Thomas Clark, MD, MPHCenters for Disease Control and Prevention

Immunization Program Managers MeetingNovember 16, 2010

Pertussis Epidemiology in the United States

National Center for Immunization & Respiratory Diseases

Meningitis and Vaccine Preventable Diseases Branch/Division of Bacterial Diseases

BACKGROUND AND OVERVIEW

Impact of Vaccines in the United States

Vaccine-Preventable Disease

Number of Reported Cases

20th Century Annual

Morbidity*

2008**

Smallpox 48,164 0

Diphtheria 175,885 0

Pertussis 147,271 13,278†

Tetanus 1,314 19

Polio (paralytic) 16,316 0

Measles 503,282 140

Mumps 152,209 454

Rubella 47,745 16

Congenital rubella 823 0

H. influenza (invasive <5 yrs)

20,000 30* CDC, MMWR, April 2, 1999. 48(12); :242-264** CDC, MMWR, January 8, 2010. 58(51 & 52); 1460-1468† National Notifiable Diseases Surveillance System, CDC, 2008

Pertussis Immunization in the US

• Infants (1997)– DTaP at 2, 4, 6 months

• Toddler (1992)– DTaP at 15-18 months

• Pre-school (1992)– DTaP at4-6 years

• Adolescent/adult (2005)– Single Tdap preferred at 11-12 years

DTaP coverage among children aged 19 through 35 months

2004 2005 2006 2007 2008 200978

80

82

84

86

88

90

92

94

96

98

3+4+

CDC National Immunization Survey

1922

1930

1940

1950

1960

1970

1980

1990

2000

2009

0

50,000

100,000

150,000

200,000

250,000

300,000

Year

Nu

mb

er

of

ca

se

s

Reported pertussis cases – 1922-2009

DTP

1990

1995

2000

2005

2009

0

5,000

10,000

15,000

20,000

25,000

30,000

Tdap

DTaP

SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the Public Health Service

Annual incidence (per 100,000) by state - 2009

Source: CDC National Notifiable Disease Surveillance System, 2009CDC Wonder Population Estimates (Vintage 2009)

0-2.7

2.8-4.6

4.7-6.6

6.7-21.5

Incidence

2009 incidence 5.5

Annual incidence by State (per 100,000) by state - preliminary 2010*

Source : CDC National Notifiable Disease Surveillance System , *Provisional data, cumulative to week

ending September 25, 2010 (MMWR Week 38) CDC Wonder Population Estimates (Vintage 2009)

0.0-1.8

1.9-3.2

3.2-5.0

5.1-10.0

Incidence

Reported pertussis incidence by age group - 1990-2009

1990

1995

2000

2005

2009

0

20

40

60

80

100

<1 yr

1-6 yrs

7-10 yrs

11-19

20+ yrs

Year

Inc

ide

nc

e r

ate

(p

er

10

0,0

00

)

SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System

TDAP IMPLEMENTATION AND EVALUATION

Proportion of reported pertussis cases by age group - 1990-2009

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

0.00

20.00

40.00

60.00

80.00

100.00

all other ages20+ years11-19 years

Year

Perc

en

t

Source: CDC National Notifiable Disease Surveillance System, 2009CDC Wonder Population Estimates (Vintage 2009)

Tdap coverage among adolescents aged 13-17 years – 2006-2009

Series10

10

20

30

40

50

60

70

80

90

100

10.8

30.4

40.8

55.6

CDC. National, State, and Local Area Vaccination Coverage Among Adolescents Aged 33-17 Years - United States, 2008. MMWR 2008;58(36);997-1001.CDC. Vaccination Coverage Among Adolescents Aged 13-17 Years – United States, 2007. MMWR 2008;57(40)1100-1103.CDC. Vaccination Coverage Among Adolescents Aged 13-17 Years– United States, 2006. MMWR 2007;56(34) 885-888. CDC. National, State, and Local Area Vaccination Coverage among Adolescents Aged 13-17 Years - United States, 2009 MMWR 2010 ;59(32);1018-1023.

