Health and Economic Consequences of an Outbreak of Pertussis Among Healthcare Workers in a Hospital in France

Healthcare personnel absenteeism, presenteeism, and staffing challenges during epidemics

Objective:

Presenteeism is an expensive and challenging problem in the healthcare industry. In anticipation of the staffing challenges expected with the COVID-19 pandemic, we examined a decade of payroll data for a healthcare workforce. We aimed to determine the effect of seasonal influenza-like illness (ILI) on absences to support COVID-19 staffing plans.

Design:

Retrospective cohort study.

Setting:

Large academic medical center in the United States.

Participants:

Employees of the academic medical center who were on payroll between the years of 2009 and 2019.

Methods:

Biweekly institutional payroll data was evaluated for unscheduled absences as a marker for acute illness-related work absences. Linear regression models, stratified by payroll status (salaried vs hourly employees) were developed for unscheduled absences as a function of local ILI.

Results:

Both hours worked and unscheduled absences were significantly related to the community prevalence of influenza-like illness in our cohort. These effects were stronger in hourly employees.

Conclusions:

Organizations should target their messaging at encouraging salaried staff to stay home when ill.

Pertussis immunization in healthcare workers working in pediatric settings: Knowledge, Attitudes and Practices (KAP) of Occupational Physicians. Preliminary results from a web-based survey (2017)

Introduction

The present study aims to characterize knowledge, attitudes and practices in a sample of occupational physicians (OPh) towards pertussis immunization in healthcare workers (HCWs) from pediatric settings.

Material and methods

A total of 148 OPh (45.9% males, mean age of 40.3 ± 13.2 years) compiled a web questionnaire including a knowledge test on Italian recommendations for HCWs, epidemiology and pathology of pertussis infection, being then investigated about risk perceptions and vaccination practices. A General Knowledge Score (GKS) and a Risk Perception Score (RPS) were calculated. Multivariate odds ratios (OR) for predictors of vaccine propensity were calculated through regression analysis.

Results

78 participants regularly recalled pertussis vaccination status and/or performed pertussis vaccination in HCWs (52.7%). Proactive status was correlated with the aim to avoid pertussis infection in HCWs and its diffusion to other adults (p < 0.001, both statements). GKS was satisfying (72.4% ± 14.9), but participants underestimated the clinical issues of pertussis infection (RPS 60.8% ± 9.5) when confronted with influenza (73.9% ± 10.9) and HBV infection (68.1% ± 10.1). GKS and RPS were well correlated (r = 0.244, p = 0.003). Eventually, a better GKS and the aim to avoid pertussis infection in HCWs were predictive of a proactive status for pertussis vaccination (OR 4.186 95%CI 1.809-9.685 and OR 11.459, 95%CI 3.312-39.651, respectively).

Conclusions

Adherence of OPh to HCWs pertussis vaccination was unsatisfying. As knowledge status was predictive for vaccine propensity, information programs for OPh should be more appropriately designed, stressing that HCWs may represent a significant reservoir for pertussis infection in high risk groups (e.g. children/newborns, frail elderly).

Contact tracing with a real-time location system: A case study of increasing relative effectiveness in an emergency department

•

Contact tracing is an essential step in infectious disease control and prevention.

•

Using Electronic medical record (EMR) is challenging and misses a number of potential exposures.

•

Real time location system (RTLS) doubled the potential exposures list for pertussis disease beyond the conventional method of EMR-based contact identification

•

RTLS is more efficient and timely in the process of contact tracing.

•

Further studies with larger sample size are needed to confirm the findings.

Background

Contact tracing is the systematic method of identifying individuals potentially exposed to infectious diseases. Electronic medical record (EMR) use for contact tracing is time-consuming and may miss exposed individuals. Real-time location systems (RTLSs) may improve contact identification. Therefore, the relative effectiveness of these 2 contact tracing methodologies were evaluated.

Methods

During a pertussis outbreak in the United States, a retrospective case study was conducted between June 14 and August 31, 2016, to identify the contacts of confirmed pertussis cases, using EMR and RTLS data in the emergency department of a tertiary care medical center. Descriptive statistics and a paired t test (α = 0.05) were performed to compare contacts identified by EMR versus RTLS, as was correlation between pertussis patient length of stay and the number of potential contacts.

Results

Nine cases of pertussis presented to the emergency department during the identified time period. RTLS doubled the potential exposure list (P < .01). Length of stay had significant positive correlation with contacts identified by RTLS (ρ = 0.79; P = .01) but not with EMR (ρ = 0.43; P = .25).

Conclusions

RTLS doubled the potential pertussis exposures beyond EMR-based contact identification. Thus, RTLS may be a valuable addition to the practice of contact tracing and infectious disease monitoring.

Sickness presenteeism among health care providers in an academic tertiary care center in Riyadh

The term sickness presenteeism (SP) has been described as the act of going to work despite having a state of health that may be regarded as poor enough to justify sick leave. SP has been observed to be prevalent among three-quarters of health care providers (HCPs). Working while sick not only puts patients at risk but also decreases productivity and increases the probability of medical errors. Moreover, SP has been identified as a risk factor for many negative health outcomes among the HCPs themselves, such as depression, burnout, and serious cardiac events. The aim of this study was to identify the reasons for and prevalence of SP and perceptions of the impact of this practice on patient safety among HCPs. A cross-sectional study was conducted, including 279 purposively selected healthcare professionals (doctors, nurses, dentists, pharmacists and other health care professionals) working at the Ministry of National Guard Health Affairs-King Abdulaziz Medical City (MNGHA-KAMC). While nearly all of the participants (91%) believed that working while sick exposed patients to risk, the rate of SP during the past year was reported as 74%, and one fourth of respondents reported working while sick 3-4 times during the past year. More than half of the participants were not aware of the existence of a departmental policy regarding sick leave. The most common reasons reported for working while sick were not wanting to burden co-workers (71%), feelings of duty toward patients (67%), and avoiding an increased future workload caused by absence (59%). A lack of awareness regarding the existing rules and polices related to sick leave was reported by more than half of the participants. Several predisposing and enabling factors were reported as determinants influencing SP, e.g., observation of the practice of SP by peers and feelings of sympathy towards coworkers, including not wanting to overburden them, were reported to be determinants informing the decision of whether to work while sick.

