M A J O R A R T I C L E
Implementation of Cocooning against Pertussis
in a High-Risk Population
C. Mary Healy,1,2,3Marcia A Rench,1,3and Carol J. Baker1,2,3,4
1Center for Vaccine Awareness and Research Hospital, Texas Children's Hospital;2Ben Taub General Hospital;3Department of Pediatrics and
4Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, Texas
acellular pertussis (Tdap) vaccination of all caregivers of infants aged ,1 year (‘‘cocooning’’) to prevent pertussis-
related complications and deaths. We implemented cocooning in a predominantly Hispanic, medically
underserved, uninsured population at a Houston hospital. Phase 1 (January 2008–January 2010) provided
maternal postpartum Tdap vaccine; Phase 2 (June 2009–January 2010) also vaccinated infant contacts on-site.
Methods. Pertussis education was provided to health care personnel and mothers. Standing orders for maternal
postpartum Tdap vaccination were initiated. Mothers were interviewed to ascertain the number of additional infant
contacts eligible to receive Tdap vaccine. Consenting eligible contacts received Tdap vaccine as soon as possible after
Results. From 7 January 2008 through 31 January 2010, 8334 (75%) of 11,174 postpartum women received
Tdap vaccine. During Phase 2, 2969 (86%) of 3455 postpartum women were vaccinated; another 197 (6%) had
previously received Tdap vaccine. Mothers were Hispanic (91.4%), black (5.4%), white (0.8%), Asian (1.4%) and
other (1.0%). A median of 3 (range, 1–11) other Tdap-eligible contacts per infant were identified, and a median of 2
(range, 0–10) contacts per infant received Tdap vaccine. Of 1860 contacts vaccinated, 1813 (98%) anticipated daily
infant contact. A total of 1697 (91%) received Tdap vaccine before infant hospital discharge, and 144 (8%) received
Tdap vaccine within 7 days after hospital discharge. Barriers to full cocooning included the need for extended
vaccination hours, visiting restrictions because of pandemic H1N1 influenza, and inaccurate recall of vaccination
Conclusion. Although practical and logistical barriers exist, Tdap cocooning was well accepted by and
successfully implemented in a high-risk population by using standing orders and providing vaccinations on-site.
In 2006, the Advisory Committee on Immunization Practices recommended tetanus, diphtheria,
Pertussis vaccination in the United States reduced an-
nual pertussis-attributable morbidity and mortality by
92% and 99%, respectively . Despite this fact, and
despite pertussis vaccination rates in US children of
80%–95%, the annual incidence of pertussis has in-
creased since the nadir of 1010 cases reported in 1976
[2, 3]. The Centers for Disease Control and Prevention
(CDC) report that infants under 6 months of age, who
are too young to have completed the primary vaccina-
tion series, have up to a 20-fold higher incidence of
pertussis than does the general population (69.99 versus
3.62 cases per 100,000 population in 2007). Two-thirds
of pertussis-infected infants in this age group are hos-
pitalized . Furthermore, pertussis-related deaths oc-
cur almost exclusively in young infants, the risk being
inversely proportional to age and number of infant
DTaP vaccine doses received [5–7]. Studies also dem-
onstrate that 75% of infants are infected by a household
contact or caregiver, most commonly their mother
(33%) or father (16%) [8, 9]. Pertussis incidence and
mortality are higher in infants of Hispanic ethnicity, for
reasons that are not understood [6, 7, 10].
Since June 2006, in an effort to prevent pertussis in
Practices (ACIP) to the CDC has recommended that
Received 21 May 2010; accepted 31 August 2010.
Presented in part: National Immunization Conference, Atlanta, Georgia, April
19–22, 2010. Abstract # 22776
Correspondence: C. Mary Healy, MD, 1102 Bates St, Ste 1120, Houston, TX
77030, USA (firstname.lastname@example.org).
Clinical Infectious Diseases
? The Author 2011. Published by Oxford University Press on behalf of the Infectious
Diseases Society of America. All rights reserved. For Permissions, please e-mail:
Implementing Cocooning against Pertussis
d CID 2011:52 (15 January)
operative fashion that a successful infant cocoon program can
Fund and Children’s Health Fund of the Harris County Hospital District
Foundation, for funding to establish and run this program; Sanofi Pasteur,
for donating Tdap vaccine; Kenneth Mattox, Harold Miller, Amy Young,
Joseph Garcia-Prats, Lori Sielski, Rachelle Nurse, and Frances Kelly (Ben
Taub General Hospital, Houston, TX), for their assistance in establishing
and ongoing support for this program; Betsy H. Mayes and Nancy Ng
(Center for Vaccine Awareness and Research, Texas Children’s Hospital,
Houston, TX) and Carolyn Fairchild (Coordinator of Data Informatics for
Women and Infants, Ben Taub General Hospital, Houston, TX), for as-
sistance in data collection; and Robin Schroeder (Baylor College of Medi-
cine, Houston, TX), for assistance in preparing this manuscript.
Potential conflicts of interest. Tdap vaccine was donated by Sanofi
Pasteur. C.M.H. receives a research grant from Sanofi Pasteur and has
served as on an advisory board for Novartis Vaccines. All other authors: no
Wethank theBaylorMethodistCommunity Health
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