Pertussis. Faculty/Presenter Disclosure. Disclosure of Commercial Support. Mitigating Potential Bias. True Case 07/10/2013 DISCLOSURE

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1 Pertussis Outbreaks first described in the 16th Century Major cause of childhood fatality prior to vaccination Alan Kaplan Chair, Respiratory Medicine Group of College of Family Physicians of Canada Thanks to Dr.Anthony Ciavarella for assistance in formatting these slides DISCLOSURE Dr. Alan G. Kaplan Chair, Family Physician Airways Group of Canada Perceive no conflict of interest with giving this presentation, ti but present the following companies that I have worked with or consulted for: Astra Zeneca, Bayer, Boehringer Ingeleheim, Graceway, GSK, JOI, Merck Frosst, Novartis, Nycomed, Pfizer, Purdue, and Talecris,. In addition, I am on Health Canada committee for Section of Allergy and Respiratory Therapeutics and Public Health Agency of Canada Section of Respiratory Surveillance CFPC CoI Templates: Slide 1 Faculty/Presenter Disclosure Faculty: Alan Kaplan MD CCFP(EM) FCFP Chair Family Physician Airways Group of Canada Chair of Special Interest Focused Practice, College of Family Physicians in Respiratory Medicine. Relationships with commercial interests: Grants/Research Support: none Speakers Bureau/Honoraria: Astra Zeneca, Boehringer Ingelheim, Griffols, Pfizer, Purdue, Merck Frosst, Novartis, sanofi, Takeda. Consulting Fees: Aerocrine, Novartis, Takeda, Purdue, Pfizer Other: Member of Health Canada Section on Allergy and Respiratory Therapeutics. Member of Public Health Agency of Canada section on Respiratory Surveillance CFPC CoI Templates: Slide 2 Disclosure of Commercial Support This program has received financial support from [none]. This program has received in kind support from none in the form of. Potential for conflict(s) of interest: Alan Kaplan has received [consultancy fees, speakers fees or been involved in research ] from A) there are no organizations supporting this program B) The following companies make respiratory products that I may mention in this talk including: Aerocrine, Astra Zeneca, Boehringer Ingelheim, Griffols, GSK, Merck Frosst, Pfizer, Purdue, Novartis, Sanofi, Takeda, There are no organizations supporting a product that will be discussed in this program. CFPC CoI Templates: Slide 3 Mitigating Potential Bias I will mitigate any bias by discussing appropriately all treatement and diagnostic options for respiratory care in my talk today True Case 13 year old girl with a cough for three days In cabin at camp with 20 other girls her age Wakes her at night No history of asthma or lung problems Had her boosters at 6 years old What should you consider? 6 1

2 Pertussis A great imitator in early stages How do you diagnose pertussis? What are the complications of it? How can we prevent it? Pertussis: Bordetella Pertussis Highly Contagious Respiratory Infection Respiratory Tract Lumen Normal Ciliary Movement Ciliary Stasis Ciliated Respiratory Epithelial Cells Pertussis Toxin B. Pertussis Bacterium Filamentous Hemagglutinin 7 Catarrhal: Mild cough Runny nose Mild fever Apnea in infants Catarrhal Pertussis: Clinical Phases Typical Course of Pertussis* Paroxysmal Cough Cough Paroxysmal Cough Whooping Vomiting Cyanosis Apnea Paroxysmal Cough 1 6 weeks accessed October 05, 2013 Convalescent: Cough less paroxysmal disappears in weeks *The illness can be milder and the typical "whoop" absent in children, teens, and adults who have been vaccinated with a pertussis vaccine. Convalescence Pertussis: Contagious* Period Pertussis is most contagious during the first 2 weeks when symptoms resemble those of a common cold. Contagiousness declines rapidly after that, t but may last up to three weeks. Patients are no longer infectious after 5 days of treatment with appropriate antibiotics. *Older persons often source of infection for children. most contagious aspc.gc.ca/id mi/pertussis coqueluche eng.php 2013 October 02 Pertussis:Diagnosis The diagnosis of pertussis is based on a characteristic clinical history: cough for more than 2 weeks with whoop, paroxysms, or post tussive vomiting And a variety it of lb laboratory tests: t culture polymerase chain reaction [PCR] direct fluorescent antibody [DFA] serology. Paroxysmal Cough > 2 weeks Pertussis: Nasopharyngeal Swab* posterior nasopharynx not the throat Dacron or calcium alginate plated directly on selective media. not cotton *Isolation rates are highest during the first 3 to 4 weeks of illness (catarrhal and early paroxysmal stages). isolation rates are highest 2

