California DPH: Whooping Cough Epidemic Continues

Credit CDC

 

# 8791

 

California’s Whooping cough (Pertussis) outbreak – which officials declared as an epidemic two weeks ago -  continues to grow at a rate comparable to what we saw in 2010 – when the last major epidemic broke out. 

 

Over the past two weeks, 1100 new cases have been identified, including one fatality.

Pertussis report 2014-6-24

Almost eliminated in this country by the mid-1970s, Whooping cough has made a worrisome comeback over the past decade, with roughly 50,000 cases reported in 2012. The reasons behind these increases are complex, and not entirely understood, but some factors are believed to be:

 

• lower vaccination uptakes in children and adults
• the move away from whole cell pertussis vaccines to safer (but somewhat less protective) acellular vaccines in the 1990s
• evolutionary changes in the Bordetella pertussis bacteria.

Whooping cough outbreaks are cyclical, and we see localized outbreaks increase every three to five years.  The last `big’ year for Whooping cough in California was 2010, but  2014 is shaping up to be another bad year.   This from the California Department of Public Health.

 

California Whooping Cough Epidemic Continues

Date: 6/27/2014

Number: 14-060

Contact: Anita Gore, (916) 440-7259

SACRAMENTO

1,100 new cases have been reported in the last two weeks

The number of pertussis (whooping cough) cases in the state continues to climb, Dr. Ron Chapman, director of the California Department of Public Health (CDPH) and state health officer reported today.

In the past two weeks, 1,100 new cases of pertussis have been reported to CDPH. This brings the total number of cases to 4,558 (as of June 24). This far surpasses the total number of reported cases in 2013, which was 2,532. One additional infant has died, bringing the total number of infant deaths to three. Children four-months-old or younger account for nearly 2/3 of all pertussis hospitalizations.

“Infants are at the greatest risk of illness and death from pertussis,” said Dr. Chapman. “Vaccination is the best form of protection. We’re encouraging all parents to vaccinate their children, and for pregnant women to be vaccinated to protect their babies. This will ensure maximum protection against this potentially fatal disease.”

The Tdap vaccination for pregnant women is the best way to protect infants who are too young to be vaccinated. All pregnant women should be vaccinated with Tdap in the third trimester of each pregnancy, regardless of previous Tdap vaccination. Inoculated women pass immunity to their unborn babies that protect them until they can be vaccinated. Infants should be vaccinated as soon as possible. The first dose of pertussis vaccine can be given as early as 6 weeks of age.

Older children, pre-adolescents and adults should also be vaccinated against pertussis according to current recommendations.

“It’s particularly important that people who will be around newborns also be vaccinated,” added Dr. Chapman. “This includes babysitters, older siblings, parents and grandparents. When those people are vaccinated they will help protect infants who are too young for immunization.”

The symptoms of pertussis vary by age. For children, pertussis typically starts with a cough and runny nose that can last up to two weeks. The cough then worsens and turns into rapid coughing spells that end with a tell-tale “whooping” sound. Young infants may not have typical pertussis symptoms and may have no apparent cough. Parents describe episodes in which the infant’s face turns red or purple. For adults, pertussis may simply be a cough that lasts for several weeks.

CDPH is working closely with local health departments, schools, media outlets and other partners to inform the general public about the importance of vaccination against pertussis.

California Declares Whooping Cough (Pertussis) Epidemic

Credit CDC’s Pertussis page.

# 8743

 

Two weeks ago, in California: Pertussis Rising (Again), we looked at the early, steep rise in Pertussis cases reported in California this year, along with a look back at the the history of the disease, and the vaccine used to combat it.

Credit CDC

 

After all but eliminating the disease in the United States in the 1970s, Pertussis is back, albeit at only 1/10th the levels it once was. The reasons behind these increases are complex, and not entirely understood, but some factors are believed to be:

• lower vaccination uptakes in children and adults
• the move away from whole cell pertussis vaccines to safer (but somewhat less protective) acellular vaccines in the 1990s
• evolutionary changes in the Bordetella pertussis bacteria.

 

Whooping cough outbreaks are cyclical, and we see localized outbreaks increase every three to five years.  The last `big’ year for Whooping cough in California was 2010, but 2014 looks like another contender.   Yesterday, the state of California formally declared this year’s outbreak an epidemic.

 

More than 800 new cases have been reported in the last two weeks

The number of pertussis (whooping cough) cases in the state has reached epidemic proportions it was reported today by Dr. Ron Chapman, director of the California Department of Public Health (CDPH) and state health officer.

As of June 10, there have been 3,458 cases of pertussis reported to CDPH in 2014, more than were reported in all of 2013. Over 800 new cases have been reported in the past two weeks.

Pertussis is cyclical and peaks every 3-5 years. The last peak in California occurred in 2010, so it is likely another peak is underway.

“Preventing severe disease and death in infants is our highest priority,” says Dr. Chapman. “We urge all pregnant women to get vaccinated. We also urge parents to vaccinate infants as soon as possible.”

Infants too young to be fully immunized remain most vulnerable to severe and fatal cases of pertussis. Two-thirds of pertussis hospitalizations have been in children four months or younger. Two infant deaths have been reported.

The Tdap vaccination for pregnant women is the best way to protect infants who are too young to be vaccinated. All pregnant women should be vaccinated with Tdap in the third trimester of each pregnancy, regardless of previous Tdap vaccination. In addition, infants should be vaccinated as soon as possible. The first dose of pertussis vaccine can be given as early as 6 weeks of age.

Older children, pre-adolescents, and adults should also be vaccinated against pertussis according to current recommendations. It is particularly important that persons who will be around newborns also be vaccinated.
“Unlike some other vaccine-preventable diseases, like measles, neither vaccination nor illness from pertussis offers lifetime immunity,” says Dr. Ron Chapman. “However, vaccination is still the best defense against this potentially fatal disease.”

