PHC 6002 Infectious Disease Epidemiology

Homework 1-Evaluating a Public Health Surveillance Program

Pertussis

Courtney Vaughan

University of North Florida

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Section 1. Describing the Surveillance System to be Evaluated.

Section 1-1: Describe the public health importance of the disease/event under surveillance

Pertussis, also known as whooping cough, is an endemic across all countries and is

highly contagious affecting the human population. As a respiratory illness, this can spread

person to person through droplets from sneezes or coughs and occurs in close contact with

those who are infected (Pertussis, 2017). The bacterium responsible for this infection is

Bordetella pertussis)” (Pertussis (whooping cough) (bordetella pertussis)2020 case definition,

2020). The targeted population for surveillance is mainly infants due to the high mortality and

morbidity among this vulnerable population but pregnant women and newborn mothers also

must be closely monitored to prevent transmission. Before deeming pertussis as the disease,

other more common sicknesses will be eliminated and then a person must meet clinical and

laboratory criteria to be diagnosed with the infection of pertussis The clinical criteria for

pertussis is defined as “a cough illness lasting greater than or equal to 2 weeks with at least one

of the following signs or symptoms: paroxysms of cough or, inspiratory whoop, or post-tussive

vomiting, or apnea (with or without cyanosis)” (Pertussis (whooping cough) (bordetella

pertussis)2020 case definition, 2020). To confirm the case of pertussis, lab reports must provide

an isolation of and a Positive Polymerase Chain Reaction (PCR) for the bacterium B. pertussis

(Pertussis (whooping cough) (bordetella pertussis)2020 case definition, 2020). Pertussis cases

probable and confirmed are to be reported to the state health departments and are classified

by case. For a probable case, an epidemiological linkage must be confirmed in a laboratory

setting and either meets the clinical criteria or presents any duration of a cough along with

illness paired with any of the signs and symptoms listed previously (Pertussis (whooping cough)

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(bordetella pertussis)2020 case definition, 2020). If there is a confirmed case, a duration of an

acute cough and either the isolation of B. pertussis from clinical collection or PCR positive with

B. pertussis will be present (Pertussis (whooping cough) (bordetella pertussis)2020 case

definition, 2020).

Although pertussis can affect the population at all ages, infants are monitored closely

due to the pertussis-related complications and mortality that can occur once they become

infected (Blain et al., 2020). Infants account for the majority of incidences of pertussis-related

deaths and throughout the years of 2012-2017 infants under the 2 months of age made up

66.7% of these pertussis-related deaths (Blain et al., 2020). Pertussis in Florida has been tracked

and reported through the FDOH and data from years 2009-2012 provided an average of 428

confirmed pertussis per year (Pertussis (whooping cough), 2021). The CDC’s surveillance system

from 2019 reported the incidence of pertussis in the United States to be 4.79 per 100,000 with

total number of cases amounting to 15,662 and in Florida 1.85 per 100,000 with total cases

amounting to 395 (Pertussis, 2019). Pertussis is classified as a National Notifiable Disease and

must be reported to state health departments then to the CDC if disease is suspected and/or a

confirmed case. However, pertussis cases are often not diagnosed and go unreported due to

the infection mimicking other illnesses. Difficulties attributed to identify and manage due to the

symptoms being common in other respiratory pathogens and in some instances, pertussis can

co-circulate with other pathogens being either viral or bacterial (Pertussis- Outbreaks, 2019).

