Welcome to the California Immunization Coalition Education Hour

Welcome to the California Immunization Coalition Education Hour 1

Pertussis Update: Where Are We and Where Are We Going? 2

. Webinar Objectives Learn about the current epidemiology and trends regarding pertussis in CA. Find out which strategies are the most effective in preventing disease and protecting infants. Learn about what experts see as a way to control the disease in the future. Learn what resources are available to conduct outreach and education to key populations. 3

Welcome to the Webcast! We Will Be Starting Momentarily. 4

TITLE of PRESENATION Pertussis in California Kathleen T. Winter, MPH Epidemiologist, Supervisor Vaccine-Preventable Disease Epidemiology and Surveillance Section California Department of Public Health 5

Chasing Pertussis in California: Update on disease activity, vaccine effectiveness and current prevention and control recommendations Kathleen Winter, MPH California Department of Public Health

Pertussis (whooping cough) Caused by Bordetella pertusssis Primarily a toxin-mediated disease; bacteria attach to cilia of respiratory epithelial cells Most severe disease and death occurs in infants <4 months of age Highly infectious; R0 estimated to be 15-17 Has been described in writings as early as 14 th century and first isolated by Bordet and Gengou in 1906

Pertussis Epidemiology Cyclical peaks (every 2-5 years) have been increasing nationwide since 1990s 2010 pertussis epidemic in CA with >9,000 cases Many other states observed peaks in 2012 highest disease incidence since mid-1950s Incidence among children and adolescents has been increasing nationwide In 2010 in CA, peak incidence among older children/adolescents was 10 years of age Increased incidence among older children/adolescents, especially 7-10 year-olds, was seen in 2012 in most other states

Current Status of Pertussis in CA 1,456 cases with onset in 2013 have been reported This is nearly twice as many cases reported during the same time period in 2012 Most (82%) have been children <18 years of age Half of reported cases have been in older children/adolescents 7-16 years of age, many of whom received pertussis vaccine (DTaP or Tdap) in the prior 1-4 years Many health jurisdictions are reporting substantial increases in incidence over 2012 58 hospitalized infants <3 months have been reported Several critically ill infants requiring extensive medical care No deaths

Why have the numbers of pertussis cases been increasing? Use of less effective acellular vaccines more rapid waning of immunity General availability of more sensitive laboratory tests (PCR) since the 1990s Predominant testing method in California since 2002 More clinician and public awareness of pertussis Many vaccine studies published in the 1980s and 1990s Genetic changes in B. pertussis?

Pertussis Vaccines - Background Whole-cell pertussis vaccine (DTP) is composed of a suspension of formalin-inactivated B. pertussis cells Developed in 1930s; in wide use by 1940s 70% 90% effective in preventing serious pertussis disease after primary series of 4 doses Protection decreased with time Little or no protection 5 to 10 years following last dose DTP not licensed for anyone older than 6 years of age Acellular pertussis vaccines are subunit vaccines that contain purified, inactivated components of B. pertussis Less reactogenic, but less effective than whole cell vaccines DTaP recommended in 1992 for the 4 th /5 th doses of childhood series and for entire series in 1997 Tdap licensed in 2005 for adolescents and adults

New Data on DTaP Duration of Protection Recent studies conducted during and after the 2010 pertussis epidemic indicate that immunity from DTaP vaccine is high immediately following receipt but quickly wanes within a few years 1-3 Three studies also suggest that immunity wanes faster in children and adolescents born in 1998 and later who have only received acellular pertussis vaccines (DTaP and Tdap) 4-6 (i.e., no doses of whole cell vaccine) 1. Klein et al. Waning protection after fifth dose of acellular pertussis vaccine in children. N Engl J Med. 2012 Sep 13;367(11):1012-9. 2. Misegades et al. Association of childhood pertussis with receipt of 5 doses of pertussis vaccine by time since last vaccine dose, California, 2010. JAMA. 2012. Nov 28;308(20):2126-32. 3. Tartof et al. Waning immunity to pertussis following 5 doses of DTaP. Pediatrics. 2013 Apr;131(4):e1047-52. 4. Klein et al. Comparative effectiveness of aceullular versus whole-cell pertussis vaccines in teenagers. Pediatrics. 2013;131:1716-e1722. 5. Sheridan et al. Number and order of whole cell pertussis vaccines in infancy and disease protection. JAMA. 2012 6. Witt et all. Reduced risk of pertussis among persons ever vaccinated with whole cell pertussis vaccine compared to recipients of acellular pertussis vaccines in a large US cohort. CID. 2013:56.

