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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


The Rise Of Adolescent And Adult Pertussis In The United States


GOAL
To provide pediatricians and family practice physicians with the latest information on pertussis incidence in adolescents and adults.

TARGET AUDIENCE
This activity is designed for pediatricians and family practice physicians. No prerequisites required.

LEARNING OBJECTIVES
After reading this issue, participants should be able to:

  • Review the epidemiology of pertussis and its impact on disease transmission.
  • Identify strategies to standardize diagnostic parameters/process.
  • Evaluate strategies to raise awareness among child contact/consumer organizations.
  • Interpret current and future prevention interventions as well as potential strategies to facilitate their implementation.

SPONSORSHIP STATEMENT
This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education. The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The Johns Hopkins School of Medicine takes responsibility for the content, quality, and scientific integrity of this activity.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from sanofi pasteur.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Dennis A. Brooks, MD, MPH, MBA
Assistant Professor of Pediatrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Brooks reports receiving honoraria from sanofi pasteur and GlaxoSmithKline.

PARTICIPATING FACULTY

James D. Cherry, MD, MSc
Professor of Pediatrics
David Geffen School of Medicine
University of California at Los Angeles
Los Angeles, California
Dr Cherry reports serving as a consultant to and receiving honoraria from sanofi pasteur and GlaxoSmithKline.

Richard D. Clover, MD
DeanSchool of Public Health and Information Sciences
University of Louisville School of Medicine
Louisville, Kentucky
Dr Clover reports serving as a consultant to sanofi pasteur.

Kathryn M. Edwards, MD
Professor of Pediatrics
Vice Chair for Clinical Research
Vanderbilt University School of Medicine
Nashville, Tennessee
Dr Edwards reports receiving grants/research support from sanofi aventis, MedImmune, Inc, and VaxGen Inc and serving as a consultant to MedImmune Inc.

Sarah S. Long, MD
Professor of Pediatrics
Drexel University College of Medicine
Chief Section of Infectious Diseases
St. Christopher's Hospital for Children
Philadelphia, Pennsylvania
Dr Long reports having no financial or advisory relationships with corporate organizations related to this activity.

Notice: The audience is advised that an article in this CME activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Cherry—azithromycin, clarithromycin.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Trends In Pertussis: Increasing Disease Incidence Across All Ages
Dennis A. Brooks, MD, MPH, MBA*

Following introduction of immunization in the 1940s, pertussis incidence declined more than 99% to an all-time low of just over 1000 reported cases in 1976. Since then, cases have been on the rise in the Unites States, increasing over 10-fold to more than 11 000 reported cases in 2003, the most in a single year since 1964.1,2 While incidence remains highest among infants, increases have been noted across all age groups. For example, rates in persons ages 10 to 19 years have increased in parallel with the 10-fold overall increase over the last decade.1 While pertussis-related deaths continue to be clustered among infants younger than 6 months, deaths have also been reported in older children and even adults.1


It appears pertussis immunity is not lifelong, whether conferred by childhood vaccination or natural exposure to disease. Immunity wanes and the disease may be much more prevalent in adolescents and adults than most healthcare providers or the public appreciate. Outbreaks in school settings illustrate how quickly and easily pertussis infection can spread in noninfant populations.

During 2003, 2 pertussis cases in an eighth-grade classroom in Arizona led to increased surveillance that documented 485 cases in 6 communities (580.5 cases per 100 000).3 Of the 203 cases associated with schools, 56% were in students, 4% were in school staff, and 40% were in family members. School staff may have been much less affected during this outbreak because they are more likely to have come in contact with pertussis more recently, affording them some level of protective immunity from subsequent exposure.

A 1996 outbreak in a school in Vermont prompted a countywide examination of cases.4 The 280 documented cases occurred in patients ages 27 days to 87 years. The majority (64%) of the 171 cases in school-aged children were culture-confirmed. Cases were identified in children and/or adults in 69 schools, with 1 to 19 cases per school. Seventy-one percent of the cases in adults occurred among persons reporting contact with one of the children with culture-confirmed pertussis. These outbreaks demonstrate that adolescents are sources for pertussis spread throughout communities and are the probable source for a substantial proportion of cases in infants.

Although, clinically, pertussis is generally a much milder disease after infancy, it can still cause serious morbidity (eg, pneumonia, hospitalization) in adolescents and adults. This in itself may be a reason to be concerned about pertussis in adolescents and adults. However, an even more important issue is that adolescents and adults serve as a reservoir of disease for neonates and young infants, those most susceptible to serious complications, including death.

In September 2004, Advanced Studies in Medicine convened a panel of experts in Baltimore to review epidemiology and burden of pertussis among all age groups. Presenters detailed epidemiology and transmission of Bordetella pertussis infection, reviewed disease presentation by age, and discussed issues affecting accurate laboratory diagnosis in adolescents and adults. The panel agreed that pertussis is a significant problem that needs to be addressed in the United States today.

Further discussion focused on the barriers that compromise the goal of decreasing pertussis incidence. Among such issues are low levels of awareness about the burden of pertussis disease among healthcare providers and the general public, insufficient data gathered in countrywide surveillance, absence of a simple and effective diagnostic tool, and lack of a vaccine to provide protection and potentially reduce the disease reservoir in persons ages 7 years and older.

REFERENCES
1. Centers for Disease Control and Prevention. PertussisÑUnited States, 1997-2000. MMWR Morb Mortal Wkly Rep. 2002;51(4):73-76.
2. Centers for Disease Control and Prevention. Notice to readers: Final 2003 report of notifiable diseases. MMWR Morb Mortal Wkly Rep. 2004;53(30):687, 693.
3. Centers for Disease Control and Prevention. School-associated pertussis outbreakÑYavapai County, Arizona, September 2002-February 2003. MMWR Morb Mortal Wkly Rep. 2004;53(10):216-219.
4. Centers for Disease Control and Prevention. Pertussis outbreakÑVermont, 1996. MMWR Morb Mortal Wkly Rep. 1997;46(35):822-826.

*Assistant Professor of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Dennis A. Brooks, MD, MPH, MBA, 3100 Wyman Park Drive, Baltimore, MD 21211. E-mail:
dbrooksa@jhmi.edu.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.