Running head: PERTUSSIS IN ARIZONA

Bordetella Pertussis Knowledge in Arizona

by

Sandra Adrianne Pena

M.A., Concordia, 2014

Applied Research Project Paper

Submitted in Partial Fulfillment

of the Requirements for the Degree of

Master in Public Health

Concordia University, Nebraska

December 2014

PERTUSSIS IN ARIZONA

Abstract

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 may help 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

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PERTUSSIS IN ARIZONA

Table of Contents

List of Tables.......................................................................................................................ii

List of Figures.....................................................................................................................iii

Chapter 1: Introduction (Level 0 Heading)..........................................................................1

APA Level 1 Heading....................................................................................................1

APA Level 2 Heading..............................................................................................1

Chapter 2: Literature Review...............................................................................................3

Chapter 3: Research Design.................................................................................................4

First Heading..................................................................................................................4

Chapter 4: Results................................................................................................................5

Chapter 5: Discussion, Conclusions, and Recommendations..............................................7

First Heading..................................................................................................................7

References............................................................................................................................8

Appendix A: Title of Appendix(if applicable)...................................................................10

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PERTUSSIS IN ARIZONA

List of Tables

Table 1. A Sample Table Showing Correct Formatting…………………………….5

Table 2. A Sample Table Showing Correct Formatting…………………………….25

The List of Tables is not set up to automatically update. If you have tables in your

document, type them in manually here, following the examples above.

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PERTUSSIS IN ARIZONA

List of Figures

Figure 1. Figure caption goes here.....................................................................................xx

Figure 2. Figure caption goes here.....................................................................................xx

The List of Figures is not set up to automatically update. If you have figures in your

document, type them in manually here, following the example above.

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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.

Figure 1.

1

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 unvaccinated by 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 was accomplished 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 countless families around the world and consequently made parents

and individuals question if vaccines are the right choice for themselves and their families.

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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, who are 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

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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

diagnosis of 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.

Since pertussis 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

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the number of cases of outbreaks and a decrease in the morbidity and mortality of this

specific communicable disease in the state of Arizona. The hope is that this information

can, 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 individuals identify 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 data will be analyzed and the information used to determine whether there are any

identifiable deficits in knowledge regarding pertussis among healthcare providers within

the State of Arizona; that information can be used to create educational programs and

initiatives.

Thesis Statement

An assessment of the level of knowledge on pertussis and the identification of

deficits in this knowledge among healthcare providers and public health professionals in

Arizona, will provide 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

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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 Arizona to define the

knowledge level of healthcare practitioners in Arizona and determine the areas that need

to be focused on in ongoing continuing education programs provided to practitioners to

ensure the accurate 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 patients and/or prevent

cases or outbreaks of pertussis?”

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 a quantitative analysis. Quantitative analysis is

best suited for deductive reasoning and hypothesis 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).

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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, “antibodies that 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. PCR is used to reproduce

(amplify) selected sections of DNA or RNA” (MedicineNet.Com. 2014).

Pertussis: Pertussis is also 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).

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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.).

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Lastly, it was essential that individuals provide the answers they believed to be correct to

the best of their ability; otherwise, there is a possibility of having skewed data or flawed

results.

Delimitations

In this study, the population surveyed were certified and licensed healthcare

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 in hospitals 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

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educational needs of these practitioners to ensure appropriate and timely diagnosis, which

will, in turn decrease morbidity and mortality within the state.

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 to identify 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

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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 imperative to 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 pertussis that 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 of pertussis,

specifically in the three categories of: assessment and management, barriers to obtaining

vaccinations, and problems with or beliefs about existing 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.

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Assessment and Management of Pertussis

This article discusses a serious outbreak of pertussis in Arkansas during 2001

through 2002. The reason why this was so concerning was because this outbreak

happened shortly after the terrorist acts of September 11th. The primary concern was

identifying where vulnerabilities were within the public health infrastructure. When it

comes to communicable disease outbreaks, public health professionals play a major role

during the investigation and mitigation of these outbreaks. Communicable disease

outbreaks identify the public health weaknesses that require immediate attention in order

for all agencies to be prepared if a bioterrorist event occurs. The purpose of this study

was to identify and rectify the weaknesses within the local, county, and state health

infrastructures within the state of Arkansas. At the conclusion of this study, the hope was

that the information rendered might be beneficial to other states to learn from the

weaknesses discovered in Arkansas (Wheeler et al., 2004). There were many

observations made during the statewide, private-public, management of the outbreaks that

suggested areas that needed more focus on in order to function effectively during

emergencies. Since terrorist acts aim to induce fear, many individuals rushed to do

everything possible to protect themselves and their families, which resulted in a

worsening of the national vaccination shortage that existed prior to this outbreak. It was

recommended by the Centers for Disease Control and Prevention (CDC) that individuals

who had contracted the disease, and those that were identified as close contact to infected

individuals, begin a recommended 10–14 day course of antibiotics. The procedure that

was performed was a retrospective study using the medical records of the individuals that

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were affected by this outbreak of pertussis to evaluate how they were diagnosed, how

quickly they were diagnosed, and how they were treated. Ideally there would be one

national accepted testing standard, but during this outbreak, the state of Arkansas was

using a DFA test that has been frequently linked to false positives, which can lead to a

delay in diagnosis, and consequently, in treatment (Wheeler et al., 2004), which

precipitated a worsening of the already existing outbreak. Four different types of patients

were used during this study, including the ones that met the state definition of a

confirmed pertussis case, patients that did not meet the state definition, asymptomatic

patients, and misdiagnosed patients. During the data analysis portion of this study,

symptomatic and asymptomatic patients were compared to the state definition created in

