PERTUSSIS IN ARIZONA
Bordetella Pertussis Knowledge in Arizona[A1][A2]
by
Sandra Adrianne Pena
M.A., Concordia, 2014
Applied Research Project Paper
Submitted in Partial Fulfillment
of the Requirements for the Degree of
Masterin Public Health
Concordia University, Nebraska
December2014
Abstract[A3]
The incidence of vaccine-preventable diseases continues to steadily rise. There is a growing urgency being placed on health care and public health professionals to intensify the focus on individuals and communities obtaining vaccines as scheduled, as well as increasing awareness and education of vaccination recommendations, which health providers believe will decrease the incidence of this growing problem. The aim of this study was to determine the level of knowledge of health care providers regarding pertussis in the state of Arizona to determine if proper recognition and treatment of pertussis is occurring; this will consequently lead to a decrease in the incidence of vaccine-preventable disease outbreaks. To obtain information on provider’s diagnoses of pertussis, surveys where administered to 34 RNs, 1 nurse practitioners, 3 physician assistants, 4 physicians with medical degrees (MDs), and 4 doctors of osteopathy (DO), 27 Emergency Medical Technicians (EMTs) and 28 Certified Emergency Paramedics (CEPs). Data was analyzed using [insert statistical tests] statistical tests in a quantitative analysis. The results of this study show that pertussis is often [misdiagnosed/correctly diagnosed] and is therefore [undertreated/ treated appropriately], which increases [or does not increasen’t] the likelihood of outbreaks within communities. The roles identified in this study mayhelp to determine an approximate baseline of knowledge for providers in this rural community. These findings will be beneficial to know the extent of education needed for these providers to be able to properly recognition and treatment this disease.31.25
Tableof Contents
List of Tables
List of Figures
Chapter 1: Introduction (Level 0 Heading)
APA Level 1 Heading
APA Level 2 Heading
Chapter 2: Literature Review
Chapter 3: Research Design
First Heading
Chapter 4: Results
Chapter 5: Discussion, Conclusions, and Recommendations
First Heading
References
Appendix A: Title of Appendix(if applicable)
List of Tables
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Table 2. A Sample Table Showing Correct Formatting…………………………….25
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List of Figures
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Chapter 1: Introduction
Background
The Centers for Disease Control and Prevention (CDC) currently considers there to be 28 vaccine-preventable diseases. Of those 28-diseases, Bordetella pertussis (B. pertussis), also known as pertussis or whooping cough, is one of the few diseases that is considered to be highly virulent and is currently on the upsurge in the US and around the world. Since the development of the whole cell vaccine in the 1940’s pertussis steadily declined until a resurgence in the late 80s. The next few decades saw the rates of pertussis alternatingly increase and decrease, until a steady decline began in conjunction with the acellular vaccine in 1997. In 1999, the adolescent acellular vaccine was introduced and by 2011, pertussis was nearly eradicated. However, by 2012, there was a sharp increase of more than 70% (Figure 1) (Ganguli, 2014).Since then, pertussis has continued a steady resurgence in the United States.[A4]
Figure 1.
[A5]
2014 by Pertussis Surveillance in Canada: Trends to 2012. Reprinted with permission
The problem contributing to this upsurge in cases is a specific population that is under- and unvaccinatedby current recommended standards set forth by the World Health Organization (WHO). As this group continues to become more popular, they have been labeled by many as the ‘the anti-vaccinators. Although there are numerous reasons why an individual or a family may choose to refuse vaccines, there is a high a price to pay as the death toll and incidence rate of outbreaks continue to rise.It is becoming clear that more efforts need to be made at the community and local levels to educate the population on the benefits of vaccinations in their own community and around the world.