Is the current pertussis incidence only the results of testing? A spatial and space-time analysis of pertussis surveillance data using cluster detection methods and geographically weighted regression modelling

BACKGROUND

Despite high vaccination coverage, pertussis incidence in the Netherlands is amongst the highest in Europe with a shifting tendency towards adults and elderly. Early detection of outbreaks and preventive actions are necessary to prevent severe complications in infants. Efficient pertussis control requires additional background knowledge about the determinants of testing and possible determinants of the current pertussis incidence. Therefore, the aim of our study is to examine the possibility of locating possible pertussis outbreaks using space-time cluster detection and to examine the determinants of pertussis testing and incidence using geographically weighted regression models.

METHODS

We analysed laboratory registry data including all geocoded pertussis tests in the southern area of the Netherlands between 2007 and 2013. Socio-demographic and infrastructure-related population data were matched to the geo-coded laboratory data. The spatial scan statistic was applied to detect spatial and space-time clusters of testing, incidence and test-positivity. Geographically weighted Poisson regression (GWPR) models were then constructed to model the associations between the age-specific rates of testing and incidence and possible population-based determinants.

RESULTS

Space-time clusters for pertussis incidence overlapped with space-time clusters for testing, reflecting a strong relationship between testing and incidence, irrespective of the examined age group. Testing for pertussis itself was overall associated with lower socio-economic status, multi-person-households, proximity to primary school and availability of healthcare. The current incidence in contradiction is mainly determined by testing and is not associated with a lower socioeconomic status.

DISCUSSION

Testing for pertussis follows to an extent the general healthcare seeking behaviour for common respiratory infections, whereas the current pertussis incidence is largely the result of testing. More testing would thus not necessarily improve pertussis control. Detecting outbreaks using space-time cluster detection is feasible but needs to adjust for the strong impact of testing on the detection of pertussis cases.

Feasibility of Azithromycin Prophylaxis During a Pertussis Outbreak Among Healthcare Workers in a University Hospital in Paris

The objective of the present study was to evaluate the feasibility of azithromycin prophylaxis with respect to tolerability and compliance during a pertussis outbreak among healthcare workers in a university hospital ward. Compliance with the prophylaxis regimen was 89%; compliance was 75% from intent-to-treat perspective. The rate of adverse events was 33%. Female sex was associated with reporting of adverse events. Nonstudents and healthcare workers who reported adverse events were less compliant with the prophylaxis regimen.

Seroprevalence of pertussis amongst healthcare professionals in Spain

INTRODUCTION

This multi-center, hospital-based observational study determined the seroprevalence of pertussis antibodies amongst healthcare professionals from three different hospitals in Spain to ascertain the health status of professionals attending to susceptible groups who are at risk of contracting and transmitting pertussis.

METHODS

Medical professionals from three hospitals in Spain were recruited for this study (NCT01706224). Serum samples from subjects were assessed for anti-pertussis antibodies by ELISA. The percentage of subjects positive for anti-pertussis antibodies were determined by age-strata, gender, vaccination status, professional level (physicians, nurses, ancillary nurses and midwives), hospital department, number of working years, numbers of hours spent with the patient as well as number of children in the household.

RESULTS

Overall, 31.2% of subjects were seropositive; 3.3% of these healthcare professionals had ELISA values indicative of current or recent infection. There were no significant differences in terms of pertussis prevalence with respect to age, gender, hospital department, profession, number of working years and number of hours spent with patients. These levels of seronegativity amongst healthcare workers further strengthen the rationale for vaccination amongst this specific population against pertussis.

Modelling the return on investment of preventively vaccinating healthcare workers against pertussis

Background

Healthcare workers (HCWs) are at particular risk of acquiring pertussis and transmitting the infection to high-risk susceptible patients and colleagues. In this paper, the return on investment (ROI) of preventively vaccinating HCWs against pertussis to prevent nosocomial pertussis outbreaks is estimated using a hospital ward perspective, presuming an outbreak occurs once in 10 years.

Methods

Data on the pertussis outbreak on the neonatology ward in 2004 in the Academic Medical Center Amsterdam (The Netherlands) was used to calculate control costs and other outbreak related costs. The study population was: neonatology ward staff members (n = 133), parents (n = 40), neonates (n = 20), and newborns transferred to other hospitals (n = 23). ROI is presented as the amount of Euros saved in averting outbreaks by investing one Euro in preventively vaccinating HCWs. Sensitivity analysis was performed to study the robustness of the ROI. Results are presented at 2012 price level.

Results

Total nosocomial pertussis outbreak costs were €48,682. Direct control costs (i.e. antibiotic therapy, laboratory investigation and outbreak management control) were €11,464. Other outbreak related costs (i.e. sick leave of HCWs; restrictions on the neonatology ward, savings due to reduced working force required) accounted for €37,218. Vaccination costs were estimated at €12,208. The ROI of preventively vaccinating HCWs against pertussis was 1:4, meaning 4 Euros could be saved by every Euro invested in vaccinating HCWs to avert outbreaks. ROI was sensitive to a lower vaccine price, considering direct control costs only, average length of stay of neonates on the neonatology ward, length of patient uptake restrictions, assuming no reduced work force due to ward closer and presuming more than one outbreak to occur in 10 years’ time.

Conclusion

From a hospital ward perspective, preventive vaccination of HCWs against pertussis to prevent nosocomial pertussis outbreaks results in a positive ROI, presuming an outbreak occurs once in 10 years.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-0800-8) contains supplementary material, which is available to authorized users.

