Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
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SARS-CoV-2 coinfections among pertussis cases identified through the Enhanced Pertussis Surveillance system in the United States, January 2020-February 2023
Berry I , Cole M , Silk B , Havers FP , Youngkin E , Misiorski A , Sefton S , Vang Y , Stanislawski E , McGuire S , Silhan N , Skoff TH , Rubis AB . PLoS One 2024 19 (12) e0311488 BACKGROUND: Bacterial and viral respiratory coinfections are common, but the prevalence of SARS-CoV-2 infections among pertussis cases has not been estimated. We examine the prevalence and temporality of SARS-CoV-2 infections among pertussis patients and describe pertussis clinical severity among patients with and without SARS-CoV-2 coinfections. METHODS: Confirmed and probable pertussis cases among individuals with cough onset between January 1, 2020 and February 15, 2023 were identified through surveillance in seven Enhanced Pertussis Surveillance (EPS) sites. Pertussis cases with a laboratory-confirmed SARS-CoV-2 infection detected within 30 days before or after pertussis cough onset were defined as coinfections. We describe patient demographics, symptoms, and severe complications and outcomes (seizures, encephalopathy, pneumonia, hospitalization, or death) by coinfection status. RESULTS: Among 765 pertussis cases reported during the study period, the prevalence of SARS-CoV-2 coinfections was 0.78% [6/765]. Among the six patients meeting the coinfection definition, the majority (83.3% [5/6]) had SARS-CoV-2 infections detected following pertussis cough onset. Compared to those with no known coinfection, a higher proportion of those with coinfections reported severe complications or outcomes (50.0% [3/6] vs. 5.2% [36/694]). DISCUSSION: Although the prevalence of pertussis patients with SARS-CoV-2 coinfections was low, patients with coinfections reported more severe complications and outcomes compared to those with pertussis alone. Given the decline in reported pertussis cases during the COVID-19 pandemic, continued monitoring of pertussis incidence alongside respiratory viral infections will be important as the pertussis burden returns to pre-pandemic levels. |
Impact of the US maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination program on preventing pertussis in infants 2 to <6 months of age: A case-control evaluation
Skoff TH , Rubis AB , Kirley PD , Scherzinger K , McMahon M , McGuire S , Kudish K , Cieslak PR , Shang N , Hariri S . Open Forum Infect Dis 2024 11 (11) ofae655 BACKGROUND: To protect infants aged <2 months against pertussis, the United States recommends Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccination during each pregnancy. Data are limited on the strategy's effectiveness against pertussis in infants aged ≥2 months. METHODS: Pertussis case infants aged 2 to <6 months with cough onset between 1 January 2011 and 31 December 2014 were identified in 6 US states. Controls were 2 to <6 months of age, hospital matched, and selected by birth certificate. Mothers were interviewed to collect demographic and healthcare information. Provider-verified vaccination history was obtained for infants and mothers. Adjusted odds ratios (aORs) were calculated using conditional logistic regression; overall vaccine effectiveness (VE) was estimated as (1 - aOR)×100. To describe maternal Tdap VE modified by infant DTaP (diphtheria and tetanus toxoids and acellular pertussis) doses, case-control sets were unmatched, and a time-to-event analysis was conducted through a generalized linear mixed model. RESULTS: A total of 335 cases and 927 controls were enrolled. The overall adjusted VE estimate for Tdap during pregnancy was 45.6% (95% confidence interval [CI], 5.8%-68.5%) and increased slightly, but not significantly, against infant hospitalization (55.7% [-116.8% to 90.9%]). Although point estimates were not significant, VE was modified by infant DTaP doses (58.8% [95% CI, -6.0% to 84.0%] for 0 DTaP doses, 30.5% [-21.4% to 60.2%] for 1 dose, and 3.2% [-170.8% to 65.4%] for 2 doses). CONCLUSIONS: Our study suggests that there is some benefit of maternal Tdap vaccination beyond the first 2 months of life, however, on-time vaccination of infants remains critical to maintain protection from pertussis. |
Comparison of Bordetella species identification among differing rt-PCR assays in the United States
Cole M , Simon AK , Faulkner A , Skoff T , Tondella ML , Montero C , Nye MB , Williams M . Microbiol Spectr 2024 e0078324 ![]() ![]() In the United States, the general laboratory method for diagnosing pertussis, caused by Bordetella pertussis, is real-time PCR (rt-PCR) targeting insertion sequence 481 (IS481). Other Bordetella species (parapertussis, holmesii, and bronchiseptica) can also cause a pertussis-like syndrome, and some commercial laboratory assays include the insertion sequence 1001 (pIS1001) that can detect B. parapertussis/B. bronchiseptica (BppBb). Because IS481 exists in B. pertussis and B. holmesii, current commercial assays cannot differentiate these two species. We used a multiplex rt-PCR assay containing species-specific targets to Bordetella to evaluate clinical specimens detected as B. pertussis/B. holmesii (BpBh) or BppBb by commercial laboratories. A sample of 3,984 clinical specimens positive for IS481 or pIS1001 from two commercial laboratories during 2012-2019 were re-tested at CDC. Agreement of Bordetella species between the CDC and commercial laboratory assays, and the proportion of commercial laboratory specimens that were non-B. pertussis by CDC's assay was assessed. Overall agreement in Bordetella species detection and identification between the CDC and commercial lab assays was 85%. Agreement for identifying B. pertussis was 87% for 3,663 BpBh specimens and 98% for identifying B. parapertussis in 310 BppBb specimens. CDC's assay detected B. holmesii in 55/3,984 (1.4%) specimens. Most discrepant results (410/490, 82%) were BpBh specimens interpreted as indeterminate B. pertussis at CDC. We found a small portion of B. holmesii in a sample of IS481-positive clinical specimens originally identified by commercial laboratory rt-PCR assays, suggesting that commercial PCR assays are a reliable diagnostic tool for correctly identifying Bordetella species in most patients with suspected pertussis. IMPORTANCE: When testing specimens collected from patients with suspected pertussis, large-scale commercial laboratories in the United States employ an IS481-based assay that cannot differentiate between Bordetella pertussis and Bordetella holmseii. The level of B. holmesii causing pertussis-like illness in the United States is not well-understood given that only B. pertussis is nationally notifiable. After re-testing with a multiplex, species-specific rt-PCR assay, our data show low levels of B. holmesii identified in a sample of IS481-positive clinical specimens originally identified by commercial laboratory rt-PCR assays. These results reinforce the validity of large-scale commercial rt-PCR testing as a reliable diagnostic tool for pertussis in the United States. |
Differences in pertussis incidence by race and ethnicity in the United States, 2010-2017
Patel JC , Cole M , Rubis AB , Burzalff K , Cruz V , Edge K , Kudish K , Liko J , Pena S , Thomas ES , Skoff TH , McNamara LA . Open Forum Infect Dis 2024 11 (4) ofae177 BACKGROUND: An increased pertussis burden has been demonstrated among Hispanic or Latino and American Indian or Alaska Native (AI/AN) infants. However, data on potential disparities among other age and racial groups are limited. METHODS: We analyzed pertussis cases reported through Enhanced Pertussis Surveillance from 2010 to 2017. Pertussis and severe pertussis incidence were calculated by race (White, Black or African American, AI/AN, and Asian or Pacific Islanders), ethnicity (Hispanic or Latino and non-Hispanic or non-Latino), and age. RESULTS: Compared with White persons, overall incidence was lower among Black or African American (incidence rate ratio [IRR], .57; 95% confidence interval [CI], .53-.61), AI/AN (IRR, 0.65; 95% CI, .58-.72), and Asian or Pacific Islander persons (IRR, 0.39; 95% CI, .35-.43). Overall incidence of pertussis was higher (1.5-fold; 95% CI, 1.37-1.60) among Hispanic or Latino compared with non-Hispanic or non-Latino adults, potentially related to household size or lower pertussis vaccine uptake among adult Hispanic or Latino cases. Severe pertussis incidence was similar among Black or African American and AI/AN persons compared with White persons. Among infants, severe pertussis incidence was 1.4-fold higher (95% CI, 1.03-1.82) among Black or African American infants than among White infants, and 2.1-fold higher (95% CI, 1.67-2.57) among Hispanic or Latino infants than non-Hispanic or non-Latino infants. CONCLUSIONS: The contrast between lower reported incidence but similar or higher severe pertussis incidence among Black or African American and AI/AN persons compared with White persons warrants further investigation and may reflect underdiagnosis or underreporting of mild disease. |
