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Jadual Imunisasi IMUNISASI UMUR ( BULAN )
0 1 2 3 4 5 6 12 18
BCG
Hepatitis B
DTaP
Hib
Polio
Measles
MMR
Dos Primer Dos Tambahan Sabah sahaja
OUTLINE INTRODUCTION
CLINICAL PRESENTATION
COMPLICATION
LAB INVESTIGATION
TREATMENT AND PROPHYLAXIS
DISEASE SURVEILLANCE
PERTUSSIS Respiratory infection caused by Bordetella
Pertussis
Highly contagious
Spread through
1)respiratory droplets
11) direct contacts with fluids from
nose or mouth of infected people
100 day’s cough or cough of 100 days
I.P of the disease is 5-10 days (max is up to 21 days)
The infectious period is at the beginning of catarrhal period which is prior to cough onset and up to 21 days after the cough started.
Antibiotics shorten the period of infectivity/lessen severity
Predominantly illness of infants under 2 years of age
Infant within the first week of life are susceptible, when mortality from whooping cough is the highest
In adolescent & adult pertussis often present as chronic bronchitis.
CLINICAL PRESENTATION Illness is characterised by 3 stages
a) catarrhal stage
b) paroxysmal
c) convalescent
Classic symptoms are paroxysmal cough, inspiratory whoop and vomiting after coughing
Catarrhal
Runny nose ( coryza)
Sneezing
Low grade fever ,malaise
Conjunctival inflammation
Occasional cough,similar to common cold. Cough becomes more severe but non productive
Duration
Insidious
Gradually worsening symptoms, lasted 1-2weeks
Paroxysmal Coughing spells with
inspiratory whoop. Whoop is absent under
6/12 of age, teenage & adult.
Post tussive gagging/ vomiting /cyanosis.
Convalescent Gradual resolution of
symptoms.
Duration 2-4 weeks Weight loss,
leucocytosis, and lymphocytosis are common
Several weeks - months
Stages of pertussis inf and period of communicability
P---- P = period of communicability
cough onset
----P----l--------P------------------------------
-2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12
(weeks of cough)
/Catharral/ paroxysmal / convalescent /
complication Asphyxia
Hypoxia
Encephalopathy
Convulsion
Cerebral hemorrhage
Pulmonary complication-atelectasis,pneumonia, pneumothorax
Death
Laboratory diagnosis Detection of B Pertussis- Culture, Polymerase chain
reaction (PCR), direct immunofluorescence (DFA) and serological methods
Culture special media – Regan Lowe charcoal agar media/Bordet –
Gengou media Gold standard Sensitivity 15 - 80 %, specificity 100 % Isolation during catarrhal stage is most succesful (first 1-2
weeks of cough) Culture requires 7-12 days Affected by antibioticis
Specimen collection and transport
A) Pernasal swab or posterior nasopharynx specimen must be obtained.Throat swab should not be taken.
B) A dacron or calcium alginate (not cotton swab)on a soft flexible wire is passed through the nostrils and along floor of the nasal cavity into the posterior nasopharynx, rotate the swab and withdraw it, orlet it be there for 15 to 30 sec or until a cough is produced
C) Inoculate sample into special media and incubate for 7 days
PCR assay for B pertussis
Recommended to detect B Pertussis
Better than culture as it is not affected by antibiotic
Specimen from health is sent to Sungai Buloh
Serial number (16) KKM – 171/BKP/09/43/0640)
Treatment and Prophylaxis Tx reduces transmission The spread can be limited by decrease infectivity and
protecting close contact. Infectious starts from catarrhal stage thro third week
after onset of paroxysms or until 5days after starting antibiotic
If begins in catarrhal stage , b4 paroxysmal cough- lessen severity.
If tx begins later it reduce period of infectivity not the severity
Recommended doses for tx and chemoprophylaxis is the same.
Prophylaxis Significant exposure to a confirmed case In day care centre or school children Check pattern of exposure/ exposure time other coughing persons in the class any other reported pertussis case presence of high risk individuals
The need for prophylaxis in high risk group is imp Infants Non Immunized children Immunocompromised individual Pregnant women Individuals with chronic respiratory illness,inc asthmatics
DRUG
ERYTHRO
MYCIN
INFANT
<7 d 20mg/kg /d into bd dose – 14/7
8-28 d – 30 mg/kg/d into3 doses -14/7
CHILD
40-50mg/kg/d
Into 4 doses/d
14/7
Max 2 gm /d
ADULT
1-2 g/d into 4x/d-14/7
CLARITHRO
MYCIN
X in pregnant
AZITHRO
MYCIN
5/7 course
TRIMETOPRIM
SULFAMETHO
XAZOLE
X in pregnant
Not recommended infant < 6/12
Preferred use in < 6/12
Not recommended
Infant <2/12
15mg/kg/dinto 2 doses- 1/52 (max 1 g/d)
10mg/kg/d on 1st d then 5mg/kg/d once daily for next 5d (max250mg/d)
8mgTMP/40mg SMXinto bd dose -14/7 (max320mgTMP/1600mg SMX /d)
1 g orally into bd/d
-min 1/52
500 mg on 1st d
250 mg OD -5/7
320mgTMP/1600mg
SMX
Into bd -14/7
Case Definition; Clinical case definition:
A person with a cough lasting at least two weeks with at least With one of the following: 1. Paroxysms (i.e. fits) of coughing 2. Inspiratory "whooping" 3. Post-tussive vomiting (i.e. vomiting immediately after fits of coughing)
And without other apparent cause. ·
Disease Surveillance
Case Definition Laboratory criteria for diagnosis
Isolation of Bordetella pertussis from clinical specimen,
OR
Positive polymerase chain reaction (PCR) assay for B.pertussis.
OR
Positive paired sera for B.pertussis.
Case Classification; Pertussis Suspected: A case that meets the clinical case definition.
Confirmed:
i. A clinical compatible case with B.pertussis isolation,OR
ii. A case that meet the clinical case definition and is confirmed by PCR, OR
iii. A case that meet the clinical case definition and is confirmed serology test with 4 fold rise of antibody in paired sera, OR
iv. 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.
In an outbreak settings with two or more cases epidemiologically linked, a case may be defined as a case with cough illness lasting more than 14 days.
Reporting & case Investigation 1. Purpose of reporting & investigation
2. Reporting & follow-up
Any case of suspected pertussis must be notified to the nearest District Health Office
within 7 days from the date of diagnosis
3. Case Investigation
4. Outbreak Mx
5. Identify Contact
Purpose of reporting & investigation i. To investigate case, identify and evaluate contacts
and recommend appropriate preventive measures, including exclusion, antibiotic prophylaxis and/or immunization.
ii. To assist in the diagnosis of cases.
iii. To educate exposed persons regarding signs and symptoms of the disease, thereby facilitating early diagnosis.
iv. To identify situations of under vaccination or vaccine failure.
Reporting & Follow-up Any case of suspected pertussis must be notified to the
nearest District Health Office
within 7 days from the date of diagnosis
Case Investigation a.In order to assess the likelihood a suspected case is a true
case prior to laboratory testing, public health staff should collect necessary information using Pertussis Case Investigation Form including the contact worksheet.
b. Investigate all contacts and possible source of infection. A
search for early and missed atypical cases is indicated where a non-immune infant or young child is or might be at risk.
c. It is important that information on the duration of cough
be obtained, especially if the first interview is conducted within 14 days of cough onset and cough is still present. In these circumstances, a follow-up interview after 14days of onset must be conducted to identify persons with 14 days cough duration.
Outbreak investigation Definition of an outbreak
• 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.
• Investigate cases and their contacts as stated above.
• Develop a line listing of the cases and their contacts for easy reference.
Identify Contact Identify close contacts that had significant exposure to
the case during the infectious period. “Close Contact “ is defined as:
- Direct face-face
- Shared confined space; household,family
members,classmate
- Direct contact (medical staff)
Examine all high risk contact
Treat & give prophylaxis
Control of Patient & Contacts Isolation
Suspected cases not received antibiotics-isolated for 3 weeks esp from young child & un-immunized infant.
Isolation of contact:
- symptomatic-3 week
- asymptomatic h/care worker not
receiving a/b- ? 5 day- 3 week
Quarantine
- excluded from school/daycare/public gatherings for 3 weeks
Treatment & Prophylaxis Tx- recommended antimicrobial agents
The need for prophylaxis in the following high risk groups is particularly important:
i. infants
ii.non-immunized children
iii.immunocompromised individuals
iv.pregnant women
v.individuals with chronic respiratory illness,
including asthmatics
Control in Healthcare settings Control measure should be Implemented when one or
more cases are recognized in hospital, institution, OPD or other health care setting
Apply the control measures to all patient,
families & staff in close contact with confirm cases
Treat & given prophylaxis accordingly
HCW who used surgical mask during treating cases do not required prophylaxis.
Infectious control
Asses 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.
Preventive Measures Educate the public, particularly parents of infants, about
the dangers of whooping cough and on the advantages of initiating immunization at 2 months of age and adhering to the immunization schedule.
Evaluate the immunization coverage of the locality. Do mop-up if the coverage is less than 90%.
Active primary immunization against B. pertussis infection is recommended with 3 doses of pertussis vaccine consisting of a suspension of killed bacteria.
Routine childhood vaccination and post – exposure antimicrobial prophylaxis is the best preventive measures against Pertussis.