The economic burden that pertussis causes can affect the population as individuals

(indirect/direct cost) and the healthcare system as a whole including the outbreak cost,

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diagnosis cost, treatment pay out, and the cost of vaccinations. Indirect cost affects the adult

population more due to the work that one might or the time it takes away from normal life with

visits to the doctor when pertussis is present (Caro et al., 2005). When an infant is infected,

these indirect costs also are present in loss of wages because a parent might have to take time

off to stay home with the sick child (Caro et al., 2005). However, direct cost poses more of an

impact because these are the costs related to healthcare resources, including doctor visits,

hospitalization, laboratory testing, vaccinations, and medications resulting from the infection of

pertussis (Caro et al., 2005). These costs are seen more frequently and amount to more of an

economic burden dealing with the infant population due to this being the population more at

risk and medical care (hospitalization) is necessary to decrease the morbidity and mortality of

this disease (Caro et al., 2005). These direct medical care cost also can be affected depending

on the severity and course that the infection takes in one’s body. Complications can arise and

lead to other infections caused by an pertussis infection including pneumonia and

encephalopathy (Caro et al., 2005).

Case severity can also affect the economic burden on direct cost of acquiring the

infection pertussis. Complicated studies where other infections develop is estimated to range

from anywhere between $2,084 to $6,337, while uncomplicated cases are estimated to cost

$257 (Caro et al., 2005). However, the target population of infants’ cases direct cost are higher

due to the severity, in patient status, and higher risk of complications when infected producing

an estimate of $2,302 (Caro et al., 2005). There are efforts to decrease the economic burden of

this infection and that is in the form of vaccination. However, there is limited data supporting

this finding and needs to be evaluated in future studies to truly determine the effectiveness

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pertaining to cost burdens. There are several different DTap vaccines available for our target

population and price differs depending on what sector one receives their dose from. The CDC

prices for vaccines ranges from $18.546-$61.648 per dose, while private sectors are more

expensive ranging in prices of $32.88-$90.045 per dose (VFC, 2021).

Pertussis still poses a threat to newborns, infants, and the population as a whole despite

the fact that this infection is preventable with certain actions that are available to the public.

When dealing with this highly contagious disease, prevention should be at the forefront of the

battle against pertussis. One method of prevention that makes the biggest impact in decreasing

the targeted populations risk is vaccination. The Tdap vaccine is available for pregnant women

and is highly recommended for expecting mothers to receive prior to birth, due to the inability

to vaccinate newborns in their first few months of life (Blain et al., 2020). This vaccine is only

useful in a preventive method and will not prevent illness if a person is already infected with B.

pertussis (Blain et al., 2020). If pertussis is caught early, then treatment can begin to decrease

the spread of this infection. Chemoprophylaxis is a common way to treat pertussis and

treatment should occur to those infected and others who have been in close contact with a

person who is strongly suspected of having this infection (Blain et al., 2020). If there is a low

suspicion of the infection delaying the treatment process is normal until a laboratory test

confirms pertussis in the body (Blain et al., 2020). There is however an expectation, if a woman

is pregnant or any infant is suspected of having the pertussis infection, chemoprophylaxis is to

begin immediately to those high risk and their household members to preventive the infection

from spreading (Blain et al., 2020). Active screening during outbreaks is also a method of

prevention and can aid in reduction of spread of pertussis, early diagnosis/treatment, and to

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prescribe antibiotics to high-risk persons who have might of come in contact with those

infected (Pertussis- Outbreaks, 2019). Active screening in schools, day care centers and

hospitals is suggested to be put into effect when these outbreaks occur (Pertussis- Outbreaks,

2019). Without these preventive methods this highly contagious infection could spread quickly

and lead to a multitude of underdiagnosed cases once again since the symptoms mimic other

less serve illnesses.

Surveillance on pertussis should be in the public’s interest and especially in the interest

of those high-risk populations. Due to the disease pertussis being highly contagious and spread

easily during an outbreak, public interest should be high. The high-risk population including

expecting mother, young infants, and those who interact with said mothers and infants should

take preventive methods to reduce risk of disease and report any symptoms that they have. To

reduce pertussis and reduce outbreaks the CDC has certain surveillance methods in place.

These methods include monitoring national trends, to identify populations at risk, assess impact

of disease, and to monitor changes in epidemiology over time (Blain et al., 2020). The health

departments of the states also utilize the surveillance data to predict future outbreaks and

track clusters to identify if an outbreak will occur (Blain et al., 2020). Prevention and control

strategies, along with health policies use this data also to update their current plans of action

trying to make a healthier community setting for those at risk (Blain et al., 2020).