1997 by the CDC and the Council of State and Territorial Epidemiologists (CSTE). After

the conclusion of this study, it was determined that outbreak management at the state

level faced many challenges that they were not prepared for, which affected the way in

which patients were diagnosed and treated. Those challenges were the need for more

diagnostic facilities, a need for improved communication networks, more personnel

reserved for periods of crisis and emergencies, and lastly, more funds to support the

above listed activities. The barriers identified by the Arkansas public health management

during this specific pertussis outbreak were time and funding; since pertussis outbreaks

do not occur every day, the solutions for outbreak management need to be flexible and

allow for change between outbreaks, which makes it difficult for those involved to be

continuously ready for the worst-case scenario. The goal is to correct these barriers to

public health management for future outbreak-related use. It is impossible to generalize

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these findings for use in other states for the mere reason that the resources available in

one particular state are not always the resources available in every other state; available

resources are based on the population, so some regions may have more assistance than

others.

In a study by Dworkin, 2005 , the researchers were specifically looking at cases of

pertussis. This study looked at physician knowledge about pertussis and it showed that at

least in Washington State that the minimum amount of knowledge required to identify

and diagnosis pertussis was lacking substantially. “A survey of 130 Washington State

internists demonstrated that only 38% of respondents were aware that childhood

immunization with pertussis vaccine did not provide lifelong immunity, only 36% knew

that the nasopharyngeal swab was the preferred method for collection of a sample, and

only 45% knew that two weeks of antimicrobial prophylaxis was indicated for all close

contact of case-patients” (Dworking, 2005). In this study, it was determined that there is a

certain degree of resistance that manifested itself in the refusal of medical providers and

prescribers to appropriately identify and treat these cases the first time and to proactively

report to appropriate agencies and treat persons that are complaining about signs and

symptoms consistent with a pertussis diagnosis. The need that was identified was that

providers often do not include or even consider pertussis in their differential diagnoses as

pertussis cases, which often has many different ways of clinical presentation (Dworkin,

2005). This study focuses on outbreak management at the state level, which calls for

effective staffing levels and an appropriate material for diagnostic testing within these

facilities. Improved communication networks are essential to breaking the cycle of

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transmission. Finally, yet perhaps more importantly, there is a need for personnel

reserves for periods of crisis and more funds to support mitigation activities. Pertussis is a

disease process, which has to be recognized and diagnosed promptly. Without prompt

identification and treatment, this disease spreads rapidly and one case can quickly

become an unmanageable number of cases. The recommended treatment for pertussis is a

14-day course of erythromycin that once started, should not be stopped without notifying

a physician. Research asserts that the recommended test for diagnosis is the PCR

(polymerase chain reaction) nasopharyngeal swab (NP swab) with a culture for a

definitive diagnosis. If the PCR results are negative, it is very rare that the culture that

takes seven days to incubate will be positive. Treatment and intervention should not be

delayed while waiting for definitive test results. Having this information published in a

recognized and credible journal is important because it may affect how providers treat

pertussis. Currently, it takes a minimum of five to 10 hours to get the PCR results back

on a rushed sample and seven days to get the culture result back; this means that a one to

three day delay in treatment can lead to anywhere between one to 100 new cases by the

time that treatment of the index case is initiated.

In this study, the immediate response of the Epidemiological Intelligence

Surveillance Officer (EIS) wanted to side with the physician that was refusing to treat a

suspected case of pertussis which could have easily lead to an alarmingly fast spread of

the disease. Surveillance data was used to demonstrate an increase in pertussis cases. This

was important because the initial problem was numerous false-positives that were a result

of using the less reliable DFA test. The positive that resulted from the negative of

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identifying the poor reliability of the DFA test was that it determined that treatment

decisions for pertussis patients should not focus solely on test results, but rather,

consideration should also be given to a patient’s symptomology. It was also determined

that PCR testing with a culture was far more effective. This study concluded that there

needs to be increased awareness about pertussis because of the ease in which this disease

spreads. The prevalence of pertussis among patients with chronic cough is likely to vary

by region and time, and studies may tend to overestimate the true prevalence of pertussis

due to limitations such as inclusion or exclusion of serologic methods for the definitive

diagnosis of pertussis.

Those without a complete understanding of the virology of pertussis might

believe that it is a disease that only affects children. To date, many educational

campaigns have been geared towards how it affects children, but it is essential to increase

awareness about pertussis, how it is spread, and how it is treated. Healthcare

professionals and the general population must be made aware that pertussis is not just a

disease that affects children, but rather, it is a disease that can and does affect adolescents

and adults as well. This is of increasing importance because if potentially dangerous

complications are to be avoided, this disease needs to be identified from the earliest stage

possible. In an article written by De Serres et al., (2000) there is an attempt to bring

attention to the fact that pertussis is not just a childhood disease and that morbidity from

this disease is increasing. In this study, trained public health department personnel were

used to determine what the cause of this diseases resurgence was by evaluating 280

adolescents and 384 adult cases of pertussis. The results showed that there was a sharp

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decrease between adolescents who were vaccinated (78%) and adults that had received

vaccination (15%). In this study it was determined that the appropriate diagnosis was

only made during the first medical visit in 58% of the case while 27% where diagnosed in

the second visit and 10% in the third visit. With over 40% not receiving the appropriate

diagnosis at the first medical visit, the risk for complications severely increases, as does

the danger of the spread of this highly virulent disease. During this study, participants

were asked to rate their symptomology on a scale of 1 to 10 and include the duration of

those symptoms. Those responses were later analyzed using a Fisher’s exact test to

produce a linear trend for responses. Through this study, it was determined that since the

implementation of the pertussis vaccine in Canada in the mid-1940s, immunity against

the disease cannot be measured and no herd immunity existed within households,

indicating that the burden of pertussis increased with age. This ultimately meant that

there needed to be increased efforts for campaigns to provide lifelong prevention of

pertussis in age categories that extend far beyond childhood.