Assessing the impact of the 2020 Council of State and Territorial Epidemiologists case definition for pertussis on reported pertussis cases
Rubis AB , Cole M , Tondella ML , Pawloski LC , Youngkin E , Firmender P , Aden V , Cruz V , Stanislawski E , Wester R , Cieslak PR , Acosta AM , Skoff TH . Clin Infect Dis 2024 BACKGROUND: In 2020, the Council of State and Territorial Epidemiologists (CSTE) pertussis case definition was modified; the main change was classifying PCR-positive cases as confirmed, regardless of cough duration. Pertussis data reported through Enhanced Pertussis Surveillance (EPS) in seven sites and the National Notifiable Diseases Surveillance System (NNDSS) were used to evaluate the impact of the new case definition. METHODS: We compared the number of EPS cases with cough onset in 2020 to the number that would have been reported based on the prior (2014) CSTE case definition. To assess the impact of the change nationally, the proportion of EPS cases newly reportable under the 2020 CSTE case definition was applied to 2020 NNDSS data to estimate how many additional cases were captured nationally. RESULTS: Among 442 confirmed and probable cases reported to EPS states in 2020, 42 (9.5%) were newly reportable according to the 2020 case definition. Applying this proportion to the 6,124 confirmed and probable cases reported nationally in 2020, we estimated that the new definition added 582 cases. Had the case definition not changed, reported cases in 2020 would have decreased by 70% from 2019; the observed decrease was 67%. CONCLUSIONS: Despite a substantial decrease in reported pertussis cases in the setting of COVID-19, our data show that the 2020 pertussis case definition change resulted in additional case reporting compared with the previous case definition, providing greater opportunities for public health interventions such as prophylaxis of close contacts. |
Evaluation of asymptomatic Bordetella carriage in a convenience sample of children and adolescents in Atlanta, Georgia, United States
Acosta AM , Simon A , Thomas S , Tunali A , Satola S , Jain S , Farley MM , Tondella ML , Skoff TH . J Pediatric Infect Dis Soc 2023 Few data exist on asymptomatic carriage of Bordetella species among populations receiving acellular pertussis vaccine. We conducted a cross-sectional study among acellular-vaccinated children presenting to an emergency department. B. pertussis carriage prevalence was <1% in this population, a lower prevalence than that found in recent studies among whole-cell pertussis-vaccinated participants. |
Tetanus, diphtheria, and acellular pertussis vaccination coverage among publicly insured pregnant women, U.S., 2016-2019
Isenhour CJ , Skoff TH , Lindley MC , Zhou F , Hariri S . AJPM Focus 2023 2 (1) 100060 INTRODUCTION: Vaccination with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine during pregnancy is highly effective against Bordetella pertussis in young infants. We aimed to evaluate the uptake of maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination during the recommended gestation period of 27 through 36 weeks among women enrolled in a public medical insurance plan in the U.S. METHODS: In this analysis using Centers for Medicare and Medicaid Services insurance claims data, we identified women aged 15 through 49 years who delivered a live-born infant from 2016 through 2019. We identified claims for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination to calculate the proportion of women who were vaccinated during Weeks 27 through 36 of gestation in each calendar year. We also assessed the average annual maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis coverage by age group, race and ethnicity, U.S. Census region of residence, and plan type. Data were analyzed in 2021. RESULTS: Among 4,318,823 deliveries, the 4-year national average for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccination was 26%, improving from 22% in 2016 to 31% in 2019 (p<0.001). Within subgroups, the lowest 4-year average coverage was among women aged 15 through 18 years (22%); Black, non-Hispanic (23%) and Hispanic women (24%); those residing in the South (18%); those enrolled in a Children's Health Insurance Program plan (22%); and those covered by a fee-for-service plan (19%). Coverage increased across all subgroups from 2016 through 2019. CONCLUSIONS: Although maternal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis coverage among publicly insured women in the U.S. increased from 2016 through 2019, it remained considerably lower than estimated national coverage, with notable differences by race and ethnicity. |
Influenza, tdap, and COVID-19 vaccination coverage and hesitancy among pregnant women - United States, April 2023
Razzaghi H , Kahn KE , Calhoun K , Garacci E , Skoff TH , Ellington SR , Jatlaoui TC , Black CL . MMWR Morb Mortal Wkly Rep 2023 72 (39) 1065-1071 Influenza, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), and COVID-19 vaccines can reduce the risk for influenza, pertussis, and COVID-19 among pregnant women and their infants. To assess influenza, Tdap, and COVID-19 vaccination coverage among women pregnant during the 2022-23 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 16, 2023. Among 1,814 survey respondents who were pregnant at any time during October 2022-January 2023, 47.2% reported receiving influenza vaccine before or during their pregnancy. Among 776 respondents with a live birth by their survey date, 55.4% reported receiving Tdap vaccine during pregnancy. Among 1,252 women pregnant at the time of the survey, 27.3% reported receipt of a COVID-19 bivalent booster dose before or during the current pregnancy. Data from the same questions included in surveys conducted during influenza seasons 2019-20 through 2022-23 show that the proportion of pregnant women who reported being very hesitant about influenza and Tdap vaccinations during pregnancy increased from 2019-20 to 2022-23. Pregnant women who received a provider recommendation for vaccination were less hesitant about influenza and Tdap vaccines. Promotion of efforts to improve vaccination coverage among pregnant women, such as provider recommendation for vaccination and informative conversations with patients to address vaccine hesitancy, might reduce vaccine hesitancy and increase coverage with these important vaccines to protect mothers and their infants against severe respiratory diseases. |
High post-exposure prophylaxis (PEP) uptake among household contacts of pertussis patients enrolled in a PEP effectiveness evaluation - United States, 2015-2017
McNamara LA , Rubis AB , Pawloski L , Briere E , Misegades L , Brusseau AA , Peña S , Edge K , Wester R , Burzlaff K , Cruz V , Tondella L , Skoff TH . PLoS One 2023 18 (5) e0285953 BACKGROUND: Post-exposure prophylaxis (PEP) for pertussis is recommended for household contacts of pertussis cases in the United States within 21 days of exposure, but data on PEP effectiveness for prevention of secondary cases in the setting of widespread pertussis vaccination are limited. We implemented a multi-state evaluation of azithromycin PEP use and effectiveness among household contacts. METHODS: Culture- or PCR-confirmed pertussis cases were identified through surveillance. Household contacts were interviewed within 7 days of case report and again 14-21 days later. Interviewers collected information on exposure, demographics, vaccine history, prior pertussis diagnosis, underlying conditions, PEP receipt, pertussis symptoms, and pertussis testing. A subset of household contacts provided nasopharyngeal and blood specimens during interviews. RESULTS: Of 299 household contacts who completed both interviews, 12 (4%) reported not receiving PEP. There was no evidence of higher prevalence of cough or pertussis symptoms among contacts who did not receive PEP. Of 168 household contacts who provided at least one nasopharyngeal specimen, four (2.4%) were culture or PCR positive for B. pertussis; three of these received PEP prior to their positive test result. Of 156 contacts with serologic results, 14 (9%) had blood specimens that were positive for IgG anti-pertussis toxin (PT) antibodies; all had received PEP. CONCLUSIONS: Very high PEP uptake was observed among household contacts of pertussis patients. Although the number of contacts who did not receive PEP was small, there was no difference in prevalence of pertussis symptoms or positive laboratory results among these contacts compared with those who did receive PEP. |
