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Press Briefing Transcript

Pertussis Epidemic in Washington State- 2012 Telebriefing

Thursday July 19, 2012, Noon ET

OPERATOR: Welcome.  I would like to thank you all for holding and inform you that your lines are on listen only for today’s conference until the question and answer session.  At that time, press star 1 on the touch tone phone.  This call is being recorded.  If you have any objections, you may disconnect at this time.  Sir, you may begin. 

TOM SKINNER: Thank you, Ed.  Thank you for joining this telebriefing where Dr. Schuchat and Secretary Mary Selecky will give us an overview of the whooping cough situation as outlined in today’s MMWR, which hopefully you all have.  Dr. Anne Schuchat is the director for the National Center for Immunization and Respiratory Diseases here at CDC.  Her name is spelled a-n-n-e and her last name is spelled s-c-h-u-c-h-a-t.  She is an MD and she will give us opening remarks to give us a national perspective on pertussis.  Ms. Selecky is the Secretary of the Washington state health department.  Her name is spelled m-a-r-y and her last name is spelled s-e-l-e-c-k-y.  She will provide us with information specific to Washington and then we’ll get to your questions and answers.  Dr. Schuchat?

ANNE SCHUCHAT: Thanks, Tom.  Today, we're releasing an MMWR report on whooping cough or pertussis on the epidemic that’s occurring in Washington state.  What is happening in Washington state is a reflection of the larger national picture which is very difficult to control disease.  Today, I want to give an update on what we're seeing regarding whooping cough cases in the U.S. and above all, I want to urge vaccination for pregnant women and anyone who will have contact with babies.  We're seeing a substantial increase in pertussis cases in the United States and in individual states like Washington.  There is a graph that looks back at pertussis-reported cases since 1922 that I think the media have gotten access to.  You might want to look at that while I make a few more comments about what's going on.  Many states are seeing higher than expected cases of pertussis.  As you all know, Washington declared an epidemic.  As of today, nationwide, nearly 18,000 cases have been reported to CDC.  That's more than twice as many as we had at the same time last year.  In fact, it's more than we had in each of the past five years.  We may be on track for record high pertussis rates this year.  We may need to go back to 1959 to find a year with as many cases reported by this time so far.  So, there is a lot of pertussis out there and I think there may be more coming to a place near you. 

Unfortunately, so far this year, nine babies have died from whooping cough according to the reports we got through today.  That's one more than is in the MMWR.  Since then MMWR went to print, we learned of an additional case.  Pertussis is most dangerous for babies and very young children.  In general, more than half of babies younger than 1 year of age who get the disease need to be cared for in the hospital.  Pertussis occurs in waves.  You can see this on the graph.  It occurs in waves with peaks that occur around every three-to-five years.  Not all states will have peaks in exactly the same time.  We may be in one of those cycles where we are in the upswing around the country.  While it is a cyclical season, a gradual and sustained increase in pertussis has been seen in the U.S. after we reached historic low levels in the 1970s.  There are probably several factors that contribute to this slow increase that we're seeing, including immunity provided by the pertussis vaccine which can wane over time.  But there may also be increased reporting and increased diagnosis to compare with the 1970s with the information we have today.  2010 was our last peak year nationally.  We had over 27,000 reported cases that year and 27 deaths, 25 of which occurred in infants. 

When we have these waves occurring, we look at trends and try to understand how we can best reduce the impact of disease.  So in this current wave nationally, we're seeing the highest rates of pertussis in infants younger than one year of age.  About half of these cases are babies under three months of age.  That's because those very young babies are too young to be protected by vaccines that they start getting at two months of age.  Their protection instead depends on the immunity of the people around them, especially pregnant women, their mothers.  That is why we strongly urge pregnant women and all who will be around babies to be vaccinated.  Infants often get pertussis from a family member or household member. 