The symptoms of pertussis vary by age. For children, a typical case of pertussis starts with a cough and runny nose for one to two weeks. The cough then worsens and children may have rapid coughing spells that end with a “whooping” sound. Young infants may not have typical pertussis symptoms and may have no apparent cough. Parents may describe episodes in which the infant’s face turns red or purple. For adults, pertussis may simply be a cough that persists for several weeks.

CDPH is working closely with local health departments, schools, media outlets and other partners to inform the general public about the importance of vaccination against pertussis. 

Pertussis data, including the number of cases in each county, can be found on the CDPH website, and is updated regularly

California: Pertussis Rising (Again)

Credit CDC’s Pertussis page.

 

Key Points:

• 5/30/14 - California Warns on Rising Pertussis Cases

 

# 8688

 

In June of 2010 we started to follow what would end up being the worst Pertussis (Whooping cough) outbreak in the State of California (see California: Pertussis Epidemic) in at least a half century.  

 

During the summer and fall we revisited the outbreak (see here, and here), and in December the State of California released the following summary:

 

Pertussis Report

December 15, 2010

New in this report: Disease activity is slowing statewide, however relatively high numbers of cases continue to be reported each week

7,824 confirmed, probable and suspect cases of pertussis with onset from January 1 through December 15, 2010 reported to CDPH for a state rate of 20.0 cases/100,000.

527 new cases have been reported to CDPH since November 30 (Figure 1).

This is the most cases reported in 63 years when 9,394  cases were reported in 1947, a peak year,and the highest incidence in 52 years when a rate of 26.0 cases/100,000 was reported in 1958. Previously, the peak was in 2005 when there were 3,182 cases reported (Figure 2).

 

By the time all of the numbers were in for 2010, the number of cases had exceeded 9,000, including 10 deaths.  Since then, Pertussis numbers in California have remained elevated – particularly when compared to the the 1970s, 1980s, and 1990s – but not record setting.

 

 

During my parent’s day, whooping cough infected more than a 250,000 Americans each year, and killed about 5,000 of them. All that began to change in the 1940s when the first whole-cell pertussis vaccine - combined with diphtheria and tetanus toxoids (DTP) - was introduced.

 

It what was such remarkable success, that by the time my daughter was born (1977) the number of reported cases had just reached a record-low of 1,010 cases, a decrease of 99%.

 

But since then, the number of cases has increased dramatically, with 2012 seeing nearly 50,000 cases reported in the United States.

Credit CDC

 

 

The reasons behind these increases are complex, and not entirely understood, but some factors are believed to be:

• lower vaccination uptakes in children and adults
• the move away from whole cell pertussis vaccines to safer (but somewhat less protective) acellular vaccines in the 1990s
• evolutionary changes in the Bordetella pertussis bacteria.

 

Whooping cough outbreaks are cyclical, and we see localized outbreaks increase every three to five years.  As it has been four years since the last major epidemic in California, there are concerns that this year could be another banner year for the disease.

 

This from the California Department of Public Health.

 

Whooping Cough Cases Increase

Date: 5/30/2014

Number: 14-051

Contact: Anita Gore - (916) 440-7259

SACRAMENTO

Dr. Ron Chapman, director of the California Department of Public Health (CDPH) and state health officer, today warned that the number of pertussis (whooping cough) cases continue to increase in California.

CDPH has received reports of 2,649 cases of pertussis occurring from January through May 27, 2014, more than the number of cases reported in all of 2013. More than 800 cases were reported in April alone, the highest monthly count since the 2010 epidemic.

“The number of pertussis cases is likely to continue to increase,” says Dr. Ron Chapman. “As an important preventive measure, we recommend that pregnant women receive a pertussis vaccine booster during the third trimester of each pregnancy, and that infants be vaccinated as soon as possible.”

Infants too young to be fully immunized remain most vulnerable to severe and fatal cases of pertussis. Sixty-six of the hospitalized cases to date in 2014 have been in children four months of age or younger. Two infant deaths have been reported this year, one with onset in 2013, the second with onset in 2014.
Eighty-three percent of the cases have occurred in infants and children younger than 18 years of age. Of the pediatric cases, 8 percent who were younger than 6 months-old and 70 percent were 7 through 16 years of age.
It’s important that both children and adults are up-to-date on their immunizations. Booster shots for pertussis are critical because, unlike some other vaccine-preventable diseases, neither the pertussis disease nor vaccine offers lifelong immunity.

To prevent pertussis, CDPH recommends that: 

• Pregnant women receive a pertussis vaccine booster during the third trimester of each pregnancy, even if they’ve received it before.                        
• Infants be vaccinated against pertussis as soon as possible. The first dose is recommended at two months of age but can be given as early as 6 weeks of age during pertussis outbreaks. Children need five doses of pertussis vaccine by kindergarten (ages 4-6).
• California 7th grade students receive the pertussis vaccine booster as required by state law.
• Adults receive a one-time pertussis vaccine booster, especially if they are in contact with infants or if they are health care workers who may have contact with infants or pregnant women.

The symptoms of pertussis vary by age. For children, a typical case of pertussis starts with a cough and runny nose for one to two weeks. The cough then worsens and children may have rapid coughing spells that end with a whooping sound. Young infants may not have typical pertussis symptoms and may have no apparent cough. Parents may describe episodes in which the infant’s face turns red or purple. For adults, pertussis may simply be a cough that persists for several weeks.

Pertussis numbers will be updated every two weeks on the CDPH website.

 

  
Globally, Pertussis remains a serious public health issue, with the World Health Organization estimating that in 2008 about 16 million people were infected, and roughly 195,000 children died from the disease (cite).  And much like we discussed yesterday with measles, Pertussis can be reintroduced into a susceptible population by unvaccinated international travelers coming from areas where the disease is endemic.