There was a Cochrane review of the efficacy of antibiotics used for the treatment

of pertussis (whooping cough) that concluded there was insufficient evidence to

determine the benefits of prophylactic (PEP) treatment of whooping cough among study

participants. Observations provided an early indication that more complex intervention

may be required for the treatment of pertussis. This data resulted from two groups

determining two factors that played a role in this study; the first was that there were

individuals at risk of severe complications and the second factor was that certain groups

were at an increased risk of transmitting the disease to vulnerable individuals. As in other

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studies, negative results, also known as false-negatives, should not be used to rule out

pertussis as with other diseases, if there is strong suspicion of a specific disease and the

first test comes back suspiciously negative, a second test cancould always be ordered to

validate any results. This study showed that in many cases, nurses did not take complete

histories as the nurses perceived the responsibility of taking histories the physicians’ role,

while doctors believed that it was the responsibility of the nurses; this resulted in patient

complaints and symptomology being omitted, which led to delays in diagnosis and

treatment. This article states that most study participants do not develop severe health

complications however, 24% of children experienced health related problems that had the

potential to lead to severe medical complications.

Vaccines and Pertussis

In a study by Zinnerman et al. (1998), it was asserted that there is a need to

understand physicians’ concerns about litigation and the various beliefs regarding vaccine

safety so that when questions arose they could intelligently and confidently answer those

questions with scientific based evidence that will leave individuals and family confident

that vaccinations are the superlative choice. The purpose of this study was to identify

whether vaccine are considered to be safe or not and what the potential legal implications

are for healthcare providers that develop or administer vaccinations are if after admiration

of a vaccine results in a complication such as a vaccine reaction, permeant injury, or

death. (Zinnerman, Schlesselman, Mieczhowski, Medsger, & Raymund, 1998). This

study was composed of physicians from pediatric practices that were seeing more than

five children, weekly, that were under the age of six, this study was completed using a

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stratified random sampling method. This study included 3,681 participants from all 50

US states. Information was obtained through a telephone interview and participants were

provided a $30 honorarium as compensation for their time. This study focused on the

mitigation of pertussis cases and reduction of outbreaks using the existing belief that

vaccines do not lead to potential adverse reactions such as Autism and permeant injury or

death from vaccination is rare occurrence, but the rare occurrence has resulted in fear that

subjecting individuals and families to question vaccine administration which is resulting

in questions from providers if adverse reaction occurs if it would lead to the potential for

future liability and costly litigation. The measurement utilized within this study was an

attempt to identify alleged vaccine-related injuries exist. Statistical analysis was

performed using a regression analysis to analyze the data obtained regarding the

prevalence of pertussis among patients that came from answers from the telephone

survey. The difficulty that resulted from this survey came for the varied presentation that

individuals with pertussis maymight have, those with chronic cough, leaving the true

prevalence of the disease to be unknown for the purposes of this study due to limitations

such as inclusion or exclusion of serologic methods for conclusive diagnosis of pertussis.

A total of 1,236 of the 3,681 participants were physicians and gave interviews. It was

determined that the prevalence of pertussis in this study varied and other studies may

overestimate the true prevalence due to limitations that included a requirement to first be

eligible and the second factor was to expect honesty if the study was going to be credible

and valid.

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Another study that was conducted to determine the reason why healthcare

providers are frequently under- or un-vaccinated. This study was conducted by looking at

knowledge, beliefs, and recommendations from the WHO about vaccination practices.

With the ultimate purpose ofto assessing the relationship between healthcare providers’

knowledge and attitudes with regard to vaccinations. The sample size of this study was

relativity small, using only 135 participants, and it was performed during a conference in

Germany. The ultimate goal of the study was to identify and correct misconceptions

about vaccinations, while reducing fears about complications related to vaccines and

provide additional education in a neutral setting where people would be most receptive to

learning and behavior change (Betsch & Wicker, 2014). In order to better understand the

apparent differences between vaccinations, there was a comparison between average

attitudes and general knowledge. The factors examined where age, gendersex, and the

frequency that physicians treated healthcare providers with vaccine-preventable diseases.

Healthcare providers where considered to be the controlled variables that were used in

this study. An analysis was completed using a cross-sectional survey that included

calculations of general knowledge about STIKO recommendations, which were used to

assess the extent to which physicians pass on official recommendations to their patients.

At the end of this study, it was concluded that there where misconceptions about vaccines

as well as a lack of knowledge regarding STIKO recommendations. It was determined

that the status of healthcare workers vaccination status reflected on the quality of care

that hospitals or facilities provide to patients while they are were ill. The one factor that

could potentially be implicated as a weakness in this study was a potential for social

20

desirability bias. This form of bias might have been present because individuals may have

provided the answer that they considered might be most socially favorable or accepted.

Around 1982, a major liability crisis began that made many individuals and

providers questions the safety of the combination vaccine used to protect individuals

from diphtheria, tetanus, and pertussis. A study conducted by Evans (2002), sought to

strengthen the availability of the recommended vaccinations that face such a tumultuous

shortage three decades ago that was caused by rising concerns about vaccine safety This

study took place in Rockville, Maryland, in conjunction with multiple agencies including

Health and Human Services (HHS), the Health Resources and Services Administration,

and the Vaccine Injury Compensation Program (VICP). The results of this study was

compensation based on a vaccine injury table that looked at many factors, such as

hospitalization, death, and other adverse effects that lasted greater than six months. This

study was conducted using simple justice to identify individuals that were inadvertently

injured by “properly produced vaccines that were administered through health programs”

(Evans, 2002). Because of the pressures from society to obtain vaccinations, and

litigation leading to the increased costs of vaccines to cover the anticipated costs that

would be incurred by prolonged litigation, there where national shortages of vaccines.