US infant pertussis incidence trends before and after implementation of the maternal tetanus, diphtheria, and pertussis vaccine
Skoff TH , Deng L , Bozio CH , Hariri S . JAMA Pediatr 2023 177 (4) 395-400 IMPORTANCE: Infants younger than 1 year have the highest burden of pertussis morbidity and mortality. In 2011, the US introduced tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination during pregnancy to protect infants before vaccinations begin. OBJECTIVE: To assess the association of maternal Tdap vaccination during pregnancy with the incidence of pertussis among infants in the US. DESIGN, SETTING, AND PARTICIPANTS: In this ecologic study, a time-trend analysis was performed of infant pertussis cases reported through the National Notifiable Diseases Surveillance System between January 1, 2000, and December 31, 2019, in the US. Statistical analysis was performed from April 1, 2020, to October 31, 2022. EXPOSURES: Maternal Tdap vaccination during pregnancy. MAIN OUTCOMES AND MEASURES: Pertussis incidence rates were calculated and compared between 2 periods-the pre-maternal Tdap vaccination period (2000-2010) and the post-maternal Tdap vaccination period (2012-2019)-for 2 age groups: infants younger than 2 months (target group of maternal vaccination) and infants aged 6 months to less than 12 months (comparison group). Incidence rate differences between the 2 age groups were modeled using weighted segmented linear regression. The slope difference between the 2 periods was estimated to assess the association of maternal Tdap vaccination with pertussis incidence among infants. RESULTS: A total of 57 460 pertussis cases were reported in infants younger than 1 year between 2000 and 2019; 19 322 cases (33.6%) were in infants younger than 2 months. During the pre-maternal Tdap vaccination period, annual pertussis incidence did not change among infants younger than 2 months (slope, 3.29 per 100 000 infants per year; P = .28) but increased slightly among infants aged 6 months to less than 12 months (slope, 2.10 per 100 000 infants per year; P = .01). There was no change in the difference in incidence between the 2 age groups (slope, 0.08 per 100 000 infants per year; P = .97) during the pre-maternal Tdap vaccination period overall. However, in the post-maternal Tdap vaccination period, incidence decreased among infants younger than 2 months (slope, -14.53 per 100 000 infants per year; P = .001) while remaining unchanged among infants aged 6 months to less than 12 months (slope, 1.42 per 100 000 infants per year; P = .29). The incidence rate difference between the 2 age groups significantly decreased during the post-maternal Tdap vaccination period (slope, -14.43 per 100 000 infants per year; P < .001). Pertussis incidence rate differences were significantly different between the pre-maternal and post-maternal Tdap vaccination periods (slope difference, -14.51 per 100 000 infants per year; P = .01). CONCLUSIONS AND RELEVANCE: In this study, following maternal Tdap vaccine introduction, a sustained decrease in pertussis incidence was observed among infants younger than 2 months, narrowing the incidence gap with infants aged 6 months to less than 12 months. These findings suggest that maternal Tdap vaccination is associated with a reduction in pertussis burden in the target age group (<2 months) and that further increases in coverage may be associated with additional reductions in infant disease. |
Maternal Tdap vaccination during pregnancy: Impact on infant anti-pertussis antibody concentrations by maternal pertussis priming series
Havers FP , Skoff TH , Rench MA , Epperson M , Rajam G , Schiffer J , Hariri S , Swaim LS , Baker CJ , Mary Healy C . Clin Infect Dis 2022 76 (3) e1087-e1093 BACKGROUND: Acellular pertussis (aP) vaccines replaced whole cell pertussis (wP) vaccines for the U.S. childhood primary series in 1997. As women primed with aP vaccines enter childbearing age, protection of infants through Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccination during pregnancy may be impacted. METHODS: Term infants born to women vaccinated with Tdap during pregnancy were included. Geometric mean concentrations (GMC) of pertussis-specific IgG antibodies (IU/mL) in cord blood of infants born to women born after 1997 (aP-primed) were compared with those born to women born before 1992 (wP-primed). RESULTS: 253 and 506 infants born to aP- and wP-primed women, respectively, were included. Compared with wP-primed women, aP-primed women were younger, more likely to be Hispanic or non-Hispanic Black, and had lower birthweight infants (p < 0.01 for all). Antibodies against pertussis toxin (PT) and filamentous hemagglutinin (FHA) were lower among infants born to aP-primed versus wP-primed women (PT: 17.3 vs. 36.4, GMC ratio 0.475 (95% Confidence Interval [CI], 0.408-0.552); FHA: 104.6 vs. 121.4, GMC ratio 0.861 (95% CI, 0.776-0.958)). No differences were observed for anti-fimbriae or anti-pertactin antibodies. CONCLUSIONS: Transplacental anti-pertussis antibody concentrations in infants of women vaccinated with Tdap during pregnancy differed by type of childhood vaccine the woman received. Notably, anti-PT antibody levels, considered most important in preventing severe infant disease, were lower in infants born to aP- vs. wP-primed women. Maternal Tdap vaccination may confer less protection against pertussis in young infants born to aP-primed than those born to wP-primed women. |
Pertussis Infections among pregnant women in the United States, 2012-2017
Skoff TH , Faulkner AE , Liang JL , Barnes M , Kudish K , Thomas E , Kenyon C , Hoffman M , Pradhan E , Liko J , Hariri S . Clin Infect Dis 2020 73 (11) e3836-e3841 BACKGROUND: Little is known about pertussis among pregnant women, a population at increased risk for severe morbidity from respiratory infections such as influenza. We used CDC's Enhanced Pertussis Surveillance (EPS) system to describe pertussis epidemiology among pregnant and non-pregnant women of childbearing age. METHODS: Pertussis cases in women aged 18-44 years with cough onset between 1/1/2012-12/31/2017 were identified in 7 EPS states. Surveillance data were collected through patient and provider interview and immunization registries. Bridged-race, intercensal population data and live birth estimates were used as denominators. RESULTS: 1,582 pertussis cases were identified among women aged 18-44 years; 5.1% (76/1499) of patients with known pregnancy status were pregnant at cough onset. Of pregnant patients with complete information, 81.7% (49/60) reported onset during the second or third trimester. The median age of pregnant and non-pregnant patients was 29.0 and 33.0 years, respectively. Most pregnant and non-pregnant patients were white (78.3% vs. 86.4%, p=0.09) and non-Hispanic (72.6% vs. 77.3%, p=0.35). Average annual pertussis incidence was 5.7/100,000 among pregnant and 7.3/100,000 among non-pregnant women. Compared to non-pregnant patients, more pregnant patients reported whoop (41.9% vs. 31.3%), post-tussive vomiting (58.1% vs. 47.9%) and apnea (37.3% vs. 29.0%); however, differences were not statistically significant (p>0.05 for all). A similar proportion of pregnant and non-pregnant patients reported ever having received Tdap (31.6% vs. 32.7%, p=0.84). CONCLUSIONS: Our analysis suggests that pertussis incidence and clinical characteristics of disease are similar among pregnant and non-pregnant women. Continued monitoring is important to further define pertussis epidemiology in pregnant women. |
Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 - United States, February 12-March 28, 2020.
