Whooping Cough Makes a Comeback

If you go to a web site called www.whoopingcough.net you can listen to the awful, inhalational whine that is characteristic of whooping cough. It doesn’t sound anything like whooping cranes. It sounds like a small pair of lungs struggling for air. Once upon a time, it was a tragically familiar sound in the United States. Once upon a time, there were roughly 200,000 annual cases of whooping cough in the United States. Today, that number is in the thousands, but the possibility of catching this preventable infection remains. Whooping cough, or pertussis, is a highly contagious bacterial infection caused by Bordetella pertussis. Pertussis infections begin in two stages. The bacteria first colonize the respiratory tract and begin to produce fever, coughing and malaise in the human host. Then the bacteria begin to pump out a variety of toxins. Severe coughing and cyanosis begins. One of these toxins, the Pertussis Toxin (PT) inhibits some immune functions and kills host cells. PT is largely responsible for whooping cough deaths and the ability of the bacteria to re-infect people. After Bordetella pertussis was isolated a century ago, work began on a vaccine against this sometimes fatal infection. In 1948, a vaccine was licensed in the U.S. Its widespread use led to a dramatic decline in the number of pertussis cases. The low point was 1976 when just over a thousand cases were reported. Since then pertussis cases have been increasing steadily. During the 1980-1990 period, for example, the annual number of reported cases averaged 2,900. Why the increase? Part of the reason may have been the vaccine. The original vaccine was a crude concoction of killed bacterial cells, which was given in combination with vaccines for diphtheria


and tetanus (the DPT shot). Sometimes there were unpleasant side effects from the pertussis vaccine, and in rare cases, seizures occurred in young children. With the overall risk of pertussis declining after decades of childhood vaccinations, the risk of adverse events from the vaccine began to look less and less acceptable to many people. Some parents stopped having their children vaccinated, and public rejection of the vaccine added to the jump in annual cases of pertussis. Someone needed to build a better vaccine. In 1996 a new “acellular” pertussis vaccine was licensed. This vaccine consists largely of inactivated pertussis toxin instead of whole bacterial cells. It has none of the serious side effects of the old vaccine. It too is given with diphtheria and tetanus vaccines, and that trivalent mix is designated, DTaP. But the new vaccine did not put an end to pertussis. High numbers of cases were still being reported. In 2005, the Centers for Disease Control and Prevention (CDC) recorded 21,003 cases. (Maryland had 199.) That was up from 9,784 in 2003 and 18,957 cases in 2004. Clearly, something else is going on with pertussis and vaccination. That something is waning immunity. After ten years or so the protective immunity provided by the whooping cough vaccine begins to fade away and people again become susceptible to infection. This may be why sixty percent of newly diagnosed cases now are found among teens and adults. Among adults, one clue to suggest a lack of immunity may be the appearance of a relentless cough. Persistent, painful coughing from unrecognized pertussis can lead to pneumonia and hospitalization. It can also lead to fractured ribs in some cases. All that coughing is also spraying B. pertussis into the air and creating opportunities for infecting other people. Once the cough is recognized as pertussis antibiotics are used to treat the infection and


prevent infections among family, friends and co-workers. Then re-vaccination has to be considered. Fortunately, two new pertussis vaccines are now available for those with waning immunity. Last year, the Food and Drug Administration approved Boostrix from GlaxoSmithKline and Aadcel from Sanofi-Aventis. Boostrix is for 10- to 18-year-olds and Adacel is for people aged 11 to 64. As with the standard DTaP vaccine, both of these new boosters also contain tetanus and diphtheria toxoids to protect against tetanus and diphtheria. The CDC’s Advisory Committee on Immunization Practices is recommending that teens and adults receive one of the new boosters in lieu of DTaP. The persistence of whooping cough in the U.S. is an important reminder that public and personal health is never static. Immunity declines, populations change, and bacteria persist. In the end, the best defense against disease is routine immunization and periodic booster shots. Check with your personal physician to make sure you are up to date on childhood immunizations and recommended boosters.