Pertussis

Whooping cough is back

Adapted for BugLine from presentation by:

Cassandra D. Youmans, MD, MPH, MS-HCM, FAAP
District Health Director
East Central Health District VI
 Objectives
 Enhance East Central Public Health District VI’s ability to recognize
and respond appropriately to pertussis
 Refresh University Hospital healthcare personnel to allow
appropriate treatment and reporting of pertussis

 Give Tdap* vaccine to healthcare personnel to protect our:

 Highest risk patients by surrounding them immunity
 A circle of immunity made up of vaccinated caregivers
 Healthcare personnel from “catching” pertussis

* Tdap, Tetanus, diphtheria and pertussis

Two Pupils Treated for Pertussis
Saturday, April 15, 2006

 Columbia County School officials confirmed

that at least one pupil tested positive for
whooping cough, and the two siblings are
being treated. One attended Evans High
School, and the other Evans Middle School…
highly contagious, spread through the air by
cough and begins with cold symptoms and a
cough…

 The case was not properly reported to the

public health department, allowing for the
above Augusta Chronicle
 And the article included a warning to parents
Resurgence of Pertussis
 Mutation
 Waning vaccine-induced immunity
5 to 7 years after vaccination,
leaving adolescents and adults
unprotected
 Waning disease-induced immunity
doesn’t last much longer than that of
vaccination
 Enhanced identification: Public
health awareness, surveillance,
diagnostic programs
Bordetella pertussis, the germ
 Gram-negative rod
 Humans are the only host
 Incubation period 6-to-21 days (usually
7-to-10 days)
 Duration of illness 6-to-10 weeks
(usually 6 weeks)
 Expected occurrence 3-to-5 year cycles
of increased disease
 Pertussis is under reported, 40-160 fold
less than actual illness
 Asymptomatic infections are 4–22 times
more common than symptomatic
infections
Spread
 Close person to person contact via
aerosolized droplets from
respiratory secretions of patients
with disease
 90% of nonimmune household
contacts acquire the disease
 Adolescents and adults (27% of
reported cases in 2004) are the
major source of infection in
unvaccinated children
 Infants and young children are
infected by older siblings who
have mild to asymptomatic
disease (43% of reported cases)
 Clinical Symptoms

 Initially mild upper respiratory tract

symptoms (catarrhal stage,1-2wks),
most contagious period progressive
paroxysms of cough (paroxysmal
stage 2-4 wks)
 Inspiratory whoop, followed by
vomiting
 Fever minimal to absent
 Symptoms subside gradually over
months (convalescent stage1-2 wks)
Clinical Symptoms in Infants
 Most severe in infants <6
months
 Atypical presentation
 Apnea most common symptom
 Whoop is absent
 Hospitalization often needed
 Lymphocyte predominant,
increased white count can
match severity of the cough
Infant Complications
 Seizures (3%)
 Pneumonia (22%)
 Encephalopathy (1%)
 Death
 Case fatality rate:
1.3% in infants <1 month
0.3% in infants 2-11 months
 Diagnosis
 Increase of pertussis antibody
 IgA antibody titer to pertussis is becoming the method of choice
 IgG antibody to pertussis toxin indicative of recent infection
 Single serum test for significantly high pertussis specific antibody can
confirm the diagnosis

 Adolescents and adults with B. pertussis cough illness don’t seek

care until the week 3-4 of illness
 Organism most frequently recovered in catarrhal or early paroxysmal
stage
 PCR on nasopharyngeal secretions obtained with Dacron swab, put
on special media, with 10 to 14 day incubation
 Alert the Lab when pertussis is suspected - the culture media is not
readily available
 Negative cultures are common
Treatment
 Aim is to eradicate nasopharyngeal carriage
 Treatment duration usually 14 days with erythromycin sulfate
(EES), newer Macrolides 5-7 days
 Macrolides-erythromycin, azithromycin, and clarithromycin
 Azithromycin eradicates naso-pharyngeal carriage the fastest
 Hypertrophic pyloric stenosis has been reported with oral EES in
infants younger than 6 weeks
 Trimethoprim-sulfamethoxazole is an alternative to
erythromycin-resistant strain, or for intolerance to macrolides
 Penicillins, first and second generation cephalosporins are not
effective
 Supportive Care
 Hospitalized patients need to be on Droplet Isolation for 5 days
after therapy
 Monitor exposed children for respiratory symptoms for 20 days
 Laboratory confirmation is difficult, so diagnosis often based on
characteristic clinical manifestations
 Children may return to school after 5 days of appropriate antibiotic
therapy
Prevention - Terms

 Tetanus Diphtheria (Td)

 Tetanus Toxoid, Reduced

Diphtheria Toxoid and Acellular
Pertussis Vaccine, Adsorbed
(Tdap)
Prevention = Immunization
 Universal immunization of all children <7
years of age is recommended by the AAP
 U.S. pertussis is an acellular vaccine in
combination with diphtheria and tetanus
toxoids
 Acellular vaccines contain one or more
immunogens from B pertussis
 Acellular vaccines are absorbed on
aluminum salt and must be given
intramuscularly
 3 DTaP, and 1 combined vaccine that
includes DTaP and Haemophilus
influenzae type b conjugate vaccine is
given at 15-18 months
 Recommendations of the Advisory
Committee on Adult Immunization Practices
(ACIP)

 One dose of Tdap for adults 19– 64 years

of age to replace the next booster does of
tetanus and diphtheria toxoids vaccine (Td)
 Tdap for adults who have close contact
with infants <12 months of age
 May give Tdap within 2 year intervals to
protect against pertussis
 Tdap is not licensed for adults >65 years
Contraindications and Precautions
Contraindications to Tdap
 History of serious allergic reaction
(anaphylaxis) to vaccine components
 History of encephalopathy not attributable
to an identifiable cause within 7 days of vaccination
with pertussis vaccine

Precautions to Tdap
 Guillain-Barre Syndrome, 6 weeks
after a dose of tetanus toxoid
 Moderate to severe acute illness
 Unstable neurological condition
 References
 ACIP Votes to Recommend Use of
Combined Tetanus Diphtheria and
Pertussis (Tdap) Vaccine for Adults.
Advisory Committee on Immunization
Practices. 2006
 Cherry, JD. MD, MSc. The
epidemiology of pertussis, Pediatric
Infectious Disease Journal. 2006;
25:4:361-362
 Pickering, LK. Pertussis.The Red
Book. 2003; 26:472-486
 Gilbert, D.N. The Sanford Guide to
Antimicrobial Therapy. 2005; 35:24
Questions?