Whooping cough immunisation

Executive Summary

Clinical Issue

New Zealand is currently in the middle of a whooping cough (pertussis) epidemic which since it began in August 2011, over 8000 cases of whooping cough has been reported and two deaths have been a result of the disease. It is a major health issue in New Zealand as the most vulnerable population is the younger generations between the ages of zero to four years. Even if these children have had the immunisation against whooping cough it takes all three immunisations and the booster at four and 11 years to get the best chance of immunity. It’s a growing concern that the country is lacking in education about this health issue. Adults often transfer the disease to children because of the misconception that they are immune due to the illness presenting differently in children compared to adults. The rate of whooping cough is very high in New Zealand at the moment and it shows no signs of slowing down. This is why something more needs to be done in order for this epidemic to be controlled and eventually over-come.

Recommendations:

To use different media to educate and acknowledge the need for immunisation against whooping cough, and the requirements for the immunisations to be most effective.
To ensure that all adults in contact with infants and children are aware of their reduced immunity and offer them a booster injection against whooping cough.

Clinical Issue

I have taken an interest in the whooping cough epidemic as I am passionate about neonatal and paediatric nursing. The whooping cough epidemic in New Zealand is a health issue that has affected the younger population aged between zero and four years the greatest.

Pertussis or more commonly referred to as the whooping cough is a present health concern throughout New Zealand. The ‘100 day cough’ peaks every four to five years, with the most recent epidemics occurring in the years 2000, 2004. The present epidemic started in August 2011 (Ministry of Health, 2013) and as of 5^th of April 2013, 8817 cases have been reported. Two people have died due to whooping cough and hundreds of patients have been hospitalised (The Institute of Environmental Science and Research Ltd, 2013). Children under the age of one year have accounted for approximately two thirds of these hospitalisations, followed by children in the one to four year age group (Glaxo Smith Kline Vaccines, 2012). We know that immunisations is the most effective way to prevent whooping cough (Ridda & McIntyre, 2012) however, I believe that New Zealanders need more education than what is presently out there, as the present awareness of whooping cough does not appear to be enough to minimise this epidemic.

Literature Review

Immunisation rates in New Zealand have often been lower than countries such as Australia and England which has meant New Zealand often has higher rates of preventable diseases such as whooping cough (Grant et al., 2003). However the New Zealand Ministry of Health (MOH), has recognised the need for better immunisation and for the past four years ‘increased immunisation’ has been one of the six nationwide health targets.

The MOH has set a target of to 85% of eight month old infants to be fully immunised by July 2013, 90% by July 2014, and 95% fully immunised by December 2014 (Ministry of Health, 2012). The term ‘fully immunised’ refers to completing the three immunisations against whooping cough at six weeks, three months and five months (Grant, Turner, York, Goodyear-Smith & Petousis-Harris, 2010). Currently almost 90% of eight month olds have been fully immunised which means the ideal 95% target is close to achieving a year in advance (Ministry of Health, 2013). In an interview with Doctor John Adie on New Zealand’s ‘Breakfast’ television programme, he explained that besides staying clear of infected people, immunisation is the only way of protecting oneself from whooping cough. Further he stated that for the spread of this whooping cough epidemic to be slowed down, the immunisation rate needs to be up at 92-94%, which we currently have not reached (ONE News, 2013).

Children under the age of one year are the most vulnerable population due to their body systems being less developed and they are often not fully immunised. Knowledge of the importance of on time vaccine administration is an area lacking in caregivers and even if a child does receive all three doses, its effectiveness can be tarnished if not given within 30 days of the recommended age of administration (Grant, et al., 2003). In their study of 97 infants conducted in Auckland in 1995-7, Grant et al. (2003) found that a delay in any of the immunisations at six weeks, three months or five months, or a combination of any of the three, decreased the effectiveness of the vaccine therefore increasing the risk of that infant contracting the disease. Factors such as socioeconomic status, income, living environment, gender or age did not alter the findings of delayed immunisation resulting in an increased risk of the infant contracting whooping cough (Grant, et al., 2003). A booster vaccine against whooping cough is administered at four years of age and again at 11 years. This is to extend the vaccine’s protection in the body into adolescence, protecting younger siblings and peers that may be at risk (Ministry of Health, 2011).

