Tdap: The Need to Educate and Immunize Chad Rittle, DNP, MPH, RN, FAAOHN; Yolanda C. Lang, DrPH, MSN, CRNP, COHN, FAAOHN; John E. Wenskovitch, Jr., MS

ABSTRACT The resurgence of pertussis is puzzling, especially given the requirement that children complete recommended immunizations prior to school entry. Are adult carriers unknowingly infecting children? What do adult caregivers know about pertussis and the tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccine? How can the incidence of pertussis in children younger than 2 years, a group most at risk for complications of the disease, be reduced? This article examines the incidence of pertussis and strategies to reduce pertussis incidence in the United States. If the need for Tdap vaccine is identified and favorably received by adults, immunization programs can be arranged at worksites to better protect infants who are most at risk for pertussis. [Workplace Health Saf 2014;62(11):468-474.]

A

fter many years of decline, 41,880 cases of pertussis (whooping cough) were reported in the United States in 2012 (Centers for Disease Control and Prevention [CDC], 2013a). These cases demonstrated a dramatic increase from the 18,719 cases reported in 2011 (CDC, 2013a). In 2012, several pertussis outbreaks were reported in the United States, including 5,994 cases in Wisconsin (i.e., incidence rate of 104.9 per 100,000 residents); 2,649 cases in New York (i.e., incidence rate of 23.6 per 100,000 residents); and 630 cases in Vermont (i.e., incidence rate of 100.6 per 100,000 residents) (CDC, 2013a). The outbreaks continued into 2013 and 2014: Washtenaw County, Michigan, reported 104 total cases as of July 23, 2013 (Washtenaw County Public Health, 2013) and Vermont declared a statewide epidemic of pertussis (Experimentalvaccines.org, 2013). The Greeley Tribune (2013) in Weld County, Colorado, reported on April 23, 2013, that 15 schools had reported cases of pertussis since December 2012. Additional outbreaks were reported later in 2013 and 2014. ABOUT THE AUTHORS

Dr. Rittle is Assistant Professor, Department of Nursing, and Mr. Wenskovitch is from Chatham University, Pittsburgh, Pennsylvania. Dr. Lang is from University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Submitted: February 17, 2014; Accepted: July 28, 2014; Posted online: September 16, 2014 The authors have disclosed no conflicts, financial or otherwise. Correspondence: Chad Rittle, DNP, MPH, RN, FAAOHN, 1825 Foxcroft Lane, Unit 406, Allison Park, PA 15101. E-mail: [email protected] doi:10.3928/21650799-20140909-01

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Reported cases were not confined to children. Research studies in recent years have shown significant incidence rates of pertussis among both adults and adolescents. Davis (2005) indicated that 38% of all cases reported are in the 10- to 19-year-old age group. As an update, the CDC (2012b) reported that “approximately 60% [of] reported cases were among persons 11 years of age and older” (p. 220). Rendi-Wagner, Paulke-Korinek, Stanek, Khanakah, and Kollaritsch (2007) indicated that 69% of all cases of pertussis in Austria were among individuals 16 years of age or older. Mancuso et al. (2007) studied a U.S. military community and reported that 24% of pertussis cases were among adults older than 20 years. In Yavapai County, Arizona, the CDC (2004) reported that, of 485 pertussis cases, “203 were associated with schools. . .and 82 (40%) were in family members or close contacts of ill students or staff members” (p. 217). Finally, Forsyth, von Konig, Tan, Caro, and Plotkin (2007) reported in the Global Pertussis Initiative that adults and adolescents are regularly infected with pertussis, a major source of infection among infants. No newer studies were found to update the Rendi-Wagner et al., Mancuso et al., or Yavapai County, Arizona reports. The tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccine was licensed by the CDC in 2005 as a single-dose booster for individuals 11 to 64 years of age (Gall, 2011). According to the Morbidity and Mortality Weekly Report (CDC, 2012a), only 8.2% of adults aged 19 to 64 years have been vaccinated with the Tdap vaccine, demonstrating limited use of the vaccine. Low