 

But the truth is, with anywhere between 10,000 and 50,000 cases being reported in the United States each year, you don’t have to travel far to be exposed.  

 

Pertussis, after decades of near elimination, is a disease that is once again available locally.

WHO Human H7N9 Update – Jan 14th

 

# 8168

 

 

This morning the World Health Organization’s GAR (Global Alert & Response) team has released another H7N9 update, this time covering 5 recently announced cases, one of which proved fatal.

 

Despite the mounting number of cases, thus far they’ve been widely scattered across a large expanse of Eastern China,and we’ve seen faint evidence of clustering.

 

While investigations into the source of these infections are ongoing, for now this virus does not appear to be transmitting from human-to-human in a sustained or efficient manner.

 

 

Human infection with avian influenza A(H7N9) virus – update

Disease outbreak news

14 January 2014 - The National Health and Family Planning Commission of China notified WHO of 5 additional laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus, including 1 death.

On the 11 January 2014, WHO was notified of the following cases:

• 58-year-old woman from Shanghai who became ill on 1 January and was admitted to hospital on 8 January. She is currently in a critical condition. The patient had a history of exposure to poultry.
• 56-year-old man from Shanghai who became ill on 6 January and was admitted to hospital on 9 January. He is currently in a critical condition. The patient had a history of exposure to poultry.
• 75-year-old woman from Zhuji City, Zhejiang Province who became ill on 1 January, was admitted to hospital on 5 January, and died on 9 January. The patient had a history of exposure to poultry.

On 12 January 2014, WHO was notified of the following cases:

• 29 year old man from Guangzhou City, Guangdong Province who became ill on 3 January and was admitted to hospital on 9 January. He is currently in a critical condition. The patient works near to a poultry market.
• 76 year old man from Shenzhen City, Guangdong Province who became ill on 3 January and was admitted to hospital on 9 January. He is currently in a stable condition. The patient had no history of exposure to poultry.

The source of infection is still under investigation. So far, there is no evidence of sustained human-to-human transmission.

The Chinese government continues to take the following measures:

• strengthen surveillance and situation analysis;
• reinforce case management and treatment;
• conduct risk communication with the public and release information;
• strengthen international collaboration and communication; and
• conduct scientific studies.

WHO does not advise special screening at points of entry with regard to this event, nor does it currently recommend any travel or trade restrictions.

UK: Whooping Cough Numbers Decline After Record Year

 

Credit CDC

# 6902

 

Reports of Pertussis or `whooping cough’ have been on the ascendant around the globe the past few years, including in the United States, Australia, and the UK.

 

Over the past few months I’ve blogged on the UK’s record setting year for Whooping cough several times, including:

 

HPA: Whooping Cough Cases Remain High

UK: Three Whooping Cough Deaths In October

The UK’s Whooping Cough Outbreak

 

Today, a little bit of encouraging news, as the number of new Pertussis cases reported by the HPA have declined for the second month in a row. It is too early, however, to read much into what this means for the rest of 2013.

 

Cases of whooping cough decline after record numbers in 2012

1 February 2013

There were 9,741* confirmed cases of whooping cough reported in England and Wales in 2012, according to figures published today by the Health Protection Agency (HPA). The total figure for 2012 is almost 10 times higher than the number of cases reported in 2011 (1,119) and in 2008 (902) – the last peak year before this current outbreak.

 

The December figures show a decrease for the second month running in cases of whooping cough with 832 confirmed cases reported compared with 1,168 cases in November 2012. One further death in an infant with laboratory confirmed whooping cough was reported in December bringing the 2012 total number of deaths in babies under three months to 14.

 

The highest number of cases were reported in those aged 15 and over, with a total of 8,059 cases in 2012, compared to 740 cases in 2011 and 493 cases in 2008.

 

Dr. Mary Ramsay, head of immunisation at the HPA, said: “The December figures show another welcome decrease in the overall number of whooping cough cases since the peak in October. However, it is very important to note that we usually see a reduction in cases of whooping cough at this time of year so this decrease is in line with normal seasonal patterns.

(Continue . . .)

 

Before we pop the Champaign corks, it is important to note that the total number of cases reported during the month of December (n=832) is nearly double the total reported in all of 2010 (n=422).

Still, any decline is welcome news.

 

The reasons behind the spike in Pertussis cases are complex, and not completely understood, but some factors may include:

• lower vaccination uptakes
• the move away from whole cell pertussis vaccines to safer – but less broadly protective  - acellular vaccines in the 1990s
• evolutionary changes in the Bordetella pertussis bacteria.

 

Recent evidence published in the NEJM suggests that protection from the newer acellular pertussis vaccine – introduced in the early 1990s – may wane sooner than previously suspected. 

 

Waning Protection after Fifth Dose of Acellular Pertussis Vaccine in Children

Nicola P. Klein, M.D., Ph.D., Joan Bartlett, M.P.H., M.P.P., Ali Rowhani-Rahbar, M.D., M.P.H., Ph.D., Bruce Fireman, M.A., and Roger Baxter, M.D.

N Engl J Med 2012; 367:1012-1019 September 13, 2012DOI: 10.1056/NEJMoa1200850

 

In November of last year, in JAMA: Waning Pertussis Vaccine Effectiveness Over Time, we saw another study that found that the protective effect of the Pertussis vaccine begins to wane after the fifth dose (normally given at age 5) is received, leaving 7 to 10 year olds at greater risk of infection.

 

For more information, the CDC maintains an extensive Whooping Cough website, including audio files designed to help you identify the often distinctive `whooping’ sound made by those infected.

