How California beat down whooping cough

October 14, 2012

By Daniel Weintraub

California government has a reputation, rightly deserved, for being dysfunctional. Voters rank legislators down there with car salesman on the trust scale, and the bureaucracy doesn’t do much better with the public.

So it’s worth taking notice when the state does something right, especially when it happens in a matter of life and death.

That was the case with California’s response to an epidemic of pertussis, better known as whooping cough.

The disease is a nasty respiratory infection that can last for months and is sometimes deadly, especially in infants, who typically don’t get immunized until they are three months old. The illness cycles through the population on a somewhat regular rhythm, with peaks every three to five years.

So it did not come as a shock to doctors at the state Department of Public Health when they got a call early in 2010 from staff at a children’s hospital in Madera County. We just want to make sure, the caller said, that you know about this spike in whooping cough that we’ve been seeing.

Pertussis is a “reportable disease,” which means doctors and other health workers are required to notify their local health department when they treat a case, and each one is investigated. So the mounting number of cases in the Central Valley and elsewhere would have come to the attention of health officials in Sacramento in due course. But the phone call let them know what was coming.

“We hopped on that right away,” Dr. John Talarico, who heads the department’s immunization branch, told me in an interview.

By then, however, the disease was already in full flower across most of California.
And it soon became apparent that this epidemic was going to be worse than the last one, in 2005. Eventually, it would become the most serious in 50 years.

The severity of the epidemic seemed tied to a relatively new vaccine introduced in the 1990s. The new drug replaced one that was effective but was the subject of complaints about side effects, including high fevers and seizures. The new vaccine had fewer side effects, but it also wore off more quickly. Unlike immunizations for measles, the whooping cough vaccine does not last a lifetime.

The result was that even children who had received a full series of five vaccinations before starting kindergarten were coming down with the disease a few years later, before they got their booster shot at age 11 or 12, and when they should have still been protected.

People were still more likely to get the disease if they had not been immunized, but the number of victims who had been fully vaccinated surprised many experts. One study in Marin County found that 80 percent of those with whooping cough in 2010 had been vaccinated.

Once the magnitude of the problem became clear, the Department of Public Health swung into action with a massive public information campaign warning Californians about the epidemic and encouraging people to be vaccinated. The department also increased awareness of the epidemic among doctors and clinics to prompt earlier diagnosis and treatment. And using federal funds, the state offered free vaccine to local health departments and hospitals.

In a key move, the state also expanded the population targeted for vaccines to include seniors, children between 7 and 10 years old who had not completed the vaccination series already, and women of childbearing age before, during or after pregnancy.

This was important move because infants who have not yet been immunized are at the greatest risk for catching the disease, and they usually get it from their mother or another close relative.

“There is a concept called cocooning,” Dr. Talarico said. “You try to immunize all of those around an infant who have close contact with it, so they don’t get the disease and the baby is protected.”

It took some time for all of these moves to penetrate doctor’s offices, clinics and hospitals across the state. Meanwhile, the epidemic gained strength.

By the end of June, 1,337 cases had been reported, and there were five deaths, all infants aged two months or less. A month later the number of cases had grown to more than 2,400, six times as many as at the same point in 2009. And the death toll had climbed to seven. Before the year was over, more than 9,000 people would be infected, and 10 infants were dead. Only one of them had been vaccinated – and that was a baby who had been born premature at 28 weeks gestation.

But the epidemic peaked in July of 2010. That month, the rate was 45 cases per 100,000 Californians. It fell to just two per 100,000 in December, 2011. And so far this year the rate is less than 1 per 100,000 — near historic lows. Most significantly, there has not been a death attributed to the disease since October of 2010.

In the midst of the crisis, the Legislature, on bipartisan votes, passed a law requiring all students entering or continuing school from seventh through 12th grade to have had a booster shot protecting them against whooping cough. While that law did not take effect until the summer of 2011, it appears to be helping to keep the disease at bay, and it will likely help prevent the next spike in cases from being anything like the one the state endured in 2010.

Unfortunately, much of the rest of the country is now going through what California experienced two years ago, and many states have it far worse. In Wisconsin, the rate is 79 per 100,000; in Minnesota it is 63 per 100,000; in Washington, 58.

Learning from California’s misery, other states are implementing many of the same strategies that helped end the epidemic here. National guidelines for immunizations have also been tweaked to reflect the lessons learned in California.

It’s nice to know that while California led the nation going into this epidemic, the state’s public health establishment reacted quickly and effectively. And now other Americans might benefit from our experience.

Daniel Weintraub has covered California public policy for 25 years. He is editor of the California Health Report at www.healthycal.org

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