FINAL PAPER

REVISIONS SUGGESTED BY FELLOW STUDENTS

1. I was suggested to add Social ecological model and CBPR in addition to the Health

Belief Model to develop our new program. I did add the constructs of SEM at the

organizational and community level by deciding to add the community leaders and

community churches, mosques and mandirs to have talks by Healthcare staff like nurse

practitioners and physician assistants on the topic. The advice by religious leaders and

medical staff holds weight and motivates the community to seek more information.

CBPR is a research and not a method to develop a program so I did not implement it in

my program.

2. I was also advised to evaluate the physicians. I did not consider that in my program either

because they have sufficient background knowledge to understand our program.

Vaccination and pertussis are basic knowledge for the medical field, and they are

evaluated every five years by the Medical Board on their knowledge base and

competency. I do think that we can work with the testing organizations and medical

board to develop a CME credit in cocooning but that is outside the scope of our

program's budget.

3. I also had a suggestion to evaluate the understanding of the patients and their family of

the Tdap familiarization section. I addressed it by adding a few questions on Tdap

vaccination in our survey and also guiding the reader to pharmacists who can help them

understand the Tdap vaccine information sheet in case clarification is needed.

4. I was suggested to use standardized patients to train physicians which I feel is

unnecessary since the physicians we are including in our intervention are already in
 practice and have exposure to a lot of patients and have an in-depth understanding of

patient-physician communication techniques.

5. One suggestion was to target mothers to be and to write material addressing the partner of

pregnant women. Conducting the intervention in the obgyn clinics does include the

population that is trying to get pregnant. The material can be designed specifically

targeting the partners of the patients but is not proven by any research that will yield

better results.

6. During the Mock Teach, I was advised to use an icebreaker. I added a short activity to let

the physicians introduce each other and describe in a short sentence why they decided to

attend this session.

7. It was designed as a lunch and learn, and we had donuts. I was advised to have a healthier

snack, so I added a fruit platter and a veggie tray to our session.

8. I was also advised to add a PowerPoint presentation to the education session with the

physicians. I like the idea of it being interactive and short. Adding a power point will take

that aspect of it out and will become like an everyday presentation that might go

unnoticed.

9. To convince the hesitant practitioners and physicians, I will carry some research papers

and interventions that I reviewed while developing this intervention. I will provide those

for the physicians to read and help them change their mind.

10. I was given a suggestion of developing a sheet or a flyer that becomes a part of the EMR

so the physician does not have to look for a brochure and vis to give to the patients.

These can be easily printed whenever needed. It's an excellent suggestion and I think I

can develop it under the SEM's organizational construct where the insurance companies
 and hospital groups come together to develop a fact sheet that can be made part of the

EMR.

11. I was given the advice to design waiting room posters that can be posted in the waiting

areas in the physician offices. They will serve to initiate the thought process in the patient

even before the physician introduces and recommends cocooning. I have included those a

part of the program and will be provided to the physician.

12. Monthly check-ins by the physicians was another suggestion which I don't feel is

practical since the physicians already have a very busy schedule. I think it will be a good

idea in the event we can train the nurse practitioners and physician assistants to introduce

cocooning to the patients and their families. They can give us feedback on the response,

and it can be a very successful evaluation tool as well.

Huda Khan
PM 562
Final Paper
New Project Overview

Preventing Pertussis in Infants via Familial Cocoon Vaccination

Pertussis Background:

Pertussis also is known as whooping cough is a disease caused by a bacterium Bordetella

Pertussis. This disease attacks the respiratory system of the individual and is very contagious.

Whooping cough is known for uncontrollable, violent coughing spells which makes it hard to

breathe. After cough fits, someone with pertussis needs deep breaths which often makes the

whooping sounds hence the name whooping cough. The spread is especially rapid in newborns

and infants and can be fatal in certain cases. Best way to protect against this disease is by

vaccination.

We selected Pertussis prevention as our topic for a new project since it is a major cause of infant

morbidity and mortality worldwide. In 2015, the World Health Organization reported 142,512

pertussis cases globally and estimated that there were 89,000 deaths. A recent publication

modeling pertussis cases and deaths estimate that there were 24.1 million pertussis cases and

160,700 deaths in children younger than 5 years 2014 worldwide1. In 2014, the USA alone had

over 28,000 reported cases of pertussis2. On average 50% of these cases result in hospitalization
1
https://www.cdc.gov/pertussis/countries/index.html
2
Centers for Disease Control and Prevention. 2104 Provisional Pertussis Surveillance Report. 2014.
and 2% of these hospitalizations end in death. The average length of stay for infant

hospitalizations is 6 days and on an average cost $9,586 per day3.