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TABLE 1

Reported Cases of Pertussis in the United States Year

Number of Cases

2008

13,278

2009

16,858

2010

27,550

2011

18,719

2012

41,880

2013a

24,231

a

Figure 1. Reported pertussis incidence by age group, 19902012. Retrieved August 7, 2013, from http://www.cdc.gov/ pertussis/surv-reporting.html

vaccination rates among adolescents and adults may be one cause of the dramatic increase in the number of pertussis cases. The Pink Book (CDC, 2012b) reports that adolescents and adults are the primary carriers of the Bordatella pertussis pathogen and are often the source of infection for infants, who are prone to secondary pneumonia, “the most common complication, and the cause of most pertussis-related deaths” (p. 216). Figure 1 (CDC, n.d.a) supports the need for vaccination programs based on data from 1990 to 2012 that show a steady increase in pertussis incidence among almost all age groups (with the exception of 2006–2007), particularly among children younger than 1 year. Similarly, CDC statistics (CDC, n.d.b) show a steady annual increase in reported cases (Table 1), with the exception of 2011 and 2013. Waning Vaccine Effectiveness

A possible explanation for the increasing number of cases is that a progressive decrease in estimated vaccine effectiveness is realized as time since the last Tdap dose increases (Misegades et al., 2012). Schnirring (2012) reported that the “odds of getting sick increased with the passage of time after the last vaccine dose” (p. 1). Guiso, Liese, and Plotkin (2011) reported that one of the main factors in increasing incidence of pertussis is a decline in both natural immunity and vaccine effectiveness over time. The decline in immunization effectiveness can lead to more pertussis cases, resulting in complicating pneumonia and increased associated health care cost. Costs Associated With Potential Pertussis Outbreaks

To identify the costs associated with pertussis outbreaks, Olyarchuk, Willoughby, Davis, and Newsom (2012) examined expenditures at a Massachusetts medical center and found between $84,546 and $97,656 had been spent on “testing, treatments, and loss of work time as a result of potential (pertussis) exposures of 353 health care workers” (p. 591). The variation in costs was related to the cost of salaried employees’ time. Olyarchuk et al. estimated vaccination costs for the 353 exposed employ-

2013 statistics are “provisional” as of February 26, 2014. Source: Centers for Disease Control and Prevention (n.d.). Pertussis cases by year (1922-2012). Retrieved from http:// www.cdc.gov/pertussis/surv-reporting/cases-by-year.html

ees at $17,297, based on an estimated pertussis booster vaccine charge of $37 per dose plus $12 administrative and record keeping fees, potentially saving thousands of dollars. The Global Pertussis Initiative

To avoid unnecessary health care costs, the Global Pertussis Initiative was founded to “raise awareness about pertussis. . .” and to “recommend effective vaccination strategies for disease control” (Guiso et al., 2011, p. 481). The Global Pertussis Initiative examined two approaches to increase adolescent and adult Tdap vaccination rates. The first approach was maternal immunization. The American College of Obstetricians and Gynecologists (2013) has recommended Tdap vaccination during each pregnancy, with administration between weeks 27 and 36 of gestation resulting in optimal protection. If Tdap is not administered during pregnancy, they recommend giving it immediately postpartum. A second strategy, the “Cocoon Strategy,” was designed to increase herd immunity and aid in reducing the risk of transmission to infants by vaccinating siblings, spouses, grandparents, and other caregivers, providing booster pertussis immunizations to those who are most often in close contact with at-risk infants. Gall (2011) described vaccinating this cohort as a “logistical and financing nightmare (e.g., determining who is responsible for rounding up all the caregivers and paying for their vaccines)” (p. 40). Munoz and Englund (2011) noted that cocooning has many barriers, including cost, insurance coverage, reimbursement, vaccine acceptance by the population at risk, and lack of education among providers (e.g., physicians and nurses), parents, and grandparents. They noted that cocooning does not always directly benefit infants, postulating that maternal immunization might be more effective by reducing disease incidence for the mother and passing antibodies directly to the infant. The Cocoon Strategy has not been widely implemented in any country, mostly due to problems with as-

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sembling all infant contacts and funding vaccinations (Guiso, Liese, & Plotkin, 2011). However, Caceres-Mejia, Pereya-Elias, and Suarez-Ognio (2013) noted that the CDC (2013b) and Wiley, Zuo, Macartney, and McIntyre (2013) in recent research “suggest that cocooning is an effective measure in controlling the disease in the infants, the most important in-household contacts being the mother and the father” (p. 1145). Research Objectives

