- Email: [email protected]
Pertussis: An Ounce of Prevention
In Practice
Pertussis An Ounce of Prevention
t
The Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP) and the Department of Health and Human Services (DHHS) recommend that all women in the immediate postpartum period receive vaccination for prevention of pertussis. In January 2010, we implemented an immunization program that has resulted in 58 percent of our postpartum patients receiving Tdap vaccine before discharge. This article reviews pertinent facts about pertussis and discusses how we implemented our vaccination program.
About Pertussis Pertussis is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. It’s spread from person to person by coughing or sneezing while in close contact with others. Pertussis is diagnosed through a detailed history that indicates exposure to the disease,
http://nwh.awhonn.org
Anne Shea-Lewis, RNC-NIC, BS, MBA Cecilia Hill, RN, BS Susan Soper, RNC, BSN, MSN
physical exam and a culture of nasopharyngeal secretions (CDC, 2006).
Clinical Course The clinical course of pertussis is divided into three stages: catarrhal, paroxysmal and convalescent. Symptoms of the catarrhal stage are similar to those of the common cold and include mild upper respiratory symptoms, lowgrade fever, runny nose, sneezing and a mild cough. As the illness progresses over 7 to 14 days, the cough becomes more severe. This, the paroxysmal phase, is distinguished by episodes of spasmodic coughing, sometimes followed by an inspiratory whooping sound. The attacks occur more frequently at night, and vomiting and exhaustion commonly follow the coughing episodes. The paroxysmal stage usually lasts from
© 2011, AWHONN
325
In Practice
1 to 6 weeks, but can persist for up to 10 weeks. Recovery is gradual, with the final phase, the convalescent phase, lasting for weeks to months. The gradual onset and recovery associated with pertussis has earned it the nickname “the 100day cough” (New York State Department of Health, Bureau of Immunization, 2011).
pneumonia, 50 percent exhibit apnea and 1 percent die (CDC, 2006, 2008). Up to 83 percent of infants who contract pertussis are infected by parents and caregivers. Therefore, revaccination of adolescents and adults in close contact with infants will reduce the incidence of pertussis infection in infancy (Wendelboe et al., 2007).
Pertussis in Infants
Recent Resurgence
Symptoms and complications of pertussis infection in adults tend to be milder than in the pediatric population (CDC, 2006, 2008). In infants younger than 6 months of age, pertussis has a shorter catarrhal stage and is more severe, especially in the preterm population (New York State Department of Health, Bureau of Immunization, 2011). According to the CDC, more than half of infants younger than 1 year of age who
Resurgence in pertussis infection in the United States has been well-documented over the last several years, most notably in California, where the number of cases reported in 2010 was seven times the number in 2009, and there were eight infant deaths. Pennsylvania, New York, South Carolina, Ohio and Michigan have also reported a significant increase in the incidence of pertussis infection (Roehr, 2010). The resurgence of pertussis has resulted in an increased risk for pertussis infection among health care workers. This is thought to be related to an increased opportunity for exposure and to weakening vaccine-induced immunity (He & Mertsola, 2008).
Of infants who are hospitalized with pertussis, approximately 20 percent develop pneumonia, 50 percent exhibit apnea and 1 percent die
become infected with pertussis must be hospitalized. Of infants who are hospitalized with pertussis, approximately 20 percent develop
Prevention Through Vaccination Pertussis can be treated with antibiotics, which, if started early, may make the infection less severe and help prevent transmission. However, the best way to prevent pertussis is through vaccination. The recommended pertussis vaccine for infants and children is a combination vaccine, DTaP,
Anne Shea-Lewis, RNCNIC, BS, MBA, is director of maternal-child health; Cecilia Hill, RN, BS, is director of infection control; Susan Soper, RNC, BSN, MSN, is assistant nursing care coordinator of maternal-child health; all authors are at St. Charles Hospital in Port Jefferson, NY. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: anne.shea-lewis@ chsli.org. DOI: 10.1111/j.1751-486X.2011.01653.x
326
Nursing for Women’s Health
Volume 15
Issue 4
Box 1.