3 Pertussis: Complications Youth Major* Complications Infants & Young Children Hypoxia Apnea Secondary Pneumonia Seizures Encephalopathy Death** *Major complications are most common among infants and young children. ** Most deaths occur among unvaccinated children or children too young to be vaccinated Paroxysmal Cough Phase Pertussis: Complications Adults B. Pertussis Bacterium Pertussis Toxin Filamentous Hemagglutinin Major* Complications Adults Pneumonia Rib Fracture Loss of consciousness Hernias Urinary Incontinence Weight Loss ** In older children and adults, the disease is less serious and complications are rare. Paroxysmal Cough Phase nt Percen 70% 60% 50% Pertussis: Complications* by Age *Most complications occur in children <12 months of age, especially those <6 months. 40% 30% 20% 10% 0% Pneumonia Hospitalization Condition % Reported Pneumonia 5.2% Seizures 0.8% Encephalopathy 0.1% Hospitalization 20.0% Death 0.2% <6 m 6 11 m 1 4 y 5 9 y y 20+ y Age group Pertussis:Treatment Antibiotic Therapy Erythromycin Azithromycin Clarithromycin Trimethoprim sulfamethoxazole Maintaining high vaccination coverage rates among preschool children, adolescents, and adults and minimizing exposures of infants and persons at high risk for pertussis is the most effective way to prevent pertussis. ; Cases reported to CDC (N=28, 187) Centers for Disease Control and Prevention; 1600 Clifton Rd; Atlanta, GA accessed 2013 October accessed 2013 October03 Pertussis: Prevention A. Vaccination: Children < 6 years need 5 doses of the Pertussis vaccine, starting at age 2 months An additional booster dose, combined with tetanus and diphtheria (Tdap) vaccine, is given routinely to adolescents between 14 to 16 years of age across Canada. Adults not previously immunized against pertussis receive 1dose of the Tdap vaccine B. Clinical Assessment: anyone with a cough that lasts longer than a week should see your health care provider. C. Proper hand washing. Fully Immunize Adults & Children Public Health Agency of Canada; home > Infectious Diseases > Pertussis (Whooping Cough) Fact Sheet aspc.gc.ca/id mi/pertussis coqueluche eng.php accessed 06 October 2013 Pertussis containing Vaccines Pertussis vaccine is only available as an acellular preparation in a combination vaccine A. ap Petussis full antigen dose Pediatric formulation uato children < 7 years of age (DTaP HB IPV Hib); (DTaP IPV Hib); (DTaP IPV) B. ap * Petussis reduced antigen dose adolescent/adult formulation Tdap*; Tdap IPV* 10 to 18 years [Boostrix]; 11 to 64 years (Adacel *may be administered as a booster dose to children 4 to 7 years of age 3

4 Canada: Authorized Preparations A. ap Petussis full antigen dose: DTaP HB IPV Hib: INFANRIX hexa DTaP IPV Hib: PEDIACEL DTaP IPV: QUADRACEL Pertussis Vaccination Programs Work Pertussis Reported Incidence in Canada B. ap Petussis reduced antigen dose: Tdap: ADACEL ; BOOSTRIX : Tdap IPV: ADACEL POLIO; BOOSTRIX POLIO Pertussis Containing Vaccines Storage and Handling: Stored at F (2 8 C) at all times; Must never be frozen Vaccine exposed to freezing temperature must not be administered and should be discarded Do not be used after the expiration date printed on the box or label aspc.gc.ca/publicat/cig gci/index eng.php accessed 06 October 2013 Case data obtained from the Canadian Notifiable Disease Surveillance System. Population data obtained from Statistics Canada July 1 st annual estimates. Pertussis Vaccinations need re working Pertussis incidence in adolescents/ adults by age &year Infants & children (2 months to 6 years): A typical vaccination program for baby born on: 06 October 2013 in British Columbia CANADA DTaP HB IPV Hib: Hib: DTaP IPV Hib: DTaP IPV: 2, 4, 6 months of age 18 months of age 4 to 6 years of age 1980 year 2010 *Case data obtained from the Canadian Notifiable Disease Surveillance System. Data for 2009 and 2010 are preliminary. Population data obtained from Statistics Canada July 1 st annual estimates. Public Health Agency of Canada: Home > Immunization & Vaccines > Immunize your Child > Your immunization schedule > Immunization Results aspc.gc.ca/im/iyc vve/immunizationresults eng.php?p%2ft=2&months=10&days=6&years=2013#scheduler frm Adolescents A typical vaccination program for Adolescents in British Columbia CANADA Tdap*: Grade 9 (or between years old). * Should be received 10 years after 4 6 year old DTaP IPV booster dose. Tetanus vaccine (Td) should then follow Tdap every 10 years thereafter. Adults 19 Through 64 Years of Age Adults who have not previously received Tdap vaccine in adulthood should receive 1 dose of Tdap vaccine. Tdap can be administered regardless of the interval since the last dose of tetanus and diphtheria toxoid containing vaccine Public Health Agency of Canada: Home > Immunization & Vaccines > Immunize your Child > Your immunization schedule > Immunization Results aspc.gc.ca/im/iyc vve/immunizationresults eng.php?p%2ft=2&months=10&days=6&years=2013#scheduler frm 4