With the many possible causes and consequences of increasing pertussis incidence (e.g., waning vaccine effectiveness, adult and adolescent carriers, recommendations of the Global Pertussis Initiative, and the substantial costs of pertussis outbreaks), the research team investigated adult faculty immunization status at a local university. Might faculty demographic characteristics or differences in individuals’ knowledge about pertussis indicate possible solutions for increasing vaccination rates and preventing pertussis in children of this community? The three research questions formulated by the research team included: 1. Is there a difference in knowledge level about pertussis and the Tdap pertussis booster vaccine between science, math, and health sciences faculty and other university faculty? 2. Is there a difference in vaccination rates between science, math, and health sciences faculty and other university faculty? 3. Is there a difference between younger faculty members and older faculty members in terms of pertussis vaccination rates and their knowledge about pertussis and the pertussis booster vaccine? The study was approved by the University’s Institutional Review Board. The study sample group of university faculty members could be parents or grandparents and were potential caregivers of infants in their extended families. If favorably received, immunization of this population via implementation of the Cocoon Strategy may ultimately protect the youngest members of U.S. society, who are most at risk for pertussis infection. METHODS To determine participants’ knowledge of pertussis, the researchers conducted a descriptive study using a researcher-developed short 10-question survey (Appendix A, available in the online version of this article) and distributed it to all full-time and adjunct faculty members at a regional university using SurveyMonkey. The content validity of the survey questions was supported by a panel of experts. A Cronbach’s alpha metric of internal consistency was calculated on the two knowledge questions and the related question about vaccination. The survey responses were found to be acceptably consistent (3 items; p = .67). However, it is worth noting that the Cronbach’s alpha statistic can be deflated by a small sample of questions and inflated by a larger number of questions

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(Cortina, 1993). Because the survey includes only a small sample of relevant questions, the authors are satisfied with the consistency of the survey responses. The survey solicited data about sample demographics, knowledge of pertussis, and acceptance of the Tdap vaccine by this group. The survey was sent to faculty during the first week of a 5-week data collection period. During weeks 2 through 5, reminders were sent encouraging faculty to participate. Because the survey was initially sent at the beginning of summer break and many faculty members do not come to campus regularly during this time, reminders were deemed necessary to ensure an adequate response. At the end of the 5-week period, the survey was closed and data received were evaluated. Data from the survey were analyzed using Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA). The significance level was set at less than .05 for hypothesis testing for the three research questions. RESULTS Of the 142 respondents completing the survey, 111 were women (78.7%). Interestingly, a report of “faculty headcount” in June 2013 included 230 (71.2%) women; the overall response to the survey was in approximate proportion to the representation of women and men on faculty. In contrast, the 2011 national statistics of fulltime and adjunct faculty reported that only 48.2% were women (Digest of Education Statistics, 2012). The presence of more women in this institution could have affected the results. The percentage of women on faculty may be due to the University’s prior history as a women’s college until 2007. The age distribution of responding faculty is listed in Table 2. The largest proportion of responding faculty were 48 years and older (54.22%). The surveyed University reported the average age of full-time faculty to be 47 years and the average age of adjuncts to be 44 years. These results indicate that survey respondents were older than university averages. The American Association of State Colleges and Universities (2006) noted that “fulltime faculty average 50 years of age, with about a third 55 years of age or older” (p. 1). Faculty at the surveyed university were younger on average than the national average. More current data defining the age of faculty were not found. In terms of faculty rank, 64 of the responding faculty were adjunct faculty (45%); the second largest group of faculty members (n = 41) were assistant professors (29%). This finding indicates that a large percentage of respondents (74%) were “junior” faculty, and may have more recently completed their academic studies. The survey did not collect data about years of service, so no conclusions can be drawn. DISCUSSION Respondents could choose multiple answers to the question “How would you describe pertussis?,” including the correct answer, “All of the above.” Seventy-seven respondents selected “All of the above” (55.4%). Faculty respondents from the departments of science, math, and

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TABLE 2 (cont’d)

