Georgia epidemiology report, Vol. 21, no. 7 (July 2005)

July 2005

volume 21 number 07

Whooping cough on the rise: A fatal case of pertussis in a Georgia infant, 2004

Cases

Introduction Pertussis, also known as whooping cough, is an infectious disease of the respiratory tract caused by the bacterium, Bordetella pertussis. The clinical manifestations of pertussis depend on the patient's age and immunization status, degree of exposure, and other host-organism factors (1). The disease in susceptible individuals is characterized by a paroxysmal cough that persists for several weeks. In young children, rapid bursts of coughs are followed by a long inspiratory gasp or whoop. Post-tussive vomiting is common. Adolescents, adults, and children partially protected by the vaccine usually have milder disease and typically present with a persistent cough and upper respiratory symptoms that may be indistinguishable from other causes of upper respiratory infection. Often these individuals are not recognized as having pertussis, and serve as a source of infection for others in the household at-risk for acquiring the disease, especially young infants.
Before the introduction of the pertussis vaccine in the 1940's, pertussis caused significant morbidity and mortality among infants and children in the United States, with over 5,000 deaths reported annually in the 1920's and 1930's (2). The vaccine made a dramatic impact on the pertussis incidence between the 1940's and the 1970's. Despite a stable or increasing vaccination rate, pertussis incidence has been increasing over the past 25 years among all age groups, including infants (3). Surveillance data from the 1980s through the mid-1990s show a rapid increase in adolescents and adults (3). Infants, however, have the highest incidence in the vaccine era, and account for the majority of hospitalizations, serious complications and deaths from pertussis (2). Figure 1 shows the number of pertussis cases reported to the Centers for Disease Control and Prevention (CDC) from 1980 to 2003 and documents the national increase in pertussis.
Figure 1. Pertussis: United States, 1980 - 2003
14000
12000
10000
8000
6000
4000
2000
0 1980 1983 1986 1989 1992 1995 1998 2001
Atkinson W. What's New in Immunization. Unpublished data, presented at the Immunize Georgia's Little Guys Conference, Atlanta, Georgia, September 28, 2004
Pertussis is a serious disease in infants. Severe complications of pertussis in infants include pneumonia, seizures, encephalopathy, meningoencephalitis, and death. Most infants with pertussis will have a paroxysmal cough, but

infants less than 3-4 months of age may not demonstrate the characteristic whoop and post-tussive vomiting (2). Young infants frequently have apneic episodes and are more likely to be hospitalized (2). Pulmonary hypertension leading to progressive shock and death has also been reported in infants (1,3). The following case report describes the clinical presentation and progression of disease in a fatal case of pertussis in a neonate.
Case Description A 17-day-old full-term male infant with no prior health problems presented to his pediatrician with sporadic fussiness and episodes of coughing and sneezing. After examination, the infant's physician suspected an upper respiratory viral illness, and the patient was sent home. In the following two days, the neonate's upper respiratory signs and symptoms worsened to include apnea, dyspnea and cyanosis and his parents brought him back to see his pediatrician. The newborn was immediately transported from the pediatrician's office via ambulance to a local children's hospital.
On admission to the emergency department (ED), the neonate had periodic episodes of apnea, cyanosis, difficulty clearing his respiratory secretions, and labored breathing. He was placed on supplemental oxygen. A chest x-ray revealed right upper lobe pneumonia. A CBC, biochemical profile, and cultures of sputum, CSF, blood and urine were obtained. During the lumbar puncture, the patient experienced increased respiratory distress that required intubation and mechanical ventilation. He was admitted and transferred to the intensive care unit for further management. The complete blood count revealed an extreme leukocytosis (WBC = 73,000). Ampicillin, rocephin, and erythromycin were administered parenterally. His cardiopulmonary status continued to deteriorate over the next several hours and he was placed on high frequency oscillatory ventilation. An echocardiogram showed an enlarged right ventricle with decreased right ventricular contractility consistent with the development of pulmonary hypertension. The infant was unresponsive to the high frequency oscillatory ventilation and was placed on nitric oxide therapy with no significant improvement in his clinical status. Volume infusion and inotropic support were begun. Early the following day, during preparations to transfer the patient to another regional children's hospital for extracorporeal membrane oxygenation (ECMO), the neonate's cardiopulmonary status decompensated severely. He was hand bagged with 100% oxygen but failed to respond, and went into cardiopulmonary arrest. Despite repeated attempts at resuscitation, he expired.
Discussion The infant was delivered at full-term gestation with no complications. He had been doing very well at home until 2 days before admission to the hospital when he was noted to have increased irritability and mild URI (upper respiratory infections) symptoms. His upper respiratory disease progressed rapidly over 48 hours and he was referred to a large children's hospital. Respiratory failure was recognized and treated imme-