CDC COVID-19 Response Team , Chow Nancy , Fleming-Dutra Katherine , Gierke Ryan , Hall Aron , Hughes Michelle , Pilishvili Tamara , Ritchey Matthew , Roguski Katherine , Skoff Tami , Ussery Emily . MMWR Morb Mortal Wkly Rep 2020 69 (13) 382-386 On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic (1). As of March 28, 2020, a total of 571,678 confirmed COVID-19 cases and 26,494 deaths have been reported worldwide (2). Reports from China and Italy suggest that risk factors for severe disease include older age and the presence of at least one of several underlying health conditions (3,4). U.S. older adults, including those aged ≥65 years and particularly those aged ≥85 years, also appear to be at higher risk for severe COVID-19-associated outcomes; however, data describing underlying health conditions among U.S. COVID-19 patients have not yet been reported (5). As of March 28, 2020, U.S. states and territories have reported 122,653 U.S. COVID-19 cases to CDC, including 7,162 (5.8%) for whom data on underlying health conditions and other known risk factors for severe outcomes from respiratory infections were reported. Among these 7,162 cases, 2,692 (37.6%) patients had one or more underlying health condition or risk factor, and 4,470 (62.4%) had none of these conditions reported. The percentage of COVID-19 patients with at least one underlying health condition or risk factor was higher among those requiring intensive care unit (ICU) admission (358 of 457, 78%) and those requiring hospitalization without ICU admission (732 of 1,037, 71%) than that among those who were not hospitalized (1,388 of 5,143, 27%). The most commonly reported conditions were diabetes mellitus, chronic lung disease, and cardiovascular disease. These preliminary findings suggest that in the United States, persons with underlying health conditions or other recognized risk factors for severe outcomes from respiratory infections appear to be at a higher risk for severe disease from COVID-19 than are persons without these conditions. |
Coronavirus Disease 2019 in Children - United States, February 12-April 2, 2020.
CDC COVID-19 Response Team , Bialek Stephanie , Gierke Ryan , Hughes Michelle , McNamara Lucy A , Pilishvili Tamara , Skoff Tami . MMWR Morb Mortal Wkly Rep 2020 69 (14) 422-426 As of April 2, 2020, the coronavirus disease 2019 (COVID-19) pandemic has resulted in >890,000 cases and >45,000 deaths worldwide, including 239,279 cases and 5,443 deaths in the United States (1,2). In the United States, 22% of the population is made up of infants, children, and adolescents aged <18 years (children) (3). Data from China suggest that pediatric COVID-19 cases might be less severe than cases in adults and that children might experience different symptoms than do adults (4,5); however, disease characteristics among pediatric patients in the United States have not been described. Data from 149,760 laboratory-confirmed COVID-19 cases in the United States occurring during February 12-April 2, 2020 were analyzed. Among 149,082 (99.6%) reported cases for which age was known, 2,572 (1.7%) were among children aged <18 years. Data were available for a small proportion of patients on many important variables, including symptoms (9.4%), underlying conditions (13%), and hospitalization status (33%). Among those with available information, 73% of pediatric patients had symptoms of fever, cough, or shortness of breath compared with 93% of adults aged 18-64 years during the same period; 5.7% of all pediatric patients, or 20% of those for whom hospitalization status was known, were hospitalized, lower than the percentages hospitalized among all adults aged 18-64 years (10%) or those with known hospitalization status (33%). Three deaths were reported among the pediatric cases included in this analysis. These data support previous findings that children with COVID-19 might not have reported fever or cough as often as do adults (4). Whereas most COVID-19 cases in children are not severe, serious COVID-19 illness resulting in hospitalization still occurs in this age group. Social distancing and everyday preventive behaviors remain important for all age groups as patients with less serious illness and those without symptoms likely play an important role in disease transmission (6,7). |
Geographic Differences in COVID-19 Cases, Deaths, and Incidence - United States, February 12-April 7, 2020.
CDC COVID-19 Response Team , Bialek Stephanie , Bowen Virginia , Chow Nancy , Curns Aaron , Gierke Ryan , Hall Aron , Hughes Michelle , Pilishvili Tamara , Ritchey Matthew , Roguski Katherine , Silk Benjamin , Skoff Tami , Sundararaman Preethi , Ussery Emily , Vasser Michael , Whitham Hilary , Wen John . MMWR Morb Mortal Wkly Rep 2020 69 (15) 465-471 Community transmission of coronavirus disease 2019 (COVID-19) was first detected in the United States in February 2020. By mid-March, all 50 states, the District of Columbia (DC), New York City (NYC), and four U.S. territories had reported cases of COVID-19. This report describes the geographic distribution of laboratory-confirmed COVID-19 cases and related deaths reported by each U.S. state, each territory and freely associated state,* DC, and NYC during February 12-April 7, 2020, and estimates cumulative incidence for each jurisdiction. In addition, it projects the jurisdiction-level trajectory of this pandemic by estimating case doubling times on April 7 and changes in cumulative incidence during the most recent 7-day period (March 31-April 7). As of April 7, 2020, a total of 395,926 cases of COVID-19, including 12,757 related deaths, were reported in the United States. Cumulative COVID-19 incidence varied substantially by jurisdiction, ranging from 20.6 cases per 100,000 in Minnesota to 915.3 in NYC. On April 7, national case doubling time was approximately 6.5 days, although this ranged from 5.5 to 8.0 days in the 10 jurisdictions reporting the most cases. Absolute change in cumulative incidence during March 31-April 7 also varied widely, ranging from an increase of 8.3 cases per 100,000 in Minnesota to 418.0 in NYC. Geographic differences in numbers of COVID-19 cases and deaths, cumulative incidence, and changes in incidence likely reflect a combination of jurisdiction-specific epidemiologic and population-level factors, including 1) the timing of COVID-19 introductions; 2) population density; 3) age distribution and prevalence of underlying medical conditions among COVID-19 patients (1-3); 4) the timing and extent of community mitigation measures; 5) diagnostic testing capacity; and 6) public health reporting practices. Monitoring jurisdiction-level numbers of COVID-19 cases, deaths, and changes in incidence is critical for understanding community risk and making decisions about community mitigation, including social distancing, and strategic health care resource allocation. |
Vital signs: Burden and prevention of influenza and pertussis among pregnant women and infants - United States
Lindley MC , Kahn KE , Bardenheier BH , D'Angelo DV , Dawood FS , Fink RV , Havers F , Skoff TH . MMWR Morb Mortal Wkly Rep 2019 68 (40) 885-892 INTRODUCTION: Vaccinating pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can reduce influenza and pertussis risk for themselves and their infants. METHODS: Surveillance data were analyzed to ascertain influenza-associated hospitalization among pregnant women and infant hospitalization and death associated with influenza and pertussis. An Internet panel survey was conducted during March 27-April 8, 2019, among women aged 18-49 years who reported being pregnant any time since August 1, 2018. Influenza vaccination before or during pregnancy was assessed among respondents with known influenza vaccination status who were pregnant any time during October 2018-January 2019 (2,097). Tdap receipt during pregnancy was assessed among respondents with known Tdap status who reported a live birth by their survey date (817). RESULTS: From 2010-11 to 2017-18, pregnant women accounted for 24%-34% of influenza-associated hospitalizations per season among females aged 15-44 years. From 2010 to 2017, a total of 3,928 pertussis-related hospitalizations were reported among infants aged <2 months (annual range = 262-743). Maternal influenza and Tdap vaccination coverage rates reported as of April 2019 were 53.7% and 54.9%, respectively. Among women whose health care providers offered vaccination or provided referrals, 65.7% received influenza vaccine and 70.5% received Tdap. The most commonly reported reasons for nonvaccination were believing the vaccine is not effective (influenza; 17.6%) and not knowing that vaccination is needed during each pregnancy (Tdap; 37.9%), followed by safety concerns for the infant (influenza =15.9%; Tdap = 17.1%). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Many pregnant women do not receive the vaccines recommended to protect themselves and their infants, even when vaccination is offered. CDC and provider organizations' resources are available to help providers convey strong, specific recommendations for influenza and Tdap vaccination that are responsive to pregnant women's concerns. |
