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1 Identification of a Pseudo-Epidemic of Pertussis West Virginia 2010-2011 Carrie A. Thomas, PhD Vaccine-Preventable Disease Epidemiologist WVDHHR/BPH [email protected] 06/04/2012 Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 2 West Virginia Regional Map Region 5 Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 3 Number of Patients <19 Years Old Reported to WVBPH as Having Pertussis by Quarter Number of Patients Reported (2008 through Q3-2011) 200 180 160 140 120 100 80 60 40 20 0 HF-A Region 5 State (including Region 5) 108 31 18 Year by Quarter Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 4 Initial Intervention Attempts Pertussis PCR Results Several attempts by local Percent Positive Data courtesy of LabCorp health, local physicians, Month HF-A Overall and state staff to educate Oct. 2010 100% 8.7% providers of HF-A Nov. 2010 87.5% 22.3% Dec. 2010 79.4% 17.1% Jan. 2011 82.4% 9.5% Feb. 2011 83.9% 8.9% Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 5 Number of Patients <19 Years Old Reported to WVBPH as Having Pertussis by Quarter Number of Patients Reported (2008 through Q4-2011) - UPDATED 200 180 160 140 120 100 80 60 40 20 0 HF-A Region 5 State (including Region 5) 108 75 47 31 18 Year by Quarter 10 Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 6 HF-A Site Visit 12/2011 CDC Case Definitions for Pertussis1 1(http://www.cdc.gov/osels/ph_surveillance/nndss/casedef/pertussis_current.htm) Probable Confirmed In the absence of a more likely diagnosis, a cough illness lasting ≥2 weeks, with at least one of the following symptoms: Acute cough illness of any duration, with isolation of B. pertussis from a clinical specimen (culture); paroxysms of coughing; inspiratory "whoop”; post-tussive vomiting; AND absence of laboratory confirmation; AND no epidemiologic linkage to a laboratory-confirmed case of pertussis OR Cough illness lasting ≥2 weeks, with at least one of the following symptoms: paroxysms of coughing; inspiratory "whoop"; or post-tussive vomiting; AND polymerase chain reaction (PCR) positive for pertussis; OR Illness lasting ≥2 weeks, with at least one of the following symptoms: paroxysms of coughing; inspiratory "whoop"; or post-tussive vomiting; AND contact with a lab-confirmed case of pertussis Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 7 HF-A Site Visit 12/2011 (cont.) Testing methods for confirming a pertussis diagnosis and strategies for reducing false positive results in PCR testing CDC’s Best Practices for Health Care Professionals on the use of Polymerase Chain Reaction (PCR) for Diagnosing Pertussis http://www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-pcr-bestpractices.html Pertussis data the West Virginia Bureau for Public Health (WVBPH) has collected over the past 4 years Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 8 Number of Patients <19 Years Old Reported as Having Pertussis by Year of Report (2008 – 10/31/2011*) Number of Patients Reported 200 180 HF-A 160 140 149 Region 5 120 111 State (including Region 5) 100 80 60 41 40 20 0 68 14 14 0 2008 0 2009 5 36 59 22 Year 2010 2011* Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 9 Number of Reported Patients that Do Not Meet CDC Case Definition for Pertussis (2008 – 10/31/2011*) 200 Number of Patients 180 Not a Case 160 Case 140 120 82% 100 28% n= 122 80 60 60% 40 20 0 37% 46% 29% 44% State Region HF-A State Region HF-A State Region HF-A State Region HF-A 2008 2009 2010 2011* 43% 64% 60% Year Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 10 Number of Patients with at Least One Additional Symptom (2010 - 10/31/2011) HF-A n=97 State n=130 15% 44% 56% Case Case Not a Case Not a Case 85% Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 11 Number of Patients without One Additional Symptom (2010 - 10/31/2011) State n=26 HF-A n=107 100% 4% n=1 Case Case Not a Case Not a Case 96% Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 12 Combined 1/1/2010 – 10/31/2011 data HF-A patients had shorter cough duration (14 vs. 29 days; p<0.0001) HF-A patients were younger (3 vs. 6 years; p<0.0001) HF-A All other physicians - state p % cough 91% 96% 0.01 % cough at final interview 29% 65% < 0.0001 Meet CDC case definitions 25% 66% < 0.0001 % male 56% 46% 0.04 Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 13 Site Visit Findings PCR being used as a screening tool Vaccine preparation area located on same countertop where they stored specimen collection material and processed specimens for submission Areas “separated” by line of tape dividing counter in half Squirting vaccine in air during preparation Inadequate hand hygiene practices Inadequate environmental cleaning procedures Liquid transport media being used Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 14 Post-Site Visit Actions Provided environmental cleaning and hand hygiene materials HF-A separated vaccine preparation and specimen collection/processing areas Received 2 positive pertussis PCR results as of May 2012 from HF-A Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov 15 Conclusions Pseudo-epidemic likely caused by Inappropriate use of PCR testing Inadequate infection control practices Provider education critical to the resolution of the situation Office of Epidemiology and Prevention Services Division of Infectious Disease Epidemiology www.dide.wv.gov