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diately upon admission to the emergency department. The differential diagnoses included bacterial meningitis and pneumonia. Initial antimicrobial therapy provided broad coverage for Bordetella pertussis, listeriosis, and other causes of newborn sepsis and pneumonia. The neonate demonstrated progressive respiratory failure and the developed pulmonary hypertension. Despite aggressive therapy, he expired 18 hours after admission. The final diagnoses included respiratory failure, pneumonia, sepsis, pulmonary hypertension, shock, anemia, and metabolic acidosis. A diagnosis of pertussis was confirmed later when B. pertussis was isolated from the nasopharyngeal specimen collected on admission to the hospital.
Pertussis is a notifiable disease that requires immediate reporting in Georgia. A report of pertussis to the State or Local Health Department leads to a prompt public health investigation. Household and close contacts to the case are identified and placed on post exposure chemoprophylaxis. Investigation of this case revealed that a few days before his birth, his mother had an upper respiratory illness. A cough developed while she was in labor and continued for several days after she and the baby were discharged. She sought medical attention for her illness approximately a week after her son was born. Her chest x-ray was unremarkable and other than a lowgrade fever and bouts of coughing, she felt relatively well. When her symptoms did not improve over the next few days she went back to see her physician and was placed on Biaxin. Meanwhile, an older sibling in the household and other family members visiting from out-of-state developed clinical illness compatible with pertussis. Symptomatic family members were treated with erythromycin. Many close contacts, primarily extended family visiting for the funeral, were administered post exposure chemoprophylaxis.
Adolescents and adults in the household have been implicated as the source of infection for young infants (4). Mothers have previously been reported to be the source of infant pertussis and in a recent study by Bisgard et al., a mother was identified as the source for 32% of cases. Family members were found to be the source of infection for 75% of the case-infants with a known or suspected source documented (4). Waning immunity among adolescents and adults as well as challenges in recognizing and confirming pertussis play a significant role in the transmission of Bordetella pertussis from adults to young infants.
Pertussis in Georgia Pertussis in Georgia follows the national upward trend, although the disease is severely under-reported in our state. Surveillance for pertussis is conducted through the Georgia Notifiable Disease Surveillance System and through a special laboratory-based surveillance project in collaboration with the Centers for Disease Control and Prevention (CDC). Figure 2 shows the number of probable and confirmed pertussis cases reported to the Georgia Division of Public Health (GDPH) from 1999-2004. The distribution of signs and symptoms of pertussis among Georgia infants less than 12 months of age is consistent with national data (see Figure 3). The reasons for under-reporting of pertussis in Georgia may include reluctance of adults to seek care for URIs, health care providers' failure to recognize pertussis as an etiology for cough illness in adolescents and adults, and insensitive diagnostic tests.
Confirmatory laboratory testing should be performed for all suspect or probable cases, especially in young infants, in atypical cases, and cases modified by vaccine. The standard and preferred laboratory test for confirmation of pertussis infection is isolation of B. pertussis by culture (5). Culture should always be performed, as isolates may be required for evaluation of antimicrobial resistance, or for molecular typing (5). Nasopharyngeal (NP) swabs (collected with

Figure 2. Total Reported Pertussis Cases in Georgia 19992004

80

Probable Cases** Confirmed Cases*

70

60

50

40

30

20

10

0
1999 2000 2001 2002 2003 2004
* Confirmed: a case that is laboratory confirmed or one that meets the clinical definition and is either laboratory confirmed or epidemiologically linked to a laboratory-confirmed case (1)
** Probable: a case that meets the clinical case definition, is not laboratory confirmed, and is not epidemiologcially linked to a laboratory-confirmed case (1)
1. CDC. Case Definitions for Infectious Conditions Under Public Health Surveillance. MMWR 1997;46 (No. RR-10).