The value of childhood combination vaccines: From beliefs to evidence

Although vaccination is one of the most cost-effective health care interventions, under-vaccination and variation in coverage rates lower than policy targets is rising in developed countries, partly due to concerns about vaccination value and benefits. By merging various antigens into a single product, combination vaccines represent a valuable tool to mitigate the burden associated with the numerous injections needed to protect against vaccine preventable infectious diseases and increase coverage rate, possibly through various behavioral mechanisms which have yet to be fully explored. Beyond their cost-effectiveness in protecting against more diseases with fewer injections, combination vaccines also have several other benefits, for children, their parents/carers, as well as for the health system and the population as a whole. The objectives of this review are to identify and illustrate the value of combination vaccines for childhood immunization. Evidence was classified into 2 groups: benefits for society and benefits for public health and healthcare systems. This article also highlights the value of innovation and challenges of combination vaccine development as well as the need for an increased number of suppliers to mitigate the impact of any potential vaccine shortage. Increasing public confidence in vaccines and combination vaccines is also critical to fully exploit their benefits.

Factors affecting uptake of recommended immunizations among health care workers in South Australia

Despite the benefits of vaccination for health care workers (HCWs), uptake of recommended vaccinations is low, particularly for seasonal influenza and pertussis. In addition, there is variation in uptake within hospitals. While all vaccinations recommended for HCWs are important, vaccination against influenza and pertussis are particularly imperative, given HCWs are at risk of occupationally acquired influenza and pertussis, and may be asymptomatic, acting as a reservoir to vulnerable patients in their care. This study aimed to determine predictors of uptake of these vaccinations and explore the reasons for variation in uptake by HCWs working in different hospital wards. HCWs from wards with high and low influenza vaccine uptake in a tertiary pediatric and obstetric hospital completed a questionnaire to assess knowledge of HCW recommended immunizations. Multiple logistic regression was used to determine predictors of influenza and pertussis vaccination uptake. Of 92 HCWs who responded, 9.8% were able to identify correctly the vaccines recommended for HCWs. Overall 80% of respondents reported they had previously received influenza vaccine and 50.5% had received pertussis vaccine. Independent predictors of pertussis vaccination included length of time employed in health sector (P < 0.001), previously receiving hepatitis B/MMR (measles, mumps, rubella) vaccine (P < 0.001), and a respondent being aware influenza infections could be severe in infants (p = 0.023). Independent predictors of seasonal influenza vaccination included younger age (P < 0.001), English as first language (P < 0.001), considering it important to be vaccinated to protect themselves (P < 0.001), protect patients (p = 0.012) or awareness influenza could be serious in immunocompromised patients (p = 0.030). Independent predictors for receiving both influenza and pertussis vaccinations included younger age (P < 0.001), time in area of work (P = 0.020), previously receiving hepatitis B vaccine (P = 0.006) and awareness influenza could be severe in infants (P < 0.001). A knowledge gap exists around HCW awareness of vaccination recommendations. Assessment of the risk/benefit value for HCWs and their patients, determines uptake of HCW immunization programs and should be considered in promotional HCW vaccination programs.

Seroprevalence study of B. pertussis infection in health care workers in Catalonia, Spain

Pertussis is a re-emerging infection in countries with high infant immunization coverage. Healthcare workers (HCW) are exposed and can transmit the infection to especially-vulnerable patients. Therefore, pertussis vaccination of HCW is recommended. Between June 2008 and December 2010, 460 HCW from hospital and primary healthcare centers were recruited to determine susceptibility to pertussis. IgG antibodies against pertussis (anti-pertussis ab) were measured, using a routine technique that detects antibodies against pertussis including pertussis toxin (PT) and filamentous hemagglutinin (FHA). Positive results were confirmed with a more-specific technique that only assesses anti-PT IgG antibodies. The median age was 42 years (range, 21-65), 77.3% were female. 172 were nurses, 133 physicians, 60 other clinical workers and 95 non-clinical workers. None had received pertussis vaccination since childhood. The overall prevalence of anti-pertussis antibodies was 51.7%, (95% CI 47.1-56.4). Anti-PT antibodies were determined in the 220 HCW with positive anti-pertussis antibodies: 4 (1.8%) were negative and 33 (15%) had a high titer (≥ 45 IU/mL). No significant differences between the prevalence of anti-pertussis antibodies or anti-TP antibodies were found according to age, type of occupation or type of center. Our study confirms the need for vaccination of HCW because at least half are susceptible to pertussis. High anti-PT titers found in 15% of seropositive HCW showed that they had had recent contact with B. pertussis.

Symptomatic treatment of the cough in whooping cough

BACKGROUND

Around 16 million cases of whooping cough (pertussis) occur worldwide each year, mostly in low-income countries. Much of the morbidity of whooping cough in children and adults is due to the effects of the paroxysmal cough. Cough treatments proposed include corticosteroids, beta2-adrenergic agonists, pertussis-specific immunoglobulin, antihistamines and possibly leukotriene receptor antagonists (LTRAs).

OBJECTIVES

To assess the effectiveness and safety of interventions to reduce the severity of paroxysmal cough in whooping cough in children and adults.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 1), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, the Database of Abstracts of Reviews of Effects (DARE 2014, Issue 2), accessed from The Cochrane Library, MEDLINE (1950 to 30 January 2014), EMBASE (1980 to 30 January 2014), AMED (1985 to 30 January 2014), CINAHL (1980 to 30 January 2014) and LILACS (30 January 2014). We searched Current Controlled Trials to identify trials in progress.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and quasi-RCTs of any intervention (excluding antibiotics and vaccines) to suppress the cough in whooping cough.

DATA COLLECTION AND ANALYSIS

Two review authors (SB, MT) independently selected trials, extracted data and assessed the quality of each trial for this review in 2009. Two review authors (SB, KW) independently reviewed additional studies identified by the updated searches in 2012 and 2014. The primary outcome was frequency of paroxysms of coughing. Secondary outcomes were frequency of vomiting, frequency of whoop, frequency of cyanosis (turning blue), development of serious complications, mortality from any cause, side effects due to medication, admission to hospital and duration of hospital stay. 