As questions continue to rise as to why these outbreaks of pertussis continue to occur at such a rapid rate, practitioners and health organizations want to know if this continued upsurge is due to a lack of knowledge, appropriate and timely treatment, an increase in individuals and families refusing vaccinations, or a combination of all three of these factors. It is suspected that the rise in outbreaks is related, in some degree, to all three of these causes. The purpose of this study was to determine what the current baseline of knowledge of pertussis is in the state of Arizona;this wasaccomplished by analyzing survey data to determine if specific groups of providers need increased education or if increased education is needed in specific areas such as diagnosis or recognition of pertussis.
In the past, there has been concern that vaccines are unsafe and linked to Autism, which has terrified countlessfamiliesaround the world and consequently made parents and individuals question if vaccines are the right choice for themselves and their families. In 1998, the Lancet published a piece by Dr. Andrew Wakefield stating that, “by combining vaccines for measles, mumps, and rubella into a single shot, known as MMR, the vaccine weakened the immune system and damaged the gut. He said that this, in turn, led to the development of autism” (Childs, 2010). Twelve years later, the article was retracted on the basis that there was no medical proof that there was an actual link between vaccines and Autism, but it was far too late to repair the damage that had already occurred. Although, this article was incredibly damaging to the pro-vaccination movement, organizations like the World Health Organization (WHO) have not waivered on their position that immunizations will reduce the incidence of vaccine-preventable disease resurgence around the world.
Medical providers within the state of Arizona play a major role in the control of pertussis; they are at the helm of identifying, diagnosing, and treating the increasing number of individuals that are seeking medical attention,whoare potentially carriers of the pertussis bacteria. With proactive, knowledgeable, healthcare providers, hopefully, there can be a movement to prevent Arizona from becoming like its bordering state, California, where pertussis is endemic (Christensen, 2014). This will require those in public health and infection control around the state to finally acknowledge that there is an increasing need for practitioners in Arizona to take an aggressive, proactive,approach toward vaccine preventable diseases such as pertussis.Pertussis is often not included on the differential diagnosis because without laboratory testing, pertussis can be difficult to diagnosis and is often mistaken for many other disease processes such as allergies, simple cough, or the common cold. To accomplish this, there needs to be a better effort to ensure that individuals receive vaccinations on time as recommended by organizations such as the World Health Organization (WHO).
Medical providers, specifically physicians (MDs), doctors of Osteopathy (DOs), nurse practitioners (NPs), and physician assistants (PAs),emergency medical technician (EMTs), and paramedics (CEPs) are all responsible for the care, treatment, transport, and diagnosisof patients with cough illnesses. All of these individuals are receiving increasing pressure to see patients faster and to order less diagnostic tests to decrease the financial burden on the institution and to determine a disposition of patients within minutes of conducting the history and physical. With this pressure, there is an increasing incidence of misdiagnoses and underdiagnoses as the standards for fast patient turnover and appropriate medical care becomes more difficult to follow. Individuals who present to emergency departments, clinics, and primary care offices,or that call 911 for emergency medical services with symptoms that relate to cough-like illnesses are sometimes difficult to appropriately diagnosis; the literature clearly states that the early stages of pertussis may present like many other conditions. Since pertussis is highly virulent, misdiagnosed, and undertreated, one case is likely to lead to an outbreak due to the ease in which the disease spreads and the duration in which the bacteria stays alive on surfaces. Within the state of Arizona, there only needs to be two confirmed cases to be classified as an official pertussis outbreak.
Sincepertussis is frequently underdiagnosed or misdiagnosed, leading to the easy spread of this bacterial disease, it is essential to identify what is causing this to occur so that appropriate interventions can be made. This would likely cause a drastic decrease in the number of cases of outbreaksand a decrease in the morbidity and mortality of this specific communicable disease in the state of Arizona.The hope is that this informationcan, and will,assist other states in decreasing the incidence of pertussis cases.
