Pertussis in the Elderly

Transcription

1 Pertussis in the Elderly Equity in Disease Prevention: Vaccines for the Elderly Melbourne, Australia Friday, 20 June 2014 David R. Johnson, MD, MPH Vice President and Global Medical Expert Sanofi Pasteur Global Medical Affairs Swiftwater, Pennsylvania, USA

2 Presentation Outline I. Pertussis Overview 2

3 Images of Pertussis Disease Video courtesy of the California Department of Health Services, UCLA s Dr. James Cherry, and the Immunization Action Coalition. Available at: Last accessed on 08 June

4 Pertussis Disease Manifestations Child with subconjunctival hemorrhages and facial ecchymoses due to pertussis coughing. Incubation period: 7-10 days (range 4-21) Stages Catarrhal: runny nose, sneezing, low-grade fever, mild cough Paroxysmal: severe spasms of cough, thick mucous, whoops, vomiting, exhaustion Convalescent: gradual recovery with less frequent & less severe coughing CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W et al eds 12th ed. Washington DC: PHF, 2012;15:

5 Pertussis Stages, Period of Communicability period of communicability exposure paroxysmal cough onset weeks of cough catarrhal stage paroxysmal stage convalescent stage CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W et al eds 12th ed. Washington DC: PHF, 2012;15:

6 Presentation Outline I. Pertussis Overview II. Prior to Pertussis Vaccines 6

7 cases (thousands) Reported Pertussis Cases by Year United States, year CDC. Pertussis United States, MMWR 2002;51: [Data for from CDC s T Murphy, personal communication, 2001.] 7

8 Adult Pertussis in the Pre-Vaccine Era Relatively little on clinical aspects of adult pertussis; rarely reported in adults Madsen described grandmother s cough ; thought to be 2nd attack of pertussis, always lighter, of shorter duration than 1st attacks Friedlander noted that even older adults had pertussis, but clinical diagnosis in this age group was difficult because paroxysms were mild and there was no definite whoop Personal communication from J Cherry, June Luttinger P. The epidemiology of pertussis. Am J Dis Child 1916;12: Madsen T. Whooping cough: its bacteriology, diagnosis, prevention and treatment. Boston M & S J 1925;192: Friedlander A. Whooping cough. In: Abt IA, ed. Pediatrics. Philadelphia: W.B. Saunders; 1925:

9 Presentation Outline I. Pertussis Overview II. Prior to Pertussis Vaccines III. Changes with Widespread Vaccination of Infants / Young Children 9

10 cases (thousands) Reported Pertussis Cases by Year United States, DTP vaccine introduced year CDC. Pertussis United States, MMWR 2002;51: [Data for from CDC s T Murphy, personal communication, 2001.] Edwards KM, Decker MD. Pertussis vaccines. In: Plotkin SA, Orenstein WA, Offit PA, eds. Vaccines 6th Edition. Elsevier Saunders; 2013:

11 cases (thousands) Reported Pertussis Cases by Year United States, DTP year CDC. Pertussis United States, MMWR 2002;51: [Data for from CDC s T Murphy, personal communication, 2001.] CDC. Summary of notifiable diseases US, MMWR 1993;42(53):67, CDC. Summary of notifiable diseases US, MMWR 2005;54(53):77,

12 cases (thousands) Reported Pertussis Cases by Year United States, : 25, year CDC. Summary of notifiable diseases US, MMWR 1993;42(53):67, CDC. Summary of notifiable diseases US, MMWR 2005;54(53):77,

13 Average Number of Cases / Year Reports of Pertussis in the U.S <1 yr 1-4 yrs 5-9 yrs yrs 20+ yrs Age Group 15.6 fold 16.7 fold Güriş et al. Clin Infect Dis. 1999;28: CDC. Summaries of Notifiable Diseases US, MMWR 1997; ;54. 13