Maternal vaccination in Argentina: Tdap vaccine effectiveness during pregnancy in preventing pertussis in infants less than 2 months of age
Romanin V , Acosta AM , Juarez MDV , Briere E , Sanchez SM , Cordoba BL , Sevilla ME , Lucion MF , Urrutia A , Sagradini S , Skoff TH , Vizzotti C . Clin Infect Dis 2019 70 (3) 380-387 BACKGROUND: In 2011, Argentina experienced the highest pertussis incidence and mortality rates in the last decade; 60% of deaths were among infants aged <2 months. In response, a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine was recommended for all pregnant women at >/=20 weeks of gestation. Although recent studies suggest maternal Tdap vaccination is effective at preventing infant disease, no data have come from low or middle-income countries, nor from ones using whole-cell pertussis vaccines for primary immunization. METHODS: We conducted a matched case-control evaluation to assess the effectiveness of maternal Tdap vaccination in preventing pertussis among infants aged <2 months in Argentina. Pertussis case-patients identified from September 2012 to March 2016 at six hospital sites and confirmed by polymerase chain reaction testing were included. Five randomly selected controls were matched to each case-patient by hospital site and mother's health district. We used multivariable conditional logistic regression to calculate odds ratios (ORs). Vaccine effectiveness (VE) was estimated as (1 - OR) x 100%. RESULTS: Seventy-one case-patients and 300 controls were included in the analysis. Forty-nine percent of case-patients and 78% of controls had mothers who were vaccinated during pregnancy. Overall Tdap VE was estimated at 80.7% (95% confidence intervals: 52.1%-92.2%). We found similar VE whether Tdap was administered during the second or third trimester. CONCLUSIONS: Tdap vaccination during pregnancy is effective in preventing pertussis in infants aged <2 months in Argentina, with similar effectiveness whether administered during the second or third trimester of pregnancy. |
Severe pertussis infections in the United States, 2011-2015
Mbayei SA , Faulkner A , Miner C , Edge K , Cruz V , Pena SA , Kudish K , Coleman J , Pradhan E , Thomas S , Martin S , Skoff TH . Clin Infect Dis 2018 69 (2) 218-226 Background: The incidence of pertussis in the United States has increased in recent years. While characteristics of severe pertussis infection have been described in infants, fewer data are available in older children and adults. In this analysis, we characterize pertussis infections in hospitalized patients of all ages. Methods: Cases of pertussis with cough onset from January 1, 2011 through December 31, 2015 from 7 U.S. Emerging Infections Program Network states were reviewed. Additional information on hospitalized patients was obtained through abstraction of the inpatient medical record. Descriptive and multivariable analyses were conducted to characterize severe pertussis infection and identify potential risk factors. Results: Among 15,942 cases of pertussis reported, 515 (3.2%) were hospitalized. Three hospitalized patients died. Infants aged <2 months accounted for 1.6% of all pertussis cases but 29.3% of hospitalizations. Infants aged 2-11 months and adults aged >/=65 years also had high rates of hospitalization. Infants aged <2 months whose mothers received Tdap during the 3 rd trimester and children aged 2 months to 11 years who were up to date on pertussis-containing vaccines had a 43-66% reduced risk of hospitalization. Among adolescents aged 12-20 years, 43.5% had a history of asthma and among adults and >/=65 years, 26.8% had a history of chronic obstructive pulmonary disease. Conclusions: Individuals at the extreme ends of life may be the most vulnerable to severe pertussis infections, though hospitalization was reported across all age groups. Continued monitoring of severe pertussis infections will be important to help guide prevention, control, and treatment options. |
The epidemiology of nationally reported pertussis in the United States, 2000-2016
Skoff TH , Hadler S , Hariri S . Clin Infect Dis 2018 68 (10) 1634-1640 Background: Despite successful vaccination programs, pertussis remains endemic in the United States and increasing incidence has been reported. We used national surveillance data to describe pertussis epidemiology, including patient demographic characteristics, geographic distribution, and temporal trends. Methods: We included cases reported through the National Notifiable Diseases Surveillance System between January 1, 2000 and December 31, 2016. Differences in case characteristics were compared using Pearson's 2. Average annual incidence (cases per 100,000 population) was calculated overall, and by age (<1 year, 1-6 years, 7-10 years, 11-18 years, 19-39 years, 30-64 years, and >/=65 years) and geographic subgroup. Negative binomial regression was used to calculate annual percent change. Results: During 2000-2016, 339,420 pertussis cases were reported. The majority were in white (88.2%) and non-Hispanic (81.3%) persons, 9.9% resulted in hospitalization, and 0.1% were fatal; however, differences existed by age. Infants had the highest incidence (75.3/100,000 population), accounting for 88.8% of deaths. Incidence increased significantly over time (p=0.0019), with baseline rates rising 1.7-fold between 2000-2008 and 2009-2016; increases were observed for all groups except persons aged <1 year and 19-64 years. Elevated case counts among persons aged 7-10 and 11-18 years coincided with the aging of acellular-primed birth cohorts. Incidence varied by geographic region, with some similarities in disease cyclicity. Conclusions: Increasing baseline incidence and changing age distribution of pertussis suggest a central role of the transition to acellular vaccines in the U.S. disease resurgence. Continued monitoring of national surveillance data is important to evaluate and optimize pertussis prevention and control strategies. |
Assessment of Tdap vaccination effectiveness in adolescents in integrated health-care systems
Briere EC , Pondo T , Schmidt M , Skoff T , Shang N , Naleway A , Martin S , Jackson ML . J Adolesc Health 2018 62 (6) 661-666 PURPOSE: Despite high national vaccination coverage with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines among U.S. adolescents, rates of adolescent pertussis disease are increasing. We estimated the duration of protection after Tdap vaccination and the possible effects of the change from whole-cell to acellular childhood pertussis vaccines in the United States during the 1990s. METHODS: We conducted a retrospective cohort analysis among 11- to 18-year-olds enrolled in two integrated health-care delivery systems during 2005-2012. Cases met the Council of State and Territorial Epidemiologists' confirmed or probable definition or a polymerase chain reaction-positive suspect definition. We estimated vaccine effectiveness (VE) overall and by time since Tdap receipt. We stratified VE estimates by primary series pertussis vaccine received (based on birth year): mixed-vaccine cohort (1987-1997) and acellular vaccine cohort (1998-2001). RESULTS: The overall Tdap VE was 57% (95% confidence interval [CI]: 42%-68%); the VE in the mixed-vaccine and acellular cohorts was 65% (95% CI: 44%-78%) and 52% (95% CI: 30%-68%), respectively. Tdap VE within <2 years post vaccination (69%, 95% CI: 54%-79%) was significantly different from VE >/=2 years post vaccination (34%, 95% CI: 1%-55%, p value < .01). VE was significantly higher <2 years post vaccination compared with >/=2 years post vaccination in both mixed-vaccine (87%, 95% CI: 58%-96%, and 52%, 95% CI: 13%-73%; p value = .04) and acellular cohorts (62%, 95% CI: 41%-76%, and 21%, 95% CI: -30% to 52%; p value = .01). CONCLUSIONS: Although Tdap vaccination remains the best pertussis prevention method for adolescents, protection wanes within 2 years regardless of the type of childhood primary vaccine. Vaccines with longer duration of protection could decrease pertussis burden. |