Through this, study the number of claims where what was specifically looked at over a

22-year period; claims were self-reported by individuals that filed them. It was

determined that the spikes in number of cases claims occurred following the development

and release of a new vaccine or the modification of an already existing one. There was no

evidence that manufacturers were liable. Following this study that continued until the

21

close of 2004, Thimerosal was removed from many of the vaccines that are received in

the first years of a child’s life. The VICP determined that there was a statute of

limitations that only included claims that were within six years of the initial injury.

Barriers to Vaccinations

The goal of a study by Bond et al. (n.d.) was to identify the benefits of

vaccinations that, at one time, showed a huge decline, if not total eradication, of some

diseases. Due to under-vaccination, many children around the world are still enduring

terrible and disfiguring diseases that could have potentially been prevented. Individuals

are falling into a false comfort because as the ability to test is becoming more effective,

those participating in being vaccinated are decreasing, especially in adolescents, where

children are not getting the fourth and fifth doses recommended by organizations such as

the WHO. This decline is allowing the resurgence of diseases like pertussis to gain

strength (Bond, Nolan, Pattison, & Carlin, n.d.). The ultimate goal of this study was to

increase the numbers of individuals being vaccinated and to decrease the incidence of

disease around the world with the intermediate goal being an attempt to understand

individuals and families personal beliefs about obtaining vaccinations Thisthis study took

place in New Zealand and it specifically looked at 62 primary care providers (PCPs). In

this study, 616 audited children made over 10,000 visits to their PCPs starting in 1997.

The overwhelming issue was parental, healthcare, and provider’s barriers to vaccinations.

Those barriers included supply and demand, logistics, and a lack of knowledge, staffing

and workflow changes, timely administration of vaccinations, complicated vaccination

schedules, cost, religious objections, ethnic groups, and socioeconomic status (SES).

22

After an abundance of barriers were identified the issue was how to address the barriers

and misconceptions through education and community outreach so that vaccination

campaigns would once again be successful. Among the barrier challenges that providers

were already facing, there was inconsistency in vaccination reporting; thus, a national

system was designed and initiated. Limitations of this study included vaccine shortages

and a lack of a reminder/recall system that could bring patients back to the PCPs to

ensure timely vaccinations.

In a piece published by LaVail & Kennedy (2012), [Author (date)] looks

specifically at attitudes about vaccine safety are analyzed, which can and have played a

large role in a person’s desire to obtain vaccines. This article indicated that there is a lack

of confidence, efficiency, and efficacy in the vaccines that are currently being used.

Through this study, a specially developed calculation was used. That equation was

[personal thoughts on vaccinations + (thoughts on effectiveness of vaccines/2)]/2 (LaVail

& Kennedy, 2012). This study took place in the United States in September and October

of 2010 with 6,253 random households being surveyed with only 67% of those

households responding). This survey was conducted to assess the confidence in vaccines,

specifically confidence in safety, value of vaccines, and efficacy, with an assumption that

the biggest predictor of confidence in vaccines would be the biggest predictor of parental

behavior. The variables that this analysis was based on was race/ethnicity, age, education,

and household income. The follow up analysis using a sample group of parents with

children under six years of age, which was 376 families, was for a special report on

attitudes towards vaccinations. To determine the results of this study, a stepwise logistic

23

regression was used that ultimately determined that approximately 49% of the population

surveyed had vaccinated or intended to vaccinate their children. After this study, it was

determined that there needs to be more efforts made to assess beliefs and behaviors

related to because they can easily affect future trends in vaccination practices and

keeping the resurgence of vaccine-preventable disease low to non-existent. This study

identified numerous limitations; the most significant one was that the survey panel might

have introduced some degree of bias and that the 33% that were classified as non-

respondents might have avoided responding for specific reasons, which could have left

the percentage that did respond subject to bias. An article by Bond et al. (n.d.)

specifically looked at what is currently described as an inadequate number of individuals

receiving vaccinations, and further stating that this is a major public health crisis that

does not and will not discriminate. The ultimate goal was to define intervention measures

and improve measures to make them as successful as possible. This study was conducted

in five specific counties in Melbourne, Australia, including Yarra, Moreland, Hume,

Barebin, and Banyule (Bond, Nolan, Pattison, & Carlin, n.d.). The issue remains that

individuals beliefs, misconceptions, and attitudes about vaccines are what is making

vaccine campaigns difficult to complete. Information was obtained through, “a semi-

structured in-depth interviews that where completed by adults regarding their beliefs

about illness risk” (Bond et al., n.d.). The sample included 48 individuals of that, only 45

where eligible. The final sample size only contained 16 mothers for data analysis and

conclusions, which could lead this study to be considered statistically insignificant since

all the other studies regarding vaccine preventable disease used hundreds if not thousands

24

as a sample size. This study was completed using a method referred to as a purposeful,

stratified sampling strategy that essentially identified completely, incompletely or

partially vaccinated children. Once the respondents, who were the parents of the

identified children, were identified, all interviews were audiotaped and later transcribed

to be held for a permanent record if a later need should arise. Information that detailed

socioeconomic status was analyzed using STATA. The average age of the children

involved in thisthis, study where approximately 15 months of age. Mothers that ensured

that their children were completely immunized believed that the risk related to

immunization was far lower than the risk of actually contracting the disease (Bond et al.,

n.d.). The limitations of this study included the fact that perceptions about vaccines were

more powerful than actual factsfacts about vaccine risks and benefits. 33

Chapter 3: Research Method

Research Design and Approach

The research design of this study is quantitative with the procedure for gaining

access to the data being voluntary participant response. Descriptive statistics were used to

provide informative information on the knowledge level and training needs of licensed

healthcare providers in Arizona relating to pertussis.