 

Pertussis (Whooping Cough)

 

And from the Advisory Committee on Immunization Practices (ACIP) this week we get recommendations that adults aged 65 and older and pregnant women receive the Tdap vaccine.

 

Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Adults Aged 19 Years and Older — United States, 2013

Supplements

February 1, 2013 / 62(01);9-19

(EXCERPT)

For tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, recommendations have been expanded to include routine vaccination of adults aged 65 years and older and for pregnant women to receive Tdap vaccine with each pregnancy. The ideal timing of Tdap vaccination during pregnancy is during 27–36 weeks' gestation. This recommendation was made to increase the likelihood of optimal protection for the pregnant woman and her infant during the first few months of the infant's life, when the child is too young for vaccination but at highest risk for severe illness and death from pertussis

HPA: Whooping Cough Cases Remain High

Credit CDC

# 5798

 

Updating a story from late in November (see UK: Three Whooping Cough Deaths In October), while the number of new UK Pertussis cases reported in November dropped over the previous month, they still remain well above average.

 

The HPA released the following update this morning.

 

Whooping cough cases remain high

21 December 2012

Figures published by the Health Protection Agency (HPA) today show that cases of whooping cough have continued at high levels during November with 1,080 confirmed cases reported for England and Wales, bringing the total number of cases so far this year to 8,819*. No deaths were reported in November.

 

The total of 1,080 cases reported during November represents a decrease from October when 1,631 cases were reported for England and Wales, which is the first time we’ve seen a decrease in monthly numbers since the current outbreak began in the middle of 2011. However, a decrease in cases is usually seen at this time of year so this does not necessarily represent the end of this severe outbreak.

 

At the end of September, the Department of Health announced that pregnant women would be offered whooping cough vaccination to protect their newborn babies, who do not usually start their vaccinations against whooping cough until they are two months of age. The aim of the vaccination programme is to help to boost the short term immunity passed on by women to their babies while they are still in the womb.

 

It is too soon for this vaccination campaign to have had an impact on the case numbers we are seeing, however, the Department of Health recently reported an uptake of around 40 per cent in pregnant women.

 

Dr Gayatri Amirthalingam, consultant epidemiologist for immunisation at the HPA, said: “The November figures show a welcome decrease of whooping cough cases since October. However, it is very important to note that we usually see a reduction in cases of whooping cough at this time of year so this decrease is in line with normal seasonal patterns.

 

“The recent announcement that at least 40 per cent of pregnant women received the whooping cough vaccine in the first month of the programme is very encouraging. We would like to remind pregnant women how serious this infection can be in young babies and how it can in some cases cause death. Vaccination between 28 and 38 weeks of pregnancy should offer babies the best protection against whooping cough before they receive their own vaccines.

 

“As well as this, parents should ensure their children are vaccinated against whooping cough on time, even babies of women who’ve had the vaccine in pregnancy – this is to continue their baby’s protection through childhood."

 

Whooping cough, also known as pertussis, affects all ages. Young infants are at highest risk of severe complications and death from whooping cough as babies do not complete vaccination until they are around four months old. In older children and adults whooping cough can be an unpleasant illness but it does not usually lead to serious complications. Whooping cough is a highly infectious bacterial disease which spreads when a person with the infection coughs and sheds the bacteria which is then inhaled by another person.

 

Dr Amirthalingam continues, “Parents should also be alert to the signs and symptoms of whooping cough – which include severe coughing fits accompanied by the characteristic “whoop” sound in young children but as a prolonged cough in older children or adults.”

(Continue . . . )

 

 

 

The reasons behind the spike in Pertussis cases (not only in the UK, but in the U.S., Australia, and elsewhere) are complex, and not completely understood, but some factors may include:

 

• lower vaccination uptakes
• the move away from whole cell pertussis vaccines to safer – but less broadly protective  - acellular vaccines in the 1990s
• evolutionary changes in the Bordetella pertussis bacteria.

 

Recent evidence published in the NEJM suggests that protection from the newer acellular pertussis vaccine – introduced in the early 1990s – may wane sooner than previously suspected. 

 

Waning Protection after Fifth Dose of Acellular Pertussis Vaccine in Children

Nicola P. Klein, M.D., Ph.D., Joan Bartlett, M.P.H., M.P.P., Ali Rowhani-Rahbar, M.D., M.P.H., Ph.D., Bruce Fireman, M.A., and Roger Baxter, M.D.

N Engl J Med 2012; 367:1012-1019 September 13, 2012DOI: 10.1056/NEJMoa1200850

 

 

While not 100% perfect, the Pertussis vaccine remains the best way to prevent Whooping Cough.

 

As noted above, the rise in whooping cough isn’t just a problem in the UK.  The graphic below shows that – except for California – every state in the union has reported an increase in Pertussis cases this year over 2011 (through week 46). 

 

For more on the prevention of Whooping Cough, and the role of the Tdap vaccine, visit:

 

http://www.cdc.gov/pertussis/

 

UK: Three Whooping Cough Deaths In October

 

Credit CDC

 

# 6749

 

Whooping cough has been in the news (and in this blog) a lot this week (see Safety Of Tdap Vaccine In Older Patients and Waning Pertussis Vaccine Effectiveness Over Time), and with an announcement overnight from the HPA, today I go for the hat trick.

 

Last month (see The UK’s Whooping Cough Outbreak) we looked at the rising pertussis numbers in the UK, and the announcement that that pregnant women would be offered the Pertussis vaccine in order to protect their newborns, who cannot be vaccinated until they are 2 – 4 months of age.

 

The latest announcement from the HPA indicates that during the month of October more than 1,600 additional cases of Whooping cough were reported in England and Wales, resulting in 3 infant deaths.  This brings the death toll in 2012 to 13.