Tdap Screening Questionnaire and Consent
Nurse completing screening: _______________________ Date: _____ Time: _____ Tetanus, Diphtheria and Pertussis (Tdap) Screening Inclusion Criteria (Target Population) ¨ Postpartum patient - vaccinate ¨ Vaccination status is unknown, and patient is otherwise eligible, vaccinate Exclusion Criteria ¨ Received Td (Tetanus, Diphtheria) vaccine during pregnancy ¨ Serious reaction to prior Tdap vaccine ¨ History of Guillain-Barré Syndrome ¨ History of encephalopathy not attributable to identifiable cause within 7 days of administration of a vaccine with pertussis components ¨ Patient refusal
Breastfeeding is NOT an exclusion criterion. Patient Consent: I have read, or had explained to me, the vaccine information sheet (VIS) about the Tdap vaccination. (Print date of the VIS provided _____________). I have had a chance to ask questions which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. ¨ I request that the Tdap vaccination be given to me (or the person named above for whom I am authorized to make this request.) ¨ I decline the Tdap vaccination for myself (or the person named above for whom I am authorized to make this request.) I authorize the release of any medical or other information necessary to process an insurance claim or for other public health purpose. _________________________________________ Signature of recipient (parent or guardian)
__________________ Date
__________________________________________ __________________ Witness Signature Date STANDING Tdap VACCINE ORDER ¨ Patient has history of Guillain-Barré. Do NOT vaccinate. ¨ Patient has contraindications for vaccination. Do NOT vaccinate. ¨ Not a candidate for Tdap vaccination based on assessment. ¨ Patient has indication for vaccination. Administer Tdap vaccine 0.5 mL IM deltoid on day of discharge IF temp less than 100.4°F Affix Vaccine sticker here ______________________________ _______________ Place vaccine label here RN Signature Date
which protects against diphtheria, tetanus and acellular pertussis. For maximum protection, children need five DTaP immunizations. The DTaP immunization schedule includes vaccinations given at 2, 4 and 6 months of age; a fourth vaccination between 15 and 18 months of age and a fifth vaccination at 4 to 6 years of age (CDC, 2006, 2008). For those who have completed the recommended
August | September 2011
childhood DTaP series, ACIP recommends a single tetanus, diphtheria and acellular pertussis (Tdap) dose for people ages 11 through 18 years and for adults ages 19 through 64 years (CDC, 2011).
Implementing our Vaccination Program In January 2010, we instituted a program to offer pertussis vaccine to our
postpartum patients. By the end of the first quarter, we realized that participation in our vaccine program was less than 1 percent of postpartum patients. We developed a multidisciplinary team consisting of the chair of the pediatric department, chair of the obstetrics department, director of infection control, director of pharmacy, chief medical officer, chief nursing officer,
Nursing for Women’s Health
327
In Practice
director of maternal-child health and nursing staff in maternal-child health. A Tdap patient screening questionnaire (see Box 1), modeled on our successful influenza vaccination screening questionnaire, was instituted. The Tdap patient screening questionnaire was reviewed by all team members and presented to the Medical Board for approval. This screening questionnaire was to be completed by nurses on the mother-baby unit for all maternity patients. It included contraindications to vaccination as well as a non-patient-specific standing order to administer a single dose of Tdap vaccine on the date of discharge. In New York State, a non-patient-specific order authorizes registered nurses to administer immunizations to patients. Tdap is one of the
The best way to prevent pertussis is through vaccination
immunizations listed in the ACIP and CDC guidelines that may be administered using non-patient-specific orders and following specific protocols (New York State Department of Health, Bureau of Immunization, 2011).
328
Nursing for Women’s Health
If a postpartum patient met the inclusion criteria, she was provided with the most recent vaccine information sheet, made available by the CDC, and consent for vaccine was obtained. The vaccine was administered intramuscularly. As syncope may occur after vaccination, nursing staff observed patients for 15 minutes after they received vaccination, following ACIP recommendations (CDC, 2008). The staff nurse provided patient education regarding pertussis infection, including the symptoms of pertussis, and encouraged vaccination of household and child care provider contacts. Educational material included written information as well as on-demand video training available on the hospital’s internal television network. We installed educational posters and pamphlets in public areas of the maternity unit as well as in delivery room suites. Parents were instructed to limit infant exposures to persons who have respiratory illness and to initiate DTaP vaccination series as recommended by their pediatrician. Within 3 months, there was a modest increase (8 percent) in the number of postpartum patients accepting vaccination. These results, both encouraging and disappointing, prompted a revision of the screening questionnaire to
Volume 15
Issue 4
prompted other hospitals within our health care system to develop a similar program. NWH
http://nwhTalk.awhonn.org
References Centers for Disease Control and Prevention. (2006). Preventing tetanus, diphtheria, and pertussis among adults: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Review, 55(RR17), 1–33.