Pertussis is endemic in the USA. It is considered a disease of childhood which is a

misconception since many cases occur in adolescents and adults and go undiagnosed. The

sustained cough leads to spread of the disease to their close contacts which are family, friends,

and associates. The most vulnerable population is infants younger than 6months of age since

they are too young to start the vaccination program. Most of the cases in infants have been found

to be acquired from a close family member.

3
Obrien, J. A., & Caro, J. J. (2005). Hospitalization for pertussis: Profiles and case costs by age. BMC Infectious
Diseases,5(1). doi:10.1186/1471-2334-5-57
Pertussis is one of the most poorly controlled vaccine-preventable disease in the USA. Although

admissions to the schools require compulsory vaccination, about 2% of the population have been

found to claim an exemption to this rule while some high-risk communities show exemption
rates of as high as 20%4 .The following graph was adapted from a study conducted by

Masseria et al., in 2017 and shows the average cost by age group in pertussis cases. It shows that

it is most costly to treat the cases between the newborns and 2 and a half months old.

Review of Previous Interventions:

In designing this intervention, my team reviewed 4 different already existing programs. The first

program reviewed is called "MOMSOC". It is a non-profit organization delivering education on

prenatal and postnatal health of mothers as well as the care of newborns and infants to expectant

and new parents. This program serves the areas around Santa Ana which is mostly comprising of

Spanish and Vietnamese speaking people. They have a team of medical workers which is

4
Ventola, C. L. (2016, July). Immunization in the United States: Recommendations, Barriers, and Measures to
Improve Compliance: Part 1: Childhood Vaccinations. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4927017/
supervised by an RN case manager. They have programs like home visitations that focus on

guiding the parents and family on staying on track with immunizations and milestones of their

children. They also offer on-site classes which are conducted in Peer-led group setting and focus

on modeling exercises for prompting appropriate developmental progress in infants. The study

showed that 93% of infants whose parents were enrolled in the program were on track with their

immunization schedule.

The second program we reviewed was a study conducted at Ben Taub General Hospital in

Houston after the recommendations by CDC to vaccinate all postpartum women with Tdap

before discharge from the hospital. The study was called the Impact of Maternal Postpartum

Diphtheria and Tetanus Toxoids and Acellular Pertussis Immunization on infant pertussis

Infection5. This was a cross-sectional study which compared the preintervention period to the

post-intervention period. The study took into account the infants less than 6-months old that had

laboratory-confirmed pertussis infection. The study determined that the proportion of pertussis

infected infants born at BTGH and protected by maternal postpartum Tdap vaccination was the

same for both pre-intervention and post-intervention periods. The study concluded that all

household contacts need to be vaccinated to have a successful intervention not only the mothers.

The next intervention we reviewed was a trial intervention conducted by the University of

Pennsylvania to increase pertussis vaccination among infant caregivers. The target population of

this study was the adult population not already vaccinated against pertussis. The intervention

used various methods as questionnaires, follow-up phone calls, vouchers for full cost of

vaccination and a $5 gift card at the participating pharmacies. The intervention did not bear any

success as reported by the researchers. The effects of the intervention were evaluated by attitudes
5
reported in the questionnaire, non-utilization of the free vouchers and inability to recall the

information provided.

The last intervention reviewed was a case-control study conducted by the University of

California, San Diego which was designed to send home infants to a fully cocooned household.

This study was done during the 2010 pertussis epidemic in California. The intervention was a

success in increasing the number of fully cocooned households due to the educational material

provided about pertussis and the staff's efforts.

The review of these four interventions showed that cocooning is important in achieving a high

rate in pertussis prevention in infants 6 months and younger. It also showed us the influence of

recommendations by a healthcare professional hold weight instead of coming as a PSA or an

informational brochure alone.