With the focus on childhood immunisation, the reason why and how the children are contracting the disease can be overlooked and often it is the adults around them that are infectious and unknowingly passing it on to the younger population (Gillespie, 2013). Whooping cough is a disease in which neither immunisation or natural infection can bring 100%, life-long protection against the infection (Ridda & McIntyre, 2012). Approximately 8% of adults who see their doctors about a cough which has lasted longer than five days will have whooping cough (Reid, 2012). However due to adults not getting symptoms of the same severity as infants and children when they have the infection, many will not think they need to seek medical advice. Furthermore, many adults do not know that immunity decreases over time and that for optimal immunity status, a booster is recommended every 10 years (Glaxo Smith Kline Vaccines, 2012; Harvey, 2013).

The Ministry of Health uses the term ‘cocoon strategy’ to describe the need to immunise others who may be around and in contact with an infected child. There has been little published on the effectiveness of the ‘cocoon strategy’, and it is especially difficult to assess in the middle of an epidemic (Ministry of Health, 2011). The cocoon strategy is used when a pregnancy is confirmed and the expectant mother is made aware that a booster vaccine against whooping cough is recommended in her second or third trimester. Other members of the family such as older siblings, grandparents and others in contact with the infant and household should be offered a booster if it has been 10 years since a previous immunisation. Currently the Ministry of Health funds childhood immunisations as well as boosters against whooping cough for expectant mothers in their second or third trimester (Reid, 2012). Although not a lot of immunity crosses the placental barrier or through breast milk, a small amount does, which can help protect a new born for up to six weeks where at that age they should receive their first dose of the vaccine (ESR, 2013). It is also recommended that lead maternity carers, health professionals who work with neonates and children, older siblings, other adults in contact with the household of an infant and early childhood service personnel get boosters in 10 yearly intervals but vaccines are not currently funded and cost around $25 (Ministry of Health, 2011).

In summary, the literature clearly shows that immunisation is the key to overcoming the current whooping cough epidemic and preventing a further outbreak. The public of New Zealand need to be made more aware of the recommendation of ten yearly boosters to protect the most vulnerable from this possibly life threatening illness.

Nursing Implications

Immunisations are a common, everyday practice for nurses in primary health care settings, with around 93% of immunisations being delivered by practice nurses (Desmond, Grant, Goodyear-Smith, Turner & Petousis-Harris, 2011). It is extremely important that nurses in the primary health care setting are up-to-date with protocols, research and information about immunisations and the diseases they protect against (McKenna & Lim, 2009). When giving injections nurses are educated to know that the right drug and dose is going to the right patient at the right time via the right route and for the right reason. Nurses also spend a reasonable amount of time with a child’s caregiver discussing immunisations, the benefits, possible side effects and care needed for the child post vaccine (Desmond, et al., 2011). However nurses also need to be mindful of how long the immunity lasts from the vaccine and other ways in which the child could contract the disease such as parental contamination. This is why it is important for nurses to educate parents about their own immunity, that it fades and that a booster is recommended for them to lessen the chance of spreading the illness (Reid, 2012).

Recommendations

From the literature review I have developed two recommendations which I believe would be helpful in New Zealand to make people more aware and knowledgeable of whooping cough and what is required in order to control the epidemic. These recommendations are:

1. To use different media to educate and acknowledge the need for immunisation against whooping cough, and the requirements for the immunisations to be most effective.

