eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Pertussis

Author: Hazel Guinto-Ocampo, MD, Consulting Staff, Assistant Professor of Pediatrics, Department of Pediatrics, Division of Emergency Medicine, Nemours Children's Clinic, AI duPont Hospital for Children
Coauthor(s): Bryon K McNeil, MD, Medical Director, Bioterrorism and Emergency Preparedness, Clinical Assistant Professor, Departments of Internal Medicine and Emergency Medicine, Via Christ Regional Medical Center; Stephen C Aronoff, MD, Waldo E Nelson Chair and Professor, Department of Pediatrics, Temple University School of Medicine
Contributor Information and Disclosures

Updated: May 27, 2009

Introduction

Background

Pertussis, commonly known as whooping cough, is a respiratory tract infection characterized by a paroxysmal cough. It was first identified in the 16th century. In 1906, Bordet isolated the most common causative organism, Bordetella pertussis. Bordetella parapertussis has also been associated with whooping cough in humans. Before the advent of vaccinations, pertussis was a major cause of morbidity and mortality among infants and children. Reported cases of pertussis decreased by more than 99% after the introduction of pertussis vaccine combined with diphtheria and tetanus toxoids in the 1940s. However, despite considerable advances in the control of infectious diseases in children through global immunization programs, pertussis remains a disease of public health concern.

Pathophysiology

Humans are the sole reservoir for B pertussis and B parapertussis. B pertussis is a gram-negative pleomorphic bacillus that spreads via aerosolized droplets from coughing of infected individuals. B pertussis attaches to and damages ciliated respiratory epithelium.

Frequency

United States

Since the early 1980s, pertussis incidence has cyclically increased, with peaks occurring every 2-5 years.1 Most cases occur between June and September. Neither acquisition of the disease nor vaccination provides complete or lifelong immunity. Protection against typical disease wanes 3-5 years after vaccination and is not measurable after 12 years.

From 1980-2005, the reported incidence of pertussis in the United States dramatically increased across all age groups. Although the largest increase in pertussis cases has been among adolescents and adults, the annual reported incidence remained highest among infants younger than one year, at 55.2 cases per 100,000 population.2,3

International

In 1999, an estimated 48.5 million cases of pertussis were reported in children worldwide.

Mortality/Morbidity

Infants born prematurely and patients with underlying cardiac, pulmonary, neuromuscular, or neurologic disease are at high risk for complications of pertussis (eg, pneumonia, seizures, encephalopathy, death).

  • Older children, adolescents, and adults often have mild or atypical illness.  Approximately one half of adolescents with pertussis cough for 10 weeks or longer.
  • Complications among adolescents and adults include syncope, sleep disturbance, incontinence, rib fractures, and pneumonia.
  • Compared with older children and adults, infants younger than 6 months with pertussis are more likely to have severe disease, to develop complications, and to require hospitalization. 
  • From 2001-2003, 69% of infants younger than 6 months with pertussis required hospitalization.2
  • Pneumonia, either from B pertussis infection or from secondary infection with other pathogens, is a relatively common complication, occurring in approximately 13% of infants with pertussis.4  
  • CNS complications such as seizures and encephalopathy are less common and are thought to result from severe paroxysm-induced cerebral hypoxia and apnea, metabolic disturbances such as hypoglycemia, and small intracranial hemorrhages. 
  • Reported deaths due to pertussis in young infants have substantially increased over the past 20 years.5,6,7  From 1990-1999, the case fatality rate was approximately 1% in infants younger than 2 months and less than 0.5% in infants aged 2-11 months.
  • Pertussis has been reported as a cause of sudden infant deaths.

Race

Data on race were available for 75% of patients younger than 20 years from 1997-2000.8 Of these patients, 88% were white, 8% were black, 2% were Asian/Pacific Islander, and 2% were American Indian/Alaska Native. In comparison, the national population estimates for persons younger than 20 years in 1998 were 79% white, 16% black, 4% Asian/Pacific Islander, and 1% American Indian/Alaska Native.

Sex

From 1997-2000, among pertussis cases in patients younger than 20 years, males and females were equally affected.8

Age

From 2001-2003, of patients with pertussis, 23% were younger than 1 year, 12% were aged 1-4 years, 9% were aged 5-9 years, 33% were aged 10-19 years, and 23% were older than 20 years.4

Clinical

History

Typically, the incubation period of pertussis ranges from 3-12 days. Pertussis is a 6-week disease divided into catarrhal, paroxysmal, and convalescent stages, each lasting from 1-2 weeks. The 3 stages of disease progression are as follows:

  • Stage 1: The initial (catarrhal) phase is indistinguishable from common upper respiratory infections with nasal congestion, rhinorrhea, and sneezing, variably accompanied by low-grade fever, tearing, and conjunctival suffusion. Pertussis is most infectious when patients are in the catarrhal phase, but pertussis may remain communicable for 3 or more weeks after the onset of cough.
  • Stage 2: Patients in the second (paroxysmal) phase present with paroxysms of intense coughing lasting up to several minutes. In older infants and toddlers, the paroxysms of coughing occasionally are followed by a loud whoop as inspired air goes through a still partially closed airway. Infants younger than 6 months do not have the characteristic whoop but may have apneic episodes and are at risk for exhaustion. Posttussive vomiting and turning red with coughing are common in affected children.
  • Stage 3: Patients in the third (convalescent) stage have a chronic cough, which may last for weeks.

Older children, adolescents, and adults may not exhibit distinct stages. Symptoms in these patients include uninterrupted coughing, feelings of suffocation or strangulation, and headaches.

Physical

  • In all patients with pertussis, fever is typically absent.
  • In patients with uncomplicated pertussis, physical examination findings contribute little to the diagnosis.
  • Most patients do not have signs of lower respiratory tract disease.
  • Conjunctival hemorrhages and facial petechiae are common and result from intense coughing.

Causes

  • B pertussis and B parapertussis are the causative organisms for pertussis infection in humans. Bacteria spread via aerosolized droplets from coughing of infected individuals.
  • Humans are the sole reservoir for the organisms.
  • Transmission can occur through direct face-to-face contact, sharing a confined space, or through contact with oral, nasal, or respiratory secretions from an infected source. Pertussis is highly contagious, with as many as 80% of susceptible household contacts becoming infected after exposure. Family members or relatives were the suspected source of infection in 75% of cases.9
  • Young infants, especially those born prematurely, and patients with underlying cardiac, pulmonary, neuromuscular, or neurologic disease are at high risk for contracting the disease and for complications.

More on Pertussis

Overview: Pertussis
Differential Diagnoses & Workup: Pertussis
Treatment & Medication: Pertussis
Follow-up: Pertussis
Multimedia: Pertussis
References
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References

  1. Cherry JD, Heininger U. Pertussis and other Bordetella Infections. In: Feigin RD, Demmler GJ, Cherry JD, Kaplan SL. Textbook of Pediatric Infectious Diseases. Vol 1. 5th ed. Philadelphia, PA: WB Saunders Co.; 2004:1588-1608.

  2. Pertussis--United States, 2001-2003. MMWR Morb Mortal Wkly Rep. Dec 23 2005;54(50):1283-6. [Medline].

  3. Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0-18 years - United States, 2008. MMWR. 2008;57(1):Q1-Q4. [Full Text].

  4. Mattoo S, Cherry JD. Molecular pathogenesis, epidemiology, and clinical manifestations of respiratory infections due to Bordetella pertussis and other Bordetella subspecies. Clin Microbiol Rev. Apr 2005;18(2):326-82. [Medline].

  5. [Guideline] Bisgard K. Background. Guidelines for the Control of Pertussis Outbreaks. 2000;1-1-1-11. [Full Text].

  6. Vitek CR, Pascual FB, Baughman AL, Murphy TV. Increase in deaths from pertussis among young infants in the United States in the 1990s. Pediatr Infect Dis J. Jul 2003;22(7):628-34. [Medline].

  7. Centers for Disease Control. Pertussis. In: Atkinson W, Hamborsky J, McIntyre L, Wolfe S. Epidemiology and Prevention of Vaccine-Preventable Diseases. 10th ed. Washington DC: Public Health Foundation; 2007:80-96. [Full Text].

  8. Centers for Disease Control and Prevention. Pertussis--United States, 1997-2000. MMWR Morb Mortal Wkly Rep. Feb 1 2002;51(4):73-6. [Medline].

  9. Bisgard KM, Pascual FB, Ehresmann KR, et al. Infant pertussis: who was the source?. Pediatr Infect Dis J. Nov 2004;23(11):985-9. [Medline].

  10. Edwards K, Decker MD. Pertussis vaccine. In: Plotkin SA, Orenstein WA. Vaccines. 4th ed. Philadelphia, PA: Saunders; 2004:471-528.

  11. Guinto-Ocampo H, Bennett JE, Attia MW. Predicting pertussis in infants. Pediatr Emerg Care. Jan 2008;24(1):16-20. [Medline].

  12. American Academy of Pediatrics. Pertussis. In: Pickering LK, ed. Red Book: 2006 Report of the Committee of Infectious Disease. 2006:498-520.

  13. American Academy of Pediatric Committee on Infectious Diseases. Prevention of pertussis among adolescents: recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Pediatrics. Mar 2006;117(3):965-78. [Medline].