Cocooning:

Cocooning is a practice of vaccinating a group of people who could potentially spread the

infection to an individual who is not immune. The cocoon in the context of our intervention are

all family members and friends who may come in contact with an infant before the child has

completed their immunization schedule. Cocooning is beneficial in this scenario since 0-6-

month-old infants cannot be directly vaccinated, infants have incomplete vaccination schedules

between two months and two years old, adults are more frequently infected due to a lapse in

immunity after so many years without a booster and majority of the pertussis infections in kids

are found to have been acquired from an immediate family member.

SMART Objective:

Decrease the number of infants infected and hospitalized due to pertussis infection by 5% by

increasing the number of cocooned households by the end of 2022.

Target Population:

The target population is pregnant women, their partners/fathers, family, friends, and caregivers.

This is a unique situation since we target the physicians in primary care and obgyn clinics. We

chose to work with physician population based on the review of previous interventions and

learning that the advice coming from a physician holds weight. The success rate of the

interventions that employed the combination of educating the patient in conjunction with the

recommendation from the physician had the most successful results.

Program Design:

We designed our intervention using the Health belief model and the constructs from SEM as per

the advice of some colleagues.

The important constructs of the HBM that we addressed in our intervention are perceived

susceptibility, perceived severity, perceived barriers and cues to action. The perceived

susceptibility was addressed by physician-initiated conversations and recommendations bringing

the attention of the expectant mothers and their family members to the possibility of the newborn

contracting pertussis from a family member or close contacts. The physician also played an

important role in informing the patient with the severity of the illness and the fact that the

newborn until 6 months old cannot be immunized against pertussis. This explains the gravity of

the situation to the target audience of the physician. The cues to action will be the waiting room

posters that will educate the patient about cocooning and motivate them to ask their physicians

questions on the topic. They will also be given brochures about the process as a take-home

resource. If they are further interested, they will be given vaccine information sheets that are

downloaded from the CDC's website to learn and help the family members understand the

benefits and risks associated with the vaccination.

To further extend the reach of the program some of the constructs of the Social Ecological Model

can be applied. These are the community and organizational level constructs. At the

organizational level, the hospitals, health care groups, insurance companies will develop

incentives to motivate the friends and family gets vaccinated. The cocooning and pertussis

vaccine information sheet will be made a part of the electronic medical record at the participating

hospitals. The pros to this are the ready availability of the material to the physician but at the

same token can be lost in the vast ocean of information that the physician has to skim through to

get relevant information for the patient. At the community level, we will engage the community

members, organize community outreach programs and distribute some of our resources like the

brochure and the vaccination information sheets. We can also have medical personnel like the

physician assistants and nurse practitioners come to churches, mosques, and mandirs to educate
the expectant mothers and their families in understanding the gravity of the situation and where

to seek help.

Intervention Setting:

Our primary intervention setting is healthcare clinics of the primary care physicians and the

Obstetricians/ gynecologists. This setting is helpful since the physicians have busy schedules and

to set time apart to go to a class will be hard to fit in and since this population is unique in a

sense that they already have background information on the disease such as its pathology and

risk factors, getting them to a specially scheduled class can be a challenge. The purpose of the

intervention is to put a little more emphasis on physicians to bring up cocooning in their

conversation with the patients and recommend it as a measure of prevention for their newborn or

infant. The inherent pitfall with this setting can be unavailability, busy schedules of the

physicians and no incentives for physicians like earning CME credits.

Proposed Methods:

There are multiple proposed methods for the intervention which include

1. Physician education session

2. Patient Brochure

3. Tdap familiarization through a VIS

4. Evaluation Surveys

Physician sessions are designed keeping their busy schedules in mind. These are single, short

sessions which are presented one-on-one or in a group setting or in a ‘lunch and learn’.

Physicians are talked about having a conversation with their patients and including cocooning in

it, also taking the opportunity at the regular Ob visits and talk to accompanying members of the

family and introduce cocooning as a method to protect the infant from pertussis.

The activity will be 5 – 7 minutes long. The first part of the activity is 3-4 minutes long. The

objective of this part is to discuss the complementary roles between healthcare professionals and

a patient's inner circle. During the session, the provider is allowed to discuss with each other and

share their thoughts and practices. They are also introduced to the brochure that we have

designed as a take-home resource for the patients and also a source to bring up the topic for

discussion during the regular appointment.

The following is a sample of the session described in detail.

PHYSICIAN EDUCATION SESSION:

OBJECTIVE: Promote the recruitment of patient family and friends to help spread awareness

of pertussis infection prevention through active physician participation.

