The best way to control a pertussis outbreak is to vaccinate

The Douglas County Health Department in Omaha, Neb., responded to a 26-person outbreak of pertussis from Sept. 26 to Nov. 21, 2008. Afterward, the department and the CDC assessed the total cost in time and personnel of the response.

“The elevated incidence of pertussis and the burden of response placed on health departments warrants exploring the impact of alternative response and chemoprophylaxis strategies,” the CDC said in MMWR.

The response was broken into three periods: the initial period beginning with the first reported case; the outbreak period when most cases were reported; and the follow-up phase.

The total cost of the response equaled 1% of the Douglas County Health Department’s total budget: $52,131, or $2,172 per case (24 in all because two were reported after the data had been collected). Each case consumed approximately 42 regular work hours and one overtime hour per employee, for a total of 28 overtime hours. The largest cost components were investigations (37.2%) and decisions and action implementation (22.9%). The most affected divisions were epidemiology (156% of budgeted hours), administration (46%) and media relations (41%). The most time spent was during the outbreak phase.

With the advent of the pertussis vaccine, the number of cases reported in the US of this highly infectious disease decreased from its high in 1934 of 265,269 to its lowest of 1,010 in 1976. In 2004, it resurged to 25,827. From 2044 to 2008, the average number of cases reported was 18,161 annually.

From my point of view, the main message is not a response and control measure, it’s a preventive measure. The most cost-efficient way to deal with this — and also the best for the children and the health of their parents — is to vaccinate the children. Then the outbreak doesn’t occur at all. When you vaccinate, you don’t have an outbreak, then the local health departments don’t have to respond. And clearly, outbreak response is a big stress on local health departments, which are set up to provide preventive health services. They’re not set up to respond to crises. They’re not nearly as experienced in doing that, so they have to take resources away from other day-in, day-out activities in order to deal with outbreaks.

Sometimes they have to run over budget, which gets them into trouble with the mayor or the local city council, because then they have to allocate more funds.

But, if these children had been vaccinated, there wouldn’t have been an outbreak. The reason every single state has gone through the process in their respective legislatures of discussing whether there should be “no shots, no school” laws is because first, we want to protect our children, and we know we can prevent virtually all of these diseases in all of the children. And second, we don’t want to have these disruptions affecting not just local health departments, but families and schools.

This report doesn’t address the excess costs to schools as a result of these outbreaks. Teachers don’t like them because they uproot the curriculum with so many absences that come in waves, so that they’re always catching students up. Also, in many states, local schools receive monies from their state departments of education based upon the number of days of pupil attendance. If you have an outbreak, then you have less attendance at school. So, follow the money. School principals and administrators don’t like outbreaks.

William Schaffner is Professor and Chair, Department of Preventive Medicine, Vanderbilt University School of Medicine, and blogs at Infectious Disease News.

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