OCCUPATIONAL EXPOSURE TO PERTUSSIS IN THE OUTPATIENT PRIMARY CARE NETWORK

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1 OCCUPATIONAL EXPOSURE TO PERTUSSIS IN THE OUTPATIENT PRIMARY CARE NETWORK Adrienne Smallwood, Harvard Class of 2013

2 2 Special thanks to Dr. Kristen Feemster M.D., MPH, MSHP Assistant Professor, Perelman School of Medicine Department of Infectious Diseases, Children s Hospital of Philadelphia Maria Middleton, Research Assistant Julie Fierro, MD/MPH student Joanne Levy and the SUMR Program!

3 Outline of Talk 3 1. Background on Pertussis 2. Epidemiology 3. Research Question 4. Methodology 5. Analysis 6. Future Steps and takeaways

4 4 Background

5 What is Pertussis? 5 Pertussis (Whooping cough) is a contagious respiratory infection Spread by droplets within 3 feet Symptoms: o Symptoms of common cold o Prolonged, violent coughing with whooping sound o Vomiting Treated with Antibiotics Source: Center for Disease Control and Prevention

6 Background 6 Highly contagious ~90% susceptible household contacts who are exposed to a case will become infected High transmissibility during catarrhal stage when symptoms are nonspecific Remain contagious for ~3 weeks after developing symptoms Vaccination is the most effective prevention measure but immunity wanes over time and those at highest risk for severe disease are too young to be vaccinated

7 Background 7 Serious in children/infants 75% of infants develop complications > 50% of infants hospitalized, 1% die Adolescent and adult contacts with unrecognized disease often the reservoir for infection Less severe in adults Previously vaccinated individuals can have atypical symptoms Source: Center for Disease Control and Prevention

8 Pertussis Commercial 8 https://www.youtube.com/watch?v=aq9mkrr_e7c

9 9 Epidemiology

10 Epidemiology Cases of Pertussis in the US Source: Centers for Disease Control and Prevention 232% increase in pertussis cases in the past 7 years

11 Background: Occupational Exposures 11 Healthcare workers at increased risk of exposure and subsequent transmission to susceptible patients Very important in pediatrics CDC recommends Tdap booster to all HCWs in 2006 Exposed vaccinated HCW to receive post-exposure prophylaxis or daily symptom monitoring

12 12 Occupational Exposures:

13 13 Pertussis: What Happened?

14 Pertussis: Current Situation 14 Epidemic in several communities throughout the country including metropolitan Philadelphia 450 cases over 10 years and now100 cases at CHOP in the past 6 months Many cases in fully vaccinated children Increasing number of cases in community increased number of occupational exposures (and uncountable potential patient exposures) Data suggests that we may be missing many cases

15 15 Pertussis: Are we Missing Exposures?

16 16 Pertussis in the Media

17 17 So why is there a Whooping Cough outbreak? Change from whole-cell to acellular vaccine Waning immunity in adults and adolescents Atypical presentation when infected unrecognized disease Refusal to vaccinate

18 18 Research Question and Aims

19 Research Question 19 Goal: Understand the knowledge, attitudes, and beliefs of healthcare workers develop more effective infection control policies Question: What barriers exist in using appropriate infection control measures in primary care outpatient pediatric offices? Behaviors: Physician mask use, offering patient a mask, Tdap booster use

20 20 Methodology

21 Overview of our Approach 21 To assess the barriers to the appropriate use of PPE in clinics with the highest and lowest rates of occupational exposure to pertussis Clinical survey: 25 questions including 2 vignettes Nonclinical survey: 22 questions To observe and inventory the presence of specific infection control measures at each clinic site Inventory Checklist

22 Survey Methodology 22 Questionnaire adapted from previously validated instruments Based upon an integrated behavior model Clinical vignettes to determine impact of different scenarios related to the use of PPE Compare results between clinics with the highest and lowest rates of occupational exposure to pertussis to assess the barriers to the appropriate use of PPE

23 23 Survey Design: Integrated Behavioral Model

24 Survey Methodology 24 Example Statements Knowledge: Adults can get whooping cough even if they had whooping cough as children. Personal Agency: Wearing PPE interferes with my ability to do my job due to difficulty breathing with a mask on Attitude: It is convenient to provide patients with a cough a mask when they come to the office

25 Clinical Survey Vignettes 25 Version A: In an attempt to improve quality of care, the nurse manager of your practice will be rearranging office supplies. The masks (personal protective equipment) required for use when entering the examination room of a child suspected of having pertussis will be located in bins outside of the examination rooms. All supplies will be fully in stock in sufficient quantities at all times. Based on this information, what action(s), if any, would you take? Version B: In an attempt to improve quality of care, the nurse manager of your practice will be rearranging office supplies. The masks (personal protective equipment) required for use when entering the examination room of a child suspected of having pertussis will be located in a common room at the end of the hall. All supplies will be fully in stock in sufficient quantities at all times. Based on this information, what action(s), if any, would you take? Randomized Control Trial

26 Study Sample primary care sites in the CHOP network 445 clinical staff (169 physicians, 22 nurse practitioners, 254 nurses) 216 non-clinical staff Anticipate a 75% response rate.

27 27 Inventory

28 My Roles 28 Develop the survey database in RedCap Implement the surveys to staff members at each site Conduct the inventory and direct observation Enter survey responses into the database

29 29 Analysis 8 site visits,133 surveyed 66% clinical 34% non-clinical

30 Analysis: Example Data 30 Non-clinical Staff: It is convenient to provide patients with a cough a mask when they come to the office Strongly Agree 69% Somewhat Agree 18% Neutral 10% Somewhat Disagree 3% Strongly Disagree 0%

31 Analysis: Example Data 31 Clinical Staff: Using recommended pertussis PPE interferes with patient care Strongly Agree 1% Somewhat Agree 21% Neutral 12% Somewhat Disagree 23% Strongly Disagree 43%

32 Analysis: More Findings 32 30% of clinical staff don t think they could get pertussis if they had it as a child 44% of non-clinical staff don t know that infants can get pertussis from adults. 58% of non-clinical staff believe that they could improve the frequency with which they provide masks to patients with a cough

33 Analysis: Feedback 33 High number of patients coming in with a cough Older kids do not want to wear masks Requests (barriers at front desk, kid sized masks)

34 34 Future Steps and Takeaways

35 Future Steps 35 Finish site visits & data analysis Health alert Change in practice at CHOP and other places Down the line: Intervention for adult vaccinations

36 What I learned from my SUMR 36 Experience Infectious diseases as a public health concern Survey methodology Research: Recognizing a problem, understanding the underlying reasons, and finding a logical solution Career path options!

37 37 Thank you!

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