We’re also seeing high rates in older children as well.  We're seeing high rates among children 10 years of age.  We realize that by age 10, immunity can wane from the early-childhood vaccines that kids get.  That is why we ended up recommending a booster of pertussis containing vaccine at 11-to-12 years of age.  The booster is called Tdap.  A particular note in today’s MMWR is the increased rates in Washington state in adolescents 13 and 14 years of age.  We are seeing that increase nationally in the 13-to-14 year age group.  That is different than what we saw in previous waves of pertussis.  The increased number of cases among 13-to-14 year olds is a concern we are looking at in detail.  There are a number of possible causes, including how long protection from the vaccine lasts, if the switch we made in the strain we use in young children, a switch we made back in 1997 from the whole cell pertussis vaccine to the acellular pertussis vaccine might have done something to impact how long the vaccines last.  We're investigating these questions in detail in collaboration with state health departments, including Washington.  I would be happy to go into more explanation in the questions and answers. 

Pertussis vaccine remains the single most effective approach to prevent infection.  It is critical to protect infants and others at high risk.  I want to stress that unvaccinated children are at eight times higher risk of getting pertussis compared to children fully vaccinated.  We reproduced that information recently in a study in California.  It's really important to stress that not being vaccinated really increases your risk of getting pertussis.  Vaccinated children who get pertussis typically have a milder course.  They typically have milder symptoms, a shorter illness and a reduced risk of the severe outcomes like hospitalization.  They are also less infectious in spreading the illness than unvaccinated children.  There are two types of vaccines currently recommended to protect against pertussis.  Both are acellular vaccines.  The first is called d as in diphtheria, t as tetanus, a, p as in pertussis or DTaP.  That is recommended for infants and young children in a five dose series at 2, 4 and 6 months of age, at 15 through 18 months of age, and at 4 through 6 years of age.  The second currently licensed vaccine that we use in the U.S. is called Tdap.  This is a booster dose recommended for everyone at age 11 to 12 years.  In addition, it is recommended for pregnant women and any adult who has not had a pertussis booster already. 

Vaccines have done a good job at reducing the incidence of pertussis.  But our pertussis vaccines are not perfect.  They don't provide protection for as long as we wish they would.  This adds to our challenges during these times of the increased disease.  We wish we had better ways of controlling pertussis.  But remember that without vaccines, we know we would have hundreds of thousands of pertussis cases each year.  So given how dangerous pertussis is for babies, preventing infant deaths for the disease is our primary national goal.  CDC continues to recommend that all children and adults get fully vaccinated to prevent infection and to protect infants.  Getting Tdap is especially important for women and those that will be around infants, grandparents, brothers and sisters, childcare workers, and health care providers.  However, in 2010, only 8 percent of adults had any history of receiving a Tdap booster.  I know we can do better than this.  We need to do better than this.  We're also asking clinicians who see patients with persistent cough or who may have been exposed to the disease to consider pertussis as a diagnosis.  Be proactive with treatment, especially with pregnant women, infants, and others who are around infants.  Before we handle questions, I want to turn things over to Secretary Selecky to learn more about what is going on in Washington.  I want to say they have been doing a tremendous job in Washington in responding to a very difficult situation. 

MARY SELECKY: Thank you, Dr. Schuchat.  This is Mary Selecky.  Thank you for having me on the call today.  The whooping cough situation in Washington state has been incredibly challenging.  We're seeing the largest number of cases in our state since the early 1940s.  When I first declared a pertussis epidemic on April 3rd of this year, we had 640 cases.  As of the end of last week, we had more than 3,000.  That's more than three times the number of cases we had all of last year in 2011.  Let me put that in perspective for you.  Washington had just over 200 cases at this time last year in July of 2011.  Most counties in our state have reported cases and for every case we know about, we expect there are many people out there who have pertussis and don't know about it.  My biggest concern, as Dr. Schuchat has said, is for babies.  They are the ones that get hit the hardest, usually the sickest, and many times end up hospitalized.  We have had no deaths in this current epidemic, however, two children under one year old died from whooping cough last year and two others died in 2010. 