  14. [Best Evidence] Glanz JM, McClure DL, Magid DJ, et al. Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children. Pediatrics. Jun 2009;123(6):1446-51. [Medline]. [Full Text].

  15. Cherry JD. The epidemiology of pertussis: a comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. Pediatrics. May 2005;115(5):1422-7. [Medline]. [Full Text].

  16. Crowcroft NS, Stein C, Duclos P, Birmingham M. How best to estimate the global burden of pertussis?. Lancet Infect Dis. Jul 2003;3(7):413-8. [Medline].

  17. Decker MD, Edwards KM. Acellular pertussis vaccines. Pediatr Clin North Am. Apr 2000;47(2):309-35. [Medline].

  18. Edwards KM, Halasa N. Are pertussis fatalities in infants on the rise? What can be done to prevent them?. J Pediatr. Nov 2003;143(5):552-3. [Medline].

  19. Guris D, Strebel PM, Bardenheier B, et al. Changing epidemiology of pertussis in the United States: increasing reported incidence among adolescents and adults, 1990-1996. Clin Infect Dis. Jun 1999;28(6):1230-7. [Medline].

  20. Jajosky RA, Hall PA, Adams DA, et al. Summary of notifiable diseases--United States, 2004. MMWR Morb Mortal Wkly Rep. Jun 16 2006;53(53):1-79. [Medline].

  21. Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. Dec 15 2006;55:1-37. [Medline].

  22. Long S. Academy issues policy on adolescent pertussis vaccine. AAP News. 2006;27:1.

  23. Long S. Pertussis (Bordetella pertussis and B parapertussis). In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. Vol 17. 2004:908-12.

  24. Lutwick LI, Rubin LG. Childhood immunizations 2000. Introduction. Pediatr Clin North Am. Apr 2000;47(2):xi-xiv. [Medline].

  25. McNabb SJ, Jajosky RA, Hall-Baker PA, Adams DA, Sharp P, Anderson WJ, et al. Summary of notifiable diseases --- United States, 2005. MMWR Morb Mortal Wkly Rep. Mar 30 2007;54(53):1-92. [Medline].

  26. McNabb SJ, Jajosky RA, Hall-Baker PA, Adams DA, Sharp P, Worshams C, et al. Summary of notifiable diseases--United States, 2006. MMWR Morb Mortal Wkly Rep. Mar 21 2008;55(53):1-92. [Medline].

  27. Mikelova LK, Halperin SA, Scheifele D, et al. Predictors of death in infants hospitalized with pertussis: a case-control study of 16 pertussis deaths in Canada. J Pediatr. Nov 2003;143(5):576-81. [Medline].

  28. Pierce C, Klein N, Peters M. Is leukocytosis a predictor of mortality in severe pertussis infection?. Intensive Care Med. 2000;159:898-900. [Medline].

  29. Tanaka M, Vitek CR, Pascual FB, et al. Trends in pertussis among infants in the United States, 1980-1999. JAMA. Dec 10 2003;290(22):2968-75. [Medline].

  30. Tiwari T, Murphy TV, Moran J. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines. MMWR Recomm Rep. Dec 9 2005;54:1-16. [Medline].

  31. Tozzi AE, Celentano LP, Ciofi degli Atti ML, Salmaso S. Diagnosis and management of pertussis. CMAJ. Feb 15 2005;172(4):509-15. [Medline].

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Further Reading

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Keywords

pertussis, whooping cough, coughing, infectious diseases, respiratory tract infection, Bordetella pertussis infection, B pertussis infection, Bordetella parapertussis infection, B parapertussis infection, pneumonia, prematurity, seizures, syncope, hypoglycemia, sudden infant death, upper respiratory infection, nasal congestion, rhinorrhea, sneezing, headache, posttussive vomiting

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Contributor Information and Disclosures

Author

Hazel Guinto-Ocampo, MD, Consulting Staff, Assistant Professor of Pediatrics, Department of Pediatrics, Division of Emergency Medicine, Nemours Children's Clinic, AI duPont Hospital for Children
Hazel Guinto-Ocampo, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Bryon K McNeil, MD, Medical Director, Bioterrorism and Emergency Preparedness, Clinical Assistant Professor, Departments of Internal Medicine and Emergency Medicine, Via Christ Regional Medical Center
Bryon K McNeil, MD is a member of the following medical societies: American Academy of Emergency Medicine and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Stephen C Aronoff, MD, Waldo E Nelson Chair and Professor, Department of Pediatrics, Temple University School of Medicine
Stephen C Aronoff, MD is a member of the following medical societies: Pediatric Infectious Diseases Society and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Gary J Noel, MD, Department of Pediatrics, Clinical Associate Professor, Weill Medical College of Cornell University
Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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