TABLE 2

Results of Pertussis Knowledge Questionnaire Question

Number

%

6

4.23

Results of Pertussis Knowledge Questionnaire Question

Number

%

1. What is your age? < 30

6. How long has it been since your last tetanus booster shot?

30 to 35

21

14.79

36 to 41

16

11.27

Past 12 months

19

13.57

2 to 5 years ago

47

33.57

42 to 47

22

15.49

48 to 55

29

20.42

5 to 10 years ago

24

17.14

33.8

> 10 years ago

15

10.71

Can’t remember

36

25

≥ 55

48

2. What is your gender? Male

30

21.28

2 respondents did not answer

Female

111

78.72

7. Who should receive the Tdap vaccination?

1 respondent did not answer 3. What is your position? Adjunct

64

45.07

Instructor

11

7.75

All those aged ≥ 11

35

26.52

Adults ≥ 65

15

11.36

Pregnant women after the 20th week of gestation

2

1.52

Assistant Professor

41

28.87

Associate Professor

14

9.86

Parents, grandparents, and siblings of newborn infants

27

20.45

Professor

12

8.45

All of the above

78

59.09

Science & Math

21

15.44

Business

13

9.56

Fine Arts & Media

9

6.62

Yes

67

47.86

Health Sciences

52

38.24

No

23

16.43

Don’t know

50

35.71

Yes

40

28.17

No

102

71.83

Mornings

18

12.68

Afternoons

17

11.97

Evenings

20

14.08

All day

61

42.96

Never–I conduct online classes

26

18.31

4. What is your area of teaching focus?

10 respondents did not answer

Humanities

29

21.32

Environmental

6

4.41

Sustainability

6

4.41

6 respondents did not answer 5. How would you describe pertussis? Whooping cough

59

42.45

A very contagious disease found only in humans and spread person-to-person

30

21.58

If a person is fully immunized, he can still get pertussis

3

2.16

Pertussis can cause serious complications in infants and young children, even death

48

34.53

The best way to prevent pertussis in infants, children, adolescents, and adults is through vaccination

48

34.53

All of the above

77

55.4

8. Have you received the Tdap vaccine?

9. Do you have regular contact with children younger than 2 years?

10. When are you normally on campus?

Tdap = tetanus, diphtheria, and acellular pertussis

3 respondents did not answer

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health sciences were more likely to answer the question correctly than other faculty (chi-square 3.94, p = .047), supporting Research Question 2. The researchers also found a significant association between Research Question 5 (How would you describe pertussis?) and Research Question 9 (Do you have regular contact with children younger than 2 years?). The respondents who answered “yes” to Research Question 9 were more likely to answer Research Question 5 correctly (chi-square 5.1, p = .024). The question “How long has it been since your last tetanus booster shot?” was included in the questionnaire to determine the currency of immunization in this population. Almost 65% of the respondents reported having received Tdap vaccination within the past 10 years; however, 25% of the respondents did not know the last time they had received Tdap vaccine. More than 59% of the respondents answered the question “Who should receive the Tdap vaccination?” correctly (all of the above); 10 participants did not respond. A majority of the respondents (52%) answering the question “Have you received the Tdap vaccine?” had not received the Tdap vaccine. A significant correlation was found between Tdap vaccination and correctly knowing who should be vaccinated (chi-square 17.07, p < .0001). Comparing respondents’ knowledge of who should receive the Tdap vaccine and faculty members reporting regular contact with children younger than 2 years, the researchers found that those with regular contact with young children were more knowledgeable about recommended recipients of the Tdap booster vaccine (chisquare 6.944, p = .0084). A comparison between location of faculty and correctly identifying Tdap vaccine recipients (chi-square 8.585, p = .0034) showed that online instructors who never come to campus were more likely to have received, requested, or discovered information about the Tdap vaccine online. The research team compared the effects of regular contact with young children and the likelihood a faculty member had received Tdap vaccine (chi-square 12.41, p < .001). Respondents reported they were more likely to receive the Tdap vaccine if they answered the question “Who should receive the Tdap vaccination?” correctly (chi-square 17.073, p < .0001). The data indicated that science, math, and health science faculty members were more likely to receive the Tdap vaccine than other faculty (chi-square 5.16, p = .0231). Faculty in these specific departments may be more knowledgeable about infectious diseases and vaccinations, recognizing the need to protect themselves and their families against pertussis. Finally, the respondents were more likely to receive the Tdap vaccine if they were younger than 48 years (chisquare 6.27, p = .012). Younger faculty members may be more likely to have younger children and contact with pediatric providers. It is also possible that younger faculty members are more familiar with pertussis and pertussis vaccine information available on the Internet. One or more of these factors may have contributed to their higher vaccination rate.