Arizona in located in the Southwest United States and boasts a population of just over 6.3 million residents, according to the 2010 US Census. Of that population, more than 4.6 million individualsidentify themselves as Caucasians.In this study,surveys where collected from licensed and certified health care providers that included RNs, NPs, PAs, MDs, and DOs, EMTs, and paramedics. After successful completion of this survey,he datawill be analyzed and the information used to determine whether there are any identifiable deficits in knowledge regarding pertussis among healthcare providerswithin the State of Arizona;that informationcan be usedto create educational programs and initiatives.
Thesis Statement
An assessment of the level of knowledge on pertussis and the identification of deficits in this knowledge amonghealthcare providers and public health professionals in Arizona,willprovide useful information to guide curricula and help prevent or contain outbreaks. With this information,local, county, and state governments will have an improved understanding of where educational efforts need to be focused in the future to decrease the incidence of pertussis cases and outbreaks in Arizona.
Purpose of the Study
Pertussis is a highly virulent bacterial vaccine-preventable disease. A delay in an appropriate diagnosis of an individual case can be linked to increases in outbreaks; many states consider just two cases to be official outbreak.The purpose of this study is to survey certified and licensed medical professionals in the State of Arizonato define the knowledge level of healthcare practitioners in Arizona and determine theareas that need to be focused on inongoing continuing education programs provided to practitioners to ensure theaccurate and timely treatment of pertussis in the future.
Research Questions
My research questions are: “What is the existing level of knowledge of certified and licensed medical providers in Arizona?” and “What deficits in knowledge exist that could affect the ability to accurately diagnose or treat pertussis patientsand/or prevent cases or outbreaks of pertussis?”[A6]
Null hypothesis: “There are no identifiable deficits in what most healthcare providers in Arizona know about the diagnosis, treatment, and prevention of pertussis.
Alternative hypothesis: There are currently identifiable deficits in what health care providers know in how to diagnose, treat, and prevent cases of pertussis
Theoretical Base
This study will be conducted using aquantitative analysis. Quantitative analysis is best suited for deductive reasoning andhypothesis testing, and it is usually more generalizable than other study designs.
Definition of Terms
Anti-vaccination movement: Is a growing numbers of parents and individuals in the industrialized world that are choosing not to have themselves or their children vaccinated(Blume, 2006).
Chest radiography: X-Ray
PCR/DFA Culture: “Cultures have excellent specificity; it is particularly useful for confirming pertussis diagnosis. Particularly useful since many other respiratory pathogens have similar clinical symptoms to pertussis and co-infections do occur. Furthermore, culture allows for strain identification and antimicrobial resistance testing” (Centers for Disease Control and Prevention [CDC], n.d.).
DFA:Direct fluorescent-antibody testing (DFA) is a sputum sample that tests for presence of microorganisms in lung secretions. In the laboratory,“antibodiesthat have been chemically linked to a fluorescent dye are added to the sample. These antibodies are considered "tagged." They will attach to specific antigens” resulting in a bright glow (MedlinePlus, 2014).Endemic: “Denoting an area in which a particular disease is regularly found” (Oxford Dictionaries, 2014).
Misdiagnosis: The erroneous diagnosis of an individual’s condition or illness (Oxford Dictionaries, 2014).
PCR: Is,“a method to analyze a short sequence of DNA (or RNA) even in samples containing only minute quantities of DNA or RNA.PCRis used to reproduce (amplify) selected sections of DNA or RNA” (MedicineNet.Com. 2014).
Pertussis: Pertussis isalso known as ‘whooping cough’;it is highly virulent and is associated with a violent cough that often results in post-tussive vomiting in younger patients, but can affect all ages and a characteristic whooping sound during inspiration Pertussis is considered a vaccine-preventable disease(Centers for Disease Control and Prevention [CDC], 2014).
Pertussis Outbreak: More than one confirmed positive case by laboratory standards in a given area.
Vaccine-Preventable diseases: According to the Centers for Disease Control and Prevention (CDC), there are 28-vaccine preventable diseases that there are recommended vaccinations for that will aid in keeping the number of individual cases low and preventing resurgence of outbreaks around the world (Centers for Disease Control and Prevention [CDC], 2014).