In Practice
include a decline statement to be signed by all postpartum patients who opted out of immunization. We enlisted the assistance of the nursing staff in labor and delivery, who performed a preliminary screening and provided pregnant women with initial education about pertussis infection in newborns. This revised process resulted in a significant improvement in the number of patients vaccinated, from 8 percent to 48 percent. However, there was still room for improvement. We instituted scripting so that the mother-baby nurses used the same language when addressing their patients, using the following script: “One of the easiest things you can do to keep your baby healthy is to stay current with your immuniza-
We installed educational posters and pamphlets in public areas of the maternity unit as well as in delivery room suites
tions. We provide the pertussis booster and flu vaccines.” Despite these efforts, nurses reported a percentage of patients who refused to accept the vaccine. Reasons for decline varied from fear of adverse reaction to religious objection. The nursing staff attempted to tailor patient education to the specific objection. To further enhance the number of patients accepting vaccination, we solicited additional support from pediatricians. Nurses placed a copy of the decline statement in the infant’s medical record. This allowed the pediatrician to track which patients had refused vaccination. The pediatricians were then able to follow-up with targeted education and professional advice in support of pertussis vaccination. This has resulted in a pertussis vaccination rate of up to 58 percent of our postpartum patients.
Conclusion Recognizing the significance of pertussis infection and the ease of transmission from adult to newborn, we instituted a vaccination program for women in the immediate postpartum period. All postpartum women are offered the Tdap vaccine, including those who had a history of pertussis. Using a multidisciplinary approach, we have significantly improved the number of our postpartum patients who receive Tdap vaccine before discharge. Our relative success has
August | September 2011
Centers for Disease Control and Prevention. (2008). Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants: Recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Review, 57(04), 1–47, 51. Centers for Disease Control and Prevention. (2011). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Review, 60(01), 13–15. He, Q., & Mertsola, J. (2008) Factors contributing to pertussis resurgence. Future Microbiology, 3(3), 329–339. New York State Department of Health, Bureau of Immunization. (2011). Pertussis outbreak control guidelines. Retrieved from http://www.op.nysed. gov/immunguide.htm Roehr, B. (2010). Whooping cough outbreak hits several US states. British Medical Journal, 341, c4627. Wendelboe, A. M., Njamkepo, E., Bourillon, A., Floret, D. D., Gaudelus, J., Gerber M., & Infant Pertussis Study Group. (2007). Transmission of Bordetella pertussis to young infants. Pediatric Infectious Disease Journal, 26(4), 293–299.
Nursing for Women’s Health
329
Pertussis An Ounce of Prevention
t
The Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP) and the Department of Health and Human Services (DHHS) recommend that all women in the immediate postpartum period receive vaccination for prevention of pertussis. In January 2010, we implemented an immunization program that has resulted in 58 percent of our postpartum patients receiving Tdap vaccine before discharge. This article reviews pertinent facts about pertussis and discusses how we implemented our vaccination program.
About Pertussis Pertussis is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. It’s spread from person to person by coughing or sneezing while in close contact with others. Pertussis is diagnosed through a detailed history that indicates exposure to the disease,
http://nwh.awhonn.org
Anne Shea-Lewis, RNC-NIC, BS, MBA Cecilia Hill, RN, BS Susan Soper, RNC, BSN, MSN
physical exam and a culture of nasopharyngeal secretions (CDC, 2006).
Clinical Course The clinical course of pertussis is divided into three stages: catarrhal, paroxysmal and convalescent. Symptoms of the catarrhal stage are similar to those of the common cold and include mild upper respiratory symptoms, lowgrade fever, runny nose, sneezing and a mild cough. As the illness progresses over 7 to 14 days, the cough becomes more severe. This, the paroxysmal phase, is distinguished by episodes of spasmodic coughing, sometimes followed by an inspiratory whooping sound. The attacks occur more frequently at night, and vomiting and exhaustion commonly follow the coughing episodes. The paroxysmal stage usually lasts from
© 2011, AWHONN
325
In Practice
1 to 6 weeks, but can persist for up to 10 weeks. Recovery is gradual, with the final phase, the convalescent phase, lasting for weeks to months. The gradual onset and recovery associated with pertussis has earned it the nickname “the 100day cough” (New York State Department of Health, Bureau of Immunization, 2011).
pneumonia, 50 percent exhibit apnea and 1 percent die (CDC, 2006, 2008). Up to 83 percent of infants who contract pertussis are infected by parents and caregivers. Therefore, revaccination of adolescents and adults in close contact with infants will reduce the incidence of pertussis infection in infancy (Wendelboe et al., 2007).