Section 1-2: Describe the purpose and operation of the surveillance system

Surveillance data is used at the national level (CDC) and the local/state level to identify

trends with pertussis. The CDC utilizes this data to follow national trends and to identify the

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populations who are at risk for contracting pertussis, while the local/state health departments

focus more on clusters of pertussis than could result in an outbreak (Blain et al., 2020). Using

the surveillance system, epidemiological trends are recorded and are especially useful due to

the underreporting and underdiagnosis’s of pertussis (Pertussis, 2019). Constant laboratory

surveillance also aims to keep us ahead of the game with the changes that B. pertussis makes

on a molecular level to improve the current prevention strategies set in place to decrease this

infection (Blain et al., 2020).

To obtain surveillance data on pertussis, collection must occur by health department

personnel and healthcare practitioners. Since it is a nationally notifiable disease, it must be

reported in accordance with one’s local or state jurisdiction. When the infection of pertussis is

suspected, clinicians in the medical facility are to notify the state health department regardless

if the cases is probable or confirmed (Pertussis, 2019). Then the state health department is

responsible for utilizing the National Notifiable Disease Surveillance System (NNDSS) to report

these probable or confirmed cases of pertussis to the CDC (Pertussis, 2019). Once pertussis is

suspected in a clinical setting with said signs and symptoms, obtaining cultures from person

should be the following step. Laboratory tests are the of the upmost importance when deeming

an infection of pertussis and obtaining a culture with a positive B. pertussis specimen is the gold

standard for identification (Pertussis- Diagnosis Confirmation, 2019). These cultures can help to

identify different strains of the infection and are collected from nasopharyngeal specimens

within the first 2 weeks of cough onset since viable bacteria is thriving (Pertussis- Diagnosis

Confirmation, 2019).

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Section 1-3: Describe the following components of the system

The current surveillance system of pertussis monitors trends and collects data on all

ages groups but more specifically causes the highest burden of disease on infants. The CDC

focuses mainly on children who are under the age of 1 years old due to the high infection rates

and complications that can result from a pertussis infection (Blain et al., 2020). When it comes

to the time period that data is collected through surveillance, timing is crucial for a proper

diagnosis and can help provide high sensitivity and specificity. In the clinical criteria of pertussis,

the duration of a cough must last 14 days or longer and constant monitoring of these symptoms

must occur (Blain et al., 2020). The overall optimal time for diagnostic testing starts from onset

of cough to 12 weeks (Blain et al., 2020). Serology testing provide data that is the most useful

within weeks 2 to 8 and a PCR test within weeks 2 to 4 will help lead to a diagnosis of the

infection pertussis (Blain et al., 2020).

The key component of surveillance refers to the actual data that is being collected. In a

laboratory setting the surveillance is in place to observe the bacterium B. pertussis and changes

that may occur on a molecular level (Blain et al., 2020). With that data through laboratory

surveillance, researchers then can understand and monitor the evolution of B.pertussis and use

that information to improve the current preventative measures for this bacterium (Blain et al.,

2020). The CDC provides a Pertussis Surveillance Worksheet with 2 pages of questions that

need to be asked and recorded. This worksheet begins with common questions asked among

any report including the age, race, ethnicity, sex, event date/type, the day it was reported, then

reported status (confirmed, probable, suspect, unknown), and was an outbreak associated

cases (Pertussis, 2019). Then data is collected on a number of different aspects relating to the

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disease. The first section refers to the clinical data of the patients recording data on: Any cough

(cough onset), Paroxysmal cough, Whoop, Post tussive vomiting, Apnea, Final Interview Date,

Cough at final interview, and Duration of cough at final interview (Pertussis, 2019). The next

section refers to the complications that could occur relating to the infection of pertussis

including Chest X-ray for pneumonia, Seizures due to pertussis, Acute encephalopathy due to

pertussis, Hospitalization (along with number of days), and Death (Pertussis, 2019).

