PERTUSSIS

(WHOOPING COUGH)
3-month-old child has temperature 37,8-38o C and
signs of common cold. Approximately after week
begins cough, it becomes more intensive day by
day, with vomiting and apnoe. Blood test shows
leucocytosis with predominance of lymphocytes.
Cough will slowly disappear in some weeks, but
lasts altogether 6 weeks.

- What is the agent of the disease?

- What cause such clinical symptoms (pathogenesis)
> cough
> predominance of lymphocytes
- How the disease spread (epidemiology)
- Diagnostics of the disease
- Treatment and prophylactics
 Bordetella: morphology

- Very small Gramnegative B.pertussis (Gram staining)

coccobacilli
- Obligatory aerobes
- Nonfermentative;
oxidase-positive, ureasenegative (B.
parapertussis oxydase(-),
urease(+); B.
bronchiseptica
oxydase(+), urease(+))
- Very fastidious for media:
Bordet-Gengou blood
agar, charcoal-caoline
agar
- Sensitive to
environmental conditions
Human pathogenic Bordetellae

.B.pertussis
- Pertussis . a disease with paroxysmal cough
.B.parapertussis
- Mild form of pertussis
.B.bronchiseptica
- Respiratory disease in animals, but also
bronchitis in humans
 Epidemiology of pertussis

Human disease only

Epidemiology of pertussis: USA

N Engl J Med 2005;352:1215-1222

Pertussis in some European
countries in 1945-2006
Pertussis in Estonia in different age
groups in 1991- 2005
B.pertussis: virulence factors
Adhesins
- Filamentous
hemagglutinin (FHA)
- Pertactin (P69 protein)
- Pertussis toxin (PT)
- Fimbriae
Toxins
- Pertussis toxin
- Adenylate cyclase
- Dermonecrotic toxin
- Tracheal cytotoxin
- Lipopolysaccharide
 B.pertussis: adhesins
Filamentous hemagglutinin - binds to
glycoproteins of ciliary epithelium; binds to CR3 of
PMNL; initiates phagocytosis
Pertactin (p69 protein) - as with FHA
Pertussis toxin - classic A-B exotoxin; S2
subunit binds to glycolipid of ciliary epithelial cell
and S3 subunit binds to ganglioside of phagocytes
Fimbriae - binds to mammalian cells and
stimulates humoral immunity; exact role in
pathogenesis of the disease unknown
B.pertussis uses adhesines for
binding to ciliary epithelium
 B.pertussis: toxins
Pertussis toxin - S1 subunit inactivates membrane surface
protein that controls adenylate-cyclate activity ; cAMP
augmentation of slime production (characteristic to
paroxyxsmal phase)

Adenylate-cyclase/hemolysin - intracellular cAMP;

protects from phagocytosis
Dermonecrotic toxin . necrose of skin in experimental
animal model; role in pathogenesis of pertussis not known
Tracheal cytotoxin . a fragment of peptidoglycan that kills
ciliary epithelium and induces release of IL-1
LPS . two distinct LPS (lipid A and lipid X); activates
alternative complement pathway, their role if the disease
unknown
Pertussis toxin (PT)
 Exsaturation of cAMP is
important in pathogenesis

Formation of Adenylate cyclasis

does not stop cAMP exsaturation H2O production slime
 B.pertussis: toxins
Pertussis toxin . S1 subunit inactivates membrane surface
protein that controls adenylate-cyclate activity ; cAMP
augmentation of slime production (characteristic to
paroxyxsmal phase)

Adenylate-cyclase/hemolysin - intracellular cAMP;

protects from phagocytosis
Dermonecrotic toxin . necrose of skin in experimental
animal model; role in pathogenesis of pertussis not known
Tracheal cytotoxin . a fragment of peptidoglycan that kills
ciliary epithelium and induces release of IL-1
LPS . two distinct LPS (lipid A and lipid X); activates
alternative complement pathway, their role if the disease
unknown
 Pertussis: clinical findings
Catarrhal period -
similar to common
cold
Paroxysmal cough
with slime production,
ending up with
vomiting
In vaccinated children
clinical findings are
milder
Clinical findings and diagnosis of
pertussis

Downloaded from: StudentConsult (on 26 February 2006 01:47 PM)

2005 Elsevier
 Pertussis: diagnosis
B.pertussis extremely sensitive to drying
Nasopharyngeal aspirate (epithelial cells are required) -
culture on site or use of transport media (Regan-Lowe
transport media)
Bacterial culture - charcoal-horse blood agar (Regan-
Lowe medium),
- Freshly made medium, prolonged incubation (7 days),
in humidated air, at 35 degree Celcius
- results depend on quality of sampling and transport
technique, stages of the disease, history of AB therapy
- Appr. 50% have positive results
PCR - sensitivity 80-100%
Serological tests?
- Antibodies against IgA, IgM, IgG by ELISA method
against FHA, PT
- In convalescent period significant rise of antibody titre
B. pertussis on B. pertussis -
charcoal agar Bordet-Gengou
agar