Pertussis in Infants
Recent Resurgence
Symptoms and complications of pertussis infection in adults tend to be milder than in the pediatric population (CDC, 2006, 2008). In infants younger than 6 months of age, pertussis has a shorter catarrhal stage and is more severe, especially in the preterm population (New York State Department of Health, Bureau of Immunization, 2011). According to the CDC, more than half of infants younger than 1 year of age who
Resurgence in pertussis infection in the United States has been well-documented over the last several years, most notably in California, where the number of cases reported in 2010 was seven times the number in 2009, and there were eight infant deaths. Pennsylvania, New York, South Carolina, Ohio and Michigan have also reported a significant increase in the incidence of pertussis infection (Roehr, 2010). The resurgence of pertussis has resulted in an increased risk for pertussis infection among health care workers. This is thought to be related to an increased opportunity for exposure and to weakening vaccine-induced immunity (He & Mertsola, 2008).
Of infants who are hospitalized with pertussis, approximately 20 percent develop pneumonia, 50 percent exhibit apnea and 1 percent die
become infected with pertussis must be hospitalized. Of infants who are hospitalized with pertussis, approximately 20 percent develop
Prevention Through Vaccination Pertussis can be treated with antibiotics, which, if started early, may make the infection less severe and help prevent transmission. However, the best way to prevent pertussis is through vaccination. The recommended pertussis vaccine for infants and children is a combination vaccine, DTaP,
Anne Shea-Lewis, RNCNIC, BS, MBA, is director of maternal-child health; Cecilia Hill, RN, BS, is director of infection control; Susan Soper, RNC, BSN, MSN, is assistant nursing care coordinator of maternal-child health; all authors are at St. Charles Hospital in Port Jefferson, NY. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: anne.shea-lewis@ chsli.org. DOI: 10.1111/j.1751-486X.2011.01653.x
326
Nursing for Women’s Health
Volume 15
Issue 4
Box 1.
Tdap Screening Questionnaire and Consent
Nurse completing screening: _______________________ Date: _____ Time: _____ Tetanus, Diphtheria and Pertussis (Tdap) Screening Inclusion Criteria (Target Population) ¨ Postpartum patient - vaccinate ¨ Vaccination status is unknown, and patient is otherwise eligible, vaccinate Exclusion Criteria ¨ Received Td (Tetanus, Diphtheria) vaccine during pregnancy ¨ Serious reaction to prior Tdap vaccine ¨ History of Guillain-Barré Syndrome ¨ History of encephalopathy not attributable to identifiable cause within 7 days of administration of a vaccine with pertussis components ¨ Patient refusal
Breastfeeding is NOT an exclusion criterion. Patient Consent: I have read, or had explained to me, the vaccine information sheet (VIS) about the Tdap vaccination. (Print date of the VIS provided _____________). I have had a chance to ask questions which were answered to my satisfaction, and I understand the benefits and risks of the vaccination as described. ¨ I request that the Tdap vaccination be given to me (or the person named above for whom I am authorized to make this request.) ¨ I decline the Tdap vaccination for myself (or the person named above for whom I am authorized to make this request.) I authorize the release of any medical or other information necessary to process an insurance claim or for other public health purpose. _________________________________________ Signature of recipient (parent or guardian)
__________________ Date
__________________________________________ __________________ Witness Signature Date STANDING Tdap VACCINE ORDER ¨ Patient has history of Guillain-Barré. Do NOT vaccinate. ¨ Patient has contraindications for vaccination. Do NOT vaccinate. ¨ Not a candidate for Tdap vaccination based on assessment. ¨ Patient has indication for vaccination. Administer Tdap vaccine 0.5 mL IM deltoid on day of discharge IF temp less than 100.4°F Affix Vaccine sticker here ______________________________ _______________ Place vaccine label here RN Signature Date
which protects against diphtheria, tetanus and acellular pertussis. For maximum protection, children need five DTaP immunizations. The DTaP immunization schedule includes vaccinations given at 2, 4 and 6 months of age; a fourth vaccination between 15 and 18 months of age and a fifth vaccination at 4 to 6 years of age (CDC, 2006, 2008). For those who have completed the recommended
August | September 2011
childhood DTaP series, ACIP recommends a single tetanus, diphtheria and acellular pertussis (Tdap) dose for people ages 11 through 18 years and for adults ages 19 through 64 years (CDC, 2011).