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Support of Research Questions

Research Question 1 was answered by comparing individuals’ knowledge of pertussis and the Tdap vaccine by faculty members in the science, math, and health science departments and faculty in all other departments. The data show that science, math, and health science faculty demonstrated significantly more knowledge about pertussis and the Tdap vaccine (chi-square 3.92, p = .047) and were more likely to answer the question “How would you describe pertussis?” correctly. Unfortunately, pertussis knowledge did not translate into faculty members receiving the Tdap vaccine (chi-square 1.147, p = .28); only 48% of respondents actually had received the Tdap vaccine. Regarding Research Question 2, math, science, and health science faculty were more likely to be vaccinated against pertussis than faculty from other university departments (chi-square 5.16, p = .0231). This finding may be the result of more pertussis knowledge among math, science, and health science faculty members. Evaluating Research Question 3, a correlation was found between faculty members’ age and Tdap vaccination (chi-square 6.27, p = .012). Possible explanations for faculty members younger than 48 years of age being more likely to be immunized could include more frequent contact with pediatric providers because these individuals are more likely to have younger children in their families, more knowledge of pertussis and the Tdap vaccine, or more likely to access Internet resources about pertussis and the Tdap vaccine. Limitations

Although the hypotheses were supported by the data, the following study limitations were noted. The survey did not provide a definition of “regular contact with children younger than 2 years,” a possible explanation of why 71.83% of study respondents answered “no” to the question. Interestingly, 77 of the respondents (54%) reported being 48 years of age or older, indicating that a large proportion of university faculty are older and may not have children living in their households. A possibility does exist that some faculty may have children younger than 2 years in their extended families. A third limitation is related to the ratio of women to men in this group of respondents. The ratio may have influenced respondents’ reported knowledge because women are often family caregivers and have more frequent contact with pediatric providers, resulting in more knowledge about pertussis and the booster vaccine. The ratio of women to men at the study university contrasts to a 2011 national survey (U.S. Department of Education, 2012), which reported that only 48.2% of university faculty were women. This difference between national and university gender statistics may prevent the research team from generalizing results to other institutions. Other limitations include the small sample size of the faculty and the university’s origination as a small, private women’s college. Larger institutions and long-standing coeducational facilities may produce different results. The study university has a concentration of nursing,

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physical therapy, and occupational therapy programs, a factor that may have influenced the results. This survey was conducted in an area that includes 10 institutions of higher education and two major medical centers. The concentration of educational and medical center organizations may have resulted in more demand for educators, resulting in younger faculty who are likely to know more about pertussis and the vaccine for this disease. Results may be affected by the sample size (n = 142) versus the total number of full-time and adjunct faculty at the study university (n = 323). Although the response rate was 44% of potential faculty members, the study university is considered a “small private institution,” which may prevent generalization of results to a larger private or public university. Of note, 18.3% of respondents (n = 26) reported they never come to campus. It is unknown how this proportion of online faculty compares to other universities of similar size, another fact that may preclude generalization. Another issue that might influence results is the number of online courses offered by the study university. Online educators may be “online” more often and for longer periods of time than their peers who primarily teach in a traditional “on-ground” classroom. Online educators may also tend to be younger and more comfortable with online activities. Adjunct faculty may be more likely to teach online classes than full-time tenure-track faculty and may be geographically dispersed from the university campus, two additional factors that may result in adjunct faculty being more knowledgeable about information available online. As noted above, the average age of faculty (47 years for full-time and 44 years for adjuncts) at this university was younger than the responding faculty (54% were age 48 years and older). The study university average faculty age was younger than the national average age of 50 years for full-time faculty, with approximately onethird of the faculty 55 years and older (Faculty Trends and Issues-Policy Matters, 2006). Economic conditions may have influenced the age of the faculty at this University. According to Masterson (2010), many universities are experiencing hiring freezes and older faculty delaying retirement. Although these factors may be increasing the national average age for faculty, it does not explain why the study university faculty was younger than the national average. This finding is an area for further research. Recommendations

The results of the survey suggest another area for research: the need for more educational programs, lectures, YouTube videos, literature, and Internet resources for all university faculty members, especially faculty teaching in disciplines other than science, math, or health sciences. A Tdap booster vaccination program is needed for the 52.14% of all respondents (n = 73) who either have not received the Tdap booster or do not know if they have received the vaccine at this university. Although unable to generalize the results of this study, it may be possible that other universities of comparable size have similar need for programs to vaccinate and educate.