Identifcation: small colonies on charcoal agar; oxydase.positive

 Pertussis: treatment and
prophylaxis
Treatment
- Supportive care
- Macrolides (erythromycin, clarithromycin, azitromycin)
Prophylactics
- Whole cell vaccine - inactivated bacteria
- Side effects
- Acellular vaccines (PT, pertactin, FHA, fimbriae;
monovalent and polyvalent)
- In combinations with diphtheria and tetanus toxoid
- Immunity lasts for 5-7 years; booster doses required
- Isolation of patients
- Erythromycin for contact persons
AGENT
Bordetella pertussis, a gram-negative bacillus; a
pertussis-like syndrome can also be caused by B.
parapertussis, B. bronchiseptica, respiratory syncytial
virus (RSV), and certain adenoviruses.

CASE DEFINITION
Clinical case definition
A cough illness lasting >=2 weeks with one of the following:
paroxysms of coughing, inspiratory "whoop," or post-tussive
vomiting, without other apparent cause

Laboratory criteria for diagnosis

Isolation of Bordetella pertussis from a clinical specimen,
or
Positive polymerase chain reaction [PCR] for B.
Case classification

Probable: a case that meets the clinical case

definition, is not laboratory confirmed, and is not
epidemiologically linked to a laboratory-
confirmed case
Confirmed: A case of acute cough illness of any
duration with a positive culture for B. pertussis;
or a case that meets the clinical case definition
and is confirmed by PCR; or a case that meets
the clinical definition and is epidemiologically
linked directly to a case confirmed by either
culture or PCR
Comment

The clinical case definition is appropriate for

endemic or sporadic cases. In outbreak settings, a
case may be defined as a cough illness lasting >2
weeks. Because some studies have documented
that direct fluorescent antibody [DFA] testing of
nasopharyngeal secretions has low sensitivity and
variable specificity, it should be not relied on as a
criterion for laboratory confirmation. Serologic
testing for pertussis is available in some areas but is
not standardized and, therefore, should not be relied
on as a criterion for laboratory confirmation for
national reporting purposes. Both probable and
confirmed cases should be reported to NNDSS [by
the state health department].
SIGNS AND SYMPTOMS

The clinical course is divided into three stages: catarrhal,

paroxysmal, and convalescent. The catarrhal stage has a
gradual onset and initially resembles the common cold, i.e.,
coryza, sneezing, low grade fever, and a mild cough; this
stage lasts from one to two weeks. Usually, whooping cough
is not suspected until the cough gradually becomes more
severe and paroxysms occur. These are characterized by
repeated violent coughs without intervening inhalation,
followed by a gasp for air that produces a characteristic
high-pitched whoop. The patient becomes red or cyanotic,
the eyes bulge, and the tongue protrudes. Thick mucus is
dislodged and vomiting often follows. There is no fever and
the patient appears normal between attacks.
The paroxysmal stage generally lasts from four to six weeks
but might last as long as 10
weeks. Paroxysmal attacks occur more
frequently at night. Adults, infants less than
six months old, and partially immunized
persons may lack the whoop and have few
paroxysms. In convalescence the whoop
and vomiting stop and the cough becomes
less paroxysmal, disappearing over two to
three weeks. Some patients have recurrent
bouts of all symptoms, including whoop,
during viral upper respiratory infections for
many months after pertussis.
DIAGNOSIS
Culture using Regan-Lowe medium, available at the
ODHL, is the diagnostic procedure of choice and/or
PCR. The organism is recovered best by using a
posterior nasopharyngeal swab during the catarrhal
or early paroxysmal stages. The swab should be
taken prior to antibiotic therapy. The rate of recovery
after 24 hours of therapy decreases rapidly. A high
percentage of children will have positive cultures in
the first week of illness but only 50 percent will be
positive by the end of the third week; less than 20
percent are positive after the fifth week. Cultures
may be transported on the Regan-Lowe medium at
ambient temperatures.
EPIDEMIOLOGY

Source
Humans are the only reservoir.

Occurrence
The disease is common to children worldwide. There has
been a marked decline in the United States and other
countries where immunization levels are high. The
disease might be more common in adults than previously
thought, but it is often not considered in the differential
diagnosis.

Transmission
Through direct contact with discharges from an infected
person, usually by the airborne route. Communicability is
greatest in the early catarrhal stage, before the
Period of Communicability

Communicability gradually decreases and becomes

negligible for ordinary nonfamilial contacts in about
three weeks, despite spasmodic cough with whoop.
For control purposes communicability extends from
seven days after exposure to three weeks after the
paroxysmal stage in patients not treated with
appropriate antibiotics. In treated patients,
infectiousness extends for five to seven days after
onset of therapy.