MAIN RESULTS

We included 12 trials of varying sample sizes (N = 9 to 135), mainly from high-income countries, including a total of 578 participants. Ten trials recruited children (N = 448 participants). Two trials recruited adolescents and adults (N = 130 participants). We considered only three trials to be of high methodological quality (one trial each of diphenhydramine, pertussis immunoglobulin and montelukast). Included studies did not show a statistically significant benefit for any of the interventions. Only six trials, including a total of 196 participants, reported data in sufficient detail for analysis. Diphenhydramine did not change coughing episodes; the mean difference (MD) of coughing spells per 24 hours was 1.9; 95% confidence interval (CI) -4.7 to 8.5 (N = 49 participants from one trial). One trial on pertussis immunoglobulin reported a possible mean reduction of -3.1 whoops per 24 hours (95% CI -6.2 to 0.02, N = 47 participants) but no change in hospital stay (MD -0.7 days; 95% CI -3.8 to 2.4, N = 46 participants). Dexamethasone did not show a clear decrease in length of hospital stay (MD -3.5 days; 95% CI -15.3 to 8.4, N = 11 participants from one trial) and salbutamol showed no change in coughing paroxysms per day (MD -0.2; 95% CI -4.1 to 3.7, N = 42 participants from two trials). Only one trial comparing pertussis immunoglobulin versus placebo (N = 47 participants) reported data on adverse events: 4.3% in the treatment group (rash) versus 5.3% in the placebo group (loose stools, pain and swelling at injection site).

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw conclusions about the effectiveness of interventions for the cough in whooping cough. More high-quality trials are needed to assess the effectiveness of potential antitussive treatments in patients with whooping cough.

Vaccinations for healthcare personnel: update on influenza, hepatitis B, and pertussis

PURPOSE OF REVIEW

Healthcare personnel (HCP) are at risk for exposure to and transmission of potentially life-threatening vaccine preventable diseases to patients and colleagues. The Centers for Disease Control and Advisory Committee on Immunization Practices (ACIP) recommend routine influenza immunization and maintenance of immunity to hepatitis B and pertussis, among others. In this article, we aim to review recently approved influenza vaccines, as well as address some of the issues regarding hepatitis B and pertussis vaccinations in HCP.

RECENT FINDINGS

Several new formulations of influenza vaccines are now available, including quadrivalent vaccines and non-egg-based vaccines; their use in HCP requires further study. An alarming rise in pertussis rates has led to a revision of ACIP guidelines recommending vaccination for women during each pregnancy. Persistent lack of immunity to hepatitis B after vaccine series remains a problem for many HCP.

SUMMARY

Inactivated trivalent influenza vaccines remain the safest and most widely studied influenza vaccinations for healthcare workers. A pertussis booster in the form of Tdap is now recommended for most HCP. More studies are needed regarding the issue of nonresponders in HCP who receive the three-dose hepatitis B vaccine series, as there are some promising strategies available that may boost immune responses.

Nosocomial pertussis in neonatal units

Pertussis remains a public health concern in many countries despite high vaccination coverage rates. Nosocomial outbreaks of pertussis continue to occur in neonatal units. Neonates and young infants admitted to neonatal intensive care units constitute a pool of susceptible high-risk patients given their prematurity, inadequate immune response and the fact that they are too young to have completed their primary vaccination series against pertussis. This article reviews nosocomial pertussis in neonates and infants, focusing on the role of healthcare workers (HCWs). Outbreaks in neonatal units are often traced to HCWs and are associated with serious morbidity or even a fatal outcome among susceptible young infants. A high index of suspicion is required for early recognition and isolation of patients admitted with suspected or proven pertussis, as well as for HCWs with a compatible clinical syndrome, regardless of vaccination status. Contact investigation is also essential in order to guide administration of post-exposure prophylaxis. Recommendations for a booster vaccination for HCWs are in place in several countries; however, the need of HCWs for lifelong immunity against pertussis cannot be fulfilled by the current vaccine.

Should acellular pertussis vaccine be recommended to healthcare professionals?

The aim of this study was to describe recent changes in the epidemiology of pertussis and existing policies regarding recommended and mandatory occupational vaccinations for healthcare professionals (HCPs). The authors carried out an extensive review of references on the PubMed and SciELO databases and the official sites of the World Health Organization, Pan American Health Organization, Centers for Disease Control and Prevention, and Brazilian Ministry of Health, using the keywords pertussis, vaccines and healthcare professionals. Vaccination against pertussis is recommended for HCPs in the United States, Canada, nine European countries, Australia, Hong Kong, Singapore, Costa Rica, Argentina and Uruguay, and in some countries it is compulsory. In Brazil, only one publication discussing the risk of pertussis among HCPs was found. Considering the reemergence of pertussis and the great number of associated hospitalizations and deaths registered in 2011, it is necessary to review public policies regarding HCP pertussis vaccination, particularly among workers in frequent contact with young babies.

Symptomatic treatment of the cough in whooping cough

BACKGROUND

The worldwide incidence of whooping cough (pertussis) has been estimated at 48.5 million cases and nearly 295,000 deaths per year. In low-income countries, the case-fatality rate among infants may be as high as 4%. Much of the morbidity of whooping cough in children and adults is due to the effects of the paroxysmal cough. Cough treatments proposed include corticosteroids, beta 2-adrenergic agonists, pertussis-specific immunoglobulin, antihistamines and possibly leukotriene receptor antagonists (LTRAs).

OBJECTIVES

To assess the effectiveness and safety of interventions to reduce the severity of paroxysmal cough in whooping cough in children and adults.

SEARCH METHODS

We updated searches of the Cochrane Central Register of Controlled Trials (CENTRAL Issue 2, 2012), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, the Database of Abstracts of Reviews of Effects (DARE Issue 2, 2012) accessed from The Cochrane Library, MEDLINE (1950 to January 2012), EMBASE (1980 to January 2012), AMED (1985 to January 2012), CINAHL (1980 to January 2012) and LILACS (January 2012). We searched Current Controlled Trials to identify trials in progress.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and quasi-RCTs of any intervention (excluding antibiotics and vaccines) to suppress the cough in whooping cough.