Setting and Sample

This study was conducted in Arizona in August-September of 2014. The sample

population was front line healthcare professionals including physicians, DOs, NPs, PAs,

25

RNs, CEPs, and EMTs. The participants were from a variety of settings, including in-

hospital and pre-hospital care, specifically Emergency Room (ER) professionals and the

providers that bring those patient to the hospital such as EMTs, and CEPs and public

health professionals such as epidemiologists. All participants were 18 years or older. The

method used for the collection of this data was a snowball sampling method for mid- and

high level providers and a purposive convenience sampling method for the collection of

data from CEPs and EMTs. Data from CEPs and EMTs was collected during a

mandatory employee, continuing education session in September 2014 at a Professional

Medical Transport (PMT) Ambulance training that brought certified personnel from Pinal

and Maricopa counties to Mesa, Arizona. Orlando Alcordo, CEP and Director of the

PMT Training Department, distributed the survey.

Data Collection and Analysis

The data collected from this study was continuous data as the observations were

designed to be measured to provide a baseline understanding of what current pertussis

knowledge is in Arizona healthcare providers. Descriptive statistics, including means,

standard deviations, and frequencies were used for data analysis.

Instrumentation and Materials

The data for this study was conducted using an electronic survey named, The

Pertussis Knowledge Survey (appendix A). The data that will be yielded from this survey

will assist in understanding where the knowledge deficiencies exist such as certain levels

of licensure or certifications, gender, or age categories. This research was conducted

using a quantitative research design and the data was analyzed using descriptive statistics

26

to determine if there were any correlations between professions, age range, or gender.

Once raw data was collected and analyzed, selected results were presented in tables and

[figures/graphs]. Raw data will be made available through written requests to the

researcher.

Protection of Human Participants (if applicable)

The Concordia University, Nebraska Institutional Review Board approved this

study. The purpose of the study was explained to participants and informed consent was

obtained by presenting the elements of informed consent electronically and having

participants “click” that they understood. Furthermore, informed consent was assumed

through voluntary completion of the self-administered survey; participants could opt out

at any point prior to submission of the survey. Following that, due to the anonymous

nature of the survey, there was no way to identify the surveys to withdraw participants.

All surveys were completed anonymously, no identifying information was used, and data

and responses were only viewed by the research and faculty in charge of oversight for

this research project.

27

Chapter 4: Results

Pertussis is of particular concern because of the virulence of this disease and the

fact that it is frequently misdiagnosed. With pertussis, one case can easily become 20

cases without prompt identification and appropriate treatment. This study was prompted

from a recent suspected outbreak of pertussis that was identified in Gila County, Arizona

that was misdiagnosed; the outcome was a 15-year-old patient being admitted to the

Intensive Care Unit (ICU). Due to the misidentification and lack of timely reporting, the

number of suspected cases quickly grew to 27 because the child was in an unlicensed

daycare facility during the contagious period of her illness.

A study by Hampton (2006) stated it is of essential importance to identify the

disease in infected older children and adults who may have a different clinical

presentation and who can easily carry and transmit the disease to younger, unvaccinated,

or immunocompromised children and adults (Hampton, 2006).

A self-designed survey was used to collect data to answer the following research

questions:

(1) What is the existing level of knowledge of certified and licensed medical

providers in Arizona?

(2) What deficits in knowledge exist that could affect the ability to accurately

diagnose or treat pertussis patients and/or prevent cases or outbreaks of

pertussis?

28

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

Electronic and paper copies were distributed to assess the knowledge of

healthcare providers and health departments in the State of Arizona. A total of 105

completed surveys from licensed and certified health care professionals employed in

public health departments, hospitals, and pre-hospital settings across Arizona were for

inclusion in the final data analysis.

Of the respondents, 66% (69) were male and 32.3% (34) were female with the

andremainder not answering the question the majority of the respondents were between

19 and 50 years old. The majority (85%) were licensed or certified as RNs, CEPs, and or

EMTs, and all of the respondents worked with individuals with respiratory complaints.

All respondents for Pertussis Knowledge Survey were over the age of 18 and

residents of Arizona at the time of the survey. Forty-two percent (44) of the respondents

worked in emergency rooms and 52.3% (55) worked in pre-hospital settings including

ambulance and fire services. The remaining respondents (6) worked in emergency

departments across Arizona or as county public health professionals that all identified

themselves as epidemiologists.

When respondents were asked to assess their own, personal current knowledge of

pertussis on a 0-10 scale, with zero being no knowledge and ten being a subject matter

29

expert on the topic, the majority [26%] assessed their knowledge at five, the remaining

results are shown in tTable one1. Twenty percent rated their knowledge at zero, 0.05% of

all respondents rated their knowledge at one, 0.06% a two, 0.11% at a three, 0.10% four,

0.03% at six, 0.10% at seven, 0.05% at eight and 0.02% rated their knowledge at a nine

or ten.

When asked, “Is pertussis bacterial or viral?” 64% of the respondents stated

correctly that it was bacterial. and 35% of participants selecteding viral, and less than 1%,

or more specifically seven individuals did not answer this question. Pertussis is spread via

multiple transmission methods including hand-to-hand, droplet, and airborne methods.