New Data on Tdap Duration of Protection Preliminary data on Tdap effectiveness and duration of protection was presented at ACIP in June which similarly shows moderate short-term protection (75%) and rapid waning of immunity 2-4 years after receipt 1 N. California Kaiser study estimated Tdap to be 53% (41.9%-62.0%) and 64.0% (55.5%- 70.9%) effective among adolescents and adults 2 1. Liang. Tdap Revaccination: Antibody persistence and second Tdap safety and immunogenicity. June 2013 ACIP meeting. 2. Baxter et al. Effectiveness of pertussis vaccines for adolescents and adults: case-control study. BMJ. 2013.

National Changes in Pertussis Vaccine Recommendations March 2006 Tdap for adolescents December 2006 Tdap in place of one Td booster for adults and for cocooning October 2010 removed restrictions around use of Tdap off-label and intervals between Td and Tdap October 2011 Tdap for pregnant women (preferred over postpartum) February 2013 Tdap recommended for pregnant women during every pregnancy (27-36 wks) June 2013 The ACIP pertussis working group voted not to recommend Tdap booster doses for the general population

Tdap in Pregnancy ACIP and ACOG recommend that all pregnant women receive Tdap vaccine during each pregnancy, preferably in the third trimester, regardless of their Tdap vaccination history Antibodies to pertussis (PT, FHA, PRN, FIM) are actively transported across the placenta to the baby 1,2 CDC feels this is the most important strategy to prevent infection in infants who are too young to be vaccinated 1. de Voer RM, et al. Seroprevalence and placental transportation of maternal antibodies specific for Neisseria meningitidis serogroup C, Haemophilus influenzae type B, diphtheria, tetanus, and pertussis. Clin Infect Dis. 2009 Jul 1;49(1):58-64. 2. Gall SA, et al. Maternal immunization with tetanus-diphtheria-pertussis vaccine: effect on maternal and neonatal serum antibody levels. Am J Obstet Gynecol 2011;204

Tdap in Pregnancy Safe and Effective Data from Australia indicate that infants born to women who received Tdap either during or after pregnancy had reduced risk of disease (OR 0.60) 1 Data from UK s recently implemented Tdap program for pregnant women 2 VE ~90% in preventing disease in infants up to 2 months of age Vaccine coverage among pregnant women now ~60% No increase in pregnancy adverse events 1. McIntyre. The cocoon strategy to prevent early pertussis Australian experience. June 2013 ACIP meeting. 2. Salisbury. Pertussis vaccination programme for pregnant women in the UK. June 2013 ACIP meeting.

Tdap in pregnancy uptake in CA? Recent unpublished data from Northern CA Kaiser indicate that ~50% of pregnant women in their system received Tdap during pregnancy Preliminary data from an ongoing survey of labor and delivery hospitals led by CDPH estimates Tdap coverage among pregnant women at 20-25% An additional ~50% of women were vaccinated postpartum and ~20% refused Tdap entirely

Tdap in adults uptake? Group Rate 19 64 y.o. 13% Living with an infant aged <1 yr 21% Hispanic 8% Health Care Workers 37% Source CDC. Noninfluenza Vaccination Coverage Among Adults United States, 2011 MMWR February 1, 2013 / 62(04);66-72

Tdap booster At this time, ACIP is only recommending Tdap boosters for pregnant women The ACIP Pertussis Working Group will consider adding recommendations for Tdap boosters for those who live or work with infants <1 year of age, including healthcare workers Additional studies to examine effectiveness of cocooning are ongoing

Pertussis Deaths Of note, there have been no pertussis deaths reported in California since October 2010, despite data from 1989-2009 indicating ~2-3 deaths/year even in years of low incidence This may reflect more prompt diagnosis and better treatment of infant cases. Several critically ill infants requiring ECMO treatment that have survived have been reported Alternatively or additionally, this may indicate that efforts to vaccinate pregnant women and household contacts of young infants could be reducing the incidence of severe disease in young infants

B. pertussis bacteria mutations? Recently, strains of B. pertussis that do not express the outer protein pertactin have been identified 1 Pertactin is one of the antigens included in the current acellular pertussis vaccines, however it is not known if acellular or whole cell vaccines are less effective against these variant strains To better understand the circulating strains, CDPH is collaborating with CDC and local health departments to solicit B. pertussis isolates for further characterization 1. Queenan AM, et al. Pertactin-Negative Variants of Bordetella pertussis in the United States. NEJM. 2013 Feb 7.