DATA COLLECTION AND ANALYSIS

Two review authors (SB, MT) independently selected trials, extracted data and assessed the quality of each trial for this review in 2009. Two review authors (SB, KW) independently reviewed additional studies identified by the updated search in 2012. The primary outcome was frequency of paroxysms of coughing. Secondary outcomes were frequency of vomiting, frequency of whoop, frequency of cyanosis (turning blue), development of serious complications, mortality from any cause, side effects due to medication, admission to hospital and duration of hospital stay. 

MAIN RESULTS

Ten trials were included of varying sample sizes (N = 9 to 135) from high-income countries. Study quality was generally poor. Included studies did not show a statistically significant benefit for any of the interventions. Only six trials including a total of 196 participants reported data in sufficient detail for analysis. Diphenhydramine did not change coughing episodes; the mean difference (MD) of coughing spells per 24 hours was 1.9; 95% confidence interval (CI) - 4.7 to 8.5. One study on pertussis immunoglobulin reported a possible mean reduction of -3.1 whoops per 24 hours (95% CI -6.2 to 0.02) but no change in hospital stay (MD -0.7 days; 95% CI -3.8 to 2.4). Dexamethasone did not show a clear decrease in length of hospital stay (MD -3.5 days; 95% CI -15.3 to 8.4) and salbutamol showed no change in coughing paroxysms per 24 hours (MD -0.2; 95% CI -4.1 to 3.7). Only one trial comparing pertussis immunoglobulin versus placebo reported data on adverse events: 4.3% in the treatment group (rash) versus 5.3% in the placebo group (loose stools, pain and swelling at injection site).

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw conclusions about the effectiveness of interventions for the cough in whooping cough.

Presenteeism: a public health hazard

"Presenteeism" occurs when an employee goes to work despite a medical illness that will prevent him or her from fully functioning at work. This problem has been well studied in the business and social science literature, and carries increased importance in the health care setting due to the risk of infectious disease transmission in vulnerable patient populations. In this manuscript, we discuss an outbreak of viral gastroenteritis in a long-term care facility and the role presenteeism played in disease transmission and extension of the outbreak. We use existing literature to point out the hazards of presenteeism in the health care sector. We will also discuss factors that may be involved in the decision to work while ill and propose policy changes that may reduce the incidence of presenteeism in health care organizations.

Symptomatic treatment of the cough in whooping cough

BACKGROUND

The worldwide incidence of whooping cough (pertussis) has been estimated at 48.5 million cases and nearly 295,000 deaths per year. In low-income countries, the case-fatality rate among infants may be as high as 4%. Much of the morbidity of whooping cough in children and adults is due to the effects of the paroxysmal cough. Cough treatments proposed include corticosteroids, beta 2-adrenergic agonists, pertussis-specific immunoglobulin, antihistamines and possibly leukotriene receptor antagonists (LTRAs).

OBJECTIVES

To assess the effectiveness and safety of interventions to reduce the severity of paroxysmal cough in whooping cough in children and adults.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register and the Database of Abstracts of Reviews of Effects (DARE); MEDLINE (1950 to March 2009); EMBASE (1980 to March 2009); AMED (1985 to March 2009); CINAHL (1982 to March 2009) and LILACS (March 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of any intervention (excluding antibiotics and vaccines) to suppress the cough in whooping cough.

DATA COLLECTION AND ANALYSIS

Two review authors (SB, MT) independently selected trials, extracted data and assessed the quality of each trial. The primary outcome was frequency of paroxysms of coughing. Secondary outcomes were frequency of vomiting, frequency of whoop, frequency of cyanosis (turning blue), development of serious complications, mortality from any cause, side effects due to medication, admission to hospital and duration of hospital stay.

MAIN RESULTS

Ten trials were included of varying sample sizes (N = 9 to 135) from high-income countries. Study quality was generally poor. Included studies did not show a statistically significant benefit for any of the interventions. Diphenhydramine did not change coughing episodes; the mean difference of coughing spells per 24 hours was 1.9 (95% confidence interval (CI) - 4.7 to 8.5). One study on pertussis immunoglobulin reported a possible mean reduction of -3.1 whoops per 24 hours (95% CI -6.2 to 0.02) but no change in hospital stay (-0.7 days) (95% CI -3.8 to 2.4). Dexamethasone did not show a clear decrease in length of hospital stay (-3.5 days) (95% CI -15.3 to 8.4) and salbutamol showed no change in coughing paroxysms per 24 hours (-0.22) (95% CI -4.13 to 3.69).

AUTHORS' CONCLUSIONS

Insufficient evidence exists to draw conclusions about the effects of interventions for the cough in whooping cough.

Keeping vulnerable children safe from pertussis: preventing nosocomial pertussis transmission in the neonatal intensive care unit

OBJECTIVE

To examine the impact of different acellular pertussis booster vaccination strategies on the probability of a nosocomial pertussis outbreak occurring and the distribution of outbreak sizes observed for each intervention strategy.

SETTING

Neonatal intensive care unit.

METHODS

We developed a stochastic, agent-based simulation model to examine the impact of booster vaccination strategies for pertussis on health care-related transmission.

RESULTS

Our results demonstrate that healthcare worker booster vaccination decreases the probability of secondary transmission from 49% (base case, no boosting) to 2% (if 95% of healthcare workers are boosted) and decreases final outbreak size. Boosting family caregivers did not have a clinically significant impact on nosocomial disease transmission.

CONCLUSION

The provision of booster vaccine to healthcare workers in the neonatal intensive care unit substantially reduces the risk of hospital-centered pertussis outbreaks in a manner that enhances the health of hospitalized children. A formal health economic analysis of this finding is currently under way. Policies to protect patient safety in pediatric facilities should include compliance with the United States Advisory Committee on Immunization Practices, which recommends provision of pertussis booster vaccination to healthcare workers.