5 Healthcare Personnel & Child Care Workers All health care and child care workers, regardless of age, should receive: a single dose of Tdap vaccine if not previously received in adulthood, even if not due for a Td booster. Pertussis Immunization Contraindications: anaphylaxis Pertussis containing vaccines are contraindicated in persons with a history of anaphylaxis after previous administration of the vaccine and in persons with proven immediate or anaphylactic hl hypersensitivity i i to any component* of the vaccine or its container *ADACEL POLIO: neomycin, polymyxin B, streptomycin BOOSTRIX : latex in plunger stopper of pre filled syringe BOOSTRIX POLIO: latex in plunger stopper of pre filled syringe, neomycin, polymyxin B INFANRIX hexa : latex in plunger stopper of pre filled syringe, neomycin, polymyxin B, yeast PEDIACEL : neomycin, polymyxin B, streptomycin QUADRACEL : neomycin, polymyxin B There are no currently known potential allergens in ADACEL vaccine. Hypersensitivity to yeast is very rare and a personal history of yeast allergy is not generally reliable. Pertussis Immunization Contraindications: Guillain Barre Syndrome* It is prudent to not administer further doses of tetanustoxoid containing vaccine to persons who develop Guillain Barre Syndrome* (GBS) within 6 weeks of receiving such vaccine. Those who develop GBS outside the 6 week interval may receive subsequent doses of tetanus toxoid containing vaccine. *If there is a history of both Campylobacter infection (which has been associated with GBS) and receipt of a tetanus and diphtheria toxoid containing vaccine within the 6 weeks before the onset of GBS, consultation with an infectious disease specialist is advised. Pertussis Immunization: Precautions severe acute illness Administration of pertussis containing vaccine should be postponed in persons with moderate or severe acute illness. Persons with minor acute illness (with or without fever) may be vaccinated. Pertussis Immunization: Common and local adverse events Redness, swelling and pain at the injection site are the most common adverse reactions to childhood pertussiscontaining combination vaccines. A nodule may be palpable at the injection site and persist for several weeks. Pertussis Immunization: Common and local adverse events Redness, swelling and pain at the injection site are the most common adverse reactions* to childhood pertussiscontaining combination vaccines. A nodule may be palpable at the injection site and persist for several weeks. The presence of a large injection site reaction to a previous dose is not a contraindication to continuing the recommended schedule. *swelling (greater than 5 cm) and erythema after the 4 th or 5 th doses of DTaP vaccines 15 % to 20% of vaccinees Extensive limb swelling (>10 cm in diameter) possibly involving the entire proximal limb may occur in 2% to 6% of children. 5

6 Conditions NOT Precautions for Tdap Following a dose of DTaP/DTP: temperature 105oF (40.5oC) or higher collapse or shock like state persistent crying lasting 3 hours or longer convulsions with or without fever history of an extensive limb swelling reaction Stable neurologic disorder Pregnancy Breastfeeding Immunosuppression including HIV infection Concurrent minor illness Antimicrobial use Summary Think about it, or you will miss it Treatment can decrease infectivity Immunize! Thanks 6