MODALITY: Small groups or one-on-one with physicians

MATERIALS: Paper

Pens/ Dry erase markers

Donuts/ Fruit platters/ Vege trays

Brochures

The activity is performed in the break room during the coffee/tea break or in a

conference/meeting room on site. By the end of the session, physicians will have discussed

strategies to bring up cocooning with their patient population and recommend Tdap vaccination

for members of the family and friends.

ACTIVITY 1:

Time: 1-2 minutes

Objective: Icebreaker between the moderator and members of the healthcare team.

Script: Welcome everyone. Thank you for coming. Please help yourself to a donut or some

fruits and vegetables. Let’s start with an introduction and in a short sentence please explain why

did you decide to attend this session?

2-3 minutes of providers introducing each other.

ACTIVITY 2:
Time: 3-5 minutes

Objective: Discuss the role of the physician in educating and recommending cocooning for

pertussis prevention in infants.

Script: Now that we know a little bit about each other. I want to respect your time so we will try

to keep this brief. The topic today is promoting vaccination cocooning to prevent pertussis in

infants. Now I know that whooping cough is not something your patients are usually thinking out.

Unfortunately, unless there is an outbreak, it is never a topic in the news and so this puts the

burden of education on you. Fortunately, I’m confident most of you are already addressing

prenatal vaccination for pregnant women since this has been a recommendation for a while now.

What I’d like to know is, what are you doing to educate your patients about cocooning?

2-3 minutes of provider discussion on current practices.

Facilitator: Well it seems like we’re all doing something but maybe not as much as we would

like. I hope I can help with that. Ideally, when we’re speaking to patients, we’re letting them

know that they need the Tdap vaccine, and if they have concerns, we give our strong

recommendation. After they agree to get the vaccine, we can segue into cocooning, letting them

know that the best protection comes from having all family members around the baby vaccinated

as well. We can then encourage them to take this information home to anybody that they want

around their baby. Our team has done some research on interventions in this area and we have

developed a tool we think could be useful for you.

1-2 minutes to pass out the brochure and allow time for review and comments
Facilitator: We've designed this brochure as a multi-purpose to tool inform and encourage

patients, their family, and friends to get a Tdap vaccination prior to the birth of the babies

coming into their lives.

The brochure explains in plain English, what whooping cough is and how dangerous it can be for

infants. It introduces the idea of cocooning and what or who is part of a cocoon. More

importantly, it offers suggestions on when and how to approach this topic with the friends and

family who will make up the cocoon. Finally, it directs people to how and where to get

vaccinated. Our aim is taking some of the burdens of explanation off of you and give you more

time to answer any questions your patients have.

We would like you to offer this to your patients while they are rooming and meeting with your

assistant. Alternatively, it could be given to the person who may be accompanying them to their

appointment. How do you think you would you use it?

1-2 minutes of provider discussion on how they can use the brochure while the moderator

writes down the ideas on the whiteboard available in the room

Facilitator: Of course! And we want you to feel free to put your clinic’s information on it and

add any other contact resources you think will be useful. You can put copies in your lobby, or

provide them to wherever your marketing team thinks they will be useful.
You may also want to give your patients extra copies of the Tdap VIS to give to their family and

friends. The brochure is Whooping Cough specific but since the vaccination covers Tetanus and

Diphtheria as well, the VIS can give more specific information.

I’ve brought enough copies of the brochure for you to begin using them. Do you think you can

incorporate their use into your practice right away?

2-3 minutes of provider feedback

Facilitator: Great! I’ll make sure to get the file to your clinic manager or marketing team so they

can get your information put on them and I’ll come back in a few weeks to check in with you and

see how it is going. Thank you so much for your time and please let me know if there is anything

else, I can do for you.