Incubation Period

Commonly 5-10 days, with an upper limit of 21 days.

PUBLIC HEALTH MANAGEMENT
Case
Treatment
Spread of pertussis can be limited by decreasing infectivity of the
patient and by protecting close contacts of that patient.
Antimicrobials given in the catarrhal stage may ameliorate the
disease. After paroxysms are established, however, antimicrobials
have no discernible effect on the course of the illness and are given
primarily to limit the spread of the organisms to others. The
macrolide agents azithromycin (Zithromax), erythromycin and
clarithromycin (Biaxin) are preferred for treatment of pertussis in
persons aged 1 month (see table for dosing recommendations). For
infants <1 month azithromycin is preferred, erythromycin and
clarithromycin are not recommended. For persons 2 months who
cannot tolerate macrolides, an alternative agent is trimethroprim-
sulfamethoxazole [TMP-SMX

ODH-IDCM PERTUSSIS Page 3/Section 3 Revised 1/2007

(Bactrim)]. The choice of antibiotic for treatment or prophylaxis
should take into account
Isolation

The Ohio Administrative Code (OAC 3701-3-

13[S]) states that a person with pertussis
who is not treated with appropriate
antimicrobial therapy shall be isolated,
including exclusion from school or child care
center, until three weeks after the onset of
paroxysms. If appropriate antimicrobial
therapy is given, the person shall be isolated
for five days after initiation of antimicrobial
therapy (see section 2 of this manual).
Contacts

A close contact of a patient with pertussis is a person

who had face-to-face exposure within 3 feet of a
symptomatic patient. Respiratory droplet particles can
be propelled through the air for distances of
approximately 3 feet. Close contacts also can include
persons who have direct contact with respiratory, oral
or nasal secretions from a symptomatic patient (e.g.
cough, sneeze, sharing food and eating utensils,
mouth-to-mouth resuscitation, or performing a medical
examination of the mouth, nose, and throat), or shared
the same confined space in close proximity with a
symptomatic patient for 1 hour.
Postexposure prophylaxis with an appropriate
antimicrobial agent can be administered to contacts. The
decision to prophylaxis is made after considering the
infectiousness of the patient and the intensity of the
exposure, the potential consequences of severe pertussis
in the contact, and the possibilities for secondary
exposure of persons at high risk from the contact (e.g.
infants aged<12 months, persons with some
immunodeficiency conditions, or other underlying medical
conditions such as chronic lung disease, respiratory
insufficiency, or cystic fibrosis.) Prophylaxis of
asymptomatic household contacts within 21 days of onset
of cough in the index patient can prevent symptomatic
infection. Symptomatic (coughing) household members of
a pertussis patient should be treated as if they have
pertussis.
Because severe and sometimes fatal pertussis-
related complications occur in infants aged <12
months, especially among infants aged < 4
months, postexposure prophylaxis should be
administered in exposure settings that include
infants aged < 12 months or women in the third
trimester of pregnancy. The recommended
antimicrobial agents and dosing regimens for
postexposure prophylaxis are the same as those
for treatment of pertussis (see table). All persons
should be watched closely for respiratory
symptoms for 14-21 days after contact is broken.
Vaccine (in addition to antimicrobials)
Household and other close contacts who have
had at least 4 doses of pertussis vaccine should
receive a booster dose (DTaP) unless a dose has
been given within the past three years.
Children who are unimmunized or who have
received fewer than 4 doses of DTaP should
have DTaP immunization initiated or continued
according to the recommended schedule.
Children who received their third dose six months
or more before exposure should be given their
fourth dose at this time.
Prevention and Control

Immunization with pertussis vaccine is the most important

measure for the control of pertussis. See the ODH
Immunization Manual for details. Human pertussis immune
globulin is no longer available in the United States.
Reducing the dose of pertussis vaccine or giving the full
dose in multiple small doses may result in an altered
immune response and is not recommended. Furthermore,
there is no evidence that the frequency of significant
vaccine reactions is likely to be reduced by this practice.
Interrupting the recommended primary and booster
immunization schedule or delaying doses probably does
not lead to a reduction in the level of immunity reached on
completion of the primary series. Therefore there is no
need to restart a series, regardless of the time elapsed
between doses.
What is pertussis?
Pertussis, or whooping cough, is a highly contagious
respiratory infection caused by the bacteria Bordetella
pertussis.

Who gets pertussis?

Pertussis can occur at any age. Although most of the
reported cases occur in children under five years, the
number of cases in adolescents and adults is
increasing, probably due to waning of vaccine
immunity. Adolescents and adults and those partially
protected by the vaccine may have milder disease
which is not diagnosed as pertussis. Pertussis is
thought to account for up to 7% of cough illnesses per
year in adults.
How is pertussis spread?