14 Australia Also Experienced Surge in Adults From 1995 thru 2007, pertussis rates in persons and 60 years generally < 20/100,000 Changed in 2008; rate in both and 60 years age groups approached 50/100,000 Increased further in 2009 for both these age groups to almost 100/100,000 In 2010 the rate in those 60 years climbed to ~ 125/100,000 Personal communication from J Cherry, June 2014, concerning National Pertussis Workshop sponsored by the National Center for Immunization Research and Surveillance in Sydney, Australia, August,

15 rate per 100,000 persons Incidence Rates of Reported Pertussis United States, <6 mos 6-11 mos 1-4 yr 5-9 yr yr 20+ yr age group CDC. Summary of notifiable diseases US, MMWR 2005;54(53). 15

16 Hospitalizations and complications among infants aged <1 year with pertussis, US, Total N = 25,179 Hospitalized 11,571 (63.3%) Apnea 10,127 (58.0%) * Pneumonia 1,875 (19.2%) Seizure 202 (1.2%) CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System, Data are provisional. Percentages are based on total number with information. For 19% of infant cases, no information was available on hospitalization or apnea; for 21% no information was available on seizure; and for 34%, no information was available on pneumonia. * Radiographically confirmed. 16

17 Deaths Pertussis Deaths by Decade and Age Group vs vs mos 28 4 mos Includes one case of unknown age mos 4 mos mos 4 mos data are provisional. Vitek CR et al. Increase in deaths from pertussis among young infants in the United States in the 1990s. Pediatr Infect Dis J 2003;22: Liang JL. ACIP presentation, 23 June Minutes available at 17

18 Presentation Outline I. Pertussis Overview II. Prior to Pertussis Vaccines III. Changes with Widespread Vaccination of Infants / Young Children IV. Reasons for Changing Epidemiology 18

19 Estimated Duration of Immunity After Pertussis Infection or Vaccination, Summary Source of Immunity Natural infection Duration 4 20 years Whole-cell vaccination 4 14 years Acellular vaccination 3 10 years Wendelboe AM et al. Duration of immunity against pertussis. PIDJ 2005; 24: S58 S61. 19

20 Before generalized use of pertussis vaccine After generalized use of pertussis vaccine in children Hewlett EL, Edwards KM. Pertussis Not Just for Kids. N Engl J Med 2005; 352:

21 cases (thousands) Reported Pertussis Cases by Year United States, * 250 * 2013 data are provisional 200 DTP year CDC. Pertussis United States, MMWR 2002;51: [Data for from CDC s T Murphy, personal communication, 2001.] CDC. Summary of notifiable diseases US, MMWR 1993;42(53):67, CDC. Summary of notifiable diseases US, MMWR 2011;60(53):100,102,104. CDC. Notice to Readers: Final 2012 reports of nationally notifiable infectious diseases. MMWR 2013; 62(33):678. CDC. Notifiable diseases and mortality tables. MMWR 2013; 62(52):ND

22 cases (thousands) Reported Pertussis Cases by Year United States, year CDC. Pertussis United States, MMWR 2002;51: [Data for from CDC s T Murphy, personal communication, 2001.] CDC. Summary of notifiable diseases US, MMWR 1993;42(53):67, CDC. Summary of notifiable diseases US, MMWR 2011;60(53):100,102,

23 Presentation Outline I. Pertussis Overview II. Prior to Pertussis Vaccines III. Changes with Widespread Vaccination of Infants / Young Children IV. Reasons for Changing Epidemiology V. Pertussis Manifestations in and Transmission from the Elderly 23

24 Whooping Cough in an Adult Rutledge RK, Keen EC. Whooping cough in an adult. N Engl J Med 2012;366:e39. 24

25 Vignette: 71-Year-Old Physician Case Illustrates Challenges of Diagnosis, Treatment and Recovery - At age 5 years, subject developed pertussis; wife had pertussis in late 1980s. - The subject was assumed to have been exposed on an airplane on July 5, Onset of cough illness occurred on July 15, sweating episode July 18, first whooping episode occurred July An internist diagnosed cough variant asthma on August 3 and decided to rule out insulinoma; treated with prednisone. On August 7, otorhinolaryngologist diagnosed Wegener granulomatosis; underwent head and neck CT scan. - Positive PCR results obtained on August Coughing continued through October without improvement. Relapse occurred during a cold in November Cherry JD. The present and future control of pertussis. Clin Infect Dis 2010; 51(6):