Proficiency program for real-time PCR diagnosis of Bordetella pertussis infections in French hospital laboratories and at the French National Reference Center for Whooping Cough and other Bordetelloses

With the support of a ministerial program for innovative and expensive technologies, dedicated to the economic evaluation of laboratory diagnosis of pertussis by real-time PCR, external quality assessment for real-time IS481 PCR was carried out. Coordinated by the National Centre of Reference of Pertussis and other Bordetelloses (NCR), this study aimed to harmonize and to assess the performances of eight participating microbiology hospital laboratories throughout the French territory. Between January 2006 and February 2007, 10 proficiency panels were sent by the NCR (ascending proficiency program), representing a total of 49 samples and including eight panels to analyze and evaluate the global sensitivity and specificity of real-time PCR, one to assess the limit of detection, and one to evaluate nucleic acid extraction methods. As part of the descending proficiency program, extracted DNA from clinical samples was sent by the eight participating laboratories in different panels and analyzed by the NCR. In the ascending proficiency analysis, the sensitivity and specificity of the real-time PCR methods were 92.2% and 94.3%, respectively. The limit of detection of the different methods ranged between 0.1 and 1 fg/microl (0.2 to 2 CFU/microl). The nucleic acid extraction methods showed similar performances. During the descending proficiency analysis, performed with 126 samples, the result of the NCR for 15 samples (11.9%) was discordant with the result obtained by the source laboratory. Despite several initial differences, harmonization was easy and performances were homogeneous. However, the risk of false-positive results remains quite high, and we strongly recommend establishment of uniform quality control procedures performed regularly.

Epidemiology and control of pertussis outbreaks in a tertiary care center and the resource consumption associated with these outbreaks

OBJECTIVE

To describe the epidemiology and control of 2 separate outbreaks of pertussis at a large tertiary care center and the resource consumption associated with these outbreaks.

DESIGN

Descriptive study.

SETTING

The Mayo Clinic in Rochester, Minnesota, a tertiary care center catering to both referral patients and patients from the community.

METHODS

We reviewed routine and enhanced surveillance data collected by infection prevention and control practitioners during the outbreaks. Pertussis was diagnosed either on the basis of a nasopharyngeal specimen positive for Bordetella pertussis by use of polymerase chain reaction (PCR) or on the basis of a compatible clinical syndrome along with an epidemiologic link to PCR-confirmed cases.

RESULTS

Two pertussis outbreaks, the first community based and the second hospital based (ie, due to transmission among healthcare personnel), occurred during the period from October 2004 through October 2005. In the first outbreak from November 2004 through March 2005, there were 109 cases diagnosed; 105 (96%) of these cases were diagnosed on the basis of a nasopharyngeal specimen positive for B. pertussis by use of PCR. Adolescents 10-19 years of age were most affected (77 cases [71%]). Only 13 cases (12%) occurred among healthcare personnel; however, many healthcare personnel required postexposure prophylaxis. A second outbreak of 122 cases occurred during the period from July through October 2005; of these 122 cases, 96 (79%) were diagnosed on the basis of a nasopharyngeal specimen positive for B. pertussis by use of PCR, and 64 (52%) involved healthcare personnel. There were many instances of transmission among healthcare personnel and from patients to healthcare personnel, but no documented transmission from healthcare personnel to patients. The outbreaks were controlled by aggressive case finding, treatment of those infected, prophylaxis of all healthcare personnel and patients who had contact with both probable and confirmed cases, implementation of educational efforts, and compliance with respiratory etiquette. Vaccination of healthcare personnel against pertussis began in October 2005.

CONCLUSION

Pertussis remains a public health problem. Outbreaks in healthcare facilities consume the resources of those facilities in terms of personnel, testing, treatment of cases, and prophylaxis of those individuals who were in contact with those cases. Adult vaccination may reduce the disease burden.

[Awareness and adherence to Pertussis vaccination guidelines by occupational medicine physicians in Paris healthcare institution]

OBJECTIVE

A questionnaire was used on 44 public and private hospital physicians in Paris to evaluate their knowledge of and adherence to Vaccination Guidelines, three years after their introduction.

RESULTS

Eighty per cent of the physicians answered and 92.5% were aware of the vaccination guidelines but only 2 out of 4 respected the targeted vaccination in young adults even when the vaccine was available. A policy of pertussis vaccination was applied only in 12 institutions, but even in these, the rate of vaccinated healthcare workers remained low or was not documented.

CONCLUSION

Pertussis is a potential risk to newborns not or partially vaccinated in France. Even if the vaccine is available, adherence to pertussis vaccination guidelines must be improved. Efforts should be made to better publicize and apply pertussis vaccination guidelines.

Pertussis: review of epidemiology, diagnosis, management and prevention

Bordetella pertussis--the cause of pertussis or whooping cough--is an exclusively human pathogen. Disease elimination by vaccination should, therefore, be possible, but has proved elusive. Many industrialised countries with long established immunisation programs are currently seeing a resurgence of pertussis, despite universal vaccination with high uptake, with the highest burden in the least immunised age groups (infants under 6 months of age and persons over 10 years old). However, low recognition and reporting and insensitive diagnostic tests mean that the true burden of pertussis is still underestimated. Recently, efforts to improve diagnostic yield include the expanded use of polymerase chain reaction and serological tests but both have significant limitations. The range of antibiotics available for treatment and prophylaxis has expanded to include the newer macrolides, azithromycin and clarithromycin, and a range of universal and targeted vaccination strategies have been implemented or proposed. This paper reviews the current epidemiology of pertussis in developed countries, including modes of clinical presentation, diagnosis, management and potential vaccination strategies.

Pertussis vaccination for health care workers

Pertussis, an acute respiratory infection caused by Bordetella pertussis, classically manifests as a protracted cough illness. The incidence of pertussis in the United States has been increasing in recent years. Immunity wanes after childhood vaccination, leaving adolescents and adults susceptible to infection. The transmission of pertussis in health care settings has important medical and economic consequences. Acellular pertussis booster vaccines are now available for use and have been recommended for all adolescents and adults. These vaccines are safe, immunogenic, and effective. Health care workers are a priority group for vaccination because of their increased risk of acquiring infection and the potential to transmit pertussis to high-risk patients. Health care worker vaccination programs are likely to be cost-effective, but further research is needed to determine the acceptability of pertussis vaccines among health care workers, the duration of immunity after booster doses, and the impact of vaccination on the management of pertussis exposures in health care settings.