Pertussis is primarily spread by direct contact with the

discharges from the nose and throat of infected
individuals. Frequently, older siblings or other adult
household members who may be harboring the
bacteria in their nose and throat can bring the disease
home and infect an infant in the household.
What are the symptoms of pertussis?

Pertussis begins as a mild upper respiratory infection.

Initially, symptoms resemble those of a common cold,
including sneezing, runny nose, low-grade fever and a
mild cough. Within two weeks, the cough becomes
more severe and is characterized by episodes of
numerous rapid coughs followed by a crowing or high-
pitched whoop. A thick, clear mucous may be
discharged with the coughing. These episodes may
recur for one to two months, and are more frequent at
night. Young infants, adolescents, and adults do not
have these typical coughing spells. Older people or
partially immunized children may have milder
symptoms.
How soon after infection do symptoms appear?
The incubation period is usually 7 to 10 days, with a range
of 4 to 21 days.

When and for how long is a person able to spread

pertussis?
A person can transmit pertussis from the onset of symptoms
to three weeks after the onset of coughing episodes. The
period of communicability can be reduced to five days after
appropriate antibiotic therapy is begun.

Does past infection with pertussis make a person

immune?
One attack usually confers immunity comparable to that
provided by vaccine.
What are the complications associated with
pertussis?

Young infants are at the greatest risk for

complications. Serious complications of pertussis
include pneumonia, seizures, encephalopathy
(disorders of the brain), and death. Less serious
complications include ear infections, loss of appetite,
and dehydration.
What is the vaccine for pertussis?
Children should be immunized with the DTaP (diphtheria,
tetanus, acellular pertussis) vaccine at 2, 4, 6 and 15 to 18
months of age and between 4 and 6 years of age. Children and
adults should receive Td boosters every 10 years. At present, it
is recommended that Tdap be used for one of those boosters.

What can be done to prevent the spread of pertussis?

The single most effective control measure is maintaining the
highest possible level of immunization in the community. The
treatment of cases of pertussis with the appropriate antibiotic is
important, as is the treatment of close contacts of cases. In
addition, medical professionals should consider the diagnosis of
pertussis in adolescents and adults with persistent coughs.
People who have or may have pertussis (including those with a
persistent cough) should stay away from young children and
infants until properly evaluated by a physician.
Pertussis, also known as whooping cough, a highly
contagious disease caused by the bacterium Bordetella
pertussis; it derived its name from the characteristic severe
hacking cough followed by intake of breath that sounds like
'whoop'; a similar, milder disease is caused by B.
parapertussis.[1] Although many medical sources describe
the whoop as "high-pitched," this is generally the case with
infected babies and children only, not adults. [1]
Worldwide, there are 3050 million pertussis cases and about
300,000 deaths per year. Despite generally high coverage
with the DTP and DTaP vaccines, pertussis is one of the
leading causes of vaccine-preventable deaths world-wide.
Most deaths occur in young infants who are either
unvaccinated or incompletely vaccinated; three doses of the
vaccine are necessary for complete protection against
pertussis. Ninety percent of all cases occur in the developing
world. Children tend to catch it more than adults.
Pertussis
Also listed as: Cough - whooping; Whooping cough

Signs and Symptoms

What Causes It?
What to Expect at Your Provider's Office
Treatment Options
Following Up
Special Considerations
Supporting Research
Characterization

After a two day incubation period, pertussis in infants and young

children is characterized initially by mild respiratory infection
symptoms such as cough, sneezing, and runny nose (catarrhal
stage). After one to two weeks, the cough changes character,
with an increase of coughing followed by an inspiratory
"whooping" sound (paroxysmal stage). Coughing fits may be
followed by vomiting due to the sheer violence of the fit. In
severe cases, the vomiting induced by coughing fits can lead to
malnutrition and dehydration. The fits that do occur on their own
can also be triggered by yawning, stretching, laughing, or
yelling. Coughing fits gradually diminish over one to two months
during the convalescent stage. Other complications of the
disease include pneumonia, encephalitis, pulmonary
hypertension, and secondary bacterial superinfection.[2].
Because neither vaccination nor infection confers long-term
immunity, infection of adolescents and adults is also common
[3] Most adults and adolescents who become infected with
Bordetella pertussis have been vaccinated or infected years
previously. When there is residual immunity from previous
infection or immunization, symptoms may be milder, such as
a prolonged cough without the other classic symptoms of
pertussis. Nevertheless, infected adults and adolescents can
transmit the bacteria to susceptible individuals. Adults and
adolescent family members are the major source of
transmission of the bacteria to unimmunized or partially
immunized infants, who are at greatest risk of severe
complications from pertussis.
Pertussis, also known as whooping cough, is an
extremely contagious bacterial infection characterized
by violent coughing, followed by a "whoop" sound as the
person tries to breathe in. Pertussis can be deadly to
infants and small children. Children in the U.S. are
routinely vaccinated for pertussis, but the disease is
rising again, especially in infants who have not
completed the series of vaccinations and in teens whose
immunity has worn off. The vaccine keeps children from
contracting the disease when they are most at risk, but
teens and adults who have been vaccinated can still get
a milder form of the disease.
Signs and Symptoms

The three phases of the disease are listed below.