The use of public advertising in the media is an effective way in which many issues such as smoking, family violence, cancer screening and alcohol use are acknowledged and recognised. For years these advertisements on television, internet and even on social media sites such as Facebook, have been a way in which society has educated us and made us aware of the way we act and the need to change our own behaviours to better ourselves, families and country. I believe if there was a media campaign on whooping cough, the incidence of the illness would start to decline because of the public awareness of the issue, and how serious it can be. The campaign would highlight the implications of whooping cough, how symptoms differ throughout the age groups and the need for immunisation and most importantly the need to get the immunisations on time.

2. To offer all adults in contact with infants and children a booster injection against whooping cough because of a decline in their immunity status over time

As stated in the literature the vaccine for whooping cough does not provide life-long prevention and immunity declines over time. Without the knowledge that adults are not as affected by the illness as children, they are often unaware they are carrying the disease, which is why children are often contracting the illness from these adults. Adults in contact with this at risk age group need to be advised that a booster is recommended for the safety of the children they are around. Ways of implementing this recommendation could include; offering the booster when a child comes into the healthcare setting for their immunisation, and getting schools to advise adult immunisation in school newsletters or posters around areas where children and adults interact such as health centres, Plunket rooms, pools, playgrounds and libraries.

References

Desmond, N., Grant, C., Goodyear-Smith, F., Turner, N., & Petousis-Harris, H. (2011). Nurses make a

difference in immunisation service delivery. Australian Journal of Advanced Nursing, 28(4), 28-35.

Gillespie, K. (2013, February 25). Whooping cough epidemic spreads. The New Zealand Herald. Retrieved

from http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10867716

Glaxo Smith Kline Vaccines. (2012). About whooping cough. Retrieved from:

http://www.boostrix.co.nz/index.html

Grant, C., Roberts, M., Scragg, R., Stewart, J., Lennon, D., Kivell, D., Ford, R., & Menzies, R. (2003).

Delayed immunisation and risk of pertussis in infants: unmatched case-control study. British Medical Journal, 326, 852-853.

Grant, C., Turner, N., York, D., Goodyear-Smith, F., & Petousis-Harris, H. (2010). Factors associated with

immunisation coverage and timeliness in New Zealand. British Journal of General Practice, 113-120.

Harvey, S. (2013, February 14). Whooping cough epidemic hits new high. Stuff. Retrieved from

http://www.stuff.co.nz/auckland/local-news/8304351/Whooping-cough-epidemic-hits-new-high

McKenna, L., & Lim, A, G. (2009). Medications (Ed.). Fundamentals of nursing and midwifery: A person-

centred approach to care. (pp. 758-823) NSW: Walters Kluwer-Lippincott Williams and Wilkins.

Ministry of Health. (2011). Immunisation handbook 2011.Wellington, NZ: Author

Ministry of Health. (2012). Health targets 2012/13: increased immunisation. Retrieved from

http://www.health.govt.nz/new-zealand-health-system/health-targets/2012-13-health-targets/health-targets-2012-13-increased-immunisation

Ministry of Health. (2013). Immunisation week 2013 - new immunisation health target in sight. Retrieved

from http://www.health.govt.nz/news-media/news-items/immunisation-week-2013-new-immunisation-health-target-sight

Ministry of Health. (2013). Whooping Cough. Retrieved from http://www.health.govt.nz/your-

health/conditions-and-treatments/diseases-and-illnesses/whooping-cough

Reid, S. (2012, May). The further and future evolution of the New Zealand immunisation schedule. The

New Zealand Medical Journal, 125(1354), 86-99.

Ridda, I., & McIntyre, P, B. (2012). Tdap: a new option for pertussis booster vaccination of seniors. Aging

Health, 8(5), 449-455.

ONE News (Producer). (2013, March 6). Breakfast [Television morning news and talk show]. [With Dr.

John Adie]. Auckland, NZ: Television New Zealand.

The institute of Environmental Science and Research ltd. (2013). Pertussis report: Jan-Mar 2013. Retrieved

from http://www.surv.esr.cri.nz/PDF_surveillance/PertussisRpt/2013/ PertussisreportJan-March2013.pdf