Impact of the US maternal tetanus, diphtheria, and acellular pertussis vaccination program on preventing pertussis in infants <2 months of age: A case-control evaluation
Skoff TH , Blain AE , Watt J , Scherzinger K , McMahon M , Zansky SM , Kudish K , Cieslak PR , Lewis M , Shang N , Martin SW . Clin Infect Dis 2017 65 (12) 1977-1983 Background: Infants aged <1 year are at highest risk for pertussis-related morbidity and mortality. In 2012, Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccine was recommended for women during each pregnancy to protect infants in the first months of life; data on effectiveness of this strategy are currently limited. Methods: We conducted a case-control evaluation among pertussis cases <2 months old with cough onset between 1 January 2011 and 31 December 2014 from 6 US Emerging Infection Program Network states. Controls were hospital-matched and selected by birth certificate. Mothers were interviewed to collect information on demographics, household characteristics, and healthcare providers. Provider-verified immunization history was obtained on mothers and infants. Mothers were considered vaccinated during pregnancy if Tdap was received ≥14 days before delivery; trimester was calculated using Tdap date, infant's date of birth, and gestational age. Odds ratios were calculated using multivariable conditional logistic regression; vaccine effectiveness (VE) was estimated as (1 - odds ratio) x 100%. Results: A total of 240 cases and 535 controls were included; 17 (7.1%) case mothers and 90 (16.8%) control mothers received Tdap during the third trimester of pregnancy. The multivariable VE estimate for Tdap administered during the third trimester of pregnancy was 77.7% (95% confidence interval [CI], 48.3%-90.4%); VE increased to 90.5% (95% CI, 65.2%-97.4%) against hospitalized cases. Conclusions: Vaccination during pregnancy is an effective way to protect infants during the early months of life. With a continuing resurgence in pertussis, efforts should focus on maximizing Tdap uptake among pregnant women. |
Reduced severity of pertussis in persons with age-appropriate pertussis vaccination - United States, 2010-2012
McNamara LA , Skoff T , Faulkner A , Miller L , Kudish K , Kenyon C , Bargsten M , Zansky S , Sullivan AD , Martin S , Briere E . Clin Infect Dis 2017 65 (5) 811-818 Background: In 2012, >48000 pertussis cases were reported in the United States. Many cases occurred in vaccinated persons, showing that pertussis vaccination does not prevent all pertussis cases. However, pertussis vaccination may have an impact on disease severity. Methods: We analyzed data on probable and confirmed pertussis cases reported through Enhanced Pertussis Surveillance (Emerging Infections Program Network) between 2010 and 2012. Surveillance data were collected through physician and patient interview and vaccine registries. We assessed whether having received an age-appropriate number of pertussis vaccines (AAV) (for persons aged ≥3 months) was associated with reduced odds of posttussive vomiting, a marker of more clinically significant illness, or of severe pertussis (seizure, encephalopathy, pneumonia, and/or hospitalization). Adjusted odds ratios were calculated using multivariable logistic regression. Results: Among 9801 pertussis patients aged ≥3 months, 77.6% were AAV. AAV status was associated with a 60% reduction in odds of severe disease in children aged 7 months-6 years in multivariable logistic regression and a 30% reduction in odds of posttussive vomiting in persons aged 19 months-64 years. Conclusions: Serious pertussis symptoms and complications are less common among AAV pertussis patients, demonstrating that the positive impact of pertussis vaccination extends beyond decreasing risk of disease. |
Surveillance of vaccination coverage among adult populations - United States, 2015
Williams WW , Lu PJ , O'Halloran A , Kim DK , Grohskopf LA , Pilishvili T , Skoff TH , Nelson NP , Harpaz R , Markowitz LE , Rodriguez-Lainz A , Fiebelkorn AP . MMWR Surveill Summ 2017 66 (11) 1-28 PROBLEM/CONDITION: Overall, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults is low. PERIOD COVERED: August 2014-June 2015 (for influenza vaccination) and January-December 2015 (for pneumococcal, tetanus and diphtheria [Td] and tetanus and diphtheria with acellular pertussis [Tdap], hepatitis A, hepatitis B, herpes zoster, and human papillomavirus [HPV] vaccination). DESCRIPTION OF SYSTEM: The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. The survey objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. RESULTS: Compared with data from the 2014 NHIS, increases in vaccination coverage occurred for influenza vaccine among adults aged ≥19 years (a 1.6 percentage point increase compared with the 2013-14 season to 44.8%), pneumococcal vaccine among adults aged 19-64 years at increased risk for pneumococcal disease (a 2.8 percentage point increase to 23.0%), Tdap vaccine among adults aged ≥19 years and adults aged 19-64 years (a 3.1 percentage point and 3.3 percentage point increase to 23.1% and to 24.7%, respectively), herpes zoster vaccine among adults aged ≥60 years and adults aged ≥65 years (a 2.7 percentage point and 3.2 percentage point increase to 30.6% and to 34.2%, respectively), and hepatitis B vaccine among health care personnel (HCP) aged ≥19 years (a 4.1 percentage point increase to 64.7%). Herpes zoster vaccination coverage in 2015 met the Healthy People 2020 target of 30%. Aside from these modest improvements, vaccination coverage among adults in 2015 was similar to estimates from 2014. Racial/ethnic differences in coverage persisted for all seven vaccines, with higher coverage generally for whites compared with most other groups. Adults without health insurance reported receipt of influenza vaccine (all age groups), pneumococcal vaccine (adults aged 19-64 years at increased risk), Td vaccine (adults aged ≥19 years, 19-64 years, and 50-64 years), Tdap vaccine (adults aged ≥19 years and 19-64 years), hepatitis A vaccine (adults aged ≥19 years overall and among travelers), hepatitis B vaccine (adults aged ≥19 years, 19-49 years, and among travelers), herpes zoster vaccine (adults aged ≥60 years), and HPV vaccine (males and females aged 19-26 years) less often than those with health insurance. Adults who reported having a usual place for health care generally reported receipt of recommended vaccinations more often than those who did not have such a place, regardless of whether they had health insurance. Vaccination coverage was higher among adults reporting one or more physician contacts in the past year compared with those who had not visited a physician in the past year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts within the past year, depending on the vaccine, 18.2%-85.6% reported not having received vaccinations that were recommended either for all persons or for those with specific indications. Overall, vaccination coverage among U.S.