Pertussis : what should we know? Primary care

Pertussis what should we know.pdf

1. PERTUSSIS
- What should we
know?
DR AHMAD AMIRULLAH BIN
SHAMSUDIN
Pegawai Perubatan Epidemiologi/CDC
PKD Rompin
Pahang

2. LEARNING OBJECTIVES:
1.



a.
b.
Introduction of pertussis

2. Pathophysiology and disease progression

3. Case definition of Pertussis

4. Management approach:
Clinical presentation
Investigation
Treatment

5. Prevention of Pertusis:
Global Pertussis Initiative
Close contact management

3. WHAT IS PERTUSSIS?
Jules Bordet
Born in Belgium
1870 – 1961
1906 – isolate causative
organism of whooping cough
given the name Bordetella
pertussis
•
•
•
•
An endemic disease
Common among young children
Outbreaks occur sometime
Decline in number of cases due to
successful vaccination program and good
sanitation and hygiene practice

4. EPIDEMIOLOGY - WHO
Number of case 2015
-2022
2017
20202019 2015201620172018 2014
Incidence rate 2015 -2022 2021 20162015201820192020
2021
Denominato
r
16
60
36
5
0 0
3
0
10
20
30
40
50
60
70
Year
No of Cases
No of Pertussis Case in Pahang
2017
2018
2019
2020
2021
2022
2023

5. EPIDEMIOLOGY - WHO

6. •
•
•
Small aerobic gram negative bacteria
Human the only host and reservoir
Mode of transmission – respiratory droplet and direct contact with fluid
from nose and mouth of infected person
THE CAUSATIVE ORGANISM
Incubation
period
5-10 days
Transmission
Onset of symptoms

7. PERTUSSIS IN INFANT





Most susceptible age group
Almost always severe.
Approximately 60% of hospitalisations.
Approximately 90% of pertussis fatalities occur in infants.
Almost all deaths due to pertussis occur in infants aged six months or
under.

8. PATHOPHYSIOLOGY OF PERTUSSIS

9. Communicable period will be shorten to from onset of cough until 5
th
days of antibiotic

10. BATUK KOKOL??BATUK KOKOL??BATUK KOKOL??BATUK KOKOL??

11. HOW TO DIAGNOSE
PERTUSSIS?

12. CASE DEFINITION: PERTUSSIS



Clinical case definition:
A person with a cough lasting at least 2
weeks WITH at least one of the
following :
−  Paroxysmal coughing
−  Inspiratory “whoop”
−  Post- tussive vomiting AND
without other apparent cause.

Laboratory criteria for diagnosis
Culture: isolation of Bordetella
pertussis from the clinical specimen,
OR
positive polymerase chain reaction
(PCR) assay for B. pertussis OR
positive paired sera for B. pertussis.





Case Classification
Suspected: A case that only meets the clinical
case definition.

Confirmed:
A clinical compatible case with B. pertussis
isolation, OR
A case that meet the clinical case definition
and is confirmed by PCR, OR
A case that meet the clinical case definition
and is confirmed serology test with 4 fold
rise of antibody in paired sera, OR
A case that meet the clinical case definition
and is epidemiologically linked directly to a
confirmed case (first generation contact) by
either culture or PCR.

13. DIFFERENTIAL DIAGNOSIS: PERTUSSIS











Differential diagnosis of prolonged cough, even
with paroxysms, may include:
Bordetella parapertussis,
Bordetella bronchiseptica,
Chlamydia pneumoniae,
Mycoplasma pneumoniae,
Adenoviruses,
Respiratory syncytial virus (RSV),
Human parainfluenza viruses,
Influenza viruses A and B,
Rhinovirus,
Human metapneumovirus

14. ASSESSMENT OF SUSPECTED PERTUSSIS CASE






1. A detailed history should be obtained:
Details description of symptoms: onset and progression of symptoms, duration,
“whooping” cough, post-tussive vomiting
Complications: poor feeding, dehydration, apnea (bronchopneumonia), convulsion
(hypoxia, encephalopathy)

Travel history
Similar symptoms among contact
Comorbidity
Immunisation history


2. Thorough physical examination and appropriate investigations

15. LABORATORY INVESTIGATION OF SUSPECTED PERTUSSIS
CASE


Culture:
Gold standard -> 60%
sensitivity

1.
2.
3.
Specimen collection and transport

Pernasal swab or posterior nasopharynx specimen must
be obtained. Throat swab should not be taken.

