January 2015, Vol 3, No 1 - Inside Pediatric Health
Kim Curry, PhD, ARNP

To clinicians, few sights are more frightening than an infant gasping for air, with oxygen levels falling, struggling with paroxysms of constant coughing. This is the consequence of pertussis transmission, which, in 2013, affected more than 22,000 children and 6000 adults in the United States.1

Pertussis, also known as whooping cough, is a dangerous illness with an initial presentation that many healthcare providers fail to recognize. In its early stages, it mimics other respiratory illnesses and is often misdiagnosed. The danger created by this missed diagnosis is that appropriate antibiotic therapy is not promptly initiated, and the patient suffers greatly as a consequence. Toxins released by the Bordetella pertussis bacterium trigger the symptoms of this illness.2 The terrible cough of pertussis is a paroxysmal cough, often enough to cause emesis and hypoxia. The cough is not only very difficult to suppress, but once present can last for several weeks.

Infants less than 6 months of age who have not had the opportunity to complete their primary immunization series are the most at risk for fulminant pertussis. Infants often get pertussis from older siblings, parents, and caregivers, including healthcare workers, who have not been vaccinated in many years and are no longer immune. Recently, a resurgence of pertussis, including a number of deaths, has occurred in the United States, highlighting the waning immunity from the childhood pertussis vaccine.2,3 This upward trend led to the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine for adolescents and adults, which was introduced in the United States in 2005.3

In August 2014, the Centers for Disease Control and Prevention (CDC) published a surveillance report highlighting the vaccination history of patients with pertussis.1 The report made it clear that many young children who are eligible for the vaccine are not receiving this important immunization in a timely manner. In fact, 42% of infants 6 to 11 months of age with pertussis were noted to have received 0 doses of the vaccine, or had an immunization status of “unknown.”1

How Pharmacists and Clinicians Can Advise Patients
Children should receive a total of 5 doses of the diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine, the childhood formula of the immunization.4 Specifically, they should receive doses at age 2, 4, and 6 months. A fourth dose is given between age 15 and 18 months. A final booster dose is due between age 4 and 6 years.

For patients aged 11 years and older, one dose of Tdap is recommended for those who have not previously received the vaccine.5 In 2011, the Advisory Committee on Immunization Practices recommended an additional single dose of the Tdap vaccine for adults aged ≥65 years who anticipate having contact with infants.5

A good opportunity to give Tdap is during wound treatment, for patients requiring such care, as a replacement for tetanus and diphtheria toxoids (Td). The Tdap vaccine should also be administered to women during pregnancy if it has not been previously administered. It may also be given immediately postpartum to protect the mother and infant. Healthcare workers with direct patient contact are advised to receive this vaccine as well.5

Clinicians should especially stress the need for a pertussis immunization to expectant parents (mother and father) and grandparents. Sometimes what people will not do for themselves they will do to protect the children in their lives. Get to know your customers, so that expectant parents and grandparents can receive education, and Tdap, prior to the arrival of the new family member.

Your Role in Improving Immunization Rates
First and foremost, pharmacists and clinicians should be up to date on their own immunizations. It is difficult for patients to take our advice seriously when they ask whether we have received a particular vaccine and the answer is “Well, no, but….” We should be role models as well as advocates for immunization participation.

Healthcare professionals should maintain current knowledge of annual immunization updates and revisions to the recommended schedules for infants, children, adolescents, and adults. A good place to start is by reviewing the vaccine schedules and the numerous updates on vaccine-preventable diseases provided in the CDC’s Morbidity and Mortality Weekly Report.6 When viewing vaccine schedules, always remember that the footnotes are essential for understanding the indications and updates for each vaccination.

Another way to improve immunization rates is to take advantage of every opportunity to review the patient’s immunization status and to vaccinate whenever indicated. Each visit is an opportunity to vaccinate. Too often, minor illnesses are seen as contraindications to vaccination, when only acute illnesses with high fevers are contraindications for most patients.

If your facility or pharmacy does not stock or administer vaccines, consider creating a list of locations in the community where patients can receive immunizations. Telling a patient to go to the health department may not be the correct information in some geographic areas. In some communities, private medical clinics or clinics for international travelers may be better options. In some counties, immunization services are available more readily by sending the patient to a neighboring county health department with better access. It pays to investigate.

There is always a minority of parents who are vaccine objectors, and these individuals can be very vocal. In some parts of the United States, outbreaks of vaccine-preventable diseases, including deaths, have occurred because of a consciously underimmunized local population. This regrettable situation is often largely due to an educational deficit, with the rumor mill winning out over science. It is important to listen to concerns, provide encouragement, and supply evidence-based educational resources. If patients ask for additional information before making a vaccine decision, many educational resources are available through the Immunization Action Coalition.7

We are becoming increasingly aware that any individual vaccine is not 100% effective and is unlikely to convey immunity for the entire life span. The recent history of pertussis cases in this country provides but one example of these facts. In the future, we can anticipate seeing an expansion in the recommended age ranges for many immunizations, vaccines extended to additional groups of people, and recommendations for repeated doses of certain vaccines that today are delivered as a one-time dose. Every clinician has the opportunity to be an important immunization resource and to promote primary preventive measures, saving both the patient and society from undue suffering and lessening the burden on the healthcare system.




References

  1. Centers for Disease Control and Prevention. 2013 final pertussis surveillance report. www.cdc.gov/pertussis/down loads/pertuss-surv-report-2013.pdf. Published August 15, 2014. Accessed January 6, 2015.
  2. Carbonetti N. Pertussis toxin and adenylate cyclase toxin: key virulence factors of Bordetella pertussis and cell biology tools. Future Microbiol. 2010;5:455-469.
  3. Joint Commission on Accreditation of Healthcare Organizations. Tdap vaccination: strategies from research and practice. www.jointcommission.org/assets/1/6/Tdap_Monograpgh.pdf. Published February 1, 2011. Accessed January 5, 2015.
  4. Centers for Disease Control and Prevention. Recommended immunization schedule for persons age 0 through 18 years. www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Updated January 31, 2014. Accessed January 5, 2015.
  5. Centers for Disease Control and Prevention. Recommended adult immunization schedule, by vaccine and age group. www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Updated September 18, 2014. Accessed January 5, 2015.
  6. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. www.cdc.gov/mmwr/mmwrsrch.htm. Updated January 15, 2010. Accessed January 5, 2015.
  7. Immunization Action Coalition. Handouts for patients & staff. www.immunize.org/handouts/. Accessed January 5, 2015.

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