Over the last few months, I’ve met with families who had gone through this.  It is incredibly hard.  In many cases, babies get this illness from their mothers or others who are close to them.  It is absolutely tragic.  We're using every tool that we have to fight this.  With help from the federal government and our governor's emergency fund, we bought and distributed 27,000 doses of Tdap vaccine to local communities for uninsured adults and we just ordered more.  We are focusing most of our efforts on getting adults and pregnant women vaccinated because they are the ones that usually spread this to the little ones.  We're pushing information out to health care providers to make sure they are informed and that they encourage patients to get vaccinated.  As adults, we don't think about our vaccinations and I hope everyone listening whether you are in Washington state or not, get a Tdap booster.  That is really essential and that will help us all. 

We are working closely with our local health partners and our American Indian tribes who are tracking the disease and helping us get the vaccine out in the community.  We’ve been very aggressive in informing the public. Our Governor Chris Gregoire provided money from her emergency fund to help pay for vaccine and get the information out.  Our media campaign includes TV, billboard, bus ads, social media ads and radio spots featuring real families that have been directly affected by whooping cough.  The message is best coming from them.  Their lives and their families were affected.  Reports from our health plans and our state along with the information from our immunization registry show the number of adults getting the Tdap vaccine is way up from last year, but I want more.  People are clearly getting the message and taking steps to protect family, themselves, and babies in our state, but we need help from every adult in Washington state and everywhere around the nation.  You know, epidemics don't start or end overnight.  We have a lot of work ahead of us.  We have seen a slight slowdown in the number of reported cases recently, but it's too early to draw any conclusions from that. 

So we continue to encourage adults and pregnant women to get vaccinated.  If we use up the vaccine we have now, that's a good thing.  We'll order more.  Thanks to Dr. Schuchat and the CDC for the help they’ve given us.  They sent an Epi team out to help with the investigation and have also helped with the media campaign and getting the word out quickly.  I want to conclude with three points.  You're seeing public health in action.  This is the work we do every day to make a safer and healthier country.  It also shows why it's vital to invest in the public health system at the federal, state and local level.  Third, vaccination is still the very best protection.  It can protect babies from getting very sick and possibly dying.  That's why we want everyone to make sure they are up to date on the whooping cough vaccine.  Thank you very much, Dr.  Schuchat. 

TOM SKINNER: Okay.  Thank you, Secretary Selecky.  I believe we're ready for questions.  If we could have reporters ask one question and we'll allow a follow-up question, if necessary.  Then we'll move to the next question.  Ed, we're ready to begin. 

OPERATOR: Thank you, sir.  At this time, if you would like to ask a question, please press star one on your touch tone phone.  You will be prompted to state your name and pronunciation.  Star one to ask a question.  Star two to withdraw your question.  Limit yourself to one question and follow-up question.  One moment, please.  First one comes from Mike Stobbe from Associated Press. 

MIKE STOBBE: Thank you for taking the call.  I'm curious about the U.S. experience compared to what's happened in other countries.  Have you all looked at and you probably have -- have you looked at other countries that got the vaccine, whether it was also in the '40s or whenever.  Did it also go down or has it risen a bit in recent years as it has in the U.S.?  And if the U.S. experience is different, why do you think that is? 

ANNE SCHUCHAT: Thanks, Mike.  This is Anne answering the question.  It's clear that the introduction of vaccines led to substantial reductions in pertussis.  But it is important comparing countries experiences to recognize that people track pertussis disease and outbreaks quite differently.  The kind of system for reporting and detection that we have here in the U.S. is not used in every other place.  With that caveat, I can say that other countries that are similar to the U.S. have been experiencing high rates.  In fact, Australia currently has rates of disease that are much higher than the U.S. rates.  There have been outbreaks in Canada recently that have been characterized by high rates of disease in adolescents.  It is too soon to say whether the phenomena that we are seeing in Washington state and the U.S. will be mimicked in other countries.  I would say there is good communication to share experience and compare notes and look for a way forward together.  Next question. 