Catarrhal phase (lasts 1 - 2 weeks):
Upper respiratory infection. Can be mistaken for a heavy cold
Low-grade fever (less than 100.4F)
Loss of appetite
Very runny nose

Paroxysmal phase (lasts 1 - 4 weeks):

Cough increases (2 - 50 times a day), and fever decreases
Sudden, forceful breathing in causes the whooping sound
A sudden intense bout of coughing (paroxysms) causes bulging and
tearing eyes, tongue sticking out, and bluish discoloration
Vomiting or choking may follow coughing bouts
Pneumonia may develop
Convalescent phase (lasts 2 weeks to several months):
Cough slowly goes away
What Causes It?
A type of bacteria called Bordetella pertussis causes pertussis,
and it is spread through droplets coughed into the air. It is a
highly contagious disease. Adults with a mild form can infect
those who have not yet been vaccinated.

What to Expect at Your Provider's Office

Your health care provider may take a smear from your nose or
throat. Your health care provider will prescribe an antibiotic,
which helps prevent the disease from spreading, and ask you
to avoid contact with others while you are contagious. Patients
with complications, severe coughing bouts, or who are under
one year of age are hospitalized.
Treatment Options
An infant with pertussis should be treated immediately by a
doctor. In adults, treatment is largely to control symptoms and
prevent spreading. Quarantine, parenteral fluid and nutrition,
oxygen supplementation, and mechanical ventilation may be
required.
Drug Therapies
Antibiotics -- (usually azithromycin or erythromycin) reduce
transmission and are effective even for infants.
Corticosteroids such as betamethasone (0.075 mg daily per
kilogram of body weight) may reduce severity and length of
coughing fits, especially in infants.
Albuterol (0.3 - 0.5 mg daily per kilogram of body weight)
reduces the severity of coughing fits.
Over-the-counter cough suppressants have no effect and
should not be used.
Surgical and Other Procedures
In cases of loss of consciousness, immediate
resuscitation is essential to avoid brain damage and
death.
Suctioning of secretions, oxygen administration,
parenteral fluids and electrolytes are used for infants
and in those with protracted illness.
Mist by tent may benefit infants.
Complementary and Alternative Therapies
Pertussis should be treated with antibiotics.
Supplements, herbs, and homeopathy are useful as
supportive therapies and may help quicken recovery.
Talk with your doctor if you are using alternative
therapies in addition to medication.
Nutrition
Note: Doses given are for children. Adults should
double the amounts.
Eliminate dairy, bananas, wheat, and meat
products.
Encourage small, frequent meals of vegetable
broths, steamed vegetables, and fresh fruit
(especially pineapple and grapes).
Vitamin C (200 - 500 mg two times per day.
Children over 4 years of age can have up to 3,000
mg per day in divided doses for short periods of
time), zinc (10 - 15 mg per day), and beta-carotene
(10,000 - 25,000 IU per day).
 Vaccines
History of pertussis vaccine development

Infection with pertussis induces immunity, but not lasting protective

immunity, and a second attack is possible.[4] Efforts to develop an
inactivated whole-cell pertussis vaccine began soon after B. pertussis
was grown in pure culture in 1906. In the 1920's Dr. Louis Sauer
developed a vaccine for whooping cough at Evanston Hospital (Chicago,
IL). In 1925, the Danish physician Thorvald Madsen was the first to test a
whole-cell pertussis vaccine on a wide scale.[5] He used the vaccine to
control outbreaks in the Faroe Islands in the North Sea. In 1942, the
American scientist Pearl Kendrick combined the whole-cell pertussis
vaccine with diphtheria and tetanus toxoids to generate the first DTP
combination vaccine. To minimize the frequent side effects caused by the
pertussis component of the vaccine, the Japanese scientist Yuji Sato
developed an acellular pertussis vaccine consisting of purified
haemagglutinins (HAs: filamentous HA and leucocytosis-promoting-factor
HA), which are secreted by B. pertussis into the culture medium. Sato's
acellular pertussis vaccine was used in Japan since the autumn of
1981.[6] Later versions of the acellular pertussis vaccine used in other
countries consisted of additional defined components of B. pertussis and
were often part of the DTaP combination vaccine.
Introduction:
I stood outside the closed door of the hospital room where an adorable
6-week-old baby lay all alone in her crib. As I scrubbed my hands in
the sink outside the isolation room, an electronic monitor allowed me to
hear her breathing peacefully.

