Outbreak VI

Scenario
On 7/21/02 Upshur County health

department receives a call from a
physician’s office reporting a case
of Pertussis in a 6 month old female
infant. The child has had clinical
signs/symptoms of pertussis and
laboratory results are pending.
06-Aug-03 WVDHHR/BPH/OEHP/DSDC/IDEP
What do you do?
Step 3:
Verify the Diagnosis
3. Verify the diagnosis?
1. Review clinical findings to see if patient has

signs/symptoms of pertussis
2. Review Laboratory results for:
 Isolation of Bordatella Pertussis from clinical
specimen or
 Positive polymerase chain reaction for B.
Pertussis
Clinical Findings:
 10-day history of severe coughing spells.
 The illness started with a "cold" but had gotten

progressively worse in the last week.
 The baby's coughing was so violent that she often

became cyanotic and gasped for breath when the
coughing subsided.
 In addition, the baby had several episodes of vomiting

associated with his coughing.
Laboratory Findings:
 PCR positive for Pertussis
 No culture results
Step 1:
Understanding Pertussis
What is Pertussis (Whooping cough) ?
Highly contagious disease spread by
direct or droplet contact with nasopharyngeal
secretions of an infected person.
Cause:
Bacteria Bordatella Pertussis
Incubation Period:
7-10 days; rarely up to 21 days
Infectious Period:
From prodrome (early symptom) onset to 3
weeks after paroxysm (cough) onset, or five
days after starting antibiotic treatment.
Reservoir
Pertussis is a human disease. No animal or
insect source or vector is known to exist.
Symptoms
Adults usually have milder symptoms
Children can have:

 Fever
 Coughing
 Severe cough with a "whooping" sound
 Vomiting and exhaustion after severe coughing
 Difficulty breathing
Complications
 Pneumonia
 Seizures
 Brain damage
 Death
Treatment & Prevention
 Antibiotics are given to make the illness less
contagious, but they do not reduce the symptoms
unless given very early in illness.
 Bring children up to date on their shots, especially the

diphtheria, tetanus, pertussis (DTaP) series.
 Persons who have been in very close contact with a

person with pertussis should take medication to
prevent illness. WVDHHR/BPH/OEHP/DSDC/IDEP
06-Aug-03
Epidemiology
 Most severe in infants under 1 year old.

 More than half of infants who get the disease must be
hospitalized and some even die.
 Pertussis in older children and adults is less severe and
often not recognized as pertussis.
 Adults with milder, undiagnosed symptoms can
transmit the disease to infants and children.
What Next?
Step 4:
a. Establish a Case Definition
b. Identify and Count Cases
4.a Establish a Case Definition (i)
Clinical Case Definition
A cough illness lasting greater than or equal to 2
weeks with one of the following: paroxysms of
coughing, inspiratory "whoop," or post-tussive
vomiting, without other apparent cause
4.a Establish a Case Definition (ii)
Laboratory criteria for diagnosis

 Isolation of Bordetella pertussis from clinical
specimen or
 Positive polymerase chain reaction for
B. pertussis
4.a Establish a Case Definition (iii)
 Confirmed
 Probable
 Possible
4.a Establish a Case Definition (iv)
Case Classification for Pertussis
Probable:
A case that meets the clinical case definition, is not
laboratory confirmed, and is not epidemiologically
linked to a laboratory-confirmed case
Confirmed:
A case that is laboratory confirmed or one that meets
the clinical case definition and is either laboratory

confirmed or epidemiologically linked to a
laboratory-confirmed case
Based on our case definition
the baby is:
Probable case ?
Confirmed case ?
4.b Identify and Count Cases
 Initiate active surveillance
 Individually phone/visit schools to search for
additional cases.
 Enhanced passive surveillance
 Disseminate written request for reports of
additional cases
 Cast a wide net
 Investigate forwards
 Investigate backwards
Gather critical information from your surveillance
to include:
 History of Exposure
(where the baby may have been)
 Onset dates
 Cause of illness ( What they think)
 Others (who they know or think were exposed
or have/had symptoms)
Surveillance findings
 Household contacts of the index case = 5
 3 = Cough
 2 = No symptoms
 Other close contacts of the index case = 3
 Several contacts of contacts identified.