 

As you can see by the chart below, Pertussis in 2012 is running roughly 10 times the rate seen in recent years.

 

 

The reasons behind this latest spike in Pertussis cases are complex, and not completely understood, but some factors may include:

• lower vaccination uptakes
• the move away from whole cell pertussis vaccines to safer – but less broadly protective  - acellular vaccines in the 1990s
• evolutionary changes in the Bordetella pertussis bacteria.

 

Here are some excerpts from the HPA’s press release:

 

Whooping cough cases continue to increase

30 November 2012

Figures published by the Health Protection Agency (HPA) today reveal 1,614 cases of whooping cough were reported in England and Wales in October 2012, bringing the total number of cases so far this year to 7,728*.

 

The total number of cases so far in 2012 (up to end of October) is nearly ten times higher than for the same period in 2008, the last ‘peak’ year before this current outbreak, when 797 cases were reported. There have been three deaths in infants with laboratory confirmed whooping cough reported in October bringing the total number of deaths in this age group so far this year to 13.

 

At the end of September, the Department of Health announced that pregnant women would be offered whooping cough vaccination to protect their newborn babies, who do not usually start their vaccinations against whooping cough until they are two months of age. The aim of the vaccination programme is to help to boost the short term immunity passed on by women to their babies while they are still in the womb.

 

Dr Gayatri Amirthalingam, consultant epidemiologist for immunisation at the HPA, said: “The October figures show a continuing rise in the overall number of whooping cough cases. While there has been a decline in the number of infant cases it’s important to emphasise that it’s too early to see any impact from the pregnancy vaccination programme. Working with the Department of Health we are continuing to carefully monitor whooping cough activity to evaluate the success of the programme.

 

“We strongly recommend all pregnant women take up the offer of vaccination. Parents should also ensure their children are vaccinated against whooping cough on time, even babies of women who’ve had the vaccine in pregnancy – this is to continue their baby’s protection through childhood. Parents should also be alert to the signs and symptoms of whooping cough – which include severe coughing fits accompanied by the characteristic “whoop” sound in young children but as a prolonged cough in older children or adults. It is also advisable to keep babies away from older siblings or adults who have the infection.”

 

Whooping cough, also known as pertussis, affects all ages. Young infants are at highest risk of severe complications and death from whooping cough as babies do not complete vaccination until they are around four months old. In older children and adults whooping cough can be an unpleasant illness but it does not usually lead to serious complications. Whooping cough is a highly infectious bacterial disease which spreads when a person with the infection coughs and sheds the bacteria which is then inhaled by another person.

(Continue . . . )

 

 

For more information, the CDC maintains an extensive Whooping Cough website, including audio files designed to help you identify the often distinctive `whooping’ sound made by those infected.

 

Pertussis (Whooping Cough)

Pertussis, also known as whooping cough, is a highly contagious respiratory disease. It is caused by the bacterium Bordetella pertussis.

Pertussis is known for uncontrollable, violent coughing which often makes it hard to breathe. After fits of many coughs, someone with pertussis often needs to take deep breathes which result in a "whooping" sound. Pertussis most commonly affects infants and young children and can be fatal, especially in babies less than 1 year of age.

(Continue . . . )

JAMA: Waning Pertussis Vaccine Effectiveness Over Time

Credit CDC Pink Book

 

 

 

# 6744

 

Pertussis, or `whooping cough’ was once a major childhood disease in the United States, with more than a million cases reported between 1940 and 1945, resulting in thousands of deaths. 

 

All that began to change with the introduction of a whole cell Pertussis vaccine in the 1940s.  By 1960, the number of Pertussis cases in the United States had dropped to about 15,000 cases a year – a 95% reduction over 20 years.

 

Rates dropped another 2/3rds over the next 10 years (see chart above).

 

The vaccine, while highly effective, was blamed for a variety of adverse reactions, prompting a move away from whole cell pertussis vaccines to safer – but less broadly protective  - acellular vaccines in the 1990s

 

The following chart illustrates the rise in pertussis cases, which began in earnest in the early 1990s.  The most recent years (2010-2011) are not shown, but they were among the most active in decades.

 

 

While still far below the rates seen in the 1940s, the recent rise in Pertussis cases has raised a good deal of concern these past couple of years.  A few blogs on it include:

 

The UK’s Whooping Cough Outbreak

Referral: McKenna On Pertussis Vaccines

California Reports 9th Pertussis Fatality of 2010

 

The reasons behind these increases are complex, and not completely understood, but some factors may include:

 

• lower vaccination uptakes
• the move away from whole cell pertussis vaccines to safer acellular vaccines in the 1990s
• evolutionary changes in the Bordetella pertussis bacteria.

 

Although infants are still at greatest risk from this illness, children aged 7 to 10 years old have experienced an unexpected rise in infections over the past decade.

 

A recent study published in the NEJM suggested that protection from the newer acellular pertussis vaccine – introduced in the early 1990s – may wane sooner than previously suspected. 

 

Waning Protection after Fifth Dose of Acellular Pertussis Vaccine in Children

Nicola P. Klein, M.D., Ph.D., Joan Bartlett, M.P.H., M.P.P., Ali Rowhani-Rahbar, M.D., M.P.H., Ph.D., Bruce Fireman, M.A., and Roger Baxter, M.D.

N Engl J Med 2012; 367:1012-1019 September 13, 2012DOI: 10.1056/NEJMoa1200850

 

Today we can add another study, this time appearing in JAMA, that finds that the protective effect of the Pertussis vaccine begins to wane after the fifth dose (normally given at age 5) is received, leaving 7 to 10 year olds at greater risk of infection.

