Pertussis in Adolescents and Adults Consideration of Tdap

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Pertussis in Adolescents and AdultsConsideration
of Tdap
National Immunization Program Centers
for Disease Control and Prevention
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Whooping Cough -- Pertussis

• Severe, debilitating cough illness lasting weeks
  to months (100 day cough)
• Gram-negative bacillus, Bordetella pertussis
• Characterized by paroxysms of cough, vomiting,
  inspiratory whoop apnea in young infants
• Worldwide occurrence, affects any age
• Deaths primarily among infants

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Pertussis Challenges

• Surveillance
• reliance on clinical case definitions low rate
  of culture positive cases
• Disease control strategies
• Limited options for antibiotic prophylaxis
• Effective against transmission less so against
  disease
• Vaccine
• Targets infants/children
• No vaccine for adolescents and adults

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Pertussis Challenges

• Education
• Under recognition of pertussis
• Diagnostics
• Obtaining adequate specimen
• Culture backup PCR no QC, standards
• Individual morbidity
• Symptoms, hospitalizations among
  adolescents/adults
• High risk groups outside infancy not well
  characterized (except nosocomial)

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Timeline -- Tdap

• BLA submitted
• GlaxoSmithKline Boostrix, 10-18 years of age
  (July 7, 2004)
• Aventis-Pasteur Adacel, 11-64 years of age
  (August 12, 2004)
• FDA Vaccine and Related Biologics Advisory
  Committee
• March 15, 2005

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ACIP Pertussis (Tdap) Working Group

• Formed June 2004 11 meetings
• Members 20 (ACIP, FDA, DoD, HRSA, HIS, NIH and
  CDC-NIP)
• Consultants 13 (AAP, AAFP, AAHP, ACOG, ACP,
  CNACI, HICPAC, IDSA, NMA, state DOHs)
• Presentations working group, industry, academia,
  state DOHs,

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Charge to the Working Group

• Consider strategies to improve prevention and
  control of pertussis in the United States using
  acellular pertussis vaccines formulated for
  adolescents and adults .
• Fully implemented childhood program of
  vaccination with DTaP

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Stepwise Approach

• Adolescents first
• Replace Td with Tdap
• Then, selective recommendations
• Health care workers (? others)
• Protection of infants through vaccination of
  adults
• Recommendations for adult populations

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Preference for Initial use of Tdap For
Adolescents-- Rationale

• High rates of endemic pertussis among adolescents
  
• Substantial morbidity among adolescents
• Tdap likely to be cost-effective from societal
  perspective (perhaps cost saving)
• Potential secondary benefits (reduce total burden
  of endemic and epidemic pertussis)

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Reported Pertussis in Adolescents Surveillance
Data Outside MAAge 10-19 yrs 2000-2004
Incidence per 100,000 pop
State High year, n High year, incidence Low year, incidence
MA n1082 130 41
WI n1573 195 6
VT n150 168 32
CO n486 75 22
WA n271 31 5
MN n211 28 12
NETSS data, 2004 provisional
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• Pertussis in MA Adolescents
• Average Annual Incidence and
  Cumulative Percent , 1996-2003

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Complications in Adolescents Reported with
Pertussis
MA -1 n314 MA - 2 n1679 Quebec n280
Cough Mean 3.4 mo 38 gt 1 mo _at_ dx 47 gt 9 wk
Pneumonia 2 2 2
Rib fracture 1 1
Loss of consciousness 1 0
Hospitalization 0.8 (n13) 1
At interview
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Pertussis in 314 MA AdolescentsMedical
Visits/Missed School/Work

• Medical visits 24 gt 3 visits
• Mean 2 visits (range 0-15 visits)
• Student missed school 83
• Mean 5.5 days (range 0.4-32 days)
• Parent/caretaker missed work 43
• Mean 2.4 days (range 0.1-25 days)
• 2nd parent/caretaker missed work 14
• Mean 1.8 days (range 0.1-11 days)

Lee G. et al CID 200439 1572-1580
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Statewide Pertussis Outbreak Wisconsin 2004

• Aggressive case finding and testing
• PCR available
• 5020 cases overall
• 111 hospitalizations (57 in infants age 0-5m)
• 2028 cases (40) in 10-19 year olds
• Rate 251/100,000
• 15 adolescents hospitalized
• 33 adolescents with pneumonia

Data from WI DPH, provisional
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Timeline June-October 2005 ACIP

• Tdap for adolescents
• Tdap for other age cohorts (including selective
  high risk settings)
• Reduce morbidity in adults, infants and in
  selected high risk groups

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Acknowledgements

• Massachusetts Department of Public Health
• Susan Lett, MD, MPH
• Dara S. Friedman, PhD, MPH.
• Arquimedes Areche, MPH
• Stephanie Schauer, PhD
• Fond du Lac County Health Department
• Diane Cappozzo, RN
• Carol Schmidt, RN
• Warren Post, MD

• Wisconsin Division of Public Health
• Jeffrey P. Davis, MD
• Mark Sotir, PhD, MPH
• Daniel Hopfensperger
• Alexandra Newman, DVM, MPH.
• Wisconsin State Laboratory of Hygiene
• David Warshauer, PhD
• Tim Monson, MS

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AcknowledgementsCDC-NIP Pertussis Team

• Karen Broder
• Amanda Cohn
• Margaret Cortese
• Katrina Kretsinger
• Christine Miljelski
• John Moran

• Trudy Murphy
• Pekka Nuorti
• Martha Roper
• Barbara Slade
• Pamela Srivastava
• Tej Tiwari