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Division of Community and Public Health Section: 4.0 Diseases or Conditions Subsection: Pertussis Revised 9/12 Page 1 of 10

Pertussis

Table of Contents Pertussis Fact Sheet (CDC) Disease Case Report (CD-1) Pertussis Report (IMMP-25) Pertussis: Summary of Vaccine Recommendations (CDC) Sample Letters Regarding Exposure to Pertussis: To Local Health Care Providers Regarding Pertussis Outbreaks To Parent/Guardian about Pertussis in a School To Parent/Guardian about Pertussis in a Child Care Facility To Physician ­ Referral Regarding Pertussis Prophylaxis PDF format Word format

Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual

Division of Community and Public Health Section: 4.0 Diseases or Conditions Subsection: Pertussis Revised 9/12 Page 2 of 10

Pertussis

Overview1,2,3,4,5

Pertussis is a highly communicable, vaccine-preventable disease that affects the respiratory tract. The illness is caused by Bordetella pertussis (B. pertussis) bacteria, for which humans are the only known natural reservoir. In classic cases, pertussis begins with a runny nose, mild cough, and low-grade fever (the catarrhal stage), which progresses to paroxysmal spasms of severe coughing, inspirational "whooping", and post-tussive vomiting. The duration of cough for classic pertussis is 6 to10 weeks. Approximately half of adolescents with pertussis cough for 10 weeks or longer.1 Pertussis has been called the "the 100day cough".2 Pertussis may also present as a mild to moderate cough illness in people who are partially immune, which makes diagnosis more elusive to clinicians and can result in unrecognized cases.3 In the U.S., most hospitalizations and nearly all deaths from pertussis occur in infants under six months of age. Complications are most common in infants and young children, and include pneumonia, hypoxia, apnea, seizures, encephalopathy, and malnutrition. In adults and adolescents protracted coughing episodes may also cause sleep disturbance, urinary incontinence, subconjunctival hemorrhaging, rib fractures, or other sequelae. Pertussis is transmitted through direct contact with discharges from respiratory mucous membranes of infected persons or via aerosolized droplets from coughing and sneezing. The incubation period ranges from 5-21 days, and is usually 7-10 days. Around 80% of susceptible household contacts of pertussis patients develop the disease. Transmission also occurs in child care settings, schools, clinics, and institutions including hospitals. Children who are too young to be fully vaccinated or who have not completed the primary vaccination series are at highest risk for severe illness.1,4 Pertussis is endemic in the U.S. and worldwide. Case reports averaged 175,000 per year between 1940 to 1945 in the U.S. Widespread use of whole cell pertussis vaccine resulted in a decline in incidence of more than 80%, with a historic low of 1,010 cases reached by 1976. However, incidence has been on the increase since the early 1980's for reasons that are not entirely clear. Children, adolescents, and adults who are partially protected by vaccine may become infected and have milder symptoms that go unrecognized as pertussis. Therefore, they are an important reservoir of infection for younger children. Between 2004 and 2005, approximately 60% of the reported U.S. pertussis cases were adolescents or adults.5 The majority of states in the U.S. reported increases in pertussis activity in the first half of 2012 (compared to the same time period in 2011), with several states including Missouri reporting high rates of the disease. Infants, children 7 to 10 years, and adolescents ages 13 to 14 years represent the age groups with the highest incidence rates in the mid-year 2012 report.2 For a complete description of pertussis, refer to the following texts: · Control of Communicable Diseases Manual. (CCDM), American Public Health Association. 19th ed. 2008 · American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. 2012. Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual

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Case Definition6

The current pertussis case definition is included in the list of Nationally Notifiable Diseases and Conditions available at: http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. Verify the diagnosis. Obtain demographic, clinical and laboratory information on the case from the attending physician, hospital, and/or parent to determine the case status. Obtain all information necessary to complete the Pertussis Report Form. Collection of epidemiologic and clinical data is essential for reporting cases that meet the clinical case definition. Investigators should make every attempt to collect information on paroxysms of cough, whoop, post-tussive vomiting, and duration of cough as these variables are required to determine whether an individual meets the clinical case definition for pertussis. When feasible, case investigations initiated shortly after cough onset should include follow-up calls to collect information on cough duration. Follow-up calls should be done regardless of confirmatory test results so that cases meeting the clinical case definition can be reported. Note: The limitations of laboratory diagnostics make the clinical case definition essential to pertussis surveillance. It is important to determine duration of cough - specifically whether it lasts 14 days or longer - in order to determine if a person's illness meets the definition of a clinical case. If the first interview of a suspect pertussis case is conducted within 14 days of cough onset and cough is still present at the time of interview, it is important to follow up at 14 days or later after onset. Identify contacts of the case. Determine the case's period of communicability and document all household and other close contacts during this time period, including name, address, age, sex, immunization history and circumstances of the exposure. Obtain information regarding school, work location, or other potential high risk settings of all household members. Establish the extent of illness. Determine whether household or other close contacts are or have been ill with symptoms compatible with pertussis, by contacting the health care provider, patient or family member. If the case is a child who attends a child care facility or a school, determine whether any other children in that setting are or have been ill with symptoms compatible with pertussis. Identify the most likely source of infection and risk factors for the spread of the disease. · Identify symptomatic household and other close contacts and obtain or recommend specimen collection and testing (see Laboratory Procedures). · Have the case and all appropriate close contacts been treated with an antibiotic recommended for use in treatment of pertussis (see Treatment and Post-exposure Prophylaxis)? · Does the case or a member of the case's household attend a child care center, nursery school, or any other school setting? · Does the case or a member of the case's family work as a health care provider or other high risk setting? · Determine the immunization status of the case and close contacts. · Has the case traveled to an area where there is a known outbreak or increased pertussis activity? Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual

Information Needed for Investigation

Division of Community and Public Health Section: 4.0 Diseases or Conditions Subsection: Pertussis Revised 9/12 Page 4 of 10

Notification

·

· · ·

Contact the District Communicable Disease Coordinator, or the Senior Epidemiology Specialist, or the Department of Health and Senior Services' Situation Room (DSR) at 800-392-0272 (24/7) immediately if an outbreak* of pertussis is suspected. Contact the Bureau of Environmental Health Services at (573) 751-6095 and the Section for Child Care Regulation (573-751-2450) if the case is associated with a child care facility. Contact the Section for Long Term Care Regulation (573-526-8524) if the case is associated with a long-term care facility. Contact the Bureau of Health Services Regulation (573-751-6303) if the case is associated with a hospital, hospital-based long-term care facility, or ambulatory surgical center.

*Outbreak is defined as the occurrence in a community or region, illness(es) similar in nature, clearly in excess of normal expectancy and derived from a common or a propagated source.

Control Measures 1,5,7,8.9

General: Control of this disease depends on several key control measures including: · High levels of pertussis immunization, especially among young children and their close contacts. · Prompt diagnosis and appropriate treatment of persons with Pertussis. · Prompt antibiotic prophylaxis of close contacts of pertussis cases (particularly persons associated with high-risk settings). · Appropriate isolation of hospitalized pertussis patients. · Appropriate exclusion of pertussis cases from child care/school/employment settings during the infectious period. Immunization:5,7,8 Immunization with a pertussis containing vaccine is an important control measure that has resulted in a dramatic decrease in the incidence of pertussis in the United States. In 2011, the Advisory Committee on Immunizations Practices (ACIP) expanded recommendations on pertussis-containing vaccine to include all age groups. Universal immunization of infants and children less than 7 years is recommended. In addition, it is believed that widespread boosting of pertussis immunity in older children, teens and adults can bring down pertussis incidence and mortality in the U.S. Pertussis vaccine is also recommended for certain groups that may be at increased risk of transmitting the disease to infants who are at greatest risk for severe disease and death. These groups include pregnant women, family members and caregivers of an infant, and health care workers. Among health care workers, priority should be given to those who have direct contact with babies younger than 12 months of age. A complete summary of the recommended pertussis vaccine schedule for all ages is available at: http://www.cdc.gov/vaccines/vpd-vac/pertussis/recssummary.htm. Note: There are persons for whom the pertussis vaccine should not be given due to specific contraindications. For a complete description of the pertussis vaccines including contraindications and precautions refer to CDC - The Pink Book at: http://www.cdc.gov/vaccines/pubs/pinkbook/pert.html for guidance. Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual

Division of Community and Public Health Section: 4.0 Diseases or Conditions Subsection: Pertussis Revised 9/12 Page 5 of 10

Diagnosis:9 Laboratory confirmation of pertussis is important because other pathogens can cause symptoms similar to pertussis. Several laboratory tests have been developed to test for pertussis and each of the methods have limitations. It should also be noted a positive laboratory test is not required to meet the probable case definition for pertussis. Culture of B. pertussis is the most specific diagnostic test; all patients with cough and a positive B. pertussis culture should be reported as confirmed, even those with cough lasting less than 14 days. Polymerase chain reaction (PCR) is less specific than culture; cases confirmed with only a positive PCR must meet the clinical case definition to be reported as confirmed. To confirm a case by epidemiologic linkage, the case must be directly linked (i.e., a first-generation contact) to a laboratory-confirmed case by either culture or PCR. Note: commercial serologic tests are not included in the current pertussis case definition for pertussis. During case investigations it is important to determine what test methods were used and when the specimen was collected in relation to onset of symptoms and antibiotic therapy use. For specific guidance on testing for pertussis see Laboratory Procedures. Treatment and Post-Exposure Prophylaxis:1 Treatment of pertussis cases with antimicrobials shortens the period of communicability and, if given in the early stages of illness, may reduce symptoms. After the cough is established, antimicrobial agents have no discernible effect on the course of illness but are recommended to limit spread of the bacteria to others. Prophylaxis may also prevent disease from occurring in close contacts if administered during the incubation (asymptomatic) period. Antimicrobial therapy options are the same for treatment and prophylaxis, and should be recommended for cases and contacts regardless of immunization history. Azithromycin, erythromycin, or clarithromycin are appropriate first-line agents for treatment and prophylaxis (see Table 3.44 on page 556 of the Red Book, 2012). Resistance of B. pertussis to macrolide antimicrobial agents has been reported rarely. Penicillins and cephalosporins are not effective against B. pertussis. Antimicrobial agents for infants younger than 6 months of age or persons who cannot tolerate macrolides, or who are infected with a macrolide-resistant strain can require special consideration. Please refer to the Red Book, 2012 or CDC's website: http://www.cdc.gov/pertussis/clinical/treatment.html for specific treatment guidance. Isolation/Exclusion (period of communicability): The following information should be taken into consideration when ascertaining the infectiousness of a pertussis case, and making recommendations regarding isolation/exclusion from certain settings (see child care, schools, and hospital settings). If untreated, persons with pertussis are generally considered communicable for three (3) weeks following onset of symptoms or until five (5) days after appropriate antibiotic treatment begins. During this time, the person with pertussis should NOT participate in any childcare, school, or community activities. If not treated for 5 days with an appropriate antibiotic, exclusion should be for 21 days after cough onset. If there is a high index of suspicion that the person has pertussis, exclude until the individual has been evaluated by a medical provider and deemed no longer infectious by the local health department. Case Investigation: General: Investigating pertussis cases and their close contacts can be extremely complicated and resource intensive for the disease investigator. The investigator should review this CDIRM chapter and refer to the Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual

Division of Community and Public Health Section: 4.0 Diseases or Conditions Subsection: Pertussis Revised 9/12 Page 6 of 10