2006

2007

2008

Perc

en

tage (

%)

2009

Tdap Vaccine Effectiveness

• Bridging studies of ADACEL and BOOSTRIX1

– 85-89%

• APERT study2

– 92% (95% CI: 32.0-99.0)

• Australia3 – screening method– 78.0% (95% CI: 60.7-87.6)

• St. Croix outbreak4 – case-control study– 65.6% (95% CI: -35.8-91.3)

• MN case-control study – 72.3% (95% CI: 38.8-87.4)

1 Schmitt HJ et al. JAMA 1996;275:37-41; Gustafsson LH et al. NEJM 1996;334:349-3552 Ward JI et al. N Engl J Med. 2005 Oct 13;353(15):1555-63.3 Rank C, et al. Pediatr Infect Dis J. 2009 Feb;28(2):152-3. 4 Wei SC, et al. CID 2010; 51(3):315-321.

Incidence of reported pertussis - 1990-2008

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

0

2

4

6

8

10

Overall

Year

Cas

es/1

00,0

00 P

op

ula

tio

n

Tdap

CDC unpublished data

Accelerated decline of pertussis Rate ratios of pertussis incidence among

adolescents 11-18 years, 1990-2008

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

00.5

11.5

22.5

33.5

44.5

11-18 years of age vs. all other age groups combined

Year

Ra

te R

ati

o (

Inc

ide

nc

e)

CDC unpublished data

EMERGENCE OF DISEASE IN CHILDREN AGED 7-10 YEARS

Pertussis incidence by age group - 1990-2009

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

0

5

10

15

20

25

30

35

40

1-6 years7-10 years11-14 years15-19 years

Year

Incid

en

ce (

per

10

0,0

00

)

Source: CDC National Notifiable Disease Surveillance System, 2009CDC Wonder Population Estimates (Vintage 2009)

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

0

5

10

15

20

25

Proportion of all pertussis cases con-tributed by children aged 7-10 years

Year

Perc

en

t

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180

200400600800

10001200140016001800

2004

Age (years)

Cases

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180

200

400

600

800

1000

1200

1400

1600

2005

Age (years)

Cases

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180

50100150200250300350400450

2002

Age (years)

Cases

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180

100200300400

500600700800

2003

Age (years)

Cases

Pertussis cases by age – 2002-2005

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180

200

400

600

800

1000

1200

2008

Age (years)

Cases

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180

200

400

600

800

1000

1200

1400

1600

2009

Age (years)

Cases

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180

100200300400500600700800

2006

Age (years)

Cases

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 180

50100150200250300350400450

2007

Age (years)

Cases

Pertussis cases by age – 2006-2009

Incidence rate ratios of pertussis among children aged 7-10 years – 1990-

200919

9019

9119

9219

9319

9419

9519

9619

9719

9819

9920

0020

0120

0220

0320

0420

0520

0620

0720

0820

09

01234567

7-10 years of age vs. all other ages combined

Year

Rate

Rati

o

Source: CDC National Notifiable Disease Surveillance System, 2009CDC Wonder Population Estimates (Vintage 2009)

In 2005, 7-10 year old cohort includes aP vaccine recipients

1 2 3 4 5 6 7 8 9 10111213141516171819200

100

200

300

400

500

600

700

Pertussis Cases by Birth Cohort

1980-19911992-19992000-2008

Age (years)

Ca

se

s/#

of

Bir

th C

oh

ort

s i

n E

ach

Ag

e

Ye

ar

Waning Immunity by Vaccine Type

Priority Analytic Questions

• Comparative vaccine effectiveness using immunization registries

• Case-control study of effectiveness of 5th DTaP dose in California

• Modeling impact of waning immunity and changes to vaccination schedule

• Impact of changing strain diversity on disease occurrence

Additional Activities

• ACIP • Clinical Validation Study• Laboratory training and tech

transfer• External review of vaccinology

activities

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank You

National Center for Immunization & Respiratory Diseases

Meningitis and Vaccine Preventable Diseases/Division of Bacterial Diseases