OPERATOR: Next question from Elizabeth Weise from USA Today.

ELIZABETH WEISE: Hi, thanks for taking my question. You say the rates of illness are going up.  You say they are cyclical.  Is this part of the cycle or is it related to efforts by some to encourage people not to be vaccinated? 

ANNE SCHUCHAT: Yes, thank you for that question.  We think there are many things going on.  Pertussis is a cyclical disease and the vaccines are not perfect.  So even with increasing vaccination coverage, we expect to still have cycles.  We think there are some unusual epidemiologic features that have caused us to launch a more detailed investigation in Washington State.  Waning of immunity or a weakening of the time or waning of protection over time may be part of the story that we're seeing.  On the other hand, we know that people who are not vaccinated have about an eight times higher risk of disease than people who are vaccinated.  We know there are places around the country where there are large numbers of people who aren't vaccinated.  However, we don't think those exemptors are driving this current wave.  We think it is a bad thing that people aren't getting vaccinated or exempting, but we cannot blame this wave on that phenomenon.  Next question. 

OPERATOR: Tom Maugh from the L.A. Times. 

TOM MAUGH:  You said there are some unusual things epidemiologically about this, what kind of things are you talking about here? 

ANNE SCHUCHAT:  If we look at the teenage group, what we see is that disease rates start to come up after late childhood.  You know with the higher rate in 10-year-olds.  Then we actually have a decrease in the 11 and 12 year olds and higher rate in 13 and 14 year olds.  There is a lot going on in the age group that is a bit different than what we saw in the last wave, several years ago.  Part of it may be children in these teenage years are the first cohort of children who were exposed to the acellular pertussis vaccine for all of their early childhood doses. The wave at early childhood experience of vaccination goes might lead to some changes in the protection status in the teenage years.  We are also in the first phase of evaluating the Tdap booster dose given to 11 and 12-year-olds.  One of the issues in Washington State is to measure how well that is working.  Is it giving us short-term protection or lasting or dropping off or waning.  The pattern of higher rates in 11 and 13 and 14 year olds is a bit different than what we have seen in the past.  In the past, we saw rates going up in the adolescent group.  Most of the data are from before we had the booster dose to work with.  Next question. 

OPERATOR: Next question from Maggie Fox from NBC.  Your line is open. 

MAGGIE FOX: Hi, I wonder if you can review for us what the reasons were for going from the whole sale vaccine to the acellular vaccine and what the differences are in the immunity that each provides?

ANNE SCHUCHAT: That is a great question and it will take a fairly long answer.  First off, wholecell pertussis vaccines are widely used in many parts of the world.  But in the U.S., we have not been using them since 1997.  The wholecell pertussis vaccines were also different.  Some companies’ products performed differently than others. It is difficult to give a precise estimate of how well they worked because they were not all one thing.  We know the wholecell pertussis vaccines had a fairly high rate of minor and short-term side effects like fever and pain and swelling at the injection site.  Those were fairly common reactions.  And the acellular pertussis vaccines have a lower rate of the fever and transient side effects.  There were also rare, but serious neurologic adverse reactions, including chronic neurologic problems that occurred among children that recently received wholecell vaccines.  Studies have not been consistent about whether the vaccine actually caused those chronic neurologic problems.  Yet there was substantial public concern about them and not just in the U.S., but in other countries.  That led to a concerted effort to develop a vaccine with an improved safety profile.  We know that the acellular pertussis vaccines, much less local reactions than the wholecell vaccines.  Question of the neurologic issues is still not so clear.  The current acellular pertussis vaccines have a good safety record and they are fairly effective.  In young children, we think that within a couple of years of vaccination the Dtap series is 95 percent protection.  Five years later after the series, we think it wanes to 70 percent.  That going down from 95 percent effectiveness to 70 percent may be why we see this increase in the older children or young teens.  Next question. 