-born adults was higher than that among foreign-born adults, with few exceptions (influenza vaccination [adults aged 19-49 years and 50-64 years], hepatitis A vaccination [adults aged ≥19 years], and hepatitis B vaccination [adults aged ≥19 years with diabetes or chronic liver conditions]). INTERPRETATION: Coverage for all vaccines for adults remained low but modest gains occurred in vaccination coverage for influenza (adults aged ≥19 years), pneumococcal (adults aged 19-64 years with increased risk), Tdap (adults aged ≥19 years and adults aged 19-64 years), herpes zoster (adults aged ≥60 years and ≥65 years), and hepatitis B (HCP aged ≥19 years); coverage for other vaccines and groups with vaccination indications did not improve. The 30% Healthy People 2020 target for herpes zoster vaccination was met. Racial/ethnic disparities persisted for routinely recommended adult vaccines. Missed opportunities to vaccinate remained. Although having health insurance coverage and a usual place for health care were associated with higher vaccination coverage, these factors alone were not associated with optimal adult vaccination coverage. HPV vaccination coverage for males and females has increased since CDC recommended vaccination to prevent cancers caused by HPV, but many adolescents and young adults remained unvaccinated. PUBLIC HEALTH ACTIONS: Assessing factors associated with low coverage rates and disparities in vaccination is important for implementing strategies to improve vaccination coverage. Evidence-based practices that have been demonstrated to improve vaccination coverage should be used. These practices include assessment of patients' vaccination indications by health care providers and routine recommendation and offer of needed vaccines to adults, implementation of reminder-recall systems, use of standing-order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members. For vaccination coverage to be improved among those who reported lower coverage rates of recommended adult vaccines, efforts also are needed to identify adults who do not have a regular provider or insurance and who report fewer health care visits. |
An assessment of the cocooning strategy for preventing infant pertussis-United States, 2011
Blain AE , Lewis M , Banerjee E , Kudish K , Liko J , McGuire S , Selvage D , Watt J , Martin SW , Skoff TH . Clin Infect Dis 2016 63 S221-s226 BACKGROUND: Infants are at greatest risk for severe pertussis. In 2006, the Advisory Committee on Immunization Practices recommended that adolescents and adults, especially those with infant contact, receive a single dose of Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine). To assess the effectiveness of cocooning, we conducted a case-control evaluation of infant close contacts. METHODS: Pertussis cases aged <2 months with onset between 1 January 2011 and 31 December 2011 were identified in Emerging Infections Program Network sites. For each case, we recruited 3 controls from birth certificates and interviewed identified adult close contacts (CCs) or parents of CCs aged <18 years. Pertussis vaccination was verified through medical providers and/or immunization registries. RESULTS: Forty-two cases were enrolled, with 154 matched controls. Around enrolled infants, 859 CCs were identified (600 adult and 259 nonadult). An average of 5.4 CCs was identified per case and 4.1 CCs per control. Five hundred fifty-four (64.5%) CCs were enrolled (371 adult and 183 non-adult CCs); 119 (32.1% of enrolled) adult CCs had received Tdap. The proportion of Tdap-vaccinated adult CCs was similar between cases and controls (P = .89). The 600 identified adult CCs comprised 172 potential cocoons; 71 (41.3%) potential cocoons had all identified adult CCs enrolled. Of these, 9 were fully vaccinated and 43.7% contained no Tdap-vaccinated adults. The proportion of fully vaccinated case (4.8%) and control (10.0%) cocoons was similar (P = .43). CONCLUSIONS: Low Tdap coverage among adult CCs reinforces the difficulty of implementing the cocooning strategy and the importance of vaccination during pregnancy to prevent infant pertussis. |
Impact of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccinations on reported pertussis cases among those 11 to 18 years of age in an era of waning pertussis immunity: a follow-up analysis
Skoff TH , Martin SW . JAMA Pediatr 2016 170 (5) 453-8 IMPORTANCE: There is accumulating literature on waning acellular pertussis vaccine-induced immunity, confirming the results of studies assessing the duration of protection of pertussis vaccines. OBJECTIVE: To evaluate the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine's effect over time among those 11 to 18 years old, while accounting for the transition from whole-cell to acellular pertussis vaccines for the childhood primary series. DESIGN, SETTING, AND PARTICIPANTS: Extended, retrospective analysis of reported pertussis cases between January 1, 1990, and December 31, 2014, in the United States. The analysis included all nationally reported pertussis cases. Exposure: US Tdap vaccination program and the transition from whole-cell to acellular pertussis vaccines. MAIN OUTCOMES AND MEASURES: Rate ratios of reported pertussis incidence (defined as incidence among 11- to 18-year-old individuals divided by the combined incidence in all other age groups) modeled with segmented regression analysis and age-specific trends in reported pertussis incidence over time. RESULTS: Between 1990 and 2014, 356557 pertussis cases were reported in the United States. Of those, 191914 (53.8%) were female and 240665 (67.5%) were white. Overall incidence increased from 1.7 in 100000 to 4.0 in 100000 between 1990 and 2003, while latter years were dominated by epidemic peaks. Incidence was highest among infants younger than 1 year throughout the analysis period. Pertussis rates were comparable among all other age groups until the late 2000s, when an increased burden of pertussis emerged among children 1 to 10 years old, resulting in the second highest age-specific incidence. By 2014, 11- to 18-year-old individuals once again had the second highest incidence. While slope coefficients from segmented regression analysis showed a positive impact of Tdap immediately following introduction (slope, -0.4959; P < .001), a reversal in trends was observed in 2010 when rates of disease among 11- to 18-year-old individuals increased at a faster rate than all other age groups combined (slope, 0.5727; P < .001). CONCLUSIONS AND RELEVANCE: While the impact of Tdap among adolescents looked promising following vaccine introduction, our extended analysis found that trends in adolescent disease were abruptly reversed in 2010, corresponding directly to the aging of acellular pertussis-vaccinated cohorts. Despite the apparent limitations of Tdap, it remains the best prevention against disease in adolescents. |
Changes in predominance of pulsed-field gel electrophoresis profiles of Bordetella pertussis isolates, United States, 2000-2012
Cassiday PK , Skoff TH , Jawahir S , Tondella ML . Emerg Infect Dis 2016 22 (3) 442-8 To clarify the characteristics of circulating Bordetella pertussis isolates, we used pulsed-field gel electrophoresis (PFGE) to analyze 5,262 isolates collected in the United States during 2000-2012. We found 199 PFGE profiles; 5 profiles accounted for 72% of isolates. The most common profile, CDC013, accounted for 35%-46% of isolates tested from 2000-2009; however, the proportion of isolates of this profile rapidly decreased in 2010. Profile CDC237, first seen in 2009, increased rapidly and accounted for 29% of 2012 isolates. No location bias was observed among profiles during 2000-2010, but differences were observed among isolates from different states during 2012. Predominant profiles match those observed in recent European PFGE studies. PFGE profile changes are concurrent with other recent molecular changes in B. pertussis and may be contributing to the reemergence of pertussis in the United States. Continued PFGE monitoring is critical for understanding the changing epidemiology of pertussis. |
Surveillance of vaccination coverage among adult populations - United States, 2014