Pertussis in infants: preventing deaths and hospitalisations in the very young

Pertussis is a particular concern in infants under 6 months of age. They have the highest rates and severity of disease resulting in hospitalisation or death but are too young to be protected by current vaccination schedules. We outline the current epidemiology of pertussis in Australia and four potential strategies to prevent pertussis in the very young. First, universal adult and or adolescent vaccination; second, indirect protection of infants by immunisation of parents and possibly others in close contact with the newborn, such as grandparents and health-care workers; third, newborn and early infant vaccination (from birth to 1 month of age) and fourth maternal vaccination.

A modified "cover your cough" campaign prevents exposures of employees to pertussis at a children's hospital

BACKGROUND

In the 4th quarter of 2004, there was an increase in patients seeking medical care for pertussis symptoms at the Children's Hospital, Omaha, NE. The Hospital Epidemiology service noted a sharp rise in exposures of Children's Hospital employees to these patients, requiring employee testing, prophylactic antibiotic prescriptions, and relief from duty.

METHODS

Initial efforts at employee education failed to prevent the exposures. An exposure-control plan was then initiated by placing "Cover Your Cough" posters (in English and Spanish) describing appropriate cough etiquette at entrances to the emergency room, outpatient clinics, and hospital lobby. In addition, personal protective equipment (PPE) including child- and adult-sized masks, hand sanitizers, and tissues were provided at these stations for patients and their attendants.

RESULTS

Prior to the initiation of the above exposure control measures, there were 166 reports of employee exposure to patients and other employees with pertussis symptoms during a 4-week period. Of these, 140 were given prophylactic antibiotics, and 31 underwent diagnostic testing for pertussis and required paid time off from work. The cost of antibiotics and diagnostic testing was $17,407.00. After the introduction of the modified "Cover Your Cough" campaign, the number of employee exposures declined significantly to 37 in the next 4-week period. Notably, the number of patients tested for pertussis during the second 4-week period was 290 compared to 162 in the first 4-week period, indicating continuation of the epidemic.

CONCLUSIONS

Availability of PPE along with posters regarding cough etiquette at entry points of the hospital interrupted employee exposure to patients/personnel with pertussis symptoms significantly, when an employee educational initiative alone was unable to achieve this outcome.

Impact of Bordetella pertussis exposures on a Massachusetts tertiary care medical system

OBJECTIVE

To assess the impact of outbreaks of Bordetella pertussis infection on a tertiary care medical system.

DESIGN

Retrospective study.

SETTING

Academic tertiary care medical center and affiliated ambulatory care settings.

SUBJECTS

All patients and healthcare workers (HCWs) who were in close contact with patients with laboratory-confirmed cases of B. pertussis infection from October 1, 2003, through September 30, 2004.

INTERVENTION

Direct and indirect medical center costs were determined, including low and high estimates of time expended in the evaluation and management of exposed patients and HCWs during outbreak investigations of laboratory-confirmed cases of B. pertussis infection.

RESULTS

During this period, 20 primary and 3 secondary laboratory-confirmed cases of B. pertussis infection occurred, with 2 primary pertussis cases and 1 secondary case occurring in HCWs. Outbreak investigations prompted screening of 353 medical center employees. Probable or definitive exposure was identified for 296 HCWs, and 287 subsequently received treatment or prophylaxis for B. pertussis infection. Direct medical center costs for treatment and prophylaxis were $13,416 and costs for personnel time were $19,500-$31,190. Indirect medical center costs for time lost from work were $51,300-$52,300. The total cost of these investigations was estimated to be $85,066-$98,456.

CONCLUSIONS

Frequent B. pertussis exposures had a major impact on our facility. Given the impact of exposures on healthcare institutions, routine vaccination for HCWs may be beneficial.

Impact de la vaccination sur l’épidémiologie des maladies infectieuses : exemple de la coqueluche

Several vaccines are now routinely used since fifty years in different developed countries. Their principal impact has been to decrease morbidity and mortality of the infectious diseases they are targeting. One disease, smallpox, is eradicated, poliomyelitis will be soon, diphteria is controlled in several countries but pertussis is still endemic although an efficacious vaccine was used. Why? Pertussis is an example of an infection for which the immunity of the population has changed after the introduction of generalized vaccination with killed whole cell pertussis vaccines, from a natural immunity due to infection to different types of vaccine-induced immunity. These different types of immunity have changed the protection against infection, disease and transmission. The impact of the generalized vaccination in a human population has been an important change in the epidemiology of the disease. In fact, a child-to-child transmission observed before the introduction of vaccination is now replaced by an adolescent-adult to infant transmission. The major consequence is an increase in the mortality and morbidity in non vaccinated infants mostly contaminated by their parents. Researches undertaken on the agent of the disease, the bacterium, Bordetella pertussis, conducted to the development of subunits vaccines, efficacious and better tolerated by infants than whole-cell vaccines. Many developed countries decided to change vaccines but also to add vaccine boosters for adolescents and adults in order to stop the transmission of the disease to infants. However, even after 15 years of studies in many countries, pertussis is still underestimated in adults and generalized adult vaccination remains difficult. The new goal now is to give information to medical students and health care workers in general in order to increase adolescent and adult's vaccination coverage.

Two nosocomial pertussis outbreaks and their associated costs - King County, Washington, 2004

OBJECTIVE

Pertussis outbreaks in healthcare settings result in resource-intensive control activities, but studies have rarely evaluated the associated costs. We describe and estimate costs associated with 2 nosocomial pertussis outbreaks in King County, Washington, during the period from July 25 to September 15, 2004. One outbreak occurred at a 500-bed tertiary care hospital (hospital A), and the other occurred at a 250-bed pediatric hospital (hospital B).

METHODS

We estimated the costs of each outbreak from the hospitals' perspective through standardized interviews with hospital staff and review of contact tracing logs. Direct costs included personnel time and laboratory and medication costs, whereas indirect costs were those resulting from hospital staff furloughs.