What has been learned Primary goal of pertussis vaccination program is to prevent severe disease and death Acellular pertussis vaccines are protective, but duration of protection is suboptimal Resurgence of pertussis expected to continue No evidence of a herd effect from vaccination Cocooning feasibility problematic continue to recommend, but pursue other strategies that more directly protect infants Strategies to directly protect infants are likely to be most effective in preventing infant deaths Vaccination of pregnant women to protect infants via placental transfer of maternal antibodies

CDPH Conclusions Pertussis disease cannot be controlled on a population level with current vaccines Prevention efforts should be targeted at preventing infection, severe disease, and death in young infants Vaccination efforts should be focused on vaccination of pregnant women Clinicians need to be educated about: Vaccinating pregnant women Promptly diagnosing and treating pertussis in infants Waning acellular vaccine protection and the fact that pertussis can occur in recently vaccinated persons

Questions?

Supplemental Background Slides

Pediatric pertussis cases by age - California 2010 and 2013*

Current U.S. Pertussis Vaccine Recommendations DTaP Five doses recommended at age 2, 4, and 6 months, 15-18 months, and 4-6 years) Tdap Currently only one dose recommended for adolescents (11-12 years of age) and older adolescents and adults who have not yet been vaccinated Exception is pregnant women; Tdap now recommended during every pregnancy

Q & A Session 35

TITLE of PRESENATION Strategies and Resources Andrew J. Resignato, MS Director, San Francisco Immunization Coalition 36

Pertussis Update 2013 Where We Are and Where We Are Going

Strategies and Resources for Prevention

Why?

Pertussi$ Costs The average infant hospital stay for complications from pertussis infection is six days and costs $9,580 but can range from $515 to as much as $496,712. Source: Hospitalization for pertussis: profiles and case costs by age Judith A O'Brien and J Jaime Caro, BMC Infectious Diseases 2005, 5:57

Tdap During Every Pregnancy (between 27 and 36 weeks gestation) Working with Ob/Gyns Working with Maternal & Child Health, WIC, Vital Records Social Media Mom s Groups Practice Surveys / Metrics Marry to Flu Activities

Educating Providers About Clinical Symptoms of Pertussis Catarrhal stage: Onset of cold-like symptoms (coryza, sneezing, occasional cough). Fever is absent or minimal. This stage lasts approximately 1-2 weeks with cough gradually becoming more severe. Paroxysmal stage: Spasms of severe coughing are followed by a sudden deep inspiration, often resulting in a characteristic whooping noise. Post-tussive vomiting is common in all ages. Illness may be milder in previously vaccinated people. Infants <6 months of age may present differently: may have a shorter catarrhal stage may gag, gasp or stop breathing (apnea) facial color changes (may turn blue, purple or red) may not have noticeable cough or whoop likely to have leukocytosis (high white blood cell count) with an increased absolute lymphocyte count

ShotbyShot.org

EZ IZ.org (for patients)

EZ IZ.org (for providers)

EZ IZ.org (for providers)

CDC Infographic Post a web button linking to this infographic. Print infographic as a re-formatted (letter, legal or tabloid-sized) poster [9MB, 1 page]. See a version in Spanish. http://www.cdc.gov/vaccines/parents/infographics/protect-babies-from-whooping-cough.html

Giants Pertussis PSAs Sergio Panda

Looking Towards the Future

New ACIP Recs? The ACIP will look to the idea of reimmunizing subgroups with Tdap Cocooning Health Care Workers

Affordable Care Act Under the ACA, Tdap & DTaP need to be provided with no-cost sharing (i.e. no co-pay) for children, adolescents, and adults. As part of the Affordable Care Act (ACA) immunizations including human papillomavirus (HPV), influenza (flu), and tetanus, diphtheria, and pertussis (Tdap) are required to be covered at no charge for women, including those who are pregnant or nursing. SOURCE: http://www.immunizationforwomen.org/practice_management/affordable_care_act

Update: A Better Pertussis Vaccine More research into pertussis immunity (NIH, private researchers,?) Better Vaccine Possibilities - Change acellular formulation/add new circulating strain antigens - Whole-cell vaccine with reactogenic components (lipopolysacharides or endotoxins) removed. Sources: Why Do Pertussis Vaccines Fail? James D. Cherry, MD, MSc, IDSA Conference 2013 Session: Pertussis Vaccine Problems: What s to be Done?

Update: A Better Pertussis Vaccine (cont.) Better Vaccine Possibilities - Single Component Vaccine without Td - Use genetically detoxified or H202 inactivated pertussis toxoid instead of formaldehyde inactivated toxoid At least 4 years away / YOU CAN ADVOCATE! Change.org - petition for pertussis research Sources: Why Do Pertussis Vaccines Fail? James D. Cherry, MD, MSc, IDSA Conference 2013 Session: Pertussis Vaccine Problems: What s to be Done?

Thank You For Your Hard Work

Q & A Session 55

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