IN SUMMARY Tdap: The Need to Educate and Immunize Rittle, C., Lang, Y. C., & Wenskovitch, J. E., Jr. Workplace Health & Safety 2014;62(11):468-474.

1

Reported cases of pertussis continue to occur despite public health efforts to immunize the population.

2

Although children younger than 2 years of age are most seriously affected by pertussis, adults and adolescents show significant incidence of disease. This incidence is caused not only by waning vaccine effectiveness in adolescents, but by low vaccination rates of adults.

3

Educating faculty about the risks of pertussis disease and increasing vaccination rates among this population can reduce the risks of pertussis among children younger than 2 years of age.

Prior to implementing vaccination clinics at other universities, additional surveys could gather data to compare with this study. If this survey is repeated at other institutions, a more complete definition of “regular contact” with children younger than 2 years is essential to determine the risk of children developing pertussis due to exposure to adult carriers. CONCLUSIONS The results of this survey show a difference, at this university, in faculty knowledge of pertussis and Tdap pertussis booster vaccine based on academic department (Research Question 1). Science, math, and health sciences faculty had more knowledge of pertussis and associated vaccination than their non-science colleagues. This finding may be related to more awareness of childhood diseases among the science faculty, more access to resources on the Internet, more interest in the topic, and more contact with health care workers. Age of the study faculty members was significantly associated with knowledge of pertussis and Tdap vaccination rates. Respondents younger than 48 years were more likely to have young children within their immediate or extended families and may be more likely to have regular contact with pediatric providers. In addition, more contact with medical or nursing personnel could increase the likelihood that these faculty members may be searching the Internet for additional information about pertussis or Tdap vaccine. Pertussis is a disease that has been resistant to eradication by the health care and public health communities. Although children in general are adequately vaccinated, vaccines can wane in effectiveness and adults have historically been undervaccinated, leading to a need for addi-

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tional strategies to increase immunization among adolescents and adults. Programs could assist in assessing and increasing faculty vaccination rates by educating faculty, thereby reducing the risk of pertussis among children younger than 2 years. Caceres-Mejia et al. (2013) noted that “in epidemiologic terms any strategy that diminishes the number of potential infected contacts will reduce the probability of disease transmission” (p. 1145). Chiappini, Stival, Galli, and de Martino (2013) concluded that “policymakers should invest more resources in the education of public health providers and of the population about the benefits of vaccination” (p. 9), agreeing with the results of this study. REFERENCES

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Appendix A (cont’d)

Appendix A

Pertussis Knowledge Questionnaire 1. What is your age?

Pertussis Knowledge Questionnaire 7. Who should receive the Tdap vaccination? (Choose any that you believe are correct)

A. < 30

A. All those aged ≥ 11

B. 30-35 C. 36-41

B. Adults ≥ 65

D. 42-47

C. Pregnant women after the 20th week of gestation

E. 48-55

D. Parents, grandparents, and siblings of newborn infants

F. ≥ 55

E. All the above

2. What is your gender?

8. Have you received the Tdap vaccine?

A. Male

A. Yes

B. Female

B. No

3. What is your position?

C. Don’t know

A. Adjunct Faculty

9. Do you have regular contact with children younger than 2 years? (This can include children, grandchildren, or day care contacts)

B. Instructor C. Assistant Professor D. Associate Professor

A. Yes

E. Professor

B. No

4. What is your area of teaching focus?

10. When are you normally on campus?

A. Science & Math

A. Mornings

B. Business

B. Afternoons

C. Fine Arts & Media

C. Evenings

D. Health Sciences

D. All day

E. Humanities

E. Never–I conduct online classes

F. Environmental Sustainability 5. How would you describe pertussis? (Choose any that you believe are correct) A. Whooping cough B. A very contagious disease found only in humans and spread person-to-person C. If a person is fully immunized he can still get pertussis D. Pertussis can cause serious complications in infants and young children, even death E. The best way to prevent pertussis in infants, children adolescents and adults is through vaccination F. All the above 6. How long has it been since your last tetanus booster shot? A. Last 12 months B. 2-5 years ago C. 5-10 years ago D. Over 10 years ago E. Can’t remember

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475

Tdap: the need to educate and immunize.

The resurgence of pertussis is puzzling, especially given the requirement that children complete recommended immunizations prior to school entry. Are ...
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