Information Needed for Investigation for general steps needed for the investigation, including: verify the diagnosis, identifying contacts of the case, establishing the extent of the illness, and identifying the most likely source of infection and risk factors for the spread of the disease. The investigator must first verify the case meets the case definition for pertussis (see Case Definition). The clinical case definition was designed to increase sensitivity for detecting pertussis cases when confirmatory laboratory testing was not done or was negative. Laboratory tests can be negative even when the patient has pertussis. Collection of epidemiologic and clinical data is essential for reporting cases that meet the clinical case definition. Investigators should make every attempt to collect information on paroxysms of cough, whoop, post-tussive vomiting, and duration of cough as these variables are required to determine whether an individual meets the clinical case definition for pertussis. When feasible, case investigations initiated shortly after cough onset should include follow-up calls to collect information on cough duration. Follow-up should be done regardless of confirmatory test results so that cases meeting the clinical case definition can be reported. Identifying close contacts is important in the effort to prevent additional cases and further transmission of the bacteria by identifying individuals at risk of exposure and potentially in need of prophylaxis with a recommended antibiotic. Specific definitions for a contact are problematic and will vary with the situation. The following guidance should be used in identifying close contacts to a pertussis case for the purposes of decision-making on post-exposure prophylaxis recommendations. Transmission of pertussis can be expected with: · Household contacts: secondary attack rates of 80% among susceptible household contacts have been reported. · Direct face-to-face contact with a case-patient who is symptomatic (e.g., in the catarrhal or paroxysmal period of illness), or direct contact with respiratory, oral, or nasal secretions from a symptomatic casepatient (e.g., an explosive cough or sneeze in the face, sharing food, sharing eating utensils during a meal, kissing, mouth-to-mouth resuscitation, or performing a full medical exam including examination of the nose and throat). · Shared confined space in close proximity for a prolonged period of time, such as more than one (1) hour, with a symptomatic case-patient. Chemoprophylaxis is recommended for all household contacts of the index case and other close contacts, regardless of immunization status, including children in child care. Close contacts who are unimmunized or under immunized should have pertussis immunization initiated or continued using age-appropriate products according to the recommended schedule as soon as possible. The following groups/conditions should receive the highest priority, with regard to recommending antimicrobial prophylaxis: household contacts, children under the age of one year, pregnant women in the last three weeks of pregnancy, persons who have contact with infants, and settings where transmission is highly likely. Early use of chemoprophylaxis in household and other close contacts may limit secondary transmission.

Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual

Division of Community and Public Health Section: 4.0 Diseases or Conditions Subsection: Pertussis Revised 9/12 Page 7 of 10

The decision to administer antimicrobial post-exposure prophylaxis is based on several variables including the infectiousness of the case, the intensity of the exposure, and the time elapsed from when the exposure occurred. It is also important to take into account the potential consequences of severe pertussis in the contact and the possibility for secondary exposures and continued transmission to high risk persons. Identification and prophylaxis of contacts needs to be individualized. Take into consideration the risk of pertussis to the individual and the specifics of the exposure and weighing the risks and benefits of the antibiotic prophylaxis. For additional information regarding treatment/prophylaxis guidelines see Treatment and Post-Exposure Prophylaxis. Special groups/settings:1,10, 11 Child Care: Pertussis immunization and chemoprophylaxis should be given as recommended for household and other close contacts. Child care providers and exposed children, especially incompletely immunized children, should be monitored for respiratory tract symptoms for 21 days after contact has ended. Children and child care providers who are symptomatic or who have confirmed pertussis infection should be excluded from child care, pending physician evaluation and completion of 5 days of the recommended course of antimicrobial therapy (if pertussis is suspected). Untreated persons should be excluded until 21 days have elapsed from cough onset. A sample letter for notifying parents/guardians is available at the end of this document. Fact sheets for parents/guardians and providers are also available in the document: Prevention and Control of Communicable Diseases: A Guide for School Administrators, Nurses, Teachers, Child Care Providers, and Parents and Guardians. Schools: Students and staff members with pertussis should be excluded from school until they have completed five (5) days of the recommended course of antimicrobial therapy. Students and staff members with pertussis who do not receive appropriate antimicrobial therapy should be excluded from school for 21 days after onset of symptoms. Public health officials should be consulted for further recommendations to control pertussis transmission in schools. The immunization status of children should be reviewed, and age-appropriate pertussis containing vaccine should be given, if indicated, for household and other close contacts. Parents and employees should be notified about possible exposures to pertussis. Exclusion of exposed people with cough illness should be considered pending evaluation by a physician. A sample letter for notifying parents/guardians is available at the end of this document. Fact sheets for parents/guardians and providers are also available in the document: Prevention and Control of Communicable Diseases: A Guide for School Administrators, Nurses, Teachers, Child Care Providers, and Parents and Guardians. Health Care Settings: All health care professionals (HCPs) should observe standard precautions and wear a respiratory mask when examining a patient with a cough illness suspected or confirmed to be pertussis. Prophylaxis with a recommended antibiotic is targeted broadly to all potentially exposed people and health care professionals to successfully interrupt the first generation of transmission. Control measures should be implemented even when one case of pertussis is recognized in a hospital, institution, outpatient clinic, or other health care setting. Confirmed and suspected cases should be reported to local health departments, and their involvement should be sought in control measures. Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual

Division of Community and Public Health Section: 4.0 Diseases or Conditions Subsection: Pertussis Revised 9/12 Page 8 of 10

People (patients, health care professionals, caregivers) defined as close contacts or high-risk contacts of a patient or health care professionals with pertussis should be given chemoprophylaxis (and immunization when indicated) as recommended for household contacts. Health care professionals with symptoms of pertussis should be excluded from work for at least the first five (5) days of the recommended course of antimicrobial therapy. Health care professionals with symptoms of pertussis who cannot take, or who object to, antimicrobial therapy should be excluded from work for 21 days from onset of cough. Use of a respiratory mask is not sufficient protection during this time. Pre-exposure immunization of health care professionals with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine is recommended. The following are recommendations for administering Tdap to health care professionals1: · The CDC recommends a single booster dose of Tdap as soon as is feasible for HCPs of any age who previously have not received Tdap. There is no minimum interval suggested or required between Tdap and prior receipt of any tetanus or diphtheria toxoid-containing vaccine. Tdap is not licensed for multiple administrations. After receipt of Tdap, HCPs should receive routine decennial booster immunization against tetanus and diphtheria according to previously published guidelines. Hospitals and ambulatory-care facilities should provide Tdap for HCPs and use approaches that maximize immunization rates (eg, education about the benefits of immunization or mandatory requirement, convenient access, and provision of Tdap at no charge).

·

·

Outbreaks9,12

Outbreaks of pertussis tend to occur every 3-4 years in the U.S. and can be difficult to identify and manage. Other respiratory pathogens often cause clinical symptoms similar to pertussis, and cocirculation with other pathogens (bacterial and viral) does occur. In order to respond appropriately (e.g., provide recommendations for appropriate antibiotic prophylaxis), it is important to confirm that B. pertussis is circulating in the outbreak setting and to determine whether other pathogens are contributing to the outbreak. PCR tests vary in specificity, so obtaining culture confirmation of pertussis for at least one suspicious case is recommended any time there is suspicion of a pertussis outbreak. Pseudo outbreaks of pertussis have resulted because of false positive test results with PCR. This underscores the importance of recognizing clinical signs and symptoms and practicing careful laboratory testing. Institutional outbreaks of pertussis are common. Outbreaks at middle and high schools can occur as protection from childhood vaccines fades. In school outbreaks, prophylaxis is recommended for close classroom and team contacts, and administration of the pertussis booster vaccine (Tdap), depending on age. Pertussis outbreaks in hospitals and other clinical settings can put infants and other patients at risk. During an outbreak of pertussis it may become necessary to enhance surveillance to assist in identifying additional cases to enable the implementation of control measures previously discussed in this document. One strategy to enhance case finding is using the outbreak case definition provided below. The information provided serves as general guidance for response to the report of a suspected pertussis case or Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual

Division of Community and Public Health Section: 4.0 Diseases or Conditions Subsection: Pertussis Revised 9/12 Page 9 of 10

