Implementation of Cocooning against Pertussis in a High-Risk Population

MAJOR ARTICLE Implementation of Cocooning against Pertussis in a High-Risk Population C. Mary Healy,1,2,3 Marcia A Rench,1,3 and Carol J. Baker1,2,3,4 1Center for Vaccine Awareness and Research Hospital, Texas Children's Hospital; 2Ben Taub General Hospital; 3Department of Pediatrics and 4Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, Texas Background. In 2006, the Advisory Committee on Immunization Practices recommended tetanus, diphtheria, acellular pertussis (Tdap) vaccination of all caregivers of infants aged ,1 year (‘‘cocooning’’) to prevent pertussisrelated complications and deaths. We implemented cocooning in a predominantly Hispanic, medically underserved, uninsured population at a Houston hospital. Phase 1 (January 2008–January 2010) provided maternal postpartum Tdap vaccine; Phase 2 (June 2009–January 2010) also vaccinated infant contacts on-site. Methods. Pertussis education was provided to health care personnel and mothers. Standing orders for maternal postpartum Tdap vaccination were initiated. Mothers were interviewed to ascertain the number of additional infant contacts eligible to receive Tdap vaccine. Consenting eligible contacts received Tdap vaccine as soon as possible after delivery. Results. From 7 January 2008 through 31 January 2010, 8334 (75%) of 11,174 postpartum women received Tdap vaccine. During Phase 2, 2969 (86%) of 3455 postpartum women were vaccinated; another 197 (6%) had previously received Tdap vaccine. Mothers were Hispanic (91.4%), black (5.4%), white (0.8%), Asian (1.4%) and other (1.0%). A median of 3 (range, 1–11) other Tdap-eligible contacts per infant were identified, and a median of 2 (range, 0–10) contacts per infant received Tdap vaccine. Of 1860 contacts vaccinated, 1813 (98%) anticipated daily infant contact. A total of 1697 (91%) received Tdap vaccine before infant hospital discharge, and 144 (8%) received Tdap vaccine within 7 days after hospital discharge. Barriers to full cocooning included the need for extended vaccination hours, visiting restrictions because of pandemic H1N1 influenza, and inaccurate recall of vaccination history. Conclusion. Although practical and logistical barriers exist, Tdap cocooning was well accepted by and successfully implemented in a high-risk population by using standing orders and providing vaccinations on-site. Pertussis vaccination in the United States reduced annual pertussis-attributable morbidity and mortality by 92% and 99%, respectively [1]. Despite this fact, and despite pertussis vaccination rates in US children of 80%–95%, the annual incidence of pertussis has increased since the nadir of 1010 cases reported in 1976 [2, 3]. The Centers for Disease Control and Prevention (CDC) report that infants under 6 months of age, who Received 21 May 2010; accepted 31 August 2010. Presented in part: National Immunization Conference, Atlanta, Georgia, April 19–22, 2010. Abstract # 22776 Correspondence: C. Mary Healy, MD, 1102 Bates St, Ste 1120, Houston, TX 77030, USA (). Clinical Infectious Diseases 2011;52(2):157–162 Ó The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: . 1058-4838/2011/522-0001$37.00 DOI: 10.1093/cid/ciq001 are too young to have completed the primary vaccination series, have up to a 20-fold higher incidence of pertussis than does the general population (69.99 versus 3.62 cases per 100,000 population in 2007). Two-thirds of pertussis-infected infants in this age group are hospitalized [4]. Furthermore, pertussis-related deaths occur almost exclusively in young infants, the risk being inversely proportional to age and number of infant DTaP vaccine doses received [5–7]. Studies also demonstrate that 75% of infants are infected by a household contact or caregiver, most commonly their mother (33%) or father (16%) [8, 9]. Pertussis incidence and mortality are higher in infants of Hispanic ethnicity, for reasons that are not understood [6, 7, 10]. Since June 2006, in an effort to prevent pertussis in young infants, the Advisory Committee on Immunization Practices (ACIP) to the CDC has recommended that Implementing Cocooning against Pertussis d CID 2011:52 (15 January) d 157 Tdap vaccine be administered to postpartum women before hospital discharge and to household and caregiver contacts of newborns and infants less than 1 year of age [11]. This targeted vaccination strategy, called cocooning—the only protection against pertussis available to young infants except vaccination during pregnancy—has not been widely implemented, largely because of a lack of necessary infrastructure, a need for education, reimbursement issues, and logistical barriers [12–14]. We initiated a phased implementation of Tdap cocooning in a predominantly Hispanic, medically underserved, and underinsured population in Houston, Texas. Phase 1 implemented maternal postpartum vaccination [13]. Phase 2 expanded the program to vaccinate household contacts of newborn infants on site. This report describes the implementation of both phases of this strategy through January 2010. METHODS Patient population. Ben Taub General Hospital is 1 of 2 public hospitals of the tax-supported Harris County Hospital District in Houston, Texas. Approximately 5000 live-born infants, predominantly Hispanic (.90%), are delivered there annually. Ben Taub General Hospital cares for a largely underinsured, medically underserved, predominantly Spanishspeaking population that is likely to have inadequate antenatal care and is unlikely to receive Tdap vaccine from other sources or to have knowledge about pertussis or Tdap vaccination recommendations. Education for health care professionals (HCPs). Educational methods for HCPs have been previously described [13]. Briefly, the severity of pertussis illness in young infants and the rationale for cocooning were presented in obstetrical grand rounds and small group in-service sessions. In-service sessions targeted physicians, nurses, administrative staff, and hospital interpreters. Nursing personnel were particularly targeted because of their role as trusted advisors for new mothers and their potential to be powerful vaccine advocates. In-service sessions occurred at convenient times for day-shift and night-shift personnel to ensure optimal attendance. Education was performed at regular intervals for new personnel, to reinforce prior information, and provide updates. Physician directors and dedicated program nurses also were available to address any questions from hospital nurses and physicians. Education for postpartum women and families. Posters advocating Tdap vaccination were displayed prominently in antenatal, labor and delivery, and postpartum areas. Program education was incorporated into antenatal, baby-care, and breastfeeding classes. Each postpartum woman received a pertussis information packet that contained bilingual informatio (...truncated)