OPERATOR: The next question from Sheila Hagar from Walla Walla Union Bulletin, your line is open.  

SHEILA HAGAR:  Elizabeth echoed much of my question.  I am wondering if health officials are getting any sort of information from the number of vaccinated folks.  Any leaders in that group if you guys are hearing anything from them? 

ANNE SCHUCHAT: Secretary Selecky, do you want to say what is going on in Washington? 

MARY SELECKY: We have not -- Sheila, this is Mary Selecky.  We have had no official contact from any group of folks.  We certainly always get questions on our web site about vaccinations or people send us their opinions about vaccinations.  But as we look at what's going on with whooping cough in our state right now, most of our kids are vaccinated.  Indeed, part of what we will be studying with the CDC is the long-term effect of that vaccination.  Clearly vaccination is still the most effective way to prevent childhood diseases and many other diseases for adults.  We have not had formal contact with anyone. 

ANNE SCHUCHAT: This is Dr. Schuchat.  Let me just add on.  I have to say that I have been struck by the stories of people who have been suffering, particularly families whose babies have had a very severe pertussis illness and hospitalization or even death.  I think this whole outbreak we're seeing across the country is a reminder is such a reminder why we need vaccines.  I think that question of what are parents saying, I think there is some fear out there because this is a bad disease, particularly in babies.  A reminder we have so much more we can do in getting pregnant women vaccinated and anybody who’s going to be around babies as well as getting a baby who is ill, getting into treatment quickly.  Just a reminder that we are seeing high rates nationally compared with the past two years and it’s a really good time to make sure you and your family is up to date with your whooping cough vaccines.  Next question. 

OPERATOR: Next question is from Melinda Moyer from Discover Magazine.

MELINDA MOYER:  Thanks for taking my question.  You mentioned the growing evidence of protection from the Dtap series wanes in three-to-five years.  How similar is the Tdap vaccine to Dtap in term of how much protection it might provide and is the CDC considering changing how frequently the Tdap booster is recommended for adolescent and adults to account for waning protection?

ANNE SCHUCHAT: The Tdap vaccine effectiveness is the center piece of what we would like to be investigating in Washington State.  It has been measured to be about 60 percent to 70 percent effective.  But those measurements were carried out in children who had received their baby shots with the old wholecell vaccine.  Whether the duration of protection or the short-term effectiveness is different in Tdap among teens who got acellular protection as babies, we don't know yet.  That is one of the things we will be looking at in Washington State.  I apologize how complicated these answers are.  Tdap -- the pertussis vaccines are among our most complicated control efforts.  You need five doses as a young child.  Then a booster dose.  It is a question of whether you will need more booster doses during the adult years.  It is something we will also be looking at.  We are trying to make sure we learn as much as possible from Washington and other states right now to help provide the policymakers with good evidence to determine whether any changes and recommendations will be needed in the future.  Next question. 

OPERATOR: Our next question is from Ruby de Luna from KUOW Public Radio.  Your line is open. 

RUBY DE LUNA: Thanks for taking my question.  I wanted to clarify the higher rates in older kids.  Is that specific to Washington State or are you seeing this nationwide as well? 

ANNE SCHUCHAT: Yes, thanks for that question.  We do see that trend nationwide as well.  The MMWR actually includes a graph that compares the incidents in Washington and the incidents -- I’m sorry.  It includes the national incidents and takes out Washington so you can make sure what is going on nationally.  You can see in that graph that basically there are the highest rate is in under one year olds and then 10-year olds and 13- and 14-year-olds. Now 11- and 12-year-olds still have much higher rates than 5 or 6-year-olds.  There is certainly a lot going on in the teenage years.  But understanding how much of what we are seeing in the 10- to 14-year-old age group is a short-term or longer-term benefit of the Tdap vaccine versus variations in what children got at the earlier years versus where they live and whether they are in one of these communities that is very hard hit right now.  Nationally, we are seeing the 13- to 14-year-old group as a group we're quite interested in.  Next question. 