Name Age Cough Case Lab Rx Contacts Comments
DOB Onset Class
Amy Gold 6m Cough Conf PCR Erythro- Jane Black Follow AG’s
(INDEX) 1/20/02 7/6/02 mycin Bob Will contacts and
prophylax
8/2/03 Billy Bear
Saira Gold 25 y No Not a N/A ? N/A Need to prophylax

(Mother) 2/7/77 Cough Case SG
Roger Gold 30 y No Not a N/A ? N/A Need to prophylax

(Father) 4/4/72 Cough Case RG
Brittany Gold 4y Cough ? ? ? Stacy Todd Follow BG &

(Sister) 5/1/98 7/9/02 Keri Matt contacts
Ali King
Ted Stan
Kyle Jones 33 y Cough ? ? ? Billy Jeans Follow up KJ &

(Aunt) 1/5/69 7/18/02 Sandy Beach contacts
Barbara Hue 65 y Cough ? ? ? Martha Sue Follow up BH &

(Grandmother) 4/3/37 7/13/02 Joe Sue contacts
What Next
Step 9:
Implement Control
Measures
9. Implement Control Measures
Provide educational information to:

 Public:
(Letters to parents from the school/LHD,

public information sheets)
 Providers:
(Physicain alert, phone calls, visit, provider

information sheets)
* Communication between IDEP and LHD
important.
Pertussis Control:
1. Treatment & Prophylaxis

2. Vaccination
3. Isolation
1. Treatment & Prophylaxis:
Cases:
Initiate treatment as soon as pertussis is
suspected in a patient
1. Treatment & Prophylaxis:

Contacts:
Recommend chemoprophylaxis of all close contacts
with erythromycin regardless of age and vaccination
status
Chemoprophylaxis > 3 weeks after exposure = limited benefit

Chemoprophylaxis for high risk contacts (e.g infants) can be
considered up to 6 weeks after exposure
DRUG CHILD ADULT
Erythromycin 40-50 mg/kg per 1-2 g/day orally in
day orally in 4 4 divided doses for
divided doses; 14 days
maximum, 2 g/d) (maximum 2g/day)
for 14 days, as
tolerated.
Newer macrolides, azithrmycin 10-12 mg/kg per day orally in

1 dose) or clarithromycin (15-20 mg/kg per day orally in 2
divided doses; maximum, 1 g/d), may be effective in shorter
courses of 5-7 days; however their efficacy is unproven.
DOB Onset Class
Amy Gold 6m Cough Conf PCR Erythro- Jane Black 26yrs JB-no cough
(INDEX) 1/20/02 7/6/02 mycin Bob Will 6 mon BW-no cough
8/2/03 Billy Bear 8 mon BB-cough
Saira Gold 25 y No Not a NA Erythro- N/A
(Mother) 2/7/77 Cough case mycin
8/2/03
Roger Gold 30 y No Not a NA Erythro- N/A
(Father) Case mycin
4/4/72 Cough
8/2/03
Brittany Gold 4y Cough ? ? Erythro- Stacy Todd 4yrs ST- no cough
(Sister) 5/1/98 7/9/02 mycin Keri Matt 4 yrs KM- no cough
8/2/03 Ali King 4yrs AK- no cough
Ted Stan 5 yrs TS- cough
Kyle Jones 33 y Cough ? ? Erythro- Billy Jeans 35yrs BJ- no cough