Question nine was designed to assess the level of knowledge health care providers had

about the transmission of asked participants to state the transmission method of pertussis

(e.g. airborne, droplet, contact) pertussis. This question had multiple answers and the

responses indicated there is a lack of knowledge in this area. Only 9% (18) of the

respondents correctly selected all three modes of transmission for their response.

Questions 10-12 were related and were designed to assess knowledge about the

pertussis vaccine. Overall, respondents were very knowledgeable on the vaccine for

pertussis. When asked, “Is there a vaccine for pertussis?” the answering 84% answered

correctly in the affirmative with the remainder opting out of this question or getting the

answer wrong. When asked, “Is the vaccine 100% effective?” the vast majority, (94%)

were correct in responding that the vaccine is not 100% effective as no vaccine is ever

100% effective. When asked, “Can pertussis be treated with the vaccine?” 74.4% of the

30

respondents correctly by answering “no”; however, there was a ~ 25% non-response rate

for this question.

When asked, “How many shots are included in the vaccination series that is

recommended by the World Health Organization (WHO)?” the correct answer was five;

Answers to this varied quite widely and 6% did not answer at all; only 10% got the

answer correct (which was five shots). With the remaining respondents answering

incorrectly

When asked “Does pertussis only affect children?” 57% wrongly were incorrect

in believbelievinged that it didpertussis only affects children. Meaning that the

remainderrest, 43% either did not answer the question or did not know or were unaware

that this disease affects adolescents, adults, and elderly as well. It was disturbing to note

that the majority of the respondents that answered this question incorrectly were RNs and

CEPs.

When asked how virulent pertussis is, 82% of the respondents correctlyproperly

answered that pertussis is highly contagious. Respondents were asked about the rate at

which pertussis is increasing and 56% stated it is increasing rapidly and 40% said it was

increasing moderately; only 4% selected slow to no growth (these responses came from

two RNs and five EMTs).

Lastly, respondents were asked answer the questions “Who are the transmitters of

the disease?” Responses included: adults-to-children, children-to-adults, adults-to-adults

the correct answer: person-to-person. This question was designed because there are

currently educational Public Service AsAnnouncements (PSAs) that might confuse the

31

general public and health care providers into thinking that pertussis is only transmitted

from parent or adult-to-child which is a fallacy and can hamper the ability to identify and

treat pertussis in a timely manner. For this question, the data analysis showed that there

was a majority of representation from all levels of providers in the category of person-to-

person with a correct response rate of 82%. However it was noted that the of the

remaining 18% respondents, 13 nurses, two EMTs, and three CEPs believed that

pertussis was only spread from parent-to-child.

Validity was confirmed by a rigorous review by the Director of the Gila County

Division of Health and Emergency Services, Michael O’Driscoll. Additionally, feedback

on the layout and questions in the survey to ensure they would measure pertussis

knowledge in a consistent and understandable manner was provided by a Concordia

University professor and a class of Master’s in Public Health students.

Figure 1

Figure 2Figure 1

Participant Representation

32

Healthcare Profession 0

5

10

15

20

25

30

35

40

Registered Nurse (RN)Medical Doctor (MD)Doctor of Osteopathy (DO)EpidemologistNurse Praticioner (NP)Physician Assistant (PA)Certified Emergency Paramedic (CEP)Emergency Medical Tech. (EMT)

______________________________________________________________________________________

Figure 1. Participant Representation

Hypothesis Testing

The null hypothesis for this reasch study was as follows:Null hypothesis: “There are no identifiable deficits in what most healthcare

providers in Arizona know about the diagnosis, treatment, and prevention of

pertussis.

Based on the finding of […….insert…….. all the finding where there was a specific

deficit] ((((transmission)))))) overwhelming deficits

………Because of this the null hypothesis cannot be rejected. This is specifically true in

the _________________ area prevention transmission treatment (pick one)

Chapter 4 Summary

Summary of Results

33

In summary, 105 health care providers in Arizona completed the Pertussis

Knowledge Survey. The results showed that there were some deficiencies in the

knowledge Arizonan health care providers have that could potentially have an impact on

their ability to diagnosis, treat, and prevent cases and outbreaks of pertussis. There

arewere two areas the majority of health care providers in this arestudy were deficient in;.

thoseese areas included the multiple modes of transmission for pertussis and how many

shots are included in the vaccination series. This information could be useful for future

public health education campaigns or training programs for licensed healthcare providers.

34

Chapter 5: Discussion, Conclusions, and Recommendations

Introduction

Existing literature indicates that although pertussis is actually well known as a

highly communicable disease in the scientific and public health communities, it seems it

is poorly understood and frequently misdiagnosed by medical providers as a variety of

other cough like-illnesses that include allergies, the common cold, or flu. There is also

the distinct possibility that a current awareness campaign produced by the March of

Dimes might confuse or mislead lower level health care providers to believe that the only

way for pertussis to be spread is from parent to child. However, in actuality The Centers

for Disease Control and Prevention identify the vehicle for transmission of pertussis to

actually be from person-to-person (CDC, 2014).

................................................................................................................................................

Interpretation of Findings

Through this study, it was determined that there needs to be additional education

regarding pertussis. This conclusion was made after having analyzed the data that was

yielded from the Pertussis Knowledge Survey. It was determined that knowledge was

lacking in all areas including prevention identification, and transmission, and prevention.

Although there was a general lack of knowledge about pertussis, the area of greatest

concern was prevention, which included the questions regarding vaccination knowledge.