Figure 3. Distribution of Signs, Symptoms, and Complications of Reported Infant Pertussis Cases in Georgia, 1999-2004*

Total Number of Cases % cases w ith clinical manifestation/complication
Cough Paroxysm Whoop Vomiting Apnea Pneumonia Seizure Encephalopathy Hospitalization Death
*Chart adapted from reference 2.

Age, Months

0-1M 2-3M 4-5M 6-11M Total Cases

62 61 8

8

139

94 85 88 100

125

63 67 63 75

91

50 51 13 38

66

50 43 50 50

65

65 46 13 50

72

18 33 0

0

13

2

20

0

2

0

50

0

3

81 64 36 38

95

2

00

17

2

Dacron or calcium alginate swabs, not cotton) are the specimens of choice and should be collected as soon as possible after illness onset. Currently, the GDPH Laboratory provides Regan-Lowe medium for transportation of NP specimens, and culture at no charge to the provider. Regan-Lowe medium can be obtained from the District Epidemiologist in each Health District of Georgia. Limitations of culture for diagnosis of pertussis include timeliness, and decreased sensitivity if the patient is cultured later in his/her clinical course.

The direct fluorescent antibody (DFA) technique for identifying B. pertussis in nasopharyngeal specimens has low sensitivity and variable specificity (5). Serologic testing is not useful in practice because results are difficult to interpret due to the lack of association between antibody levels and immunity to pertussis. DFA and serologic testing should not be relied upon as a criterion for laboratory confirmation (5). Polymerase chain reaction (PCR) testing of nasopharyngeal swabs, available in some laboratories, is a rapid, sensitive and specific method for diagnosing pertussis, but should be only used as an adjunct to culture (5). Studies are currently underway to standardize serologic and PCR tests. Once a standardized test (PCR and/or serology) is available, confirming a diagnosis of pertussis will be quicker and easier.

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Conclusion Pertussis continues to be a public health problem in the United States despite a stable or increasing vaccination rate. This case emphasizes the need to prevent transmission of pertussis to infants. Waning immunity in adolescents and adults has prompted the Advisory Committee on Immunization Practices (ACIP) to consider adding a pertussis booster for adolescents and/or adults. Before this year, there was no pertussis vaccine licensed for use in persons 7 years of age or older; however the U.S. Food and Drug Administration licensed a DTaP vaccine for use in adolescents in May 2005. Guidelines for this vaccine may be developed as early as this fall. Health care providers should consider pertussis in the differential diagnosis for URI/cough illnesses in adolescents and adults. Cases should be identified, treated promptly, and confirmed appropriately. Early recognition of pertussis and prophylaxis of close/ household contacts can help reduce transmission to at-risk individuals, especially young infants.
Please notify your County, District, or State Health Department immediately of any suspect, probable or confirmed cases. Contacts of cases should be placed on chemoprophylaxis to prevent transmission to susceptible persons. Please call the Notifiable Diseases Section, Epidemiology Branch, Georgia Division of Public Health, at 404-6572588 for any questions about pertussis.
References 1. Greenberg, DP, von Konig CH, Heininger U. Health burden of
pertussis in infants and children. Pediatr Infect Dis J. 2005 May;24 (5 Suppl):S39-43. 2. Tanaka M, Vitek C, Pascual FB, Bisgard KM, Tate J, Murphy TV, Wharton M. Trends in pertussis among infants in the United States, 1980-1999. JAMA 2003;290:2968-75. 3. Vitek C, Pascual FB, Baughman AL, Murphy TV. Increase in deaths from pertussis among young infants in the Ubited States in the 1990s. Pediatr Infect Dis J. 2003;22:625-34.

4. Bisgard KM, Pascual FB, Ehresmann KR, Miller CA, Cianfrini C, Jennings CE, Rebmann CA, Gabel J, Schauer SL, Lett SM. Infant pertussis:who was the source? Pediatr Infect Dis J. 2004 Nov;23(11):985-9.
5. Atkinson W, Hamborsky J,Wolfe C. Pertussis. In: Epidemiology and Prevention of Vaccine Preventable Diseases. 8th Ed. Centers for Disease Control and Prevention: Atlanta, GA 30333, 2004:Chapter 7.
Infant Pertussis: Quick Facts
n Pertussis incidence is on the rise despite stable or increasing immunization rates
n Among all age groups, infants have the highest incidence in the vaccine era
n Infants account for the majority of hospitalizations, serious complications and deaths from pertussis
n Adolescents and adults in the household are frequently identified as the source of infection for young infants
n Laboratory confirmation (culture) should be obtained on all suspect cases
n NOTIFY public health IMMEDIATELY for any suspect or confirmed case
n All household contacts should receive post exposure chemoprophylaxis
Written by: Julie Gabel, D.V.M., M.P.H., and Beth Ward R.N., M.P.H.