Suddenly the quiet was shattered by a fit of coughing. And she couldn't
stop. The coughs came so closely together that she couldn't catch her
breath. I grabbed a mask from above the sink and, pressing it over my
face, entered her room. The coughing continued. The pulse and oxygen
monitor at her bedside complained insistently that her blood-oxygen
levels were dropping. The EKG monitor sounded an alarm that her heart
rate was dropping too. And she continued to cough. Even before I
reached her bedside, I could see that her face was turning blue. She
began to vomit.

Moments later the peace had returned. Her various monitors beeped
tranquilly. The coughing spasm was over. This little girl with pertussis
survived, but she had many more weeks of coughing spasms before she
could return home to her parents.
 Current status of pertussis vaccines

Pertussis vaccines are highly effective, strongly

recommended, and save many infant lives every
year. Though the protection they offer lasts only a
few years, they are given so that immunity lasts
through childhood, the time of greatest exposure and
greatest risk.[7] The immunizations are given in
combination with tetanus and diphtheria
immunizations, at ages 2, 4, and 6 months, and later
at 1518 months and 46 years and 11 years.
The short term effectiveness of the vaccines and the
presence of B. pertussis infection in adults and adolescents
who may transmit the bacteria to infants have caused many
in the medical field to call for booster immunizations at later
ages. Although Canada, France, the U.S. and Germany now
have approved booster shots for adolescents, adults, or both,
other countries adhere to the tradition of discontinuing
pertussis vaccination after the age of seven, from concerns
that there are side effects associated with the first available
"whole-cell" pertussis immunizations that tended to increase
with age.[citation needed] The whole-cell vaccine is still used
in poor countries, since it is cheaper than the newer and
safer acellular formulation. As the immunity from infection or
vaccination lasts only a few years, the discontinuation of
booster vaccination in older persons caused the emergence
of a large pool of older persons lacking immunity.
 Whole-cell pertussis vaccine controversy
Much of the controversy surrounding the DTP vaccine in the
1970s and 1980s related to the question of whether the
whole-cell pertussis component caused permanent brain
injury in rare cases. Although it was well-established that the
pertussis component of the DTP vaccine accounted for most
of the minor local and systemic side effects in many
vaccinated infants, several published studies failed to show a
causal relationship between administration of the DTP vaccine
and permanent brain injury. However, criticism of these
studies and well-publicized anecdotal reports of DTP-induced
permanent disability and death gave rise to anti-DTP
movements.[10] In addition, a number of children suffered
allergic reactions to the pertussis vaccination, including
severe seizures. Despite this, doctors recommended the
vaccine, and even threatened parents who refused to
vaccinate their children.
By the late 1970s, publicity about adverse reactions
and deaths following pertussis vaccination caused
the immunization rate to fall in several countries,
including Great Britain, Sweden, and Japan. In many
cases, a dramatic increase in the incidence of
pertussis followed.[11] These developments led Yuji
Sato to introduce a safer acellular version of the
pertussis vaccine for Japan in 1981. Nevertheless,
other countries continued to use the whole-cell DTP
formulation.
In the United States, low profit margins and an increase in vaccine-related
lawsuits led many manufacturers to stop producing the DTP vaccine by
the early 1980s.[citation needed] In 1982, the television documentary
"DTP: Vaccine Roulette" depicted the lives of children whose severe
disabilities were blamed on the DTP vaccine. The negative publicity
generated by the documentary led to a tremendous increase in the
number of lawsuits filed against vaccine manufacturers.[12] By 1985,
manufacturers of vaccines had difficulty obtaining liability insurance. The
price of the DTP vaccine skyrocketed, leading to shortages around the
country. Only one manufacturer of the DPT vaccine remained in the U.S.
by the end of 1985. To avert a vaccine crisis, Congress in 1986 passed
the National Childhood Vaccine Injury Act (NCVIA), which established a
federal no-fault system to compensate victims of injury caused by
mandated vaccines.[13] Since then, the prices of vaccines have stabilized,
and the number of lawsuits filed against DTP manufacturers has dwindled.
The majority of claims that have been filed through
the NCVIA have been related to injuries allegedly
caused by the whole-cell DTP vaccine. The acellular
pertussis vaccine was approved in the United States
in 1992 for use in the combination DTaP vaccine.
Research has shown the acellular vaccine to be
safe, with few reports of adverse effects.[2] Although
the whole-cell DTP vaccine is no longer used in the
United States, it is still purchased by the World
Health Organization and distributed to developing
nations because of its much reduced cost compared
to the acellular DTaP vaccine.
What is it?