(Aunt) 1/5/69 7/18/02 mycin Sandy Beach 38yrs SB-no cough
8/2/03
Barbara Hue 65 y Cough ? ? Erythro- Martha Sue 68yrs MS-cough
(Grandmother) 4/3/37 7/13/02 mycin Joe Sue 70 yrs JS- cough
8/2/03
2. Vaccination:
 All close contacts < to 6 years of age should be
brought up-to-date with pertussis immunization.
 Contacts < to 6 years who have not completed
the four-dose series should complete the series with
minimum intervals.
 Children aged 4-6 years who have completed a
primary series but have not received the pertussis
vaccination booster dose should be given this
dose.
DOB Onset Class
Amy Gold 6m Cough Conf PCR Erythro- Jane Black 26yrs JW-no cough
8/2/03
(Father) 4/4/72 Cough Case mycin
8/2/03

8/2/03
8/2/03
3. Isolation:
Patients should refrain from contact
outside the household for first 5 days after
start of a full course of antimicrobial treatment
or until 21 days from onset of cough in those
who do not receive antimicrobial therapy.
DOB Onset Class
Amy Gold 6m Cough Conf PCR Erythro- Jane Black 26yr JW-no cough
8/2/03
(Father) Cough Case mycin
4/4/72
8/2/03

8/2/03
8/2/03
What Next
Step 2:
Establish Existence
of Outbreak
Establish Existence of Outbreak
Outbreak (epidemic):
Occurrence of more cases than expected in a
given area or among a specific group of people
over a particular period of time
Cluster:
Aggregation of cases in a given area over a
particular period without regard to whether the
number is more than expected
PERTUSSIS WEST VIRGINIA
TOTAL NUMBER OF CASES - 1993-2002
40
37
35
30
25
CASES
20
15
8 6 7 7
10 6 6
6 3
5
0 1
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
YEAR
For Pertussis:
Two or more cases involving two or more
households clustered in time and space where
transmission is suspected to have occurred (e.g. a
school).
* One case in an outbreak must be lab confirmed

(PCR positive and meets case definition, or
culture positive).
* In outbreak settings a case may be defined as

a cough illness lasting 14 days or more.
DOB Onset Class
Amy Gold 6m Cough Conf PCR Erythro- Jane Black 26yr JW-no cough
(INDEX) 1/20/02 7/6/02 mycin Bob Will 6 m BW-no cough
8/2/03 Billy Bear 8 m BB-cough
8/2/03
Roger Gold 30 y No Not a Case NA Erythro- N/A
(Father) 4/4/72 Cough mycin
8/2/03
Brittany Gold 4y Cough Conf No Erythro- Stacy Todd 4yr ST- no cough
(Sister) 5/1/98 7/9/02 Epi-Linked Labs mycin Keri Matt 4 yr KM- no cough
8/2/03 Ali King 4yr AK- no cough
Ted Stan 5 yr TS- cough
Kyle Jones 33 y Cough ? ? Erythro- Billy Jeans 35yr BJ- no cough

(Aunt) 1/5/69 7/18/02 mycin Sandy Beach SB-no cough
8/2/03 38yrs
Barbara Hue 65 y Cough ? ? Erythro- Martha Sue 68y MS-cough
8/2/03
Do we have
an outbreak?
YES
What Next
Step 5:
Perform Descriptive
Epidemiology
Perform Descriptive Epidemiology
 Describe outbreak by
 Person: - Age, Sex, Exposure (Occupation)
Vaccination
history
 Place: - Community, Facility, School,
Hospital, etc.
 Time: - Determine time course

- Future course
- Exposure period
Cases
30
Person Time
20 Place
10
0
1 2 3 4 5 6 7 8 9 10
Perform Descriptive Epidemiology
Your conclusions:
 Number of Confirmed cases = 2
(1 PCR confirmed, 1 Epi linked)
 Place = Upshur County
 Population at-risk = household
 Vaccination history = both cases

inadequately immunized
 Future course of action
Step 6-8
6. Develop Hypothesis
7. Evaluate Hypothesis
8. As necessary, reconsider/refine
hypothesis.
Step 6-8
 Vaccine failure or failure to
vaccinate?
 Is the age distribution similar
to the national, state
trend?
PERTUSSIS CASES BY YEAR
West Virginia, 1970-2003 (Present)
80
70
60
50
Reported Cases
40
Accellular Vaccine
30 First Licensed.
20
10
0
'72
'74
'76
'78
'80
'84
'86
'88
'90
'92
'94
'96
'98
'70
'82
"00
"02
Year
Pertussis WV- 2002 Data Analysis
Total Cases 2002 = 37
Vaccination status available = 24
Of the 24 cases with known vaccination status