New Tuberculosis Bill Takes Effect July 1, 2005

The new Georgia law, Senate Bill 56, updates the state's tuberculosis (TB) laws. It permits public health authorities to confine a patient with active TB who is persistently non-adherent to treatment, for up to two years. The law defines active TB as a diagnosis of TB demonstrated by clinical, bacteriologic, or diagnostic imaging evidence, or a combination thereof. Persons who have been diagnosed as having active TB and have not completed a course of antiTB treatment are still considered to have active TB and may be infectious.
The old TB law which limited confinement to "contagious" TB patients for up to 6 months was not sufficient for TB treatment since the Centers for Disease Control recommends a minimum of 6 months to 1 year to treat active TB and 1 to 2 years to treat multidrug resistant TB (MDR-TB). A patient is considered to be no longer infectious after successfully completing a prescribed treatment regimen.

In 2003-2004, only 8 of 1,060 TB patients (less than 1%) reported in Georgia were confined for persistent non-adherence to TB treatment after less restrictive measures were tried such as frequent reminders about medical appointments by phone calls and letters, home visits, providing incentives such as transportation tokens and food coupons, temporary housing, and directly observed therapy.
The legislation will result in fewer persons being lost to follow-up and not completing treatment, reduction of transmission to the community, fewer persons acquiring drug-resistant TB, and fewer deaths from TB. The bill was sponsored by Senator Don Thomas, a physician, and was favorably reported out of the Senate and House Health and Human Services Committees. The Senate passed the bill unanimously 53-0; the House also passed the bill unanimously 152-0 on World TB Day. The Governor signed the bill on May 10, making it effective July 1, 2005.

Division of Public Health http://health.state.ga.us
Stuart T. Brown, M.D. Director
State Health Officer

Epidemiology Branch http://health.state.ga.us/epi
Susan Lance, D.V.M., Ph.D. Director
State Epidemiologist

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. Editor Kathryn E. Arnold, M.D.
Susan Lance, D.V.M., Ph.D. Stuart T. Brown, M.D.
Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
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PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

July 2005

Volume 21 Number 07

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for April 2005

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for April 2005
2005
43 2301
11 0 45 935 9 8 11 1 0 0 0 2 0 106 34 1 12 8 30 0 19

Previous 3 Months Total

Ending April

2003

2004 2005

16

17

107

8255

8038

7795

10

8

32

0

0

3

65

60

137

3589

3120

3344

0

1

30

5

3

18

20

26

43

0

0

3

0

0

0

0

0

2

0

0

0

0

0

7

0

0

0

34

46

229

29

27

108

9

20

11

70

89

52

120

74

42

85

101

139

0

0

0

31

43

74

Previous 12 Months Total

Ending in April

2003

2004

2005

70

67

228

32172

31872

31639

29

34

74

0

0

7

312

284

485

15573

14053

13948

0

1

62

16

14

37

77

112

166

0

0

5

0

0

0

0

0

8

0

0

0

2

1

16

0

0

0

250

316

670

192

123

253

45

76

54

239

328

289

351

350

143

271

330

461

0

0

0

118

139

192

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

AIDS Profile Update

Report Period
Latest 12 Months: 07/04-06/05 Five Years Ago: 07/00-06/01 Cumulative: 07/81-06/05

Total Cases Reported* <13yrs >=13yrs Total

8

1,495 1,503

10

1,254 1,264

224

28,452 28,676

Percent Female
25.8
26.2
19.3

Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown

32.8

6.2

2.1

11.7

1.7

45.6

30.6

10.6

2.4

17.8

2.0

36.6

45.6

15.9

4.9

14.4

1.9

17.2

Race Distribution (%) White Black Other

21.6 76.4

2.0

19.7 75.6

4.7

31.9 65.5

2.5

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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