Implementing our Vaccination Program In January 2010, we instituted a program to offer pertussis vaccine to our
postpartum patients. By the end of the first quarter, we realized that participation in our vaccine program was less than 1 percent of postpartum patients. We developed a multidisciplinary team consisting of the chair of the pediatric department, chair of the obstetrics department, director of infection control, director of pharmacy, chief medical officer, chief nursing officer,
Nursing for Women’s Health
327
In Practice
director of maternal-child health and nursing staff in maternal-child health. A Tdap patient screening questionnaire (see Box 1), modeled on our successful influenza vaccination screening questionnaire, was instituted. The Tdap patient screening questionnaire was reviewed by all team members and presented to the Medical Board for approval. This screening questionnaire was to be completed by nurses on the mother-baby unit for all maternity patients. It included contraindications to vaccination as well as a non-patient-specific standing order to administer a single dose of Tdap vaccine on the date of discharge. In New York State, a non-patient-specific order authorizes registered nurses to administer immunizations to patients. Tdap is one of the
The best way to prevent pertussis is through vaccination
immunizations listed in the ACIP and CDC guidelines that may be administered using non-patient-specific orders and following specific protocols (New York State Department of Health, Bureau of Immunization, 2011).
328
Nursing for Women’s Health
If a postpartum patient met the inclusion criteria, she was provided with the most recent vaccine information sheet, made available by the CDC, and consent for vaccine was obtained. The vaccine was administered intramuscularly. As syncope may occur after vaccination, nursing staff observed patients for 15 minutes after they received vaccination, following ACIP recommendations (CDC, 2008). The staff nurse provided patient education regarding pertussis infection, including the symptoms of pertussis, and encouraged vaccination of household and child care provider contacts. Educational material included written information as well as on-demand video training available on the hospital’s internal television network. We installed educational posters and pamphlets in public areas of the maternity unit as well as in delivery room suites. Parents were instructed to limit infant exposures to persons who have respiratory illness and to initiate DTaP vaccination series as recommended by their pediatrician. Within 3 months, there was a modest increase (8 percent) in the number of postpartum patients accepting vaccination. These results, both encouraging and disappointing, prompted a revision of the screening questionnaire to
Volume 15
Issue 4
prompted other hospitals within our health care system to develop a similar program. NWH
http://nwhTalk.awhonn.org
References Centers for Disease Control and Prevention. (2006). Preventing tetanus, diphtheria, and pertussis among adults: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Review, 55(RR17), 1–33.
In Practice
include a decline statement to be signed by all postpartum patients who opted out of immunization. We enlisted the assistance of the nursing staff in labor and delivery, who performed a preliminary screening and provided pregnant women with initial education about pertussis infection in newborns. This revised process resulted in a significant improvement in the number of patients vaccinated, from 8 percent to 48 percent. However, there was still room for improvement. We instituted scripting so that the mother-baby nurses used the same language when addressing their patients, using the following script: “One of the easiest things you can do to keep your baby healthy is to stay current with your immuniza-
We installed educational posters and pamphlets in public areas of the maternity unit as well as in delivery room suites
tions. We provide the pertussis booster and flu vaccines.” Despite these efforts, nurses reported a percentage of patients who refused to accept the vaccine. Reasons for decline varied from fear of adverse reaction to religious objection. The nursing staff attempted to tailor patient education to the specific objection. To further enhance the number of patients accepting vaccination, we solicited additional support from pediatricians. Nurses placed a copy of the decline statement in the infant’s medical record. This allowed the pediatrician to track which patients had refused vaccination. The pediatricians were then able to follow-up with targeted education and professional advice in support of pertussis vaccination. This has resulted in a pertussis vaccination rate of up to 58 percent of our postpartum patients.
Conclusion Recognizing the significance of pertussis infection and the ease of transmission from adult to newborn, we instituted a vaccination program for women in the immediate postpartum period. All postpartum women are offered the Tdap vaccine, including those who had a history of pertussis. Using a multidisciplinary approach, we have significantly improved the number of our postpartum patients who receive Tdap vaccine before discharge. Our relative success has
August | September 2011
Centers for Disease Control and Prevention. (2008). Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants: Recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Review, 57(04), 1–47, 51. Centers for Disease Control and Prevention. (2011). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Review, 60(01), 13–15. He, Q., & Mertsola, J. (2008) Factors contributing to pertussis resurgence. Future Microbiology, 3(3), 329–339. New York State Department of Health, Bureau of Immunization. (2011). Pertussis outbreak control guidelines. Retrieved from http://www.op.nysed. gov/immunguide.htm Roehr, B. (2010). Whooping cough outbreak hits several US states. British Medical Journal, 341, c4627. Wendelboe, A. M., Njamkepo, E., Bourillon, A., Floret, D. D., Gaudelus, J., Gerber M., & Infant Pertussis Study Group. (2007). Transmission of Bordetella pertussis to young infants. Pediatric Infectious Disease Journal, 26(4), 293–299.
Nursing for Women’s Health
329