Pertussis Outbreak in

Kalamazoo County, 2006

Annie Wendt, B.S., M.P.H.
Epidemiologist
 Overview
• Incidence trends
• Pertussis case definition
• Story of our outbreak
– Descriptive analysis
– Prevention and control measures
 Bordetella Pertussis
• Bacteria that causes whooping cough
• Classic inspiratory “whoop” common in infants &
toddlers, may not be present in older children & adults.
• Symptoms resemble a cold the 1st 1-2 weeks: runny
nose, watery eyes, non-productive cough. Followed by
episodes of severe (paroxysmal) coughing, often worse
at night.
• Coughing can last for weeks.
• No long-term persistent immunity from vaccine or
illness.
 State and Region 5
Pertussis Incidence, 2006
Area Count Rate per 100,000
Michigan 626 6.3
Region 5 329 35.0
Allegan 12 11.0
Barry 7 12.0
Berrien 6 3.7
Branch 2 4.4
Calhoun 2 1.4
Cass 4 7.8
Kalamazoo 280 117.0
St Joseph 7 11.0
Van Buren 9 11.0
*Includes probable and confirmed completed cases, Michigan Disease Surveillance System as of 4/9/07
 Pertussis Incidence* Rate per 100,000 Population,
Michigan, Region 5 and Kalamazoo County
2002 - 2006
140

120
Kalamazoo County
Rate per 100,000

100

80
60

40 Region 5
20
Michigan
0
2002 2003 2004 2005 2006
Year
*Includes probable and confirmed completed cases, Michigan Disease Surveillance System as of 4/9/07
 Reported Pertussis Cases in Kalamazoo
County by Year, 1993-2007 YTD*
300 280

250
Number of cases

200

150
100
46
50 28 18
4 0 1 1 0 0 0 0 3 5 11
0

*2007 cases as of 3/26/07. Year of onset

Includes probable and confirmed completed cases, Michigan Disease Surveillance System as of 3/26/07
 Pertussis Case Definition
• Clinical Case Definition:
– A cough illness lasting at least 2 weeks with one of the
following: paroxysms of coughing, inspiratory
"whoop," or post-tussive vomiting, without other
apparent cause (as reported by a health professional)
• Laboratory Criteria for Diagnosis:
– Isolation of Bordetella pertussis from clinical specimen
– Positive polymerase chain reaction (PCR) for B.
pertussis
 Case Classification
Confirmed:
• meets clinical case definition
and confirmed by positive PCR
• or meets clinical case
definition and is
epidemiologically linked
directly to a case confirmed by
either culture or PCR
• or a case that is culture
positive and in which an acute
cough illness of any duration is
present (cultures rarely done).
Probable:
• meets clinical case
definition, but not
laboratory confirmed and
not epidemiologically
linked to a laboratory-
confirmed case
• or household contact to a
confirmed case or part of an
institutional outbreak, had
2+ weeks cough but no
additional symptoms, and
not laboratory confirmed.
 Kalamazoo County
Pertussis Outbreak
• May 15, 2006 – February 19, 2007
• Total investigations: 295 cases and 223 not
a case
– 185 Probable
– 110 Confirmed
 Kalamazoo County Pertussis Epi Curve by Week
(Probable and Confirmed Cases), 2006-2007*
35

30 Probable
Confirmed
Number of cases reported

25

20

15

10

Week of onset
*2007 cases as of 3/26/07
Includes probable and confirmed completed cases, Michigan Disease Surveillance System as of 3/26/07
Age Distribution of Cases During Kalamazoo
County Outbreak (May 15, 2006 - Feb 19, 2007)

Age Number <1 year

Group of Cases 9%
20+ years 1-4 years
<1 27 27% 13%
1-4 38
5-9 67 5-9 years
10-19 years 23%
10-19 83
28%
20+ 80
Total 295
 Clinical Symptoms Among Probable and
Confirmed Pertussis Cases Kalamazoo County
5/15/06 - 2/19/07

All Ages (n=295) Infants only (n=27)

2+ weeks cough
Post-tussive
Post-tussive with epi link to
vomiting only
vomiting only case
4%
3% 3%

Paroxysm, Post- Paroxysm, Post-

tussive vomiting, tussive vomiting,
Whoop Whoop
Paroxysms only
18% 22%
26%
Paroxysms only
Paroxysm, Whoop
33%
10%
Paroxysm, Whoop
Paroxysm, Post- 22%
Paroxysm, Post- tussive vomiting
tussive vomiting 26%
33%
 PCR Testing and Results Among Cases,
Kalamazoo County Pertussis Outbreak
5/15/06 - 2/19/07
140
119 120
120
Number of cases

100
80
60
39
40
17
20
0
positive PCR negative PCR Test done, no PCR not done
result
 Vaccination Status of Cases
Age 5 – 11 Years (n=77)
• 97% “ever” vaccinated
Number of Pertussis-Containing Vaccine
Doses Received (5 to 11 Years)
80
58
Number of cases

60

40

20 11
3
0
0 1-4 5+
Number of doses
Prevention and Control Measures
• Shortened timeframe to administer Tdap after Td
vaccination (2 year interval rather than 5); Tdap for
pregnant woman and adults aged 65+.
• Promotion of Tdap
• In-service for providers and staff at KCMS on case
management and NP swabs
• Went to superintendent meetings to talk about not
penalizing students for staying home in isolation
• School open houses and conferences (GIS mapping)
Pertussis Cases in
Kalamazoo County
Week 1 – 06-01-06
7 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
7

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 2 – 06-8-06
7 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
14

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 3 – 06-15-06
5 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
19

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 4 – 06-22-06
6 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
25

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 5 – 06-29-06
7 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
32

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 6 – 07-06-06
7 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
39

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 7 – 07-13-06
6 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
45

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 8 – 07-20-06
6 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
51

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 9 – 07-27-06
5 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
56

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 10 – 08-03-06
2 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
58

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 11 – 08-10-06
11 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
69

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 12 – 08-17-06
4 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
73

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 13 – 08-24-06
7 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
80

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 14 – 08-31-06
19 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
99

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 15 – 09-07-06
28 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
127

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 16 – 09-14-06
25 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
152

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 17 – 09-21-06
34 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
186

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 18 – 09-28-06
14 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
200

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 19 – 10-05-06
11 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
211

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 20 – 10-12-06
12 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
223

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 21 – 10-19-06
10 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
233

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 22 – 10-26-06
10 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
243

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 23 – 11-02-06
2 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
245

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
Pertussis Cases in
Kalamazoo County
Week 24 – 11-09-06
3 Confirmed /
Probable Cases
Cumulative count
since June 1, 2006:
248

Data extracted from

the Michigan
Disease
Surveillance
System (MDSS).
Includes cases
reported to the HCS
Communicable
Disease Control
Office.
 Tdap Promotion
• Letters to school parents, attended open
houses and conferences
• Broadcast faxes to providers; provider in-
service
• Media
• County website
 Number reported Number of cases reported

10
15
20
25
30
35

0
5

0
5
10
15
20
25
30
35
1/1/06 1/1/06

1/22/06 1/22/06

2/12/06 2/12/06

3/5/06 3/5/06

3/26/06 3/26/06

4/16/06 4/16/06
Probable

Not a Case
Confirmed

5/7/06 5/7/06

5/28/06 5/28/06

6/18/06 6/18/06

7/9/06 7/9/06

7/30/06 7/30/06

8/20/06 8/20/06

Week reported
Week of onset

9/10/06 9/10/06

10/1/06 10/1/06

10/22/06 10/22/06

11/12/06 11/12/06

12/3/06 12/3/06

12/24/06 12/24/06

1/14/07 1/14/07

2/4/07 2/4/07

2/25/07 2/25/07
Pertussis Cases and Non-Cases Reported by Week

3/18/07 3/18/07
Kalamazoo County Investigation
and Response Efforts:
•Michelle Thorne •Dawn Smith
•Mike Phillips •Roxanne Ellis
•Lynne Norman •Penny Born
•Teresa Klan •Michelle Delrey
•JoAnn Hyde •Pamela Richardson
•Jane Secor
…and many thanks to Kim Kutzko, Region 5
Epidemiologist and Sonya LeBrecque, Sanofi
Pasteur rep