Williams WW , Lu PJ , O'Halloran A , Kim DK , Grohskopf LA , Pilishvili T , Skoff TH , Nelson NP , Harpaz R , Markowitz LE , Rodriguez-Lainz A , Bridges CB . MMWR Surveill Summ 2016 65 (1) 1-36 PROBLEM/CONDITION: Overall, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults is low. REPORTING PERIOD: August 2013-June 2014 (for influenza vaccination) and January-December 2014 (for pneumococcal, tetanus and diphtheria [Td] and tetanus and diphtheria with acellular pertussis [Tdap], hepatitis A, hepatitis B, herpes zoster, and human papillomavirus [HPV] vaccination). DESCRIPTION OF SYSTEM: The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. The survey objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors. RESULTS: Compared with data from the 2013 NHIS, increases in vaccination coverage occurred for Tdap vaccine among adults aged ≥19 years (a 2.9 percentage point increase to 20.1%) and herpes zoster vaccine among adults aged ≥60 years (a 3.6 percentage point increase to 27.9%). Aside from these modest improvements, vaccination coverage among adults in 2014 was similar to estimates from 2013 (for influenza coverage, similar to the 2012-13 season). Influenza vaccination coverage among adults aged ≥19 years was 43.2%. Pneumococcal vaccination coverage among high-risk persons aged 19-64 years was 20.3% and among adults aged ≥65 years was 61.3%. Td vaccination coverage among adults aged ≥19 years was 62.2%. Hepatitis A vaccination coverage among adults aged ≥19 years was 9.0%. Hepatitis B vaccination coverage among adults aged ≥19 years was 24.5%. HPV vaccination coverage among adults aged 19-26 years was 40.2% for females and 8.2% for males. Racial/ethnic differences in coverage persisted for all seven vaccines, with higher coverage generally for whites compared with most other groups. Adults without health insurance were significantly less likely than those with health insurance to report receipt of influenza vaccine (aged ≥19 years), pneumococcal vaccine (aged 19-64 years with high-risk conditions and aged ≥65 years), Td vaccine (aged ≥19 years), Tdap vaccine (aged ≥19 years and 19-64 years), hepatitis A vaccine (aged ≥19 years overall and among travelers), hepatitis B vaccine (aged ≥19 years, 19-49 years, and 19-59 years with diabetes), herpes zoster vaccine (aged ≥60 years and 60-64 years), and HPV vaccine (females aged 19-26 years and males aged 19-26 years). Adults who reported having a usual place for health care generally were more likely to receive recommended vaccinations than those who did not have a usual place for health care, regardless of whether they had health insurance. Vaccination coverage was significantly higher among those reporting one or more physician contacts in the past year compared with those who had not visited a physician in the past year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended either for all persons or for those with some specific indication. Overall, vaccination coverage among U.S.-born respondents was significantly higher than that of foreign-born respondents with few exceptions (influenza vaccination [adults aged 19-49 years], hepatitis A vaccination [adults aged ≥19 years], hepatitis B vaccination [adults with diabetes aged ≥60 years], and HPV vaccination [males aged 19-26 years]). INTERPRETATION: Overall, increases in adult vaccination coverage are needed. Although modest gains occurred in Tdap vaccination coverage among adults aged ≥19 years and herpes zoster vaccination coverage among adults aged ≥60 years, coverage for other vaccines and risk groups did not improve, and racial/ethnic disparities persisted for routinely recommended adult vaccines. Coverage for all vaccines for adults remained low, and missed opportunities to vaccinate adults continued. Although having health insurance coverage and a usual place for health care are associated with higher vaccination coverage, these factors alone do not assure optimal adult vaccination coverage. PUBLIC HEALTH ACTIONS: Assessing associations with vaccination is important for understanding factors that contribute to low coverage rates and to disparities in vaccination, and for implementing strategies to improve vaccination coverage. Practices that have been demonstrated to improve vaccination coverage should be used. These practices include assessment of patients' vaccination indications by health care providers and routine recommendation and offer of needed vaccines to adults, implementation of reminder-recall systems, use of standing-order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members. For vaccination to be improved among those least likely to be up-to-date on recommended adult vaccines, efforts also are needed to identify adults who do not have a regular provider or insurance and who report fewer health care visits. |
Bordetella pertussis Strain Lacking Pertactin and Pertussis Toxin.
Williams MM , Sen K , Weigand MR , Skoff TH , Cunningham VA , Halse TA , Tondella ML . Emerg Infect Dis 2016 22 (2) 319-22 ![]() A Bordetella pertussis strain lacking 2 acellular vaccine immunogens, pertussis toxin and pertactin, was isolated from an unvaccinated infant in New York State in 2013. Comparison with a French strain that was pertussis toxin-deficient, pertactin wild-type showed that the strains carry the same 28-kb deletion in similar genomes. |
Trends in pertussis diagnostic testing in the United States, 1990-2012
Faulkner AE , Skoff TH , Tondella ML , Cohn A , Clark TA , Martin SW . Pediatr Infect Dis J 2015 35 (1) 39-44 BACKGROUND: Reports of pertussis have been increasing in the U.S. since the 1990s and pertussis diagnostics have evolved during that time. Here we describe temporal changes in pertussis diagnostic practices in the U.S. during 1990-2012 and discuss potential implications. METHODS: Pertussis cases reported through the National Notifiable Diseases Surveillance System (NNDSS) during 1990- 2012 were included in this analysis. Laboratory results were stratified by test type, case classification, age group, and case-patient state of residence. RESULTS: 291,290 cases were included with 64% (n=186,766) reporting at least one pertussis laboratory result. Culture and DFA were the primary results reported during the early 1990s; however, PCR surpassed all other test types during the late 1990s and 2000s. By 2012 more than 91% of cases with known results were tested using PCR, either alone or in combination with another test type. Before 2005, Massachusetts reported 71% of serology results, but an increasing number of states reported serologic results during 2005-2012. When stratified by age group, overall testing trends persist. As of 2012, culture confirmation is used infrequently across all ages, while use of serology increases with age and is most prevalent among adults aged ≥ 20 years. CONCLUSIONS: PCR has become the primary diagnostic method, and serologic assays now are used in a majority of states. Epidemiologic trends must be considered in the context of changing diagnostic tests, and modifications to surveillance case definitions should be considered to better reflect current testing practices. |
Sources of infant pertussis infection in the United States
Skoff TH , Kenyon C , Cocoros N , Liko J , Miller L , Kudish K , Baumbach J , Zansky S , Faulkner A , Martin SW . Pediatrics 2015 136 (4) 635-41 BACKGROUND: Pertussis is poorly controlled, with the highest rates of morbidity and mortality among infants. Although the source of infant pertussis is often unknown, when identified, mothers have historically been the most common reservoir of transmission. Despite high vaccination coverage, disease incidence has been increasing. We examined whether infant source of infection (SOI) has changed in the United States in light of the changing epidemiology. METHODS: Cases <1 year old were identified at Enhanced Pertussis Surveillance sites between January 1, 2006 to December 31, 2013. SOI was collected during patient interview and was defined as a suspected pertussis case in contact with the infant case 7 to 20 days before infant cough onset. RESULTS: A total of 1306 infant cases were identified; 24.2% were <2 months old. An SOI was identified for 569 cases. Infants 0 to 1 months old were more likely to have an SOI identified than 2- to 11-month-olds (54.1% vs 40.2%, respectively; P < .0001). More than 66% of SOIs were immediate family members, most commonly siblings (35.5%), mothers (20.6%), and fathers (10.0%); mothers predominated until the transition to siblings beginning in 2008. Overall, the SOI median age was 14 years (range: 0-74 years); median age for sibling SOIs was 8 years. CONCLUSIONS: In contrast to previous studies, our data suggest that the most common source of transmission to infants is now siblings. While continued monitoring of SOIs will optimize pertussis prevention strategies, recommendations for vaccination during pregnancy should directly increase protection of infants, regardless of SOI. |
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