RESULTS

Hospital A incurred direct costs of $195,342 and indirect costs of $68,015; hospital B incurred direct costs of $71,130 and indirect costs of $50,000. Cost differences resulted primarily from higher personnel costs at hospital A ($134,536), compared with hospital B ($21,645). Total cost per pertussis case was $43,893 for hospital A (6 cases) and $30,282 for hospital B (4 cases). Total cost per person exposed to a pertussis patient were $357 for hospital A (738 exposures) and $164 for hospital B (737 exposures).

CONCLUSIONS

Nosocomial pertussis outbreaks result in substantial costs to hospitals, even when the number of pertussis cases is low. The cost-effectiveness of strategies to prevent nosocomial pertussis outbreaks, including vaccination of healthcare workers, should be evaluated.

Resource consumption in the infection control management of pertussis exposure among healthcare workers in pediatrics

OBJECTIVE

To assess consumption of resources in the infection control management of healthcare workers (HCWs) exposed to pertussis and to assess avoidability of exposure.

SETTING

Tertiary care children's medical center.

METHODS

Analysis of the extent of and reasons for HCW exposure to pertussis during contact with children with the disease, whether exposures were avoidable (because of the failure to recognize a case or to order or adhere to isolation precautions) or unavoidable (because the case was not recognizable or because another diagnosis was confirmed), and the cost of implementing exposure management.

INTERVENTIONS

Interventions consisted of an investigation of every HCW encounter with any patient who was confirmed later to have pertussis from the time of hospital admission of the patient, use of azithromycin as postexposure prophylaxis (PEP) for exposed HCWs, performance of 21-day surveillance for cough illness, testing of symptomatic exposed HCWs for Bordetella pertussis, and enhanced preexposure education of HCWs.

RESULTS

From September 2003 through April 2005, pertussis was confirmed in 28 patients (median age, 62 days); 24 patients were admitted. For 11 patients, pertussis was suspected, appropriate precautions were taken, and no HCW was exposed. Inadequate precautions for 17 patients led to 355 HCW exposures. The median number of HCWs exposed per exposing patient was 9 (range, 1-86 HCWs; first quartile mean, 2; fourth quartile mean, 61). Exposure was definitely avoidable for only 61 (17%) of 355 HCWs and was probably unavoidable for 294 HCWs (83%). The cost of 20-month infection control management of HCWs exposed to pertussis was $69,770. The entire cohort of HCWs involved in direct patient care at the facility could be immunized for approximately $60,000.

CONCLUSIONS

Exposure of HCWs to pertussis during contact with children who have the disease is largely unavoidable, and management of this exposure is resource intensive. Universal preexposure vaccination of HCWs is a better utilization of resources than is case-based postexposure management.

Prevention of pertussis: Recommendations derived from the second Global Pertussis Initiative roundtable meeting

The Global Pertussis Initiative (GPI) was established in 2001 to assess the global extent of the ongoing problem of pertussis and to evaluate and prioritize pertussis control strategies. Exchange of data, knowledge, and experience, facilitated by discussion and debate, resulted in the formulation, in 2002, of the following recommendation: all countries should consider expanding existing vaccination strategies to include adding pertussis booster doses to pre-school children (4-6 years old), to adolescents, and to those specific adults that have the highest risk of transmitting Bordetella pertussis infection to vulnerable infants. The GPI met again in 2005, where it reinforced its previous recommendation for universal adolescent immunization. Additionally, the GPI recommended implementation of the cocoon strategy (immunization of family members and close contacts of the newborn) in countries where it is economically feasible, and encouraged efforts toward global standardization of pertussis disease clinical definitions and diagnostics. Universal adult vaccination is a logical goal for the ultimate elimination of pertussis disease, but feasibility issues remain obstacles to implementation.

Recent developments in pertussis

Pertussis causes nearly 300,000 deaths in children every year. Most deaths take place in developing countries, but the infection remains a priority everywhere. Pertussis vaccination protects infants and children against death and admission to hospital, but breakthrough disease in vaccinated people can happen. In high-mortality countries, the challenge is to improve timeliness and coverage of childhood vaccination and surveillance. In regions with low mortality and highest coverage, pertussis is frequently the least well-controlled disease in childhood vaccination programmes. Some countries have reported a rise in pertussis in adolescents, adults, and pre-vaccination infants, but how much these changes are real or a result of improved recognition and surveillance remains uncertain. In response, several countries have introduced adolescent and adult acellular pertussis vaccine boosters. The effect so far is unknown; assessment is impeded by poor data. Uncertainties still persist about key variables needed to model and design vaccination programmes, such as risk of transmission from adults and adolescents to infants. New vaccination strategies under investigation include vaccination of neonates, family members, and pregnant women.

Nosocomial pertussis: costs of an outbreak and benefits of vaccinating health care workers

BACKGROUND

In September 2003, 17 symptomatic cases of pertussis among health care workers (HCWs) resulted from a 1-day exposure to an infant who was later confirmed to have pertussis. These HCWs identified 307 close contacts. The hospital implemented extensive infection-control measures. The objective of this study was to determine direct and indirect costs incurred by the hospital and symptomatic HCWs as a result of the September 2003 outbreak and to estimate possible benefits of vaccinating HCWs from the hospital perspective.

METHODS

We determined costs by interviewing infection-control and hospital personnel, reviewing billing records, and surveying symptomatic HCWs. We calculated the benefits and costs of a vaccination program for HCWs, using a probabilistic model to estimate the number of pertussis exposures that would require control measures annually. Sensitivity and threshold analyses were performed.

RESULTS

The outbreak cost to the hospital was 74,870 dollars. The total measured cost of the outbreak was 81,382 dollars, including costs incurred by HCWs (6512 dollars). Our model predicted that vaccinating HCWs against pertussis would prevent >46% of exposures from HCWs with pertussis per year and would provide net savings. The benefit for the hospital was estimated to be 2.38 times the dollar amount invested in vaccinating HCWs. The number of exposures prevented and the benefit-cost ratio were sensitive to the number of exposures identified, the incidence of pertussis among HCWs, and HCW turnover.

CONCLUSIONS

A single nosocomial pertussis outbreak resulted in substantial disruption and costs to the hospital and to HCWs. Our model suggests that cost savings and benefits could be accrued by vaccinating HCWs against pertussis.