Pertussis is caused by bacteria that attach

themselves to the cilia (little hairs) that line the
respiratory tract. These bacteria produce a potent
toxin that inflames the respiratory tract and prevents
the cilia from functioning properly. The disease can
be serious or fatal in infants and unimmunized
children. It is much milder in teens, adults, and in
immunized children but it can still be a real
nuisance. As you might guess, it can be far worse in
people with asthma or with immune deficiencies.
Who gets it?
I have spoken with many parents who believed that pertussis was a disease
of the past. Nevertheless, pertussis is a common cause of chronic cough
illness in adults and older children. A study published in the June 15, 2001
issue of Clinical Infectious Diseases found that pertussis was the cause of
chronic cough in 19.9 percent of the patients studied.

For healthy teens and adults, this is usually nothing more than a long
nuisance (lasting months, sometimes with vomiting). For unimmunized
babies and those at high risk, pertussis can be severe or even life-
threatening.

Pertussis, or whooping cough, which once ravaged children around the

world, is again on the rise. Worldwide, about 300,000 people die from
pertussis each year. Serious disease is uncommon where immunization rates
are high. Still, about 1 out of every 200 babies who get pertussis in the US
will die from it. Another 1 out of every 200 will have lifetime brain damage. As
many as 2 percent will have seizures, 22 percent will get pneumonia, and
most (even in this modern era of reduced hospitalization) will be sick enough
to be hospitalized.

Pertussis is found only in humans.

What are the symptoms?
Classically, people with pertussis go through four stages:

Incubation. For 5 to 21 days after exposure (usually 7 to 10 days)

there are no symptoms at all while the bacteria multiply.

Prodrome. For the next 1 to 2 weeks, pertussis is not unlike a cold.

People have runny noses, sneezing, and perhaps a low-grade
fever. A mild cough begins that gradually worsens.

Paroxysms. The worst part of the illness lasts from 1 to 6 weeks.

Spasms or attacks of coughing may come up to 15 times per day.
Sometimes, especially in children, the cough is followed by a
"whoop" noise as they breathe in rapidly, attempting to get air. Even
so, young infants will often turn blue with the spells from lack of
oxygen. The coughing spasms can make it difficult to eat, drink, or
breathe. The mucus is often thick and sticky. Gagging, choking, and
vomiting are common. Sometimes young infants will stop breathing
for varying lengths of time between coughing spasms.
This stage of pertussis is much milder in adults, teens, older
children, and immunized children. Often an older child will just
report a nagging cough for a month or more. Sometimes they hack
up mucus with the cough. Sometimes the cough comes in fits.
Once or twice, they might cough until they vomit. Otherwise, they
feel pretty well -- they just can't seem to shake the cough.

4. Convalescence. As if this disease were not already long

enough, the cough continues for another 2 to 4 weeks, but
gradually becomes less severe and less frequent. Even after the
cough seems finally over, the spasms often recur briefly for the
next several months, especially during colds and during
exertion.
Is it contagious?
Pertussis is contagious through close contact via respiratory tract
secretions.

You or your child have been exposed if you spend a total of 5 hours (over
a week) in the same room with someone with the disease, if you sit next
to someone with pertussis for any length of time, or if you have any
contact at all with infected mucus or saliva. Between 70 and 100 percent
of susceptible people will catch pertussis if they are exposed.

Currently, most adults and teens are susceptible because the protective
effect of their childhood pertussis immunizations has waned. To address
this problem, it is now recommended that all teens receive a booster
vaccine at 11-18 years of age (preferably between 11-12 years).

Most infants are protected after the first 3 doses of vaccine, but this
protection begins to disappear when they are toddlers. After the 4th
immunization at 18 months old, 80 percent are protected for the next 3 to
4 years. The 5th dose, at kindergarten entry, protects them for another
few years.
A booster dose is recommended during the teen years to bolster
immunity to pertussis.

How long does it last?

Pertussis lasts for weeks or months. It has been called the 100-day
cough. People remain contagious until they have been on a
pertussis antibiotic for 5 days, or until they have been having
coughing spasms for 21 days.

How is it diagnosed?
According to the Centers for Disease Control and Prevention,
people are considered to have pertussis if they have a cough
lasting for at least 14 days (with no other confirmed cause) and
any one of the following symptoms (even if they have been
immunized):

Coughing spasms or fits (coughs coming in clusters)

A whooping noise while breathing in
Vomiting caused by a cough
The case is called confirmed pertussis if there is a positive lab
test or if there has been exposure to someone with a positive lab
test.

During a pertussis outbreak, anyone who has a cough lasting at

least 14 days (with no other known cause) probably has
pertussis, even in the absence of other specific symptoms.