 

 

Association of Childhood Pertussis With Receipt of 5 Doses of Pertussis Vaccine by Time Since Last Vaccine Dose, California, 2010

Lara K. Misegades, PhD, MS; Kathleen Winter, MPH; Kathleen Harriman, PhD, MPH, RN; John Talarico, DO, MPH; Nancy E. Messonnier, MD; Thomas A. Clark, MD, MPH; Stacey W. Martin, MSc

 

JAMA. 2012;308(20):2126-2132. doi:10.1001/jama.2012.14939

ABSTRACT (Excerpt)

Conclusion  Among children in 15 California counties, children with pertussis, compared with controls, had lower odds of having received the 5-dose DTaP series; as time since last DTaP dose increased, the odds increased, which is consistent with a progressive decrease in estimated vaccine effectiveness each year after the final dose of pertussis vaccine.

 

Pertussis remains a poorly controlled vaccine-preventable disease in the United States, despite a well-established childhood vaccination program and high coverage. Although infants have substantially higher rates of pertussis compared with other age groups, data from the National Notifiable Diseases Surveillance System reflect a recent increase in the number of reported pertussis cases among children aged 7 to 10 years. In 2010, this age group had the second highest incidence of pertussis in the United States.

 

The changing epidemiology raises important questions about possible waning protection from the childhood acellular pertussis vaccine series.

(Continue . . . )

 

 

This is a lengthy report, heavy on statistics.  For a less imposing summary, we have a nice write up today in Family Practice News:

 

Pertussis Vaccine Loses Efficacy Each Year After Fifth Dose

 

By: MARY ANN MOON, Family Practice News Digital Network

The odds of a child developing pertussis increase as the interval since he or she received the fifth and final dose of the DTaP vaccine increases, according to a report published in the November 28, 2012 issue of JAMA.

 

This pattern indicates a progressive waning of vaccine effectiveness every year after completion of the vaccine series, which would explain the recently noted surge in pertussis cases among 7- to 10-year-olds in at least 34 states, said Lara K. Misegades, Ph.D., of the Meningitis and Vaccine Preventable Disease Branch of the Centers for Disease Control and Prevention and her associates.

(Continue . . . )

 

As more confirmatory data comes in and is analyzed, the question then becomes what to do about this decline in protection for those aged 7 to 10 years of age.  The authors, in their conclusion, grant that their are no easy answers.

 

The increasing incidence of pertussis, changing epidemiology, and demonstrated decline in the estimated DTaP VE over time have raised concerns about the current US pertussis vaccine program and may prompt consideration of alternative schedules.

 

Options include delaying administration of the fifth DTaP dose or administering the Tdap booster at earlier than 11 years of age. However, a recommendation to delay the fifth DTaP dose until 6 years of age or later may unintentionally increase the burden of disease between the fourth and fifth doses of the childhood series, and implementation would likely be programmatically challenging because many states' school entry immunization requirements for pertussis are built around the current DTaP schedule.

 

Alternatively, shifting the Tdap booster to 10 years of age or earlier may have the unwanted effect of reducing coverage, as there is no established routine health care visit for children before the adolescent vaccine platform visit at 11 to 12 years of age.³²

 

Given the options for adjustments to the pertussis vaccine schedule, these issues will require careful and ongoing review of the epidemiology and vaccine program nationwide. Ultimately, improved control of pertussis may require a vaccine that provides longer duration of protection or differently affects transmission in the community.

The UK’s Whooping Cough Outbreak

Confirmed Pertussis England & Wales by year & Quarter - 2012 numbers through 2nd Quarter

 

# 6661

 

Pertussis, or `Whooping Cough’ is a highly contagious bacterial infection that can cause serious illness and even death.  Although it is thought of as a `childhood’ disease, anyone of any age can catch it.

 

It is caused by either Bordetella pertussis or Bordetella parapertussis bacteria, which are easily spread through the air by the characteristic violent coughing spasms it induces. Infection can last for 6 weeks or longer, which is why it is sometimes called the `100 days' cough’.

 

Whooping cough in England and Wales, just as we’ve seen recently in the United States (see The Never Ending Battle), is on the rise again after two very successful decades of control.

 

The chart above (from Accelerating Control of Pertussis in England and Wales – EID Journal Vol. 18, No. 1, January 2012) illustrates just how well their vaccination program worked in controlling this disease since its introduction in the mid-1940s.

 

From seeing 170,000+ cases a year before the vaccine was introduced, down to triple digits in the early 1970s, the Pertussis vaccination in England & Wales has been a huge success story.

 

While spikes in cases did occur in the 1980s, increased uptake of the vaccine brought those numbers down again by 1990.

 

The reasons behind this latest spike in Pertussis cases are complex, and not completely understood, but some factors may include:

 

• lower vaccination uptakes
• the move away from whole cell pertussis vaccines to safer – but less broadly protective  - acellular vaccines in the 1990s
• evolutionary changes in the Bordetella pertussis bacteria.

 

Recent evidence published in the NEJM suggests that protection from the newer acellular pertussis vaccine – introduced in the early 1990s – may wane sooner than previously suspected. 

 

Waning Protection after Fifth Dose of Acellular Pertussis Vaccine in Children

Nicola P. Klein, M.D., Ph.D., Joan Bartlett, M.P.H., M.P.P., Ali Rowhani-Rahbar, M.D., M.P.H., Ph.D., Bruce Fireman, M.A., and Roger Baxter, M.D.

N Engl J Med 2012; 367:1012-1019 September 13, 2012DOI: 10.1056/NEJMoa1200850

 

 

All of which brings us to an HPA press release this morning, indicating that more than 6,000 whooping cough cases have been reported through the end of September, and urging parents to follow the recommended Pertussis vaccination schedule for their kids.

.

 

Whooping cough outbreak continues

25 October 2012

According to figures published by the Health Protection Agency (HPA) today, 1,322 cases of whooping cough (pertussis) were reported in England and Wales in September 2012, bringing the total number of cases so far this year to 6,121*.