26 Clinical Characteristics and Complications of Pertussis in Adults United States Quebec years (n = 18,243) 65 years (n = 984) 18 years (n = 384) Paroxysmal cough 89% 86% 99% Apnea 32% 32% 85% Post-tussive vomiting 45% 27% 61% Whoop 37% 33% 70% Pneumonia 3% 8% 5% Seizure 0.6% 0.2% 0% Hospitalization 3% 12% 2% CDC. Preventing tetanus, diphtheria, and pertussis among adults. MMWR 2006;55(RR-17):1-37. De Serres G, Shadmani R, Duval B, et al. Morbidity of pertussis in adolescents and adults. J Infect Dis 2000;182:

27 Cough Duration in Adults With Pertussis Quebec (n=384) Sweden (n=155) Germany (n=79) Cough 3 weeks 97% - 80% Cough 9 weeks 55% - - Median or mean duration Maximum duration 12 wks 8 wks 7 wks - 26 wks 32 wks Fuse/Getty Images De Serres G, Shadmani R, Duval B, et al. Morbidity of pertussis in adolescents and adults. J Infect Dis 2000;182: Trollfors B, Rabo E. Whooping cough in adults. Br Med J 1981;283: Postels-Multani S, Schmitt HJ, Wirsing von Konig CH, et al. Symptoms and complications of pertussis in adults. Infection 1995;23:

28 CDC Study Infant Pertussis: Who Was the Source? 774 infant cases from 4 states 264 cases had source identified Sources: Mother 32% Siblings 20% Grandparents 8% Father 15% Others 25% Bisgard KM et al. Infant pertussis Who was the source? PIDJ. 2004;23:

29 Presentation Outline I. Pertussis Overview II. Prior to Pertussis Vaccines III. Changes with Widespread Vaccination of Infants / Young Children IV. Reasons for Changing Epidemiology V. Pertussis Manifestations in and Transmission from the Elderly VI. Tdap Vaccination in the Elderly 29

30 Studies of Tdap Vaccines in Elderly: Immunosenescence, Antibody Responses Consistent With Protection 1. Tdap5-IPV in Austrian elderly: humoral immune response to booster immunization is lower in older age than in young persons 2. Tdap3 in US elderly: Tdap vaccine was shown to be immunogenic in this age group, with robust increases in antibodies 3. Tdap5 in US elderly: pertussis antibodies increased by at least 4.4-fold suggesting an improved degree of protection against pertussis 1. Kaml M et al. Booster vaccination in the elderly. Vaccine 2006;24: Weston WM et al. Vaccination of adults 65 years of age and older with Tdap vaccine. Vaccine 2012;30: Tdap5 Canadian Product Monograph. Available at Last accessed 19 June

31 Presentation Outline I. Pertussis Overview II. Prior to Pertussis Vaccines III. Changes with Widespread Vaccination of Infants / Young Children IV. Reasons for Changing Epidemiology V. Pertussis Manifestations in and Transmission from the Elderly VI. Tdap Vaccination in the Elderly VII.Summary 31

32 Summary With widespread use of pertussis vaccines in multiple countries beginning mid-20 th century, pertussis dramatically decreased, but was not eliminated. In recent years, pertussis reports have increased: Only to fraction of pre-vaccination levels; Adolescents / adults (including elderly), newborns / young infants disproportionately affected. Waning of infection- and vaccine-induced protection one of important reasons for increasing reports of pertussis and changes in age distribution of cases. Tdap vaccines induce good anti-pertussis responses in older adults, and definitely should be offered to those in this age group. sanofi-aventis australia pty ltd ABN trading as SANOFI PASTEUR. Locked Bag 2227 North Ryde BC NSW SPANZ.ADAC JULY