OPERATOR: At this time, if you would like to ask a question, press star 1.  That is star 1 to ask a question.  One moment, please.  We have a few that just came in.  One moment, please.  First one from Sharon Salyer from The Herald. 

SHARON SALYER: Thank you.  Are there continuing studies the CDC will be doing on this issue and can you talk about what those will be? 

ANNE SCHUCHAT: Yes, thank you.  The focus of study going forward is going to be field studies in the context of these increased rates of disease, working with state health departments including Washington and others to measure the vaccine effect.  The effect of the vaccines that have been used in the field to understand how effective the childhood series and the teenage dose are and how long the effect lasts.  There will be further detailed look at the epidemiology and risk factors for disease to better define who is getting this disease these days.  There are certainly academic groups doing other kinds of studies looking at clinical factors and so forth.  But I would say our focus right now is to understand the impact that the Tdap dose is having. 

TOM SKINNER: And, we'll take two more questions if there are two more questions. 

OPERATOR: Thank you.  One moment, please.  Next one comes from Kelly Koopmans from KOMO News. Your line is open.

KELLY KOOPMANS: Hi, my question may be more of a clarification. I understand the rise in incidents among 13- to 14-year-olds is nationwide, but why in Washington specifically are we seeing such a rise in number of cases?  Is there something unique happening in Washington state? 

ANNE SCHUCHAT:  You know, I think Secretary Selecky, would you like to say anything about Washington state? 

MARY SELECKY: Well, this is Mary Selecky.  As we have said before, this disease is very easy to catch.  It certainly has grabbed hold of our population here in Washington state.  I think as a result of the number of cases, we have gotten attention from many folks and including those who have not been vaccinated.  That is one of the things that we are certainly discovering is that most adults don't even think about being vaccinated.  The second thing we're learning from this is that- and we appreciate the fact that the Centers for Disease Control and Prevention will be doing a follow-up study with us is how long does the effectiveness of the vaccine last.  We hope everyone is getting the message about the vaccination.  The bug does have hold of Washington state and we don't see a major slowdown happening right now. 

ANNE SCHUCHAT: I would like to add on to that.  I think that this is more than a Washington state story.  One of the reasons for us to hold the telebriefing is we really think this disease is spreading around the country.  Wherever you live, you may be at risk.  Your family may be at risk.  Especially pregnant women, please get vaccinated and please make sure those who will be around your baby will be vaccinated.  I think we're in for a tough year and a tough couple of years.  Really, we would like to mimic what Washington has done in getting the word out within their state.  We think a number of states are at risk right now. 

TOM SKINNER: Ed, we'll take one more question. 

OPERATOR: Our last question from Judy Silverman from NBC News.  Your line is open.

JUDY SILVERMAN:  Hi, could you tell us what the national coverage rate is of the childhood vaccine and the booster shot? 

ANNE SCHUCHAT: Yes, sure. The booster shot in 13- to 17-year-old children is about 69 percent have gotten the Tdap. That is from the 2010 data.  If we look at toddlers, the 19-to-35 month olds, four doses of Tdap series is about 84 percent of toddlers.  Three doses is 95 percent.  The last statistic to give you is for adults, 19-to-64 years of age, that comes from our National Household Interview Survey.  That was from 2010; that statistic was 8.2 percent.  So only 8.2 percent of adults have gotten Tdap.  We know we can do so much better.  I hope particularly in pregnant women that you will help us raise those rates. 

TOM SKINNER: And, that concludes our call.  I want to thank everyone for joining us today.  For more information about pertussis and CDC's immunization recommends, you can visit our web site at www.cdc.gov/pertussis.  For more information about the Washington state epidemic, you may visit, www.doh.wa.gov.  Thanks again for joining us. 

OPERATOR: At this time, we conclude the conference.  You may disconnect.  Thank you for your attendance.

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