Prevention of pertussis is a key to reducing what is being refered to as a global

problem. . In 2014, “the World Health Organization estimates 50 million cases with

300,000 fatalities will occur worldwide. This article presents the history of pertussis,

35

possible reasons for the rise in prevalence, symptoms, management of illness, vaccination

across the lifespan, and worldwide prevention efforts. The critical role nurses play in

vaccination and pertussis education is emphasized” (Peake & McGuire, 2014) During my

study four of the questions from the Pertussis Knowledge Survey sought to assess

healthcare providers in Arizona’s knowledge of methods to prevent pertussis. Those

questions were:

There is a vaccine for pertussis

The Pertussis vaccine is 100% effective.

Pertussis can be treated with the ‘vaccine’

The [original] vaccine series contains how many injections

It was found that there is a lack of knowledge about the role that vaccinations

can play in the overall goal of preventing pertussis. The majority of providers did not

know how many shots were in the vaccination series and how effective the

vaccination can be in preventing pertussis. The message that providers and parents

should be made aware of is that “childhood vaccination has [been proven to]

dramatically reduced reported pertussis cases and the incidence of the disease”

(Gregory, 2006).

Identification of pertussis is essential to the ability to quickly treat and mitigate

the spread. To be able to identify pertussis providers have to know where to look.

Through my study one question was included to gage providers knowledge on how to

36

identify pertussis and that questions asked, “how is pertussis spread”. With over 50 %

believing that only children were susceptible to the disease adolescents and adults that

have the disease may go undiagnosed because they may have “less severe paroxysmal

symptoms” (Gregory, 2006). Unidentified pertussis can lead to complications that could

include seizures and other neurological symptoms.

To understand the cycle of pertussis a provider needs to be aware of all the

methods in which pertussis is transmitted and the Pertussis Knowledge Survey sought to

identify if providers understood that there is more than one method for transmission of

this disease process. My survey asked two questions about the transmission of pertussis,

how pertussis is spread and how contagious the disease is. After the analysis of my

survey it showed that there was a knowledge gap in the area of transmission as there as

with prevention and identification.

Lastly, included in my survey was general knowledge about pertussis. Those

general knowledge questions about pertussis were: how would you rate your current

knowledge of Pertussis, is pertussis is bacterial or viral, and cases of pertussis are

currently increasing or decreasing. As with the other focus areas of this survey responses

showed that there is a knowledge gap in this area as well. Over 1/3 of participants did not

know that pertussis is bacterial which is an important questions because knowing if

pertussis is bacterial or viral affect how providers are able to treat the disease a viruses

are no able to be treated with antibiotics while bacterial species are able to be treated with

the appropriate antibiotic course.

37

At the conclusion of the analysis of this survey it was determined that Arizona

health care providers are not feeling confident about their knowledge of pertussis

meaning that they are impeded in the ability to quickly identify and appropriately treat

this disease.

I believe that with the knowledge gained from this study, the greatest benefit can

come from focusing efforts on increasing knowledge about identification of the disease

and how it is transmitted. If future education efforts are focused in these areas, they might

be more effective because individuals will not have to contend with such a hot-topic issue

that goes so far beyond simple health education.

Summary

Recommendations for Action

Moving forward the recommendations for action is to increase education which

can be accomplished in multiple ways. A subject matter expert can provide in-services to

ER staff. Nursing programs can offer a relevant communicable disease course that

teaches not only about pertussis, but about other vaccine preventable diseases as well

which can reduce morbidity and mortality of preventable diseases that long ago were

thought to be under control which is no longer the case. Additional continuing education

(CEUs) can be required on an annual basis for epidemiologists, mid-level, and medical

providers (MDs and DOs).

Additionally, efforts to increase education can lead to community members

becoming more knowledgeable about their own healthcare which can eventually lead to

38

more people knowing when to seek medical attention at ERs verses urgent cares or PCPs

offices. Lastly, there could be an effort to target the parents or parents-to-be because

although pertussis does not only affect children, children are among the most susceptible

groups do to their immature immune systems.

Recommendations for Further Study

Limitations. One of the limitations of this study was the small sample size. This

was due to using the snowball method, which was originally intended to be the primary

method for data collection for this survey; it was not as effective as originally hoped for

so questionnaires were delivered by hand to emergency personnel, skewing the data field

for provider type. The surveys were not distributed by those receiving it directly to the

degree that was expected. Once all of the surveys in the available collection period were

analyzed, it was discovered that there were few mid- and high-level providers included,

which made it impossible to draw definitive conclusions about the knowledge level of

NPs, PAs, MDs, and Dos, as a whole. Lastly, it would have been optimal had there been

more questions included in the survey aimed at obtaining information about identification

and treatment on pertussis. As a knowledge survey, the demographic questions were not

as important during the data analysis or recommendations.

Future Research.

To further knowledge in this area and better guide curriculum on pertussis for

healthcare providers even further, the study should be repeated with more questions about

identification (diagnosis) of pertussis and treatment of pertussis to make the survey more

39

comprehensive. It would also be useful to add questions or even examples or a case study

involving croup as this is an illness that pertussis can easily be mistaken for.

Additional studies could be focused on each provider group to assess knowledge

within specific fields, and if the research was coordinated to have homogeneity and

similar sample sizes, some comparisons could be drawn between fields. This would be

particularly useful if information is gathered on the source of pertussis knowledge forfor,

each provider group so that the education type that led to the greatest amount of

knowledge among the provider fields could be identified and duplicated in other fields.