BROCHURE:

The brochures have been designed to contain information on cocooning, what the process means

and how it protects the infants from getting pertussis infection. It also gives the symptoms of the

disease if it affects the adolescents and adults since the cough can persist which leads to the
spread of the disease to infants. The sample of the brochure is provided below. The back of the

brochure is left empty for the medical centers and offices to brand them or put their office

information. The brochure also contains information in case the patient or the family is interested

in detail. They can call the phone numbers or go to the website provided.
Tdap FAMILIARIZATION:

This is offered by printing out the vaccine information sheet by the CDC. These sheets contain

indications, benefits, and risks associated with the vaccine. VIS also explains all the components

of the vaccine in detail which are tetanus, diphtheria in addition to acellular pertussis. The con to

these sheets is they are information dense and can cause an overload of information. This can be

helped by guiding them to a pharmacist who is available in any nearby pharmacy where they can

get advice and clarification on the content of the vaccine information sheet. The understanding of

the information in the sheet can be gauged by adding a few questions to the evaluation surveys.
EVALUATION SURVEYS:

These surveys are designed to administer to the patient in the waiting room, in between

appointments and to the family while waiting for the patient to finish the appointment. They are

short multiple-choice questions or simple yes and no questions. They can be given to the

pregnant patient at the 30 weeks, 36 weeks or even postpartum. The sample format of questions

will be as follows

Evaluation Topics and Questions

o Demographics (Fill in the blank)

 Age
 City of residence / Zip code
 Number of household members
 Current Pregnancy Trimester
o Vaccine Knowledge (Multiple Choice)
 Do vaccines only protect people who receive them?
 Can newborns be vaccinated?
 How old does a child need to be to receive their full schedule of
vaccinations?
o Vaccine Practices (Y/N)
 Have you received a Tdap vaccination in the past 30 days?
 Has your spouse or other household members received a Tdap
vaccination since your current pregnancy?
 Do you plan on talking to other family members about getting
vaccinated in the next 30 days?

Timeline of Activities:

The initial physician education sessions will be spread out over the period of three months where

the sessions will be conducted at 30 different sites. The follow up at each site will be done at

week 6 and week 12.

Budget:

Personnel:

Role Salary IBS % Time

Principal Investigator $125,000 25 $31,250
Project manager $100,000 100 $100,000
Health Educator $75,000 75 $56,250
Community Liaison $100,000 10 $10,000
Data Distributor $100,000 10 $10,000

The lead investigator will be overseeing the whole project, overall coordination, and supervision

of all aspects of the study. This will include hiring, training, and supervising staff/students;

recruiting study participants; coordinating education sessions and data management.

The program manager will oversee the implementation of the program and make sure the

sessions are being carried out and the resources available.

The data management will keep the data safe and saved in cloud services so can be accessed

whenever the needed and emailed or electronically transmitted to the intervention sites.

Materials/Supplies:

Paper supplies $2000

Printing costs $1500
Cloud Storage cost $250
Posters $50 each / 30 offices
 Travel $2000

The major expense associated with this project is coming from the traveling expense of the

educator and the salary of the project manager. The cost of supplies is significant since it

includes printing brochures for distribution and posters.

The total funding needed for the project is $214,750.00

References:

Pertussis | Whooping Cough | Cases in Other Countries | CDC. (n.d.). Retrieved from
https://www.cdc.gov/pertussis/countries/index.html

Centers for Disease Control and Prevention. 2104 Provisional Pertussis Surveillance
Report. 2014.

Obrien, J. A., & Caro, J. J. (2005). Hospitalization for pertussis: Profiles and case costs by
age. BMC Infectious Diseases,5(1). doi:10.1186/1471-2334-5-57

Ventola, C. L. (2016, July). Immunization in the United States: Recommendations, Barriers, and
Measures to Improve Compliance: Part 1: Childhood Vaccinations. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4927017/

Castagnini, L. A., Healy, C. M., Rench, M. A., Wootton, S. H., Munoz, F. M., & Baker, C. J.
(2011). Impact of Maternal Postpartum Tetanus and Diphtheria Toxoids and Acellular Pertussis
Immunization on Infant Pertussis Infection. Clinical Infectious Diseases,54(1), 78-84.
doi:10.1093/cid/cir765

Buttenheim, A. M., Fiks, A. G., Ii, R. C., Wang, E., Coffin, S. E., Metlay, J. P., & Feemster, K.
A. (2016). A behavioral economics intervention to increase pertussis vaccination among infant
caregivers: A randomized feasibility trial. Vaccine,34(6), 839-845.
doi:10.1016/j.vaccine.2015.11.068

Rosenblum, E., Mcbane, S., Wang, W., & Sawyer, M. (2014). Protecting Newborns by
Immunizing Family Members in a Hospital-Based Vaccine Clinic: A Successful Tdap
Cocooning Program during the 2010 California Pertussis Epidemic. Public Health
Reports,129(3), 245-251. doi:10.1177/003335491412900306