PERTUSSIS CASE OVERVIEW
Work type: Case study
Format: APA
Pages: 2 pages ( 550 words, Double spaced
Academic level: Master’s
Subject or discipline: Health Care
Title: Case Study 1 | Statistical Analysis of Pertussis Cases
Number of sources: 2
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1.Identify immediate and basic issues within the case study, including the problem at hand, its significance and related assumptions.
2.Describe any missing information, risk factors, alternative strategies and negative outcomes.
3.Define a problem statement (see example provided in the Case Study Analysis Preparation worksheet).
4.Develop an action and implementation plan.
5.Summarize take-aways and reflections on the process, as well as the viability of the plan.
Assignment Scope
Citation requirements: 2
Word count: 600
APA formatting
Title page
Reference page
During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf Adapted From: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6348a2.htm