Additionally, there is currently an anti-vaccination movement based on misinformation

about vaccinations causing “autism” and other complications in children. This movement

will continue to be a barrier for pertussis prevention and vaccination practices unless

providers become very well informed on the benefits and risks of vaccinations, the tenets

cited by the movement, and methods in which to present the case for vaccinations to

parents making the risky decision not to vaccinate their children. Research should be

conducted on the level of education these particular parents feel their pediatricians have

regarding vaccinations. If the anti-vaccinating parent feels more informed about

vaccinations than his/her child’s pediatrician, this could have a very negative impact on

reducing the spread of this movement, which is contributing to outbreaks of previously

near-eradicated diseases all over the US. In this scenario, a lack of accurate information

on the part of providers can have deadly consequences and a determination of the

strength of the relationship between these two variables would guide health professionals

in mitigating this problem.

40

Conclusion

[Insert a few brief closing sentences summing up your findings (providers

could benefit from more education) and how they will contribute to public health

practice, here.]

It is important to understand that knowledge is

In light of a current anti-vaccination movment it is important that

______________________________________________________________________________________Criteria Poor Excellent

Chapter 5: Conclusions (Capstone Project Only) NA 1 2 3 4 5 -The interpretations of the findings include conclusions that address all research

questions and relates the findings to a larger body of literature on the topic.-Includes recommendations for action and further research study.-Comments:

Sandra, you did a good job of cleaning up some comments but very, very few of the substantial changes (none of the substantial changes, in fact) were made. You only need to write two sections. Recommendations for further action (include more training in medical and nursing programs. Offer CMEs and CEUs on pertussis, have hospitals and provider offices offer inservices (health departments could partner with them by volunteering to conduct these). Findings could guide development of the curriculum for these trainings. Now that you know what they are missing, you could build a training program prioritizing the things they missed the most (what kind of disease it is and how it operates) and what the vaccination schedule is and less time on what they already know (this is called targeted training and it produces maximum benefits). You can also suggest more training on mandatory reporting requirements, which, in and of itself, would

41

make providers more cautious and aware of the disease. You could suggest the creation of a multi-county reporting system where epidemiologists from neighboring counties have formal partnerships to report department to department of incoming cases.

The second thing you need to write is Interpretation of Findings. Simply take each one of your findings and write something about it. Right now, forget about whether it’s something in the literature. Just get something down on paper. You cannot have a 3 page Chapter 5. It is a critical chapter. It doesn’t have to be perfect but something has to be written there so we have something to build on. If you take a look at some of the changes that have been made in your paper. If you write a sentence, I add a great deal to it. So write your ideas down and see if we can get them fleshed out together. Just free flow this thing. Forget about using references for these two sections, for now. (You won’t need them at all for Future Actions and you only might need a couple for Interpretation of Findings and if you can get this back to me by Sunday evening, I will help you find them myself).

Let’s get the final draft in Sunday night, I’ll send it back Monday, and you fix the formatting and everything by Wednesday. Please email me and tell me if this plan will work. If not, call me and let’s talk about your graduation plans and what you think your schedule is going to be. – hp

Grade – was 70 – 5 points for track changes = 65/2 = 32.5

Sandra, after you read through my changes, hit Ctrl A, then “Accept Changes.” Then click ON “Track Changes.” Then make your revisions. If you do not do this, there will be a 10 point penalty on your next paper.

42

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Appendix A: Title of Appendix

Pertussis Knowledge Survey

 You may opt out of this survey at any time.

Please do not use any additional resources to complete survey.

1. Are you over 18 years of age? (Circle one) Yes or No (If no, please stop survey)

2. Are you a licensed healthcare professional or a public health practitioner? (Circle one) Yes or No (if no, please stop survey)

3. What license(s) credentials do you currently hold (Circle one) (if none of the below, Please stop survey)Registered Nurse Medical Doctor Doctor of Osteopathy Epidemiologist Physician’s Assistant EMT Nurse Practitioner CEP

4. Do you work with patients that have respiratory complaints (e.g., cough, sneezing, runny nose) (Circle one) Yes or No

5. How often do you work with people with these complaints?

___ Never (Zero interaction)___ Not too often (1-time a week)___ Sometimes (2-3 times a week)___ Frequently (Almost every day if not every day)

6. What setting do you work in? (Circle one)

Doctors office Clinic Hospital Urgent Care Pre-hospital (EMS, Fire, Flight) Office with occasional field work (epidemiologists)

7. How would you rate your current knowledge of Bordetella Pertussis (0-10) (zero is no knowledge, ten is subject matter expert) ________.

8. Pertussis is: Bacterial or viral (Circle one)

9. Pertussis is spread by… (Circle all that apply)

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Hand-to-hand contact Droplet Airborne Vector Oral-fecal

10. There is a vaccine for pertussis (Circle one) Yes or No (if ‘yes’ please answer number 11 & 12 if ‘no’ please proceed to number 13”

11. IF, you answered ‘Yes’ to # 10 please answer this questions: The Pertussis vaccine is 100% effective. (Circle one) Yes or No

12. IF, you answered ‘Yes’ to # 10 please answer this questions: Pertussis can be treated with the ‘vaccine’ (Circle one) Yes or No

13. The [original] vaccine series contains how many injections [if started on time per recommendations of the WHO] (Circle one) 1 2 3 4 5 6 7 8 9

14. Pertussis ONLY affects children (Circle one) Yes or No

15. Pertussis is… (Circle one) highly virulent or hard to contract

16. Cases of Pertussis are currently(Circle one) increasingly rapidly, increasing moderately, slow or no increases in cases

17. Pertussis is transmitted most frequently transmitted by (Circle all that apply): Parent-to-Parent Parent-to-child Child-to-parent Person-to-Person

18. What category best describes your current age (Circle one)19-28 29-39 40-50 51-60 61-70 70+

19. Is your current residence within the State of Arizona (Circle one) Yes or No

20. Gender: Male or Female (Circle one)

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