A Dacron or calcium alginate (not cotton) swab on a soft
flexible wire is passed through the nostril and along floor
of the nasal cavity into the posterior nasopharynx, rotate
the swab and withdraw it (Figure 2) OR let it be there for
15 to 30 seconds or until a cough is produced.

Promptly inoculate the sample into special media
(preferred are Regan- Lowe or Bordet-Gengou agar) and
incubate for 7 days.

16. LABORATORY INVESTIGATION OF SUSPECTED PERTUSSIS CASE


PCR:
More sensitive and a rapid than culture.
1.
2.
3.
4.
5.
Specimen collection and transportion
Nasopharyngeal aspirate is the best specimen for PCR.
Pernasal swab or posterior nasopharynx specimen can also be obtained. Do not send
throat swab.
To obtain a pernasal or posterior nasopharynx sample, a Dacron (not cotton) swab on a
soft flexible wire is passed through the nostril and along floor of the nasal cavity into the
posterior nasopharynx. The swab is rotated gently and withdrawn (figure 4) OR let it be
there for 15 to 30 seconds or until a cough is produced.
Never use calcium alginate swab or cotton-tipped swab to collect specimen for PCR. PCR
assays may be inhibited by residues present in these materials.
Place the swab into the transport medium (Stuart’s media) immediately as drying
decreases recovery of the organism and send as soon as possible to the laboratory.
f. Specimens should be stored and transported at 4
o
C and to reach the laboratory within 3
days.
Note: Even when PCR method for diagnosing pertussis is established, culturing for B. pertussis should continue.
This is especially important when an outbreak is suspected, because isolation of the bacterium confirms pertussis.
It is important to continue to culture in order to analyse the evolution of the pathogen and perform surveillance of
eventual variants that might be antigenically different from vaccine strains.

18. HOW TO TREAT PERTUSSIS?

19. TREATMENT OF SUSPECTED PERTUSSIS CASE






Antibiotic:
Macrolide
Treatment unnecessary if >21/7
since onset of cough


Hospitalisation:
Isolation and supportive
treatment

20. PERTUSSIS CASE CONTROL
AND PREVENTION

21. REPORTING CASE

22. CASE INVESTIGATION

23. CASE INVESTIGATION

24. IDENTIFY CONTACT



CLOSE CONTACT:

Direct face-to-face contact for a period (not defined) with a case-patient who is symptomatic.

Shared confined space in close proximity for a prolonged period of time such as more than 1
hour with a symptomatic case-patient; e.g. household contacts, family members, classmates,
bus seat-mates etc.

Direct contact with respiratory, oral or nasal secretions from a symptomatic case-patient (e.g
., an explosive cough or sneeze in the face, sharing food, sharing eating utensils during a
meal, kissing, mouth-to- mouth resuscitation, or performing a full medical exam including
examination of the nose and throat).

25. OUTBREAK DEFINITION
Two or more cases clustered in time
(occurring within 42 days of each other)
and space (in one child care center / class).
The outbreak case definition may be used
to count cases if one case has been
confirmed.

26. ISOLATION
Isolation at least 3/52 if not
received antibiotic
Isolation at least 5 days after
antibiotic course
Suspected / Confirmed
case
Close contact
Same restriction
as confirmed
case
symptomati
c
asymptomaticFor HCW – exclude from
workplace for 21 days after last
exposure
For non HCW – to receive
antibiotic but no isolation
required
Inadequate immunised < 7
y/o
Exclude from school/day
care/public gathering for
21/7 after last exposure or
complete 5 days antibiotic
course
Prophylaxis in the following high risk groups is important:
i. infants
ii. non-immunized children
iii. immunocompromised individuals
iv. pregnant women
v. individuals with chronic respiratory illness, including asthmatics

27. POST-EXPOSURE
PROPHYLAXIS FOR
CLOSE CONTACT


Symptomatic
close contact
within 21 days of
cough onset

Asymptomatic
close contact
within 21 days of
exposure

28. HEALTHCARE SETTING PREVENTION
Potential higher risk of transmission and complication!!!
Face to
face
contact
•
•
•
Within 3 feet of
case
Not using surgical
mask
Doing procedure or
handling case
Direct
contact
with
fluid
•
•
•
Respiratory
secretion
Oral secretion
Nasal secretion
Share
room
with
case
•Evaluated case by
case
Surveillance for cough illness
should continue through two
incubation periods
(42 days) after the date of
cough onset in last case.

29. HEALTHCARE WORKER EXPOSED TO PERTUSSIS CASE




1. Symptomatic
If it is ≤ 21 days since cough onset: exclude through the first 5 days
of full course of antibiotic or , if not treated, for 3 weeks after cough
onset.
If it is > 21 days since cough onset: they are no longer infectious
and no antibiotic treatment / exclusion is required.

2. Asymptomatic
If they are not on antibiotic prophylaxis, exclude for 21 days after
their last exposure or if unknown for 21 days after the onset of the
last case setting.
If their last exposure occurred ≥ 21 days ago, prophylaxis/ exclusion
in generally not required.

Healthcare
worker
HCW who practices standard and droplet precaution including wearing
surgical mask during treating cases do not require prophylaxis or isolation.

30. OUTPATIENTS EXPOSED TO PERTUSSIS CASE


1. Symptomatic
Restrict from public activities for the first 5 days of full
course of antibiotic therapy.

2. Asymptomatic
No need to restrict their public activities.

Patient
within the
same
confined
space with
index case

31. Assess the immunization status of close contact under age 7



Contacts who are less than 7 years of age and are non
-immunised or have received fewer than 4 dose of
DPT or DTaP should, in addition to receiving antibiotic
prophylaxis, have pertussis immunisation initiated or
continued according following guidelines, as soon as
possible after exposure :

Give 1
st
dose at ≥6 weeks of age; doses 1, 2
and 3 must be separated by at least 4 weeks

Children who receive their 3rd dose of DPT or
DTaP ≥ 6 month before exposure should
receive the 4th dose at this time.

Children who have received four doses of DTP /
DTaP should get a booster of DTP /DTaP,
unless a dose has been given within the last
three years.

32. PREVENTIVE MEASURE
-
Education
- danger of
pertussis
Importance of
vaccination
program

Evaluate
immunization
coverage of
locality
- Do vaccination
mop-up if
coverage < 90%

33. WHAT ARE THE STRATEGIES
TO PREVENT PERTUSSIS?

34. GLOBAL PERTUSSIS INITIATIVE (2001, rev. 2016)
- output of GPI’s 9th Global Roundtable Meeting, held on 11–13 November 2016,
in Cape Town, Republic of South Africa.

All countries should consider expanding existing vaccination strategies.
GLOBAL PERTUSSIS INITIATIVE(2001) :
Key Recommendation
MALAYSIA’S COMMITMENT
1. Pertussis booster doses to pre-school children (4–6 years old) National Immunisation Program - DT at 7
year old

2. Universal adolescent immunization ?
3. Universal immunization of adults Voluntarily adult immunization
4. Selective immunization of new mothers, and family and close
contacts of newborns (cocoon strategy)
?
5. Selective immunization of healthcare workers and childcare
workers
?
6. Improvement of current infant and toddler immunization
strategies
National Immunisation Program

35. GLOBAL PERTUSIS INITIATIVE (Revised 2016)
AIM TO 1) Increase awareness of pertussis as an important and preventable disease that
warrants greater global public health attention.
2) Improve understanding of the increasing incidence of reported pertussis.
3) Develop effective immunization strategies for better control of pertussis.








The strategies to achieve this goal are (LMIC):
Use of aP vaccines in all age groups, because of
their better tolerability compared with wP vaccines

Pertussis vaccination coverage DTP3 at least 90%
(NIP, mopping-up)
a fourth dose (DTP4) in toddlers (e.g.,
∼18 months old) and a fifth (DTP5) at
5–6 years old

aP vaccines in every pregnant woman

Pertussis surveillance and epidemiology data

36. In 2021, 18.2 million infants did not receive an initial dose of DTP vaccine, pointing to a lack of access to
immunization and other health services, and an additional 6.8 million are partially vaccinated. Of the 25
million, more than 60% of these children live in 10 countries: Angola, Brazil, the Democratic Republic of the
Congo, Ethiopia, India, Indonesia, Myanmar, Nigeria, Pakistan and the Philippines.
GLOBAL PERTUSIS VACCINATION – WHO

39. In Malaysia (LMIC): Recommended TDAP vaccination in
Pregnancy
ACOG recommendation: during every pregnancy, between 27-36 weeks
gestation, as early in that window as possible

40. TAKE HOME MESSAGES:
1.
2.
3.


Strengthen our pertussis immunisation

Case detection and prompt management

Case notification and surveillance
Contact tracing and isolation
Antibiotic prophylaxis for close contact

41. THANK YOU
THANK YOU
THANK YOU