Virulent: Highly infective (Oxford Dictionaries, 2014).
Assumptions
It was assumed that the practitioners included in the survey answered the questionnaire truthfully and honestly and that they answered the questionnaire based on their personal knowledge, without referring to the internet, reference books, or other available resources to answer survey questions. Finally, it was also assumed that each respondent completed the survey on their own, without help from other individuals completing the same survey and that all survey directions where read completely prior to answering the survey questions.
Limitations
There were some limitations to this study. One is the current misconceptions about pertussis and how it should be treated. Additionally, it was very difficult to get busy health care providers to respond to surveys. This is a group with typically low response rates because they are already overwhelmed by paperwork and other professional demands(National Center for Biotechnology Information [NCBI], n.d.). Lastly, it wasessential that individuals provide the answers they believedto be correct to the best of their ability; otherwise,there is a possibility of having skewed data orflawed results.
Delimitations
In this study, the population surveyed werecertified and licensedhealthcare personnel,including physicians, DOs, NPs, PAs, EMTs, CEPs, and RNs. These groups of providers were chosen because of their role in diagnosing, identifying, and treating individuals with pertussis; additionally, these healthcare providers are usually part of the process of managing an outbreak once multiple cases are identified, even if only through reporting requirements. This study was not designed to assess the knowledge base of support staff within clinics or doctor’s offices,rather only inhospitals and the pre-hospital setting. The state of Arizona was chosen because the author of this paper lives and works for the Gila County Health Department and has seen a recent increase in cases and a decrease in timely reporting to local and state health agencies. This study was not designed to provide data on incidence or prevalence rates of pertussis in Arizona or any evaluative information on how outbreaks are managed by different counties.
Significance of the Study
As vaccine-preventable disease resurgence is reaching an all-time high, it is important that researchers focus on specific gaps in the literature. We already know what pertussis is and how it is transmitted; this study will specifically contribute to what is known about the level of knowledge of licensed practitioners in Arizona. This will help identify the educational needs of these practitioners to ensure appropriate and timely diagnosis, which will, in turn decrease morbidity and mortality within thestate.
Summary
The incidence of pertussis is on the rise and has already become endemic in states surrounding Arizona; some this is due to a growing number of children not getting vaccinated for pertussis. The purpose of this study was toidentify the level of knowledge of certified and licensed personnel in Arizona about pertussis and identify areas in which training and knowledge is deficient in order to address future curriculum needs. This will result in fewer outbreaks, which will, in turn, reduce the mortality and morbidity rate associated with this disease.36/42
Chapter 2: Literature Review
Introduction
Pertussis is neither a new nor an emerging disease, yet there are still many questions about this disease that are left unanswered.It is imperativeto understand where the deficiencies in knowledge are so that health care practitioners are better prepared to identify, diagnosis, and treat pertussis at the earliest stages possible. This literature review will include articles from three areas that include the assessment and management of pertussis, vaccines and pertussis, and barriers to receiving the vaccines, all of which are believed to contribute to the spread of pertussisthat has led to endemicity in certain regions of the United States. From these articles there is evidence that pertussis is more problematic than anyone may have originally thought, as it is a problem that exceeds far beyond the borders of Arizona and of the United States as cases of endemic pertussis are occurring all over the world. Regardless of where the cases are occurring, the same problems exist: cases are spreading, outbreaks are increasing, and misunderstanding spans all levels of healthcare providers from the lowest-level providers, like emergency medical technicians,to those with greater levels of responsibility,the medical doctors. The articles used in this literature review focus on the disease process ofpertussis, specifically in the three categories of: assessment and management, barriers to obtaining vaccinations, and problems with or beliefs aboutexisting vaccines. This topic and research was selected to identify current knowledge and problems with the identification and treatment of pertussis to improve future identification and treatment, which will lead to a reduction in cases and outbreaks.