 

The total number of cases so far in 2012 (up to end of September) is more than five times higher than the annual total number of cases reported in 2011 (1,118) and almost seven times higher than the total in 2008 (902) – the last ‘peak’ year before this current outbreak. In September there was one pertussis-related death in an infants under three months of age, bringing the total number of deaths in this age group so far this year to ten.

 

<SNIP>

 

“The introduction of a vaccine for pregnant women will not have an immediate impact on serious infection in infants so vigilance remains important. Working with the Department of Health we will continue to regularly monitor figures to evaluate the success of the programme.

 

“All parents should ensure their children are vaccinated against whooping cough on time, even babies of women who’ve had the vaccine in pregnancy – this is to continue their baby’s protection through childhood. Parents should also be alert to the signs and symptoms of whooping cough – which include severe coughing fits accompanied by the characteristic “whoop” sound in young children but as a prolonged cough in older children or adults. It is also advisable to keep babies away from older siblings or adults who have the infection.”

 

(Continue . . . )

 

 

This rise in Pertussis isn’t just a problem in the UK.

 

The Untied States saw a major upsurge in 2010, with more than 27,000 Whooping cough cases reported. Earlier this year the State of Washington declared a Pertussis epidemic (see MMWR Pertussis Epidemic — Washington, 2012).

 

And Australia has a record 38,500 cases (out of a population of just over 22 million) reported in 2011.

 

While admittedly not 100% perfect, the Pertussis vaccine remains the best way to prevent Whooping Cough.

 

For more on how to protect yourself, your family, and your community, the  CDC offers the following advice on Pertussis Vaccination.

 

Pertussis Vaccination

The best way to prevent pertussis is to get vaccinated. There are vaccines for infants, children, preteens, teens and adults. The childhood vaccine is called DTaP, and the pertussis booster vaccine for adolescents and adults is called Tdap. Talk to your healthcare provider about getting vaccinated against pertussis and read more about pertussis prevention.

For Those Getting Vaccinated

Pertussis Vaccine Basics
Offers comprehensive offers information about pertussis vaccines and other educational tools.

Td or Tdap Vaccine "What You Need To Know" (66 KB, 2 pages)
This one-page CDC vaccine information statement explains who should get Td or Tdap vaccine and when.

DTaP Vaccine "What You Need To Know" (58 KB, 2 pages)
This one-page CDC vaccine information statement explains who should get DTaP vaccine and when.

Vaccine Safety

Who Should Not Be Vaccinated with DTaP or Td-Tdap?

California Reports 9th Pertussis Fatality of 2010

 

 

# 4911

 

 

The last time I updated the California Whooping Cough epidemic was in late July, and at that time 6 children had already died from this preventable disease. 

 

As of the September 14th report, 3 more babies have died. California is on track to see the worst Pertussis (Whooping Cough) outbreak in 55 years.

 

Pertussis rates going the wrong way 

 

 

As you can see, in the early 1980s Pertussis was practically eliminated – thanks to the introduction of an effective Pertussis vaccine in the 1940s. Before that was available, several thousand children died each year in the United States from Whooping cough.

 

But the incidence of Whooping cough has been creeping back up over the past 30 years (and not just in California), and large regional outbreaks occur every few years.

 

That resurgence is due in part to the reluctance of some parents to get their kids vaccinated, but is also due to a lack of adults and adolescents getting their recommended booster shots.

 

As of 9/14/2010, California reports 4,017 confirmed, probable and suspect cases of pertussis for 2010, making for a state rate of 10.3 cases/100,000.

 

This is the most cases since 1955 when 4,949 cases were reported,and the highest incidence since 1962, when a rate of 10.9 cases/100,000 was reported.

 

Up until now, the worst year in the past 40 was in 2005 when 3,182 cases reported.

 

Nine infant deaths have been reported of which  8 (89%) were Hispanic.

 

Eight of the fatalities were among infants  less than 2 months of age who had not received any doses of the Pertussis vaccine.  The remainder was a 2-month old preemie that had received only one dose of the vaccine just 15 days prior to falling ill.

 

Prevention is through vaccination, but since the vaccine offered is `inactivated’ (contains no live bacteria), it requires repeated doses during childhood and a booster shot as adults.

 

 

The CDC has a simple, 2-page pamphlet on the DTaP vaccine.

 

 

 

Although the numbers are small, in recent years an increasing number of parents are filing “personal belief exemptions”, to avoid vaccinating their children.

 

California, like all states, requires that all students be vaccinated against Whooping Cough before entering school, but parents can ask for their children to be exempted from the program if vaccines run contrary to their religious or personal beliefs.

 

The following information comes from the Johns Hopkins Bloomberg School of Public Health.

 

VACCINE EXEMPTIONS

It is law in all US states that children be properly immunized before attending school.  However, in addition to medical exemptions offered in each state, 48 states allow for religious exemptions and 21^a states allow personal belief exemptions for daycare and school.

 

(Click to view)

Other states, including Idaho, Arkansas, and Texas are reporting outbreaks of Pertussis this year as well.

 

Whether due to activism or apathy, a declining rate of vaccination for preventable diseases like Whooping Cough will almost certainly lead to more cases – and more deaths – in our communities down the road.

 

For another perspective on all this, you might want to read Maryn McKenna’s post on Pertussis from last July.

 

Whooping cough: Back, with a vengeance

California Whooping Cough (Pertussis) Update

# 4751

 

 

Once upon a time, not so very long ago, Whooping Cough infected more than a 160,000 Americans each year, and killed about 5,000 of them.

 

All that began to change in the 1940s when the first whole-cell pertussis vaccine combined with diphtheria and tetanus toxoids (DTP) was introduced.

 

In what was a remarkable success story, by 1976 the number of reported cases reached a record-low of 1,010 cases, a decrease of 99%.

 

But since then, the number of cases has increased ten-fold, and on average 8 to 40 deaths now occur each year.  

 

That resurgence is due in part to the reluctance of some parents to get their kids vaccinated, but is also due to a lack of adults getting their recommended booster shots.  

 

Exactly a month ago I blogged on the growing California Pertussis outbreak (see California: Pertussis Epidemic).  Since then, at least 500 more cases have been detected, putting California on track for having the worst year for Pertussis in half a century.

 

Pertussis, or `Whooping Cough’ is a highly contagious bacterial infection that can cause serious illness and even death.  It is sometimes called the `hundred days cough’, because it can take months to get over.

 

Although it is thought of as a `childhood’ disease, anyone of any age can catch it.

 

Whooping cough outbreaks are cyclical, with outbreaks occurring every 3 to 5 years. California saw its last big outbreak in 2005, with more than 3,000 cases reported.

 

Prevention is through vaccination, but since the vaccine offered is `inactivated’ (contains no live bacteria), it requires repeated doses during childhood and a booster shot as adults. 

 

The CDC has a simple, 2-page pamphlet on the DTaP vaccine.

 

 

This latest appeal comes from the California Department of Public Health.

 

CDPH BROADENS RECOMMENDATIONS FOR VACCINATING AGAINST PERTUSSIS: IMMUNIZATION KEY TO CONTROLLING WHOOPING COUGH 

Date: 7/19/2010

Number: 10-048U

Contact: Al Lundeen, (916) 4407259)

SACRAMENTO

To protect Californians against the current epidemic levels of pertussis (whooping cough) health experts at the California Department of Public Health (CDPH) today broadened recommendations for immunizing against pertussis and reiterated the importance of getting vaccinated.

 

“We are facing what could be the worst year for pertussis that this state has seen in more than 50 years,” said CDPH Chief of the Center for Infectious Disease Dr. Gilberto Chávez, who also is the state’s epidemiologist. “We are urging health providers to broaden their use of the pertussis vaccine and we are urging Californians to take the simple step of getting vaccinated to prevent pertussis.”

 

• In addition to the typical series of childhood pertussis immunizations, CDPH now recommends an adolescent-adult pertussis booster vaccine (Tdap) for:
• anyone 7 years and older who is not fully immunized, including those who are more than 64 years old,
• women of childbearing age, before, during, or immediately after pregnancy, and
• other people who have contact with pregnant women or infants.

“Considering that immunity from pertussis vaccine or disease wears off and that most adults are susceptible to pertussis, now is the time for Californians to get immunized to protect themselves and their families,” said Chávez. “In particular, all family members and caregivers of infants should get the booster vaccine.”

 

<SNIP>

 

Pertussis has reached an epidemic level in California. For the first six months of this year, 1,496 cases of pertussis were reported, a five-fold increase from the same period last year when 258 cases were reported. In addition, approximately 700 possible cases of pertussis are under investigation.

 

Since this alert was released, a 6th child has died from Pertussis in California.  Five out of the six fatalities have been in infants under the age of 3 months – too young to receive the vaccine.

 

Which is why health officials urge that the general community get vaccinated, in order to protect those that cannot be immunized. 

 

And that means adults and children.

 

In recent years more parents are filing “personal belief exemptions” to avoid vaccinating their children.

 

Although California, like all states, requires that all students be vaccinated against Whooping Cough before entering school, parents can ask for their children to be exempted from the program if vaccines run contrary to their religious or personal beliefs.

 

The following information comes from the Johns Hopkins Bloomberg School of Public Health.

VACCINE EXEMPTIONS

It is law in all US states that children be properly immunized before attending school.  However, in addition to medical exemptions offered in each state, 48 states allow for religious exemptions and 21^a states allow personal belief exemptions for daycare and school.

(Click to view)

 

Other states, including Idaho, Arkansas, and Texas are reporting outbreaks of Pertussis this year as well.

 

Again from Johns Hopkins:

 

October 10, 2006

High Rates of Pertussis Found in States with Easy Immunization Exemptions

Saad B. Omer

States that easily permit parents to opt out of vaccinating their children for nonmedical reasons are at increased risk of pertussis (whooping cough), according to a new study from researchers with the Johns Hopkins Bloomberg School of Public Health, the University of Florida and the Centers for Disease Control and Prevention (CDC).

States that easily grant exemptions or offer personal belief exemptions have higher nonmedical exemption rates than states that offered only religious exemptions. The study is published in the October 11, 2006, issue of the Journal of the American Medical Association.

(Continue . . .)

 

While (mostly mild to moderate) adverse effects have sometimes been associated with the Pertussis vaccine, their incidence has dropped since the adoption of the acellular or DTaP formulation in 1991.

 

The vaccine is widely regarded as being both safe and effective.  This from the From the Immunization Action Coalition

 

What side effects have been reported with this vaccine?

About 20%-40% of children have some local reaction such as pain, redness, or swelling after the first three doses of DTaP. Such local reactions seem to be more frequent after the fourth and/or fifth doses. A temperature of 101° F or higher is reported in 3%-5% of DTaP recipients. Less common reactions (e.g., persistent crying, higher fever, febrile seizure) are rare and generally occur in fewer than 1 in 10,000 doses.

If a child has a medical reason not to receive the pertussis vaccine, they can and should still be vaccinated against diphtheria and tetanus with DT (pediatric) vaccine.

The most frequently reported side effects following vaccination with Tdap are headache, generalized body aches, and tiredness.

 

Whether due to activism or apathy, a declining rate of vaccination for preventable diseases like Whooping Cough will almost certainly lead to more cases – and more deaths – in our communities down the road.