eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Pertussis

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
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

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.

Differential Diagnoses

Afebrile Pneumonia Syndrome
Bronchiolitis
Chlamydial Infections
Mycoplasma Infections
Respiratory Syncytial Virus Infection

Other Problems to Be Considered

Other illnesses that mimic clinical pertussis include the following:

• Adenoviral respiratory infection: Children present with fever, sore throat, and conjunctivitis.)
• Mycoplasmal pneumonia: Patients with mycoplasmal infections have more pronounced systemic symptoms, fever and headache may occur, and rales may be appreciated on chest auscultation.
• Chlamydial pneumonia: Young infants with chlamydial infections present with staccato cough, purulent conjunctival discharge, tachypnea, rales, and wheezing.
• Respiratory syncytial virus infection: Patients present with predominantly lower respiratory tract signs (eg, wheezing, rales).

Workup

Laboratory Studies

Laboratory confirmation of pertussis is difficult and delayed. Therefore, clinicians need to make the diagnosis of pertussis presumptively in patients with a history of intense paroxysmal coughing with or without whooping, color changes, posttussive vomiting, incomplete or absent pertussis vaccination, and finding of lymphocytosis on laboratory examination.

• A clinical case of pertussis is defined as one of the following:
  • An acute coughing illness that lasts at least 14 days in a person with at least one characteristic pertussis symptom (ie, paroxysmal cough, posttussive vomiting, or inspiratory whoop)
  • A cough that lasts at least 14 days in an outbreak setting
• A confirmed case is defined as one of the following:
  • Any cough illness in which B pertussis is isolated and cultured
  • A case consistent with the clinical case definition confirmed by polymerase chain reaction (PCR) findings or epidemiologic linkage to a laboratory-confirmed case
• The criterion standard for diagnosis of pertussis is isolation of B pertussis in culture.
  
  

  

  A photomicrograph of Bordetella (Haemophilus) pertussis bacteria using Gram stain technique.

  
  
  • Obtain the culture specimen by performing deep nasopharyngeal aspiration or holding a flexible swab (Dacron or calcium alginate) in the patient's posterior nasopharynx for 15-30 seconds or until a cough is produced.
  • Promptly inoculate the sample special media (preferred media include Regan-Lowe or Bordet-Gengou agar and modified Stainer-Scholte media). B pertussis usually grows after 3-4 days; however, culture findings cannot be considered negative for pertussis until after 10 days.
  • Recovery rates are highest during the catarrhal or early paroxysmal phase and are low after the fourth week of illness.
  • Culture findings can be negative in patients who were previously immunized, have received antimicrobial therapy, or have been coughing for more than 3 weeks. A negative culture finding does not exclude the diagnosis of pertussis.
• PCR assay and antigen detection are increasingly used to assist in diagnosing pertussis. Advantages include greater sensitivity, more rapidly available results, and use later in the disease course or after antimicrobial therapy because the tests do not rely on the isolation of viable organisms.¹⁰  Their use is limited by lack of standardization and incomplete understanding of the correlation between test results and the course of the illness.
• Although serologic tests have potential in helping diagnose pertussis, they are currently available for investigational use only.
• The use of direct fluorescent assay (DFA) of nasopharyngeal secretions is not recommended by the Centers for Disease Control and Prevention (CDC) due to its poor sensitivity and specificity.
• Leukocytosis (15,000-50,000 10³/µL) with absolute lymphocytosis occurs during the late catarrhal and paroxysmal phases. It is a nonspecific finding but correlates with severity of the disease. One study showed that among infants suspected of having pertussis, an absolute leukocyte count of less than 9400/μ L excluded almost all infants who had a negative pertussis test finding.¹¹

Imaging Studies

• Imaging studies typically add little to the diagnosis of pertussis but should be obtained when clinically indicated, based on examination or if the patient requires supplemental oxygen.
• Chest radiography may reveal perihilar infiltrates or edema with variable degrees of atelectasis. Consolidation is indicative of secondary bacterial infection or, rarely, pertussis pneumonia. Occasionally, pneumothorax, pneumomediastinum, or air in the soft tissues may be seen.