Then data on the treatment provided is recorded and refers to were antibiotics given along

with what was given and when did they start the antibiotics) and if a second dose of antibiotics

were also received (Pertussis, 2019).

Laboratory data needed for surveillance in pertussis record the date in which the

specimen was taken including a culture, DFA, Serology 1, Serology 2, and a PCR (Pertussis,

2019). To increase knowledge of why a patient contracted pertussis, their vaccination history is

recorded pertaining to the dates one received these vaccines and provides explanations as to

why a person wasn’t vaccinated (Pertussis, 2019).This helps to find a common denominator in

patients who contract pertussis and also protects practitioners to display culture competency

when trying to provide education to those who were not vaccinated because to some patients

it could be a result of religion or philosophical exemptions (Pertussis, 2019). One of the most

important sections on this surveillance worksheet refers to the epidemiological information

pertaining to the infection. This is where the dates of the report to the Health Department are

available and dates on when the case investigation began (Pertussis, 2019). Data on

epidemiological links and outbreak related information is record, along with the setting of

where pertussis was acquired (Pertussis, 2019). On the second page of the surveillance

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worksheet contact tracing is addressed and this helps to decrease the spread and transmission

of the disease to prevent an outbreak from occurring.

Laws and regulations are in place regarding who is responsible for reporting pertussis

and relay information on that jurisdiction/state health department requirements and

regulations for reporting this disease (Blain et al., 2020). Within each jurisdiction/state health

department, they are responsible to notify the CDC all confirmed case as well as probable cases

using the event code 10190 using the NNDSS (Blain et al., 2020). The data then is kept within

the CDC’s data base and utilizes electronic databases to allow for updates on case status. The

National Electronic Disease Surveillance System (NEDSS) is the current database used and

healthcare workers are required to submit the ‘Pertussis Surveillance Worksheet (Blain et al.,

2020). The information that is collected should be composed of epidemiologic information

pertaining to the CDC’s pertussis surveillance worksheet including the diagnosis time (Blain et

al., 2020).

Section 2. Indicate the Level of Usefulness of the System

The overall system is useful but has room for improvement. First, we need to address

the issue of this infection being underdiagnosed and find a way to prevent that from

happening. Trends cannot properly be tracked if the data is lacking and could lead to a

community outbreak of disease. Also, improvements in the case definitions can be made to

separate the infection of pertussis from the misdiagnosis of other illnesses that display the

similar symptoms. There is limited data on pertussis’s true economic impact relating back once

again to the unreported and undiagnosed cases of this infection, which shows the need for

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improvement on analysis and surveillance system as a whole. Time plays a major role in

pertussis diagnosis and leaves room for error due to decreases in specify and sensitivity.

Allowing for testing to be conducted up to 12 weeks should be a benefit but to provide better

results test should be conducted immediately after the 2 weeks from cough onset. The clinical

and laboratory testing should be researched and updated to try and produce a shorter

diagnosis time to decrease the spread of this infection. With that being said, contact tracing is

handled on the worksheet and community settings are contacted and information relating to

cough are recorded.

Pertussis-related complication are a big impact to the morbidity and mortality regarding

this infection. They use active screening on high-risk settings when an outbreak is suspected to

reduce the spread. The system suggests beginning active screening when outbreaks are

suspected to be occurring. This infection however can go unreported in jurisdiction and even be

not reported which shows the failure within certain areas of diagnosing this disease. Yes, the

system is in place to track trends and clusters to determine future outbreaks but when one

jurisdiction reports no cases for multiple years, there needs to be more interventions in place. If

this disease continues to go underreported then future outbreaks can occur and with the world

we live in today where more people are deciding against vaccinations, mortality and morbidity

among infants could increase.

