would need to be considered on its own merit, particularly where vulnerable contacts are involved. For the definition of a significant exposure in a healthcare setting please refer to Public Health management of Pertussis HPA Guidelines for the public health management of Pertussis Incidents in Healthcare Settings(12) Definition of contacts considered as priority groups for public health action. Group 1: Individuals at increase risk of severe complications ( Vulnerable ) Infants under 1 year who have received less than 3 doses of Pertussis containing vaccine Group 2: Individuals at increased risk of transmitting to Vulnerable individuals in group1 who have not received a Pertussis containing vaccine more than 1 week and less than 5 years ago: a) Pregnant women (>32 weeks gestation) b) Healthcare workers working with infants and pregnant women c) People whose work involves regular, close or prolonged contact with infants too young to be fully vaccinated (<4months) d) People who share a house with an infant too young to be fully vaccinated (<4months) 5

6 5.5 Chemoprophylaxis Given the limited benefit of chemoprophylaxis, antibiotic prophylaxis should only be offered to close contacts when both of the following conditions apply: AND Onset of disease in the index case is within the preceding twenty one days There is a close contact in one of the priority groups as defined above Where both these conditions are met, ALL close contacts (regardless of age and previous immunisation history) should be offered chemoprophylaxis. The dose of antibiotics for use as chemoprophylaxis is the same as for the treatment of cases (Appendix 2). Chemoprophylaxis is NOT required when there are no close contacts in the priority groups defined in section 2. Pregnant women exposed after 32 weeks pregnancy should be offered erythromycin if they have not received a Pertussis containing vaccine within the past week, chemoprophylaxis would still be indicated given the delay in antibody response. For individuals who fall into group 2b) c) or d) that happens to be pregnant as well, chemoprophylaxis and vaccine is recommended at any stage of pregnancy. For pregnant women with suspected or confirmed Pertussis, who are still infectious at delivery (i.e. within 21 days of onset), the newborn infant should be offered chemoprophylaxis with clarithromycin or azithromycin. 5.6 Immunisation Immunisation should be considered for those who have been offered chemoprophylaxis. Unimmunized and partially immunized contacts up to the age of 10 years should complete the schedule with the appropriate vaccine. A booster dose of Pertussis containing vaccine is recommended for individuals aged 10 years or older 9 including pregnant women > 32 weeks gestation), who have not received a dose of Pertussis containing vaccine in the last five years and no Td-IPV in the preceding month. 6. Outbreaks Where disease transmission is widespread, the benefit of wider chemoprophylaxis is likely to be of limited value. In the event of a community outbreak, an outbreak control team should be convened at the earliest opportunity and HPS informed. The priority in these circumstances is active case finding and therefore a less specific case definition should be used to ensure no cases are missed. Specific guidance for the public health management of Pertussis incidents in healthcare settings please refer to Public Health management of Pertussis HPA Guidelines for the public health management (12) Nursery and School Settings. Confirmed and suspected cases should be excluded from nursery or school for five days from commencing appropriate /recommended antibiotics therapy or for 21 days from onset of symptoms (in those who are not treated). Asymptomatic contacts do not need to be treated. In certain circumstances, wider chemoprophylaxis and vaccination for a school/nursery outbreak may be considered by the outbreak control team. Where there has been more than one case reported from an educational institution, other parents should be informed in order to raise awareness including emphasising the groups at risk of severe infection and to 6

7 encourage timely reporting of further cases to enhance case finding. Regardless of these control measures, this should be used as an opportunity to remind parents about routine immunisation and ensure children are up to date. 7

8 References: 1. Amirthalingham G and the Pertussis Guideline Group. HPA Guidelines for the Public Health Management of Pertussis Health Protection Agency, Dodhia H, Miller E. Review of the evidence for the use of erythromycin in the management of persons exposed to Pertussis. Epdemiol. Infect. 1998;120(2): Kirkland KB, Talbot EA, Decker MD, EdwardsKM. Kinetics of Pertussis immune responses to tetanus-diptheria-acellular Pertussis vaccine in health care personnel: implications for outbreak control. Clin.Infect. Dis.2009;49(4): Douglas J.Natural course of 500 consecutive cases of whooping cough: a general practice study.bmj 1995; de Greeff SC, Mooi FR, Westerhof A,et al. Pertussis Disease Burden in the Household: How to Protect young infants. Clinical Infectious Diseases 2010;50(10): Centres of Disease Control and prevention. Guidelines for the Control of Pertussis Outbreaks htttp:// Centres for Disease Control and Prevention. 7. McGregor J,Ogle JW, Curry-Kane G. Perinatal Pertussis. Obstetrics & Gynaecology 1986;68(4) 8.BrouwerAF, van Gils JF,Brand PL, de Graaf JH. Perinatal Pertussis:from mother to child. Ned Tijdschr Geneeskd 2001;145(47): Christie C, Baltimore R. Pertussis in neonates. Am J Dis 1989:143: Beiter A, Lewis K, pineda EF, Cherry JD. Unrecognised maternal peripartum Pertussis with subsequent fatal neonatal Pertussis. Obstetrics and Gynaecology 1993;82(4) 11. Armangil D, Tekinalp G, YurdaKök M,Yalçin E. Maternal Pertussis is hazardous for a newborn: a case report. Turk J Pediatr 2010;52(2): Health Protection Agency. Public Health Management of Pertussis HPA Guidelines for management of Pertussis incidents in healthcare settings SGHD/CMO(2012)9 Temporary Programme of Pertussis (whooping cough) Vaccination of pregnant women 14. SGHD/CMO(2013/3) Extension to Temporary Programme of Pertussis (whooping cough) Vaccination of pregnant women 8

9 Appendix 1: Algorithm for Management of Cases and Close Contacts 9

10 Appendix 2: Recommended antibiotic treatment and post exposure prophylaxis for Pertussis by age group. 10

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