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Abstract
On August 30, 2013, the Florida Department of Health in Columbia County was notified
of a Bordetella pertussis laboratory-positive unimmunized child attending a local
charter school (316 students from pre-K through 8th grade) in a large religious community
averse to health care and vaccinations. Kindergarten immunization records showed that
only five (15%) of 34 students were fully immunized with pertussis-antigen–containing
vaccines. In seventh grade, only one (5%) of 22 students was fully immunized with
pertussis-antigen–containing vaccines. Of the children who were not fully immunized
in these two grades, 84% had religious exemptions (1).
Interviews confirmed that a sibling of the patient had symptoms consistent with pertussis.
By September 3, two additional children from the same school were confirmed by polymerase
chain reaction to have pertussis. On September 12, the Florida Department of Health
in Columbia County declared a communicable disease emergency; children with cough
illness were excluded from school, and reentry required an evaluation by a health
care provider. After this declaration, 38 additional students were excluded. Prophylaxis
or treatment with antibiotics following current guidelines were provided to patients
and household contacts (2). The local health department offered to provide these services
free of charge to persons without health care coverage. Pertussis vaccine administered
at the health department was available; however, fewer than five persons from the
community used this opportunity for vaccination.
An investigation was conducted to determine disease incidence within the community
and measures to control the spread of the disease. Medical record review and household
interviews were conducted for children excluded or absent from the charter school
because of cough illness. Cases were classified as confirmed or probable using the
Council of State and Territorial Epidemiologists case definitions (3). Additionally,
a suspected case was defined as either 1) a cough illness that lasted 7–13 days but
did not meet either the confirmed or probable case definition, or 2) an illness in
a person who received treatment for pertussis without additional clinical details.
Case onset dates, vaccination status, demographics, and school attack rates were evaluated.
A total of 109 cases were identified in the community, of which eight were classified
as confirmed (five by laboratory confirmation), 61 were probable, and 40 were suspected.
Of 316 students and 16 teachers, 94 (30%) students and one teacher had illnesses that
met one of the three case definitions. Fourteen cases, including three in infants,
were in household contacts of ill charter school students. None were hospitalized.
Only one confirmed or probable case was reported in a person who reported having received
any vaccination against pertussis. Nearly 90% of persons with illnesses meeting one
of the case definitions were evaluated and prescribed antibiotics consistent with
current guidelines by a single pediatrician in the course of his normal practice;
laboratory testing was performed in only nine of 109 cases (2). Attack rates were
highest among the youngest students (57.1% among pre-kindergarten students) and decreased
with increasing age (to 14.3% among 8th-grade students).
In vaccine-averse communities, controlling vaccine-preventable disease outbreaks is
challenging, particularly when susceptible community members have prolonged contact
in multiple settings. Local public health agencies need to identify and collaborate
with institutions and health care resources to reduce morbidity from vaccine-preventable
diseases in communities where a substantial number of persons do not have immunity.
Physicians should pursue laboratory testing for pertussis in patients with symptoms
consistent with the disease. However, physicians also need to understand the importance
of reporting presumptive pertussis cases, even without laboratory confirmation, to
public health departments.
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