The system does assess the effect of prevention methods and the upmost important

and useful method is the use of vaccination against pertussis. However, in a clinical setting

there is still room for improvement, pertussis is vaccine-preventable but as stated earlier, it is

still an endemic in the United States. Educational efforts should improve on the pros of getting

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vaccinated while pregnant and efforts should be made in healthcare due to the underdiagnosed

rates of this disease. The symptoms that occur with an infection of pertussis are common in

other illness resulting in these underdiagnosed rates.

Since the CDC has a network working enhanced surveillance in a select few states, there

is definitely a need for more research and implementation among those states who are not

already involved. The system suggests for states who do not have this EIP to include other

elements to increase their surveillance which begs the question, do these states with this

network have higher reports of the infection and would it work in these areas with

underdiagnosed reports. Also, since there is common underreports of this infection, research

should be conducted to see where this occurs and how can we improve. The system is also

using the data reported to track trends and the changing molecular status of B. pertussis, which

continues the research on this bacterium already. Research is also needed to collect more

information regarding primary epidemiologic and economic data to improve the current

vaccination interventions and close some of the gaps we see in the economic analyses of

vaccinations (Caro et al., 2005).

Section 3. Describe Each of the Following System Attributes

The surveillance system and its attributes help when evaluating the system as a whole.

Simplicity of the system is one of those attributes needed for evaluation and it refers to the

ease of the operation as a whole. The changing in molecular levels of the bacterium B. pertussis

improve the current prevention strategies set in place to decrease this infection (Blain et al.,

2020). Simplicity also deals with the flexibility of the system and the efforts in public health

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surveillance. Since the NNDSS is in place across the nation does not have much flexibility and

cannot accommodate easily (Skoff, Baumbach, & Cieslak, 2015). However, the EPS case report

form has flexibility due to revisions made each year (Skoff, Baumbach, & Cieslak, 2015).

Flexibility within the working network can provide recommendations for prevention efforts and

improve overall surveillance system standardization (Skoff, Baumbach, & Cieslak, 2015).

The data quality for pertussis surveillance is thorough and provides contact tracing to

decrease an outbreak and spread of the infection. The use of this surveillance worksheet and

the electronic case reporting enhance the quality of data that is observed and reduces the

workload needed providing a more efficient system overall (Blain et al., 2020). Since pertussis is

a National Notifiable Disease, the acceptability is nationwide and required by law. This also help

with the data quality because each case, confirmed or suspected, are recorded and reported.

The worksheet the CDC provides is in-depth but is easy to follow. Certain states have decided to

enhance their surveillance over pertussis and participate in the Emerging Infections Program

monitoring pertussis and other bacterium in the Bordetella family (Blain et al., 2020). However,

we can run into problems if the willingness of the population affected is lacking.

Sensitivity, specificity, and predictive value positive are important in clinical and

laboratory settings and allow for monitoring and tracking the prevalence of the disease. False-

negatives can occur in the testing of B. pertussis, due to the window of opportunity for

sensitivity to decrease (Pertussis- Diagnosis Confirmation, 2019). This usually will occur after the

initial 2-week period of cough onset and it is essential to collect nasopharyngeal specimens

during these first two weeks to decrease the chance of undiagnosed pertussis infection

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(Pertussis- Diagnosis Confirmation, 2019). Since pertussis mimics other common illness these

windows of obtaining a culture can be missed and also leave the surveillance system with

missing data. However, a PCR test provides clinicians with rapid results and provides an

excellent sensitivity report (Pertussis- Diagnosis Confirmation, 2019). Sensitivity can decline

after 3 weeks from cough onset, so testing within the appropriate times is of the upmost

importance (Blain et al., 2020). The culture of B. pertussis is known to have an excellent

specificity and the use of swabs from the nasopharyngeal within (Pertussis- Diagnosis

Confirmation, 2019). This information is can be used in these situations suspecting an outbreak

occur and when confirming the infection pertussis as the diagnosis (Pertussis- Diagnosis

Confirmation, 20190. Results from a PCR test tend to provide variations in specificity (Pertussis-

Diagnosis Confirmation, 2019). Data provides a specificity of 98%, a sensitivity of 65% and a

predictive positive value of 95% when using a PCR test (Lind-Brandberg et al., 1998). Different

factors can affect these rates including vaccination status and when the onset of infection

occurred (Lind-Brandberg et al., 1998). Sensitivity and specificity are also affected when the

culture in collected early on in the infection and decreases the longer a person has the infection

(Lind-Brandberg et al., 1998).

