Whooping Cough

Nathalie Mielcarek. Camille Locht

Center for Infection and Immunity of Lille, Institut Pasteur de Lille, Lille, France
Inserm U1019, Lille, France
CNRS UMR8204, Lille, France
Universite´ Lille Nord de France, Lille, France

Ardian Zakaria Amien

 ABSTRACT

First described in the sixteenth century, whooping cough or

pertussis is a relatively recent disease in human history,
although some of the cough syndromes described in antiquity
may in fact be pertussis-like diseases.Whooping cough caused
by the gram-negative bacterium Bordetella pertussis is a severe
respiratory disease, especially life-threatening in early
childhood.
The disease appears to not have been known during antiquity and the Middle Ages,
although Hippocrates described Perinthus cough around 400 B.C., and Reginald
mentioned kinkehost in his Vita Godrici around 1190, and both diseases may be related
to pertussis. The first known description by the French physician Guillaume de Baillou
was subsequent to an epidemic in 1578 but was published only in 1640 by his nephew.
De Baillou called the disease quinta. The name pertussis was first given by Willis and
Sydenham in the seventeenth century to describe the syndrome as a severe cough
The disease has been given several names in different countries describing various aspects
of the disease, such as the cockcrow (coqueluche) in France, the dog’s bark (tosse canina) in
Italy, the howling of wolves (Wolfshusten) in Germany, and the cough of 100 days in China.

They examined the exudation of a 5-month-old child diagnosed with whooping cough under
the microscope and found, in addition to large amounts of leukocytes, a very high number of
small coccoı¨dal, ovoid, or rod-shaped gram-negative bacteria that were colored light blue
after staining with Ku¨hne’s dye.
In the following decades, it became apparent that pertussis like symptoms
can also be caused by other members of the genus Bordetella, such as
Bordetella parapertussis, isolated for the first time by Eldering and
Kendrick in 1938 and Bordetella bronchiseptica, first isolated from a dog
with kennel cough. Other Bordetella species have more recently been
isolated from patients with respiratory illnesses. They include Bordetella
avium, Bordetella holmesii, and Bordetella petrii.
 CLINICAL MANIFESTATIONS

Typical illness presents three stages: catarrhal, paroxysmal, and convalescent.

Following an incubation period of 6–20 days, the infected individual develops a catarrhal phase
with nonspecific cold-like symptoms consisting of nasal congestion, rhinorrhea, sneezing,
occasionally conjunctival irritation, and non productive cough.
More severe symptoms characterize the next stage, called paroxysmal in reference to the
intense bouts of coughing followed by an inspiratory ‘‘whooping’’ sound. Twelve to fifteen
episodes of coughing bouts, each lasting 1–2 min, can be experienced every day during at least
2 weeks.
The cough is supposed to clear the large amount of thick mucus usually produced in the
respiratory tract during the paroxysmal stage, and this attempt can be exhausting for the
infected individual. Vomiting and cyanosis after coughing can occur especially in young
children.
Additional clinical complications may develop during the paroxysmal phase of
whooping cough. The most severe ones are observed in neonates and in young children.
These include pneumonia, apnea, hypotension, dehydration, weight loss due to
excessive vomiting, brain damage due to oxygen deprivation, and death
 EPIDEMOLOGY

Data from the British Register General’s Report indicate that in the late
nineteenth century, 2 % of the total deaths of the year in the country were due to
whooping cough with 97 % of the cases occurring in children less than 5 years
old . Several studies suggest that in the early twentieth century, 75–80 % of all
children experienced pertussis infection by age of 12.
The introduction in most industrialized countries of the first whole-cell pertussis
vaccines combined with diphtheria and tetanus toxoids in the 1940s and the 1950s
resulted in a dramatic decrease of the incidence of whooping cough, with as much as
99% reduction of reported cases in United States (US Public Health Services 1953). In
low vaccine uptake countries, the disease burden remains high, with 12.5 million cases
both for Africa and for Southeast Asia estimated in 1999 and 170,000 deaths due to
pertussis in Africa alone each year (Crowcroft et al. 2003).
Adaptation of B. pertussis strains to vaccine-induced immunity has been pointed out as
a possible explanation for the resurgence of pertussis. Molecular epidemiology studies
on circulating B. pertussis strains showed a polymorphism of genes coding for
pertussis toxin (PTX) and pertactin (PRN), with sequences distinct from those of
vaccine strains. This phenomenon has been observed in many countries, such as
France (Weber et al. 2001), the Netherlands (Mooi et al. 1998) and the United States
(Cassiday et al. 2000).
 PATHOGENESIS
Other members of the Bordetella genus such as B. parapertussis and B.
bronchiseptica have been associated with milder forms of human illness (Mooi et al.
2007). Infection of the host by B. pertussis occurs through inhalation of droplets
containing bacteria produced during the cough of an infected individual. Once the
bacteria have entered the upper respiratory tract, they produce a range of virulence
factors, adhesins and toxins, that will promote their adherence to the ciliated
epithelial cells of the nasopharynx and the trachea
Among the adhesins expressed by B. pertussis, filamentous haemagglutinin (FHA) and
fimbriae play a major role in the interