Vaccine Preventable Diseases in North Carolina: What’s

Happening

Elizabeth T. Draper RNElizabeth T. Draper RN

Nurse ConsultantNurse Consultant

NC Immunization BranchNC Immunization Branch

August 2009August 2009

But….. Haven’t we eliminated But….. Haven’t we eliminated vaccine preventable diseases??vaccine preventable diseases??

Common myth among those that do not Common myth among those that do not want to immunize their children is that we want to immunize their children is that we have eradicated themhave eradicated them

Most are at very low levels in the U.S.Most are at very low levels in the U.S. Some are still epidemic in other parts of Some are still epidemic in other parts of

the world—and we live in a small worldthe world—and we live in a small world If vaccine rates drop in the U.S. old If vaccine rates drop in the U.S. old

diseases may reappeardiseases may reappear

So what are we seeing in NC?So what are we seeing in NC?

Hepatitis BBut you do not want me to try and speak to this—trust me!!!

But we also get calls about…..But we also get calls about…..

Tetanus

Diphtheria

MeaslesMeasles

Rubella/CRS

Polio

And if the need arose we would follow-up on

Vaccine Preventable Diseases Vaccine Preventable Diseases (* currently not reportable in NC)(* currently not reportable in NC)

AnthraxAnthraxDiphtheriaDiphtheriaHepatitis AHepatitis AHepatitis B, acuteHepatitis B, acuteHaemophilus influenzaeHaemophilus influenzae type b (Hib) – all invasive type b (Hib) – all invasive disease disease *Human Papillomavirus *Human Papillomavirus (HPV)(HPV)*Influenza (Flu) – only peds *Influenza (Flu) – only peds deathsdeathsJapanese Encephalitis (JE)Japanese Encephalitis (JE)Lyme DiseaseLyme DiseaseMeaslesMeasles

MeningococcalMeningococcalMonkeypoxMonkeypox

MumpsMumps

Pertussis (Whooping Pertussis (Whooping Cough)Cough)*Pneumococcal – other *Pneumococcal – other than meningitisthan meningitis

Poliomyelitis (Polio)Poliomyelitis (Polio)RabiesRabies*Rotavirus *Rotavirus

Rubella (German Measles) Rubella (German Measles) and congenital rubella and congenital rubella syndromesyndrome*Shingles (Herpes Zoster)*Shingles (Herpes Zoster)SmallpoxSmallpoxTetanus (Lockjaw)Tetanus (Lockjaw)Typhoid Fever, acuteTyphoid Fever, acute*Varicella (Chickenpox)*Varicella (Chickenpox)Yellow Fever Yellow Fever

*Preliminary data, as of 07/24/09*Preliminary data, as of 07/24/09

Measles 2003-2009*Measles 2003-2009*

0

1

2

3

4

5

6

2003 2004 2005 2006 2007 2008 2009

MeaslesMeasles

Clinical case definitionMeasles is an illness characterized by all of the following:· A generalized maculopapular rash lasting 3 days· A temperature 101F° (38.3°C)· Cough, coryza, or conjunctivitisLaboratory criteria for diagnosis· Positive serologic test for measles immunoglobulin M

(IgM) antibody· Significant rise in measles antibody level by any standard

serologic assay· Isolation of measles virus from a clinical specimen

MeaslesMeasles

Case classification

Probable: A case that meets the clinical case definition, has noncontributory or no serologic or virologic testing, and is not epidemiologically linked to a confirmed case.

Confirmed: A case that is laboratory confirmed or that meets the clinical case definition and is epidemiologically linked to a confirmed case. A laboratory confirmed case does not need to meet the clinical case definition.

MeaslesMeasles

Even though no cases have been reported in NC in the past 19 months we are frequently following up on NC residents that have been exposed to lab confirmed cases at camps and conferences in other states as well as air travel.

We have been lucky so far but…………a case of measles for NC could be no more than a plane ride away.

MMR vaccine is the best way to prevent this disease

Be afraid…be very afraid

*Preliminary data, as of 07/24/09*Preliminary data, as of 07/24/09

Mumps 2003-2009*Mumps 2003-2009*

0

5

10

15

20

25

30

35

40

45

2003 2004 2005 2006 2007 2008 2009

MumpsMumpsClinical case definition:• An illness with acute onset of unilateral or bilateral tender, self-limited

swelling of the parotid and or other salivary gland(s), lasting at least 2 days, and without other apparent cause.

Clinically compatible illness:• Infection with mumps virus may present as aseptic meningitis,

encephalitis, hearing loss, orchitis, oophoritis, parotitis or other salivary gland swelling, mastitis or pancreatitis.,

• Laboratory criteria• Isolation of mumps virus from clinical specimen, or●●• Detection of mumps nucleic acid (e.g., standard or real time RT-PCR

assays), or●●• Detection of mumps IgM antibody, or●●• Demonstration of specific mumps antibody response in absence of

recent vaccination, either ●●a fourfold increase in IgG titer as measured by quantitative assays, or a seroconversion from negative to positive using a standard serologic assay of paired acute and convalescent serum specimens.

MumpsMumps

Laboratory criteria• Isolation of mumps virus from clinical specimen, or●●• Detection of mumps nucleic acid (e.g., standard or real time

RT-PCR assays), or• Detection of mumps IgM antibody, or• Demonstration of specific mumps antibody response in

absence of recent vaccination, either ●●a fourfold increase in IgG titer as measured by quantitative assays, or a seroconversion from negative to positive using a standard serologic assay of paired acute and convalescent serum specimens

Mumps Mumps

Case classificationProbable: A case that meets the clinical case definition

without laboratory confirmation and is epidemiologically linked to a clinically compatible case.

Confirmed: A case that 1) meets the clinical case definition or has clinically compatible illness, and 2) is either laboratory confirmed or is epidemiologically linked to a confirmed case.

National Mumps Outbreak, 2006National Mumps Outbreak, 2006

Source of the initial cases unknownSource of the initial cases unknown Outbreak peaked in mid-AprilOutbreak peaked in mid-April Median age of persons reported with mumps Median age of persons reported with mumps

was 22 yearswas 22 years Highest incidence was among young adults 18-Highest incidence was among young adults 18-

24 years of age, many of whom were college 24 years of age, many of whom were college students students

Transmission of mumps virus occurred in many Transmission of mumps virus occurred in many settings, including college dormitories and settings, including college dormitories and healthcare facilitieshealthcare facilities

Factors Contributing To National Factors Contributing To National Mumps Outbreak, 2006Mumps Outbreak, 2006

College campus environmentCollege campus environment Lack of a 2-dose MMR college entry requirement Lack of a 2-dose MMR college entry requirement

or lack of enforcement of a requirementor lack of enforcement of a requirement Delayed recognition and diagnosis of mumpsDelayed recognition and diagnosis of mumps Mumps vaccine failureMumps vaccine failure Vaccine might be less effective in preventing Vaccine might be less effective in preventing

asymptomatic infection or atypical mumps than asymptomatic infection or atypical mumps than in preventing parotitisin preventing parotitis

Waning immunity Waning immunity

Updates during the outbreak Updates during the outbreak

In a specially convened meeting on May 17, In a specially convened meeting on May 17, 2006, ACIP redefined evidence of immunity to 2006, ACIP redefined evidence of immunity to mumps through vaccination as follows:mumps through vaccination as follows:

One dose of a live mumps virus vaccine for preschool One dose of a live mumps virus vaccine for preschool children and adults not at high riskchildren and adults not at high risk

Two doses for children in grades K–12 and adults at high Two doses for children in grades K–12 and adults at high risk (i.e., persons who work in health-care facilities, risk (i.e., persons who work in health-care facilities, international travelers, and students at post-high school international travelers, and students at post-high school educational institutions)educational institutions)

Other criteria for evidence of immunity are unchanged:Other criteria for evidence of immunity are unchanged: Birth before 1957Birth before 1957 Documentation of physician-diagnosed mumpsDocumentation of physician-diagnosed mumps Laboratory evidence of immunityLaboratory evidence of immunity

After the outbreak in NC………..After the outbreak in NC………..

June 2, 2006--MemoJune 2, 2006--Memo

“ “ Effective immediately, providers enrolled in the UCVDP may Effective immediately, providers enrolled in the UCVDP may administer two doses of state-supplied MMR vaccine to all students administer two doses of state-supplied MMR vaccine to all students attending post-high school educational institutions (i.e., colleges, attending post-high school educational institutions (i.e., colleges, universities, community and technical schools). “universities, community and technical schools). “

July 1, 2008 - -MemoJuly 1, 2008 - -Memo““This rule change also impacts mumps vaccination. Individuals will This rule change also impacts mumps vaccination. Individuals will

now be required to receive a second dose of mumps vaccine before now be required to receive a second dose of mumps vaccine before enrolling in school, college or university for the first time on or after enrolling in school, college or university for the first time on or after July 1, 2008.”July 1, 2008.”

Next………….PertussisNext………….Pertussis

Pertussis Clinical FeaturesPertussis Clinical Features

Bacterial respiratory illness Bacterial respiratory illness Bordetella pertussisBordetella pertussis, , gram-negative bacteriagram-negative bacteria

Incubation period 5-10 days (range 4-21 days)Incubation period 5-10 days (range 4-21 days) Insidious onset, similar to minor upper Insidious onset, similar to minor upper

respiratory infection with nonspecific coughrespiratory infection with nonspecific cough Fever usually minimal throughout course of Fever usually minimal throughout course of

illnessillness Cough can last for several weeks or monthsCough can last for several weeks or months

Pertussis diseasePertussis disease

Whooping CoughWhooping Cough Cough of 100 daysCough of 100 days Highly contagiousHighly contagious Spread by close contactSpread by close contact Infants less than 12 months of age suffer Infants less than 12 months of age suffer

most severe complicationsmost severe complications Incidence is increasingIncidence is increasing

Pertussis EpidemiologyPertussis Epidemiology

ReservoirReservoir Human adolescents and Human adolescents and adultsadults

TransmissionTransmission Respiratory droplets Respiratory droplets

Communicability Communicability Maximum in catarrhal stageMaximum in catarrhal stage Secondary attack rate Secondary attack rate

up to 80% up to 80%

Pertussis Clinical FeaturesPertussis Clinical Features

Catarrhal stageCatarrhal stage 1-2 weeks1-2 weeks

ParoxysmalParoxysmalcough stagecough stage 1-6 weeks1-6 weeks

ConvalescenceConvalescence Weeks toWeeks to monthsmonths

Clinical Case DefinitionClinical Case Definition

Clinical Case Definition

A cough illness lasting at least 2 weeks with one of the following: paroxysms of coughing, inspiratory “whoop,” or post-tussive vomiting, and without other apparent cause (as reported by a health professional).

Laboratory Criteria for Diagnosis

Isolation of B. pertussis from a clinical specimen, or

Positive polymerase chain (PCR) reaction assay for B. pertussis.

Reportable ClassificationsReportable ClassificationsCase Classification

Confirmed

an acute cough illness of any duration associated with B. pertussis isolation, or a case that meets the clinical case definition and is confirmed by PCR, or a case that meets the clinical definition and is epidemiologically-linked directly to a case confirmed by either culture or PCR.

Probable

Meets the clinical case definition, is not laboratory confirmed, and is not epidemiologically-linked to a laboratory confirmed case.

Initial steps for a caseInitial steps for a case

TestTest Start antibiotic treatmentStart antibiotic treatment Isolate at home for 5 daysIsolate at home for 5 days Notify the LHDNotify the LHD Identify and recommend

chemoprophylaxis to close contacts and high-risk contacts

These are not in order and may happen simultaneously

Close Contacts DefinedClose Contacts Defined

A person who had face-to-face exposure within 3 feet of a symptomatic patient. Respiratory droplets are generated during coughing, sneezing, or talking and during the performance of certain procedures such bronchoscopy or suctioning; these particles as propelled through the air for distances of approximately 3 feet.

MMWR December 9, 2005 / Vol. 54 / No. RR-14

Close contacts also can include persons who• have direct contact with respiratory, oral, or nasal secretions from a symptomatic patient (e.g., cough, sneeze, sharing food and eating utensils,mouth-to-mouth resuscitation, or performing a medical examination of the mouth, nose, and throat)• shared the same confined space in close proximity with a symptomatic patient for >1 hour

Close Contacts DefinedClose Contacts Defined

MMWR December 9, 2005 / Vol. 54 / No. RR-14

Postexposure Prophylaxis (PEP)Postexposure Prophylaxis (PEP)

CDC recommends administration of chemoprophylaxis to all close contacts and all household members of a pertussis case-patient, regardless of age and vaccination status; this might prevent or minimize transmission

Recommended TreatmentRecommended TreatmentRecommended treatment• Macrolide antibiotic— 5-day course of azithromycin— 7-day course of clarithromycin— 14-day course of erythromycin.• Alternative agent— 14-day course of trimethoprim-sulfamethoxazole.

• Treat persons aged >1 year within 3 weeks of coughonset.• Treat infants aged <1 year within 6 weeks of cough onset.

Medications and dosages for treatment of a case and PEP of close contacts is the same MMWR December 9, 2005 / Vol. 54 / No. RR-14

*Unofficial Lab confirmed only*Unofficial Lab confirmed only

Pertussis rates in NCPertussis rates in NC

050

100150200250300350400

So are pertussis rates goingSo are pertussis rates going oror ? ?

Since the 1980s, the number of reported pertussis cases has steadily increased, especially among adolescents and adults

Why increase in pertussis ??Why increase in pertussis ??

Increased awareness of the disease

Increased use of diagnostic tests for adolescents and adults.

Immunity to pertussis wanes approximately 5–10 years after completion of childhood vaccination, leaving adolescents and adults susceptible to pertussis

Adolescents and adults in turn are reservoirs for pertussis and pass onto younger children and infants

Obstacles/MisconceptionsObstacles/Misconceptions Providers not notifying LHD as soon as pertussis is Providers not notifying LHD as soon as pertussis is

suspectedsuspected Providers ordering serologies instead of NP swabProviders ordering serologies instead of NP swab Providers that refuse to treat contacts because they are Providers that refuse to treat contacts because they are

up to date on vaccineup to date on vaccine Providers that do not want to treat asymptomatic Providers that do not want to treat asymptomatic

contactscontacts Providers not acting until lab results are backProviders not acting until lab results are back Misunderstanding of isolationMisunderstanding of isolation Parents believing that this childhood illness no longer Parents believing that this childhood illness no longer

occursoccurs Belief that administration of a Tdap after exposure Belief that administration of a Tdap after exposure

eliminates need for PEP for close contacts.eliminates need for PEP for close contacts.

Talking points for media callsTalking points for media calls Pertussis is endemic in the USPertussis is endemic in the US Clusters happen on a seasonal basisClusters happen on a seasonal basis The vaccine is not 100% effectiveThe vaccine is not 100% effective Immunity wanes after time with the primary seriesImmunity wanes after time with the primary series NC mandated Tdap in 2008 for 6NC mandated Tdap in 2008 for 6thth graders and college graders and college

entry but it will take several years for this to have an entry but it will take several years for this to have an effect on the populationeffect on the population

Adults <65 need 1 Tdap as well; no mandate for thisAdults <65 need 1 Tdap as well; no mandate for this Control measures involve PEP for close contacts with Control measures involve PEP for close contacts with

antibiotics and to isolate and treat the illantibiotics and to isolate and treat the ill The goal is to prevent severe illness and save lives The goal is to prevent severe illness and save lives

particularly in infantsparticularly in infants

What can we do ????What can we do ????

Most recent tool we have is…………Most recent tool we have is…………

TdapTdap

ACIP Recommended February 2006ACIP Recommended February 2006 Available in NC March 2006Available in NC March 2006

Two Formulations:Two Formulations:Adacel Adacel (licensed for 11 through 64 years of age)(licensed for 11 through 64 years of age)Boostrix Boostrix (licensed for 10 through 18 years of age) until (licensed for 10 through 18 years of age) until

recently; recently; 12/8/0812/8/08 FDA approved for Boostrix to cover through FDA approved for Boostrix to cover through age age 64;64; NCIR will be updated soon so providers that NCIR will be updated soon so providers that administer adult Tdap can begin using in this manner.administer adult Tdap can begin using in this manner.

TdapTdap The primary objective of replacing a dose of Td with

Tdap is to protect the vaccinated adult against pertussis.

The secondary objective of adult Tdap vaccination is to reduce the reservoir of pertussis in the population at large, AND thereby potentially decrease exposure of persons at increased risk for complicated infection (e.g., infants), and reduce the cost and disruption of pertussis in health-care facilities and other institutional settings.

New Tdap RequirementNew Tdap Requirement

Effective January 1, 2008, the administrative rule, 10A NCAC Effective January 1, 2008, the administrative rule, 10A NCAC 41A.0401, has been changed, adding requirements for one booster 41A.0401, has been changed, adding requirements for one booster dose of Tdap (tetanus/diphtheria/pertussis) vaccine to be given to dose of Tdap (tetanus/diphtheria/pertussis) vaccine to be given to the following age groups: the following age groups:

All individuals attending public schoolAll individuals attending public school who are entering the 6th who are entering the 6th grade on or after August 1, 2008, if five years or more have passed grade on or after August 1, 2008, if five years or more have passed since the last dose of tetanus/diphtheria toxoid since the last dose of tetanus/diphtheria toxoid

All individuals not attending public schoolsAll individuals not attending public schools (i.e., private, home- (i.e., private, home-school, non-traditional schools) who are 12 years of age on or after school, non-traditional schools) who are 12 years of age on or after August 1, 2008, if five years or more have passed since the last August 1, 2008, if five years or more have passed since the last dose of tetanus/diphtheria toxoid. dose of tetanus/diphtheria toxoid.

Individuals enrolling in college or universityIndividuals enrolling in college or university for the first time on for the first time on or after July 1, 2008, if a tetanus/diphtheria toxoid or or after July 1, 2008, if a tetanus/diphtheria toxoid or tetanus/diphtheria/pertussis vaccine has not been administered tetanus/diphtheria/pertussis vaccine has not been administered within the past 10 years. within the past 10 years.

Tdap & AdolescentsTdap & Adolescents

Adolescents aged 11-18 should receive a Adolescents aged 11-18 should receive a single dose of Tdap instead of Td for single dose of Tdap instead of Td for boosterbooster

Tdap can be administered at the same visit as Tdap can be administered at the same visit as any other age indicated vaccineany other age indicated vaccine

Recommended interval between last dose of Recommended interval between last dose of DTaP and Tdap is 5 yearsDTaP and Tdap is 5 years

Tdap & AdultsTdap & Adults

Adults aged 19–64 years should receive a single dose of Tdap to replace a single dose of Td for active booster vaccination against tetanus, diphtheria, and pertussis if they received their last dose of Td >10 years earlier.

Replacing 1 dose of Td with Tdap will reduce the morbidity associated with pertussis in adults and

might reduce the risk for transmitting pertussis to persons at increased risk for pertussis and its complications.

Interval exceptionsInterval exceptions

Tdap may be administered at any time Tdap may be administered at any time after Td if the benefit of protection against after Td if the benefit of protection against pertussis outweighs the risk of a local pertussis outweighs the risk of a local reaction. reaction.

Some situations might be:Some situations might be: HCW that has direct patient contactHCW that has direct patient contact Adolescent or adult that has close contact Adolescent or adult that has close contact

with children < 12 months of agewith children < 12 months of age During a pertussis outbreakDuring a pertussis outbreak

Tdap & AdolescentsTdap & Adolescents

Adolescents aged 11-18 should receive a Adolescents aged 11-18 should receive a single dose of Tdap instead of Td for single dose of Tdap instead of Td for boosterbooster

Tdap can be administered at the same visit as Tdap can be administered at the same visit as any other age indicated vaccineany other age indicated vaccine

Tdap & AdultsTdap & Adults

Adults aged 19–64 years should receive a single dose of Tdap to replace a single dose of Td for active booster vaccination against tetanus, diphtheria, and pertussis if they received their last dose of Td >10 years earlier.

Replacing 1 dose of Td with Tdap will reduce the morbidity associated with pertussis in adults and

might reduce the risk for transmitting pertussis to persons at increased risk for pertussis and its complications.

Any questions ????Any questions ????

Resources Resources Guidelines for the Control of Pertussis OutbreaksGuidelines for the Control of Pertussis Outbreaks

"The Pertussis Guide", 2000-- some chapters updated in 2006"The Pertussis Guide", 2000-- some chapters updated in 2006 http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htmhttp://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm

Epidemiology and Prevention of Vaccine-Preventable DiseasesEpidemiology and Prevention of Vaccine-Preventable Diseases("The Pink Book", 10th edition; Mar. 2008) ("The Pink Book", 10th edition; Mar. 2008) http://www.cdc.gov/vaccines/pubs/pinkbook/default.htmhttp://www.cdc.gov/vaccines/pubs/pinkbook/default.htm

MMWR MMWR Recommendations and Reports December 9, 2005 / 54(RR14)

Recommended Antimicrobial Agents for the Treatment and Recommended Antimicrobial Agents for the Treatment and Postexposure Prophylaxis of Pertussis 2005 CDC Guidelines Postexposure Prophylaxis of Pertussis 2005 CDC Guidelines http://www.cdc.gov/mmwr/PDF/rr/rr5414.pdfhttp://www.cdc.gov/mmwr/PDF/rr/rr5414.pdf

Surveillance of Vaccine-Preventable Diseases (4th edition, Surveillance of Vaccine-Preventable Diseases (4th edition,

2008) 2008) http://www.cdc.gov/vaccines/pubs/surv-manual/default.htmhttp://www.cdc.gov/vaccines/pubs/surv-manual/default.htm