Treatment

Medical Care

The mainstay of therapy in patients with active pertussis infections is supportive. The goals of therapy include limiting the number of paroxysms, observing the severity of cough, providing assistance when necessary, and maximizing nutrition, rest, and recovery.

• Although antimicrobial agents initiated during the paroxysmal stage do not affect the duration and severity of illness, they can hasten the eradication of Bordetella pertussis in the respiratory tract and help prevent spread. For patients aged 1 month or older, macrolide antibiotics such as erythromycin, clarithromycin, and azithromycin, are the preferred agents. Erythromycin and clarithromycin are not recommended in infants younger than 1 month because their use has been associated with increased risk for infantile hypertrophic pyloric stenosis (IHPS). Azithromycin, which also carries some risk for IHPS, is the recommended agent in the youngest patients. Patients who are aged 2 months or older with hypersensitivity to macrolides may be treated with trimethoprim-sulfamethoxazole.
• Hospitalization should be strongly considered for patients at risk of severe disease and complications, including infants younger than 3 months; infants aged 3-6 months, unless observed paroxysms are not severe; premature young infants; and infants or children with underlying pulmonary, cardiac, or neuromuscular disease.
  • For the hospitalized patient, in addition to standard precautions, droplet precautions are recommended for 5 days after initiation of effective therapy or until 3 weeks after the onset of paroxysms if appropriate antimicrobial therapy is not given.
  • Monitor heart rate, respiratory rate, and oxygen saturation of hospitalized patients continuously, especially in relation to coughing paroxysms. Coughing, feeding, vomiting, and weight changes should be recorded.
  • Pay attention to the young infant's hydration and nutritional status.
  • Patients who are severely ill may require treatment in an ICU.

Consultations

• Consultation with subspecialists is usually not indicated; however, if diagnosis is unclear or clinical course warrants, infectious disease specialists or other subspecialists should be consulted.

Diet

• No special diet is indicated.
• A clinically age-appropriate diet should be maintained.
• Infants who cannot tolerate oral feedings may require intravenous fluids.

Activity

• Activity should be guided by clinical course. In general, activity is as tolerated.

Medication

Antimicrobial agents given during the catarrhal phase may ameliorate the disease. Once cough is established, antimicrobial agents may not alter the course of the illness but are still recommended to limit the spread of disease.

Pertussis-specific immune globulin is an investigational product that may be effective in decreasing paroxysms of cough but requires further evaluation.

The use of corticosteroids, albuterol, and other beta2-adrenergic agents for the treatment of pertussis is not supported by controlled, prospective data.

Antibiotics

The Committee on Infectious Diseases of the American Academy of Pediatrics (Red Book Committee) currently recommends promptly treating all household and other close contacts (eg, children and staff at daycare centers) with erythromycin to limit secondary transmission.¹² This is regardless of the age or immunization status of contacts. A 14-day course of oral (PO) erythromycin is the antimicrobial therapy of choice for patients with pertussis and for close contacts. Typical dosing schedule is 40-50 mg/kg/d (not to exceed 2 g/d) in 4 divided doses. Some experts prefer the estolate preparation in young infants because of more effective absorption, which may lead to decreased dosing and less frequent dosing intervals.

In infants younger than 2 weeks, an association between orally administered erythromycin and infantile hypertrophic pyloric stenosis (IHPS) has been reported. Because pertussis can be life threatening in neonates and the efficacy of alternative therapies has not been well studied, the American Academy of Pediatrics continues to recommend the use of erythromycin for treatment of and prophylaxis for pertussis. Parents and caregivers need to be informed about the risks and signs of IHPS.

The newer macrolides (eg, azithromycin [Zithromax], clarithromycin [Biaxin]), are potential alternatives for patients who cannot tolerate erythromycin. Azithromycin is typically administered in doses of 10-12 mg/kg/d PO in 1 dose for a total of 5 days. Clarithromycin is administered at 15-20 mg/kg/d PO in 2 divided doses, not to exceed 1 g/d for 5-7 days. Trimethoprim-sulfamethoxazole (Bactrim) is another antibiotic option, with the following dosage: trimethoprim 8 mg/kg/d and sulfamethoxazole 40 mg/kg/d in 2 divided doses.