The lab tests to detect pertussis are either slow, cumbersome,

not readily available, or often fail to pick up the disease. For this
reason many physicians rely on the working definition of
pertussis. Also, the number of proven cases reported to the
health department vastly underestimates the number of cases in
the community.
How is it treated?
Babies younger than 6 months, and all others with potentially
severe disease, are likely to need care in a hospital, or even a
pediatric ICU.

Several of the medicines used in asthma are often used to help

control the cough.

In addition, pertussis is treated with an antibiotic. Unless the

antibiotic is given early in the course, it doesn't much affect the
length of the illness, but is still very effective at stopping its spread.
People with pertussis are highly contagious for up to 5 days after
starting the antibiotic.

How can it be prevented?

The pertussis vaccine, even with its side effects and problems, has
saved many lives by stopping the wildfire spread of pertussis
epidemics. Recent pertussis deaths in the United States are a
haunting reminder that this disease is still lying in wait.
People who have been exposed to probable or confirmed
pertussis should either receive a course of preventative
antibiotics (and I say this as someone strongly opposed to
the overuse of antibiotics), or be kept home from day
care, school, or work for at least 3 weeks. If the exposed
individual develops symptoms, they should receive
antibiotics to prevent further spread of pertussis to others.

Children under age 7 who have been exposed should

receive a pertussis vaccine, unless they have already
had 4 doses of pertussis vaccine (and the last dose
within 3 years), or unless there is a compelling reason
not to immunize them. Exposed teens 11-18 years old
who have not already received a booster vaccine should
receive one.
Related A-to-Z Information:

Airborne Transmission, Allergies (Allergic Rhinitis),

Asthma, Bronchiolitis, Common Cold, Contact
Transmission, Cough, Diphtheria, Droplet Transmission,
Gastroesophageal Reflux, Influenza (Flu), Measles,
Mumps, Pneumonia, Respiratory Distress, RSV
Respiratory syncytial virus), Rubella (German measles),
Sinusitis, Sleep Apnea, Sudden Infant Death Syndrome
(SIDS), Tetanus, Tuberculosis, Wheezing
Whole-cell pertussis vaccine controversy

Much of the controversy surrounding the DTP vaccine in the

1970s and 1980s related to the question of whether the whole-
cell pertussis component caused permanent brain injury in rare
cases. Although it was well-established that the pertussis
component of the DTP vaccine accounted for most of the minor
local and systemic side effects in many vaccinated infants,
several published studies failed to show a causal relationship
between administration of the DTP vaccine and permanent
brain injury. However, criticism of these studies and well-
publicized anecdotal reports of DTP-induced permanent
disability and death gave rise to anti-DTP movements.[10] In
addition, a number of children suffered allergic reactions to the
pertussis vaccination, including severe seizures. Despite this,
doctors recommended the vaccine, and even threatened
parents who refused to vaccinate their children.
By the late 1970s, publicity about adverse
reactions and deaths following pertussis
vaccination caused the immunization rate to
fall in several countries, including Great
Britain, Sweden, and Japan. In many cases, a
dramatic increase in the incidence of pertussis
followed.[11] These developments led Yuji
Sato to introduce a safer acellular version of
the pertussis vaccine for Japan in 1981.
Nevertheless, other countries continued to use the
whole-cell DTP formulation.
In the United States, low profit margins and an increase in
vaccine-related lawsuits led many manufacturers to stop
producing the DTP vaccine by the early 1980s.[citation
needed] In 1982, the television documentary "DTP: Vaccine
Roulette" depicted the lives of children whose severe
disabilities were blamed on the DTP vaccine. The negative
publicity generated by the documentary led to a tremendous
increase in the number of lawsuits filed against vaccine
manufacturers.[12] By 1985, manufacturers of vaccines had
difficulty obtaining liability insurance. The price of the DTP
vaccine skyrocketed, leading to shortages around the
country. Only one manufacturer of the DPT vaccine remained
in the U.S. by the end of 1985. To avert a vaccine crisis,
Congress in 1986 passed the National Childhood Vaccine
Injury Act (NCVIA), which established a federal no-fault
system to
compensate victims of injury caused by mandated
vaccines.[13] Since then, the prices of vaccines have
stabilized, and the number of lawsuits filed against DTP
manufacturers has dwindled. The majority of claims that have
been filed through the NCVIA have been related to injuries
allegedly caused by the whole-cell DTP vaccine. The
acellular pertussis vaccine was approved in the United States
in 1992 for use in the combination DTaP vaccine. Research
has shown the acellular vaccine to be safe, with few reports
of adverse effects.[2] Although the whole-cell DTP vaccine is
no longer used in the United States, it is still purchased by the
World Health Organization and distributed to developing
nations because of its much reduced cost compared to the
acellular DTaP vaccine.