Physicians/Health Care Providers
California, including Orange County, experienced a large increase in pertussis cases in 2010, with numbers in 2011 still being elevated when compared to previous years. Rates are highest in infants less than 6 months of age and 10 infant deaths were reported in California in 2010. Pertussis is highly contagious and is spread through the respiratory route. To improve community immunity against pertussis and decrease transmission, the California Department of Public Health (CDPH) made recommendations for the expanded use of Tdap in 2010 which now have been formally adopted by the Centers for Disease Control and Prevention (CDC) Advisory Committee for Immunization Practices (ACIP).
Reporting is required for all cases, including suspect cases. Do not wait for laboratory results to report a clinically consistent case. Report within one (1) working day to Epidemiology & Assessment: phone (714) 834-8180, fax (714) 834-8196.
Pertussis Treatment and Chemoprophylaxis Dosages
Treatment of suspect and confirmed cases of pertussis within 21 days of cough onset can decrease transmission of the organism to others. Asymptomatic close contacts, including household contacts and others who have had face-to-face contact with a symptomatic suspect or confirmed case of pertussis, should receive prophylaxis for pertussis if within 21 days of cough onset in the index case. Priority should be given to provide prophylaxis to contacts who are at high risk of serious illness with pertussis or in contact with persons at high risk (e.g., infants, caregivers/contacts of infants, pregnant women, healthcare workers). Any symptomatic (coughing) contacts should be treated as if they had pertussis and reported to Epidemiology (phone 714-834-8180 or fax 714-834-8196) for further contact tracing and recommendations.
Choice of antibiotics, dosing, and duration is the same for pertussis treatment and prophylaxis. Please refer to the table below, excerpted from the 2005 CDC Guidelines for Treatment and Postexposure Prophylaxis of Pertussis (MMWR Recommendations and Reports 2005;54(RR-14):1-16, available at: www.cdc.gov/mmwr/PDF/rr/rr5414.pdf.)
||Recommended agent. 10 mg/kg per day in a single dose for 5 days (only limited safety data available.)
||Not preferred. Erythromycin is associated with infantile hypertrophic pyloric stenosis. Use if azithromycin in unavailable, 40-50 mg/kg per day in 4 divided doses for 14 days
||Not recommended (safety data unavailable)
||Contraindicated for infants <2 months old (risk for kernicterus)
|10 mg/kg per day in a single dose for 5 days
||40-50 mg/kg per day in 4 divided doses for 14 days
||15 mg/kg per day in 2 divided doses for 7 days
|Contraindicated at age <2 months. For infants aged >2 months, TMP 8 mg/ kg per day, SMZ 40 mg/kg per day in
2 divided doses for 14 days
|Infants (aged >6 months) and children
||10 mg/kg in a single dose on day 1 (maximum 500 mg) then 5 mg/kg per day (maximum: 250 mg/day) on days 2-5
||40-50 mg/kg per day
(maximum: 2 g per day) in 4 divided doses for 14 days
|15 mg/kg per day in 2 divided doses (maximum: 1 g per
day) for 7 days
|TMP 8 mg/kg per day, SMZ 40 mg/kg per day in 2 divided
doses for 14 days
||500 mg in a single dose on day 1 then 250 mg per day on days 2-5
||2 g per day in 4 divided doses for 14 days
||1 g per day in 2 divided doses for 7 days
||TMP 320 mg per day, SMZ 1,600 mg per day in 2 divided
doses for 14 days
|* Trimethoprim sulfamethoxazole (TMP-SMZ) can be used as an alternative agent to macrolides in patients aged >2 months who are allergic to macrolides, who cannot tolerate macrolides, or who are infected with a rare macrolide-resistant strain of Bordetella pertussis.
NOTE: RE: Pregnant women and breastfeeding mothers:
- Pregnant women and breastfeeding mothers should not take TMP/SMZ because of the potential risk of kernicterus in infants < 2 months of age.
- Physicians caring for pregnant women should weigh the risks and benefits of treatment/prophylaxis with the macrolides, especially in households containing infants <12 months of age or expecting a new baby, as young infants are at the highest risk for serious complications from pertussis. Azithromycin and erythromycin are classified as Pregnancy Category B drugs and clarithromycin is Pregnancy Category C.
Vaccination of Contacts following Pertussis Exposure:
NOTE: vaccination is in addition to antibiotic prophylaxis
Children less than 7 years old who are unimmunized or who have not received 4 doses of pertussis-containing vaccine (DTaP or DTP), should initiate or continue vaccination according to the recommended schedule (available at www.cdc.gov/vaccines/recs/schedules/child-schedule.htm).
- If at least 6 months have elapsed since the 3rd dose and the child is at least 12 months of age, give the 4thdose immediately.
- If the child has received 4 doses of DTaP, give a 5th dose unless the last dose was within the last 3 years. A 5thdose is not necessary if the 4th dose in the series is administered on or after the fourth birthday.
Children 7 - 10 years of age who have missed one or more of the above routine childhood pertussis vaccinations and have not received Tdap before should receive a single dose of Tdap (and then continue with catch-up immunization if indicated as per the CDC Catch-up Immunization Schedule www.cdc.gov/vaccines/recs/schedules/child-schedule.htm).**
Children 11 - 18 years of age should be given one booster dose of Tdap if they have not received Tdap before. Note: There is no minimum interval between administration of Td and Tdap.** For more information about the use of Tdap in adolescents, see the 2006 CDC ACIP Recommendations (www.cdc.gov/mmwr/PDF/rr/rr5503.pdf). If the child has not completed his/her primary childhood immunization series, see the CDC Catch-up Immunization Schedule www.cdc.gov/vaccines/recs/schedules/child-schedule.htm) to continue with catch-up immunization.
Adults should be given one dose of Tdap if they have not received Tdap before. Note: ACIP recommends that adults aged 65 years and older (e.g., grandparents, child-care providers, and health-care practitioners) who have or who anticipate having close contact with an infant less than 12 months of age and who previously have not received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission. For other adults aged 65 years and older, a single dose of Tdap vaccine may be given instead of Td vaccine, in persons who have not previously received Tdap.** If an adult has not received the primary tetanus and diphtheria series, Tdap can still be given and then the series completed with Td. For more information about the use of Tdap in adults, see the 2006 CDC ACIP Recommendations (www.cdc.gov/mmwr/PDF/rr/rr5517.pdf. Tdap is not contraindicated during pregnancy or the postpartum period. For more information about the use of Tdap in pregnant and postpartum women see the 2008 CDC ACIP Recommendations (www.cdc.gov/mmwr/PDF/rr/rr5704.pdf).
** For the updated CDC ACIP recommendations on use of Tdap, see the 1/14/11 issue of MMWR.