Erythromycin (EES, E-Mycin, Eryc, Ery-Tab, Erythrocin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

250 mg (erythromycin stearate/base) or 400 mg (ethylsuccinate) PO q6h 1 h ac, or 500 mg (stearate/base) q12h
Alternatively, 333 mg (stearate/base) q8h, may increase to 4 g/d depending on severity of infection

Pediatric

40-50 mg/kg/d (stearate/base) PO divided qid; not to exceed 2 g/d
Estolate salt may be preferred in young infants because of more effective absorption

Interactions

Inhibits CYP450 3A4 isoenzyme; may increase toxicity of substrates of CYP450 3A4 (eg, cisapride, theophylline, digoxin, carbamazepine, cyclosporine) when coadministered; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI tract effects are common (give doses pc); discontinue if nausea, vomiting, malaise, abdominal colic, or fever occur; angioedema, anaphylaxis, cholestatic jaundice, Stevens-Johnson syndrome, toxic epidermal necrolysis, pseudomembranous colitis, diarrhea, nausea, abdominal pain, vaginitis, dyspepsia, rash, vomiting, anorexia, and pruritus may occur; comprehensively review patient's medical history and current medications, doses, and interactions

Azithromycin (Zithromax)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Shown to be effective for pertussis in several small studies.

Dosing

Adult

500 mg PO on day 1, then 250 mg/d for the next 4 d (total 5-d course)

Pediatric

10-12 mg/kg/d PO for total of 5 d

Interactions

Low risk of CYP450 3A4 inhibition; may increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Clarithromycin (Biaxin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Shown to be effective for pertussis in recent small studies.

Dosing

Adult

500 mg PO bid for 7-10 d

Pediatric

15-20 mg/kg PO divided bid for 5-7 d; not to exceed 1 g/d

Interactions

Inhibits CYP450 3A4 isoenzyme; toxicity increases with coadministration of fluconazole and pimozide; clarithromycin effects decrease and adverse GI tract effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, HMG-CoA–reductase inhibitors; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents

Contraindications

Documented hypersensitivity; coadministration of pimozide

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis

Trimethoprim-sulfamethoxazole (Bactrim, Septra, Cotrim)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Alternative drug, but efficacy is unproven for pertussis.

Dosing

Adult

160 mg (trimethoprim component)/800 mg (sulfamethoxazole component) PO bid for 7-10 d (ie, 1 DS tab bid)

Pediatric

<2 months: Contraindicated
>2 months: 6-10 mg/kg/d (based on trimethoprim component) PO divided q12h for 7-10 d

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia from folate deficiency; age <2 mo

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; caution in folate deficiency (eg, elderly patients, patients with chronic alcoholism, patients receiving anticonvulsant therapy, or patients with malabsorption syndrome); hemolysis may occur in patients with G-6-PD deficiency; patients with AIDS may not tolerate or respond; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

Vaccines

Active immunization increases resistance to infection. Vaccines consist of microorganisms or cellular components that act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.

The need for prevention of pertussis through immunization cannot be overemphasized. All children younger than 7 years should receive the pertussis vaccine. In the United States, acellular pertussis vaccine is recommended and usually is combined with diphtheria and tetanus toxoids (DTaP). When possible, the same DTaP vaccine product should be used for the first 3 doses of the pertussis immunization series. Reduced-volume dosing is not recommended. Measurable antibody wanes after 3-5 years and is not measurable 12 years after vaccination has been completed. The vaccine may not prevent the illness entirely but has been shown to lessen disease severity and duration.

Adolescents and adults have been identified as the source of pertussis transmission to infants, from household contact studies and outbreak investigations. Infectious disease experts are currently investigating the most efficacious and cost-effective means of preventing disease transmission to infants, who are at highest risk of severe disease. Options include vaccination of adolescents and adults in close contact with infants, maternal vaccination to provide passive antibody protection to the infant, and vaccinating infants with acellular pertussis vaccine at birth.