- 16 (43 %) = < 3 doses
Age 7 month to 4 years = 9 cases

Of these 9 cases
- 2 (22%) = no dose
- 2 (22%) = 1 or 2 doses
- 5 (56%) = 3 or more doses
PERTUSSIS
Reported cases per 100,000 population, by year,
United States, 1971-2001
CDC
PERTUSSIS
Reported cases, by age group,
United States, 2001
CDC
PERTUSSIS PERTUSSIS
WEST VIRGINIA WEST VIRGINIA
AGE DISTRIBUTION 1993-2002 AGE DISTRIBUTION 2002
65+ yrs 6 5 + yrs

40-64 yrs 1% 4 0 -6 4 yrs 3%
8% 13%
<1 yrs
25-39 yrs 27%
9%
2 5 -3 9 yrs
15-24
<1 yrs 13%
7%
55%
5-14 yrs 1 5 -2 4 yrs
7% 3%
1-4 yrs
5 -1 4 yrs
13% 1 -4 yrs
16%
25%
Step 10:
Communicate Findings
 Conference call
 Right now

Outbreak VI

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Outbreak VI

Uploaded by

Copyright:

Available Formats

Scenario

On 7/21/02 Upshur County health

Verify the Diagnosis

1. Review clinical findings to see if patient has

 The illness started with a "cold" but had gotten

 The baby's coughing was so violent that she often

 In addition, the baby had several episodes of vomiting

Children can have:

 Severe cough with a "whooping" sound

 Vomiting and exhaustion after severe coughing

 Bring children up to date on their shots, especially the

 Persons who have been in very close contact with a

 Most severe in infants under 1 year old.

b. Identify and Count Cases

Laboratory criteria for diagnosis

the clinical case definition and is either laboratory

 Other close contacts of the index case = 3

 Several contacts of contacts identified.

Saira Gold 25 y No Not a N/A ? N/A Need to prophylax

Roger Gold 30 y No Not a N/A ? N/A Need to prophylax

Brittany Gold 4y Cough ? ? ? Stacy Todd Follow BG &

Kyle Jones 33 y Cough ? ? ? Billy Jeans Follow up KJ &

Barbara Hue 65 y Cough ? ? ? Martha Sue Follow up BH &

Provide educational information to:

(Letters to parents from the school/LHD,

(Physicain alert, phone calls, visit, provider

1. Treatment & Prophylaxis

1. Treatment & Prophylaxis:

1. Treatment & Prophylaxis:

Chemoprophylaxis > 3 weeks after exposure = limited benefit

Newer macrolides, azithrmycin 10-12 mg/kg per day orally in

Kyle Jones 33 y Cough ? ? Erythro- Billy Jeans 35yrs BJ- no cough

Kyle Jones 33 y Cough ? ? Erythro- Billy Jeans 35yrs BJ- no cough

Kyle Jones 33 y Cough ? ? Erythro- Billy Jeans 35yrs BJ- no cough

* One case in an outbreak must be lab confirmed

* In outbreak settings a case may be defined as

Kyle Jones 33 y Cough ? ? Erythro- Billy Jeans 35yr BJ- no cough

 Time: - Determine time course

 Population at-risk = household

 Vaccination history = both cases

Of the 24 cases with known vaccination status

Age 7 month to 4 years = 9 cases

65+ yrs 6 5 + yrs

You might also like