Referring to representativeness, there is room for improvement due to the consistent

under reported cases of pertussis. However, reported cases are tracked within the CDC’s

database and is required by law within a person jurisdiction (Blain et al., 2020). Also, the

surveillance is kept on all age groups but made a higher priority in high-risk individuals being

infants under the age of 1 (Blain et al., 2020). Timeliness within the surveillance system is

achieved in the evaluations of pertussis by the EPS (Skoff, Baumbach, & Cieslak, 2015). The EIP

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has also made efforts in working timely effect case control evaluations to provide data on the

proficiency of the system (Skoff, Baumbach, & Cieslak, 2015). Time is of the essence with

working surveillance systems because the bacterium is constantly evolving, and information

needs to be available for continued research. Stability of the system resides within the

local/state health departments and then within the CDC. The CDC makes it easy to collect data

with the pertussis surveillance worksheet, containing all questions needed to be asked along

with contact tracing data. Utilizing the contact tracing gives this system the ability to operate

and prevent outbreaks within community settings that pertussis occurs. This system as a whole

operates to the best of its ability and provides detailed information in data recorded.

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References:

Blain, A., Skoff, T., Cassiday, P., Tondella, M. L., & Acosta, A. (2020, May 11). Surveillance

manual-Chapter 10 Pertussis. Retrieved February, 2021, from

https://www.cdc.gov/vaccines/pubs/surv-manual/chpt10-pertussis.html

Caro, J Jaime MDCM, FRCPC, FACP*; Getsios, Denis BA*; Payne, Krista MEd*; Annemans, Lieven

PhD†; Neumann, Peter J. ScD‡; Trindade, Evelinda MD, MSc§ Economic Burden of

Pertussis and the Impact of Immunization, The Pediatric Infectious Disease Journal: May

2005 - Volume 24 - Issue 5 - p S48-S54 doi: 10.1097/01.inf.0000160929.35004.86

https://journals.lww.com/pidj/Fulltext/2005/05001/Economic_Burden_of_Pertussis_an

d_the_Impact_of.9.aspx

Lind-Brandberg, L., Welinder-Olsson, C., Lagergård, T., Taranger, J., Trollfors, B., & Zackrisson, G.

(1998). Evaluation of PCR for diagnosis of Bordetella pertussis and Bordetella

parapertussis infections. Journal of clinical microbiology, 36(3), 679–683.

https://doi.org/10.1128/JCM.36.3.679-683.1998

Pertussis. (2019, December 17). Retrieved February, 2021, from

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Pertussis. (2017, August 07). Retrieved February, 2021, from

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https://www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-confirmation.html

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Pertussis- Outbreaks. (2019, November 18). Retrieved February, 2021, from

https://www.cdc.gov/pertussis/outbreaks.html

Pertussis (whooping cough) (bordetella pertussis)2020 case definition. (2020). Retrieved

February, 2021, from https://wwwn.cdc.gov/nndss/conditions/pertussis/case-

definition/2020/

“Pertussis (Whooping Cough).” Pertussis (Whooping Cough) | Florida Department of Health, 12

Jan. 2021, www.floridahealth.gov/diseases-and-conditions/vaccine-preventable-

disease/pertussis/index.html.

Skoff, T. H., Baumbach, J., & Cieslak, P. R. (2015). Tracking Pertussis and Evaluating Control

Measures through Enhanced Pertussis Surveillance, Emerging Infections Program,

United States. Emerging infectious diseases, 21(9), 1568–1573.

https://doi.org/10.3201/eid2109.150023

“VFC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention,

11 Feb. 2021, www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-

management/price-list/index.html#f4.

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