outbreak. Investigators should also consult the CDC Guidelines for the Control of Pertussis Outbreaks, which provides more detailed information in separate chapters on how to manage and control pertussis outbreaks in specific settings. Outbreak Surveillance Case Definition: Probable: Meets the clinical case definition, is not laboratory confirmed, and is not epidemiologically linked to a laboratory-confirmed case. Confirmed: · A case of acute cough illness of any duration with a positive culture for B. pertussis; OR · A case that meets the clinical case definition and is confirmed by PCR; OR · A case that meets the clinical definition and is epidemiologically linked directly to a case confirmed by either culture or PCR. Comment: The clinical case definition is appropriate for endemic or sporadic cases. However, in outbreak settings, including household exposures, a clinical case can be defined as an acute cough illness lasting two (2) weeks or longer without other symptoms. A case definition of cough illness lasting 14 days or longer has demonstrated 84% sensitivity and 63% specificity for detecting culture-positive pertussis in outbreak settings. It is important to note that the outbreak case definition should be used for the epidemiologic investigation of the outbreak and not for general reporting purposes. 1. Lab kits for pertussis testing may be ordered from the State Public Health Laboratory (SPHL). The SPHL performs cultures and PCR testing on specimens submitted. 2. Forward specimens to the SPHL in Jefferson City. Instructions are included with the kits, online http://www.health.mo.gov/lab/pertussis.php, or contact the lab at 573-751-3334. Note: Please check the expiration date on the tubes of transport media and saline prior to collecting the specimen. 3. Recovery of these organisms is highest during the first week of infection, if the specimen is collected and inoculated properly. The percentage of positive cultures steadily declines with time. Specimens should NOT be collected from asymptomatic persons. A video of a clinician demonstrating the proper way to collect a nasopharyngeal specimen is available at: http://www.cdc.gov/pertussis/clinical/diagnostic-testing/specimen-collection.html#isolation. 4. Antimicrobial treatment affects the rate of isolation, even during the acute stage of infection. Isolations are seldom made after antimicrobial administration. Pertussis is a Category 2 disease and shall be reported to the local health authority or to DHSS within one (1) calendar day of first knowledge or suspicion by telephone, facsimile or other rapid communication. 1. For confirmed and probable cases, complete a "Disease Case Report" (CD-1) and a Pertussis Report (IMMP-25). 2. Entry of the completed CD-1 into the WebSurv database negates the need for the paper CD-1 to be forwarded to the District Health Office. Missouri Department of Health and Senior Services Communicable Disease Investigation Reference Manual

Laboratory Procedures9,13

Reporting Requirements

Division of Community and Public Health Section: 4.0 Diseases or Conditions Subsection: Pertussis Revised 9/12 Page 10 of 10

3. Send the completed Pertussis Report to the District Communicable Disease Coordinator. 4. All outbreaks or "suspected" outbreaks must be reported as soon as possible (by phone, fax, or e-mail) to the District Communicable Disease Coordinator. This can be accomplished by completing the Missouri Outbreak Surveillance Report (CD-51). 5. Within 90 days from the conclusion of an outbreak, submit the final outbreak report to the District Communicable Disease Coordinator. References 1. American Academy of Pediatrics. Pertussis. In: Pickering, L ed. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:553-566. 2. CDC. Pertussis (Whooping Cough). http://www.cdc.gov/pertussis/index.html (8/12). 3. CDC. Pertussis--United States, 2001-2003. MMWR 2005;54(No. 50):1283-1286. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5450a3.htm (8/12) 4. Control of Communicable Diseases Manual. Pertussis. In: Heymann DL, ed.19th ed. Washington, D.C.: American Public Health Association; 2008: 455-461. 5. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed. Washington DC: Public Health Foundation, 2011. Chapter 15: Pertussis http://www.cdc.gov/vaccines/pubs/pinkbook/pert.html (8/12) 6. CDC. Nationally Notifiable Conditions and Case definitions. http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm (8/12) 7. CDC. Recommended Childhood and Adolescent Immunization Schedule, United States, 2012. Available at: http://www.cdc.gov/vaccines/schedules/index.html (8/12) 8. CDC. Pertussis: Summary of Vaccine Recommendations for Health Care Professionals. http://www.cdc.gov/vaccines/vpd-vac/pertussis/recs-summary.htm (8/12) 9. CDC. Manual for the Surveillance of Vaccine-preventable Diseases, 5th ed. Chapter 10: Pertussis. Centers for Disease Control and Prevention: Atlanta, 2011. Available at: http://www.cdc.gov/vaccines/pubs/surv-manual/index.html. (8/12) 10. DHSS. Prevention and Control of Communicable Diseases: A Guide for School Administrators, Nurses, Teachers, Child Care Providers, and Parents or Guardians: http://health.mo.gov/living/families/schoolhealth/pdf/Communicable_Disease.pdf (8/12) 11. CDC. Guideline for infection control in health care personnel, 1998. http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf (8/12) 12. CDC. Guidelines for the Control of Pertussis Outbreaks 2000 (amendments 2005-2006). Centers for Disease Control and Prevention: Atlanta, GA, 2000, updated 2005. http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm (8/12) 13. CDC. Health Alert Network Advisory: Best Practices for Health Care Professionals on the use of Polymerase Chain Reaction (PCR) for Diagnosing Pertussis. (February 16, 2011). http://www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-pcr-bestpractices.html (8/12

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