In December 2005, the American Academy of Pediatrics approved recommendations from the Committee on Infectious Diseases (COID) for universal vaccination of adolescents at the 11-year or 12-year visit to boost protection against pertussis.¹³ The Food and Drug Administration (FDA) has licensed 2 tetanus toxoids (Td), reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) products, for use in children aged 10-18 years (Boostrix; GlaxoSmithKline Biologicals, Rixensart, Belgium) and aged 11-64 years (Adacel; Sanofi Pasteur, Toronto, Canada). Tdap will replace Td in the childhood immunization schedule. The effectiveness of this strategy has yet to be demonstrated.

Children of parents who refuse pertussis immunizations are at high risk for pertussis infection relative to vaccinated children. A case-control study identified 156 laboratory-confirmed pertussis cases over an 11-year period (matched controls n=595).¹⁴ Among the cases, 18 (12%) children did not receive the pertussis vaccine; among the controls, 3 (0.5%) children did not receive the pertussis vaccine. Children of parents who refused pertussis immunizations were at an increased risk for pertussis compared with children of parents who accepted vaccinations. A secondary case-control analysis confirmed these results. The study was performed within the Kaiser Permanente of Colorado, where 11% of all pertussis cases within the Colorado Kaiser Permanente system were attributed to parental vaccine refusal. Herd immunity does not seem to completely protect unvaccinated children from pertussis.

DTaP (Tripedia, Certiva, Infanrix)

In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid thigh laterally.

Dosing

Adult

0.5 mL IM diphtheria and tetanus toxoids (Td) and dose according to vaccine history

Pediatric

0.5 mL IM at 2, 4, 6, 15-18 mo, and 4-6 y
7-18 years catch-up schedule for primary immunization: 0.5 mL IM Td for 3 doses; allow 4 wk between dose 1 and 2, and 6 mo between dose 2 and 3; follow with booster dose 6 mo after 3rd dose (may substitute Tdap for booster dose if age appropriate)
Adolescent booster dose (10-18 years): Tdap 0.5 mL IM once as a single dose

Interactions

Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response (may defer immunization until treatment completed); cimetidine may enhance or augment delayed-hypersensitivity responses to skin test antigens; avoid concurrent use with systemic chloramphenicol because may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude concurrent use)

Contraindications

Documented hypersensitivity; history of neurologic symptoms or signs following DTaP administration

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Routine immunization of symptomatic and asymptomatic persons infected with HIV is recommended; may cause transient redness, swelling, or pain at site of injection; infrequently causes fever

Tdap (Adacel, Boostrix)

Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. Promotes active immunity to diphtheria, tetanus, and pertussis by inducing production of specific neutralizing antibodies and antitoxins. Indicated for active booster immunization for tetanus, diphtheria, and pertussis prevention for persons aged 10-64 y (Adacel approved for 11-64 y, Boostrix approved for 10-18 y). Preferred vaccine for adolescents scheduled for booster.

Dosing

Adult

One-time alternative to Td in adults when pertussis component is also indicated: 0.5 mL IM once as a single dose into deltoid muscle; at least 5 y should elapse since last dose of tetanus-containing, diphtheria-containing, and/or pertussis-containing vaccine; booster with Td recommended q10y
>65 years: Not indicated

Pediatric

<10 years: Not indicated
10-18 years: Administer as in adults; preferred vaccine for adolescents scheduled for booster

Interactions

Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of a poor immune response

Contraindications

Documented hypersensitivity; encephalopathy within 7 d following pertussis-containing vaccine; progressive neurologic disorder, uncontrolled epilepsy, or progressive encephalopathy

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Routine immunization of symptomatic and asymptomatic persons infected with HIV is recommended; may cause transient redness, swelling, or pain at injection site; infrequently causes fever; administer only if benefit outweighs risk to individuals with bleeding disorders (eg, hemophilia, thrombocytopenia) or those who are on anticoagulant therapy; caution if fever, shock, persistent crying, Guillain-Barré syndrome, or seizures occurred following previous DTP or DTaP vaccine (consider administering Td instead)

Follow-up

Further Inpatient Care

• Inpatient care is required for patients with pertussis who have intractable nausea and vomiting, failure to thrive, seizures, encephalopathy, or for patients with sustained hypoxemia during coughing paroxysms who require supplemental oxygen.
• Therapy is largely supportive but should include macrolide administration and possible use of steroids, beta2-agonists, or both.
• Antibiotics are most effective if started when the patient is in the catarrhal stage and may abort infection or at least make the patient noncommunicable. Antibiotics may also prevent or alleviate secondary bacterial infection.

Further Outpatient Care

• Most patients older than 1 year can be treated on an outpatient basis if they do not fulfill the criteria for hospital admission (see Further Inpatient Care).
• Frequent outpatient reevaluations are required; frequency of observation should be individualized based on the patient's age, disease severity, and presence of comorbid conditions.

Transfer

• Transfer of patients is not usually indicated unless inpatient therapy and monitoring is warranted and such facilities are not available at the original institution.
• Need for transfer should be evaluated on an individual basis.
• Standard monitoring and transfer protocols should be followed.

Deterrence/Prevention

• Prevention through immunization remains the best defense in the fight against pertussis.
• Since nearly all of the fatal cases of pertussis occur in infants who were too young to have been immunized, novel strategies must be explored to protect these vulnerable young infants.
• An option may be to immunize neonates with acellular pertussis vaccine. However, immunogenicity of the vaccine in newborns and possible induction of tolerance to B pertussis antigens need to be investigated.
• Evidence is overwhelming that parents and older siblings are the primary source of infection in young infants. The incidence of pertussis in preadolescents, adolescents, and adults has increased, and may be responsible for the increasing number of cases observed in young infants in some countries. In December 2005, the American Academy of Pediatrics approved recommendations from the COID for universal vaccination of adolescents at the 11-year or 12-year visit to boost protection against pertussis.¹³ The FDA has licensed 2 tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) products, for use in children aged 10-18 years (Boostrix; GlaxoSmithKline Biologicals, Rixensart, Belgium) and 11-64 years (Adacel; Sanofi pasteur, Toronto, Canada). Tdap will replace tetanus toxoids in the childhood immunization schedule. The effectiveness of this strategy has yet to be demonstrated.

Complications

• Complications of pertussis are usually minimal, and most patients make a gradual full recovery with supportive care and antibiotics.
• Infants younger than 6 months with pertussis are more likely to have severe disease, to develop complications, and to require hospitalization. Major complications include pneumonia (20%), encephalopathy, seizures (1%), failure to thrive, and death (0.3%).
• Minor complications during the illness include epistaxis, nausea and vomiting, subconjunctival hemorrhages, and ulcers of the frenulum.

Prognosis

• Prognosis for full recovery is excellent; however, patients with comorbid conditions as previously described have a higher risk of morbidity and mortality and should be evaluated on an individual basis.
• 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 Bordetella 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 increased substantially 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 aged2-11 months.
• Leukocytosis, particularly WBC counts of more than 100,000, has been associated with fatalities from pertussis. Another study showed that WBC counts of more than 55, 000 and pertussis complicated by pneumonia were independent predictors of fatal outcome in a multivariate model.

Patient Education

• When a diagnosis of pertussis is made, patient and parent education and individualized supportive treatment are the best options.
• All parents should receive information regarding the infectious and contagious potential of pertussis, as well as the risks derived from the vaccine.
• Prevention of pertussis involves the use of vaccine approved by the FDA and standard infection control precautions.
• For excellent patient education resources, visit eMedicine's Children's Health Center and Public Health Center. Also, see eMedicine's patient education articles Whooping Cough and Immunization Schedule, Children.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose pertussis: Potential for serious sequelae is noted. Death may occur in young infants and in patients with severe disease. Legal risks are observed as a result of the potential adverse effects of vaccines.
• Failure to advise patients adequately regarding the need for further observation and the risks of infection

Special Concerns

• Young infants have the highest risk for complications and death and require close observation or hospitalization.
• Control measures should be implemented immediately when one or more cases of pertussis are recognized in health care settings such as in a hospital, institution, or outpatient clinic. Confirmed and suspected cases should be reported to the local health departments, and their involvement in control measures should be sought.

Multimedia

Media file 1: A photomicrograph of Bordetella (Haemophilus) pertussis bacteria using Gram stain technique.

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. 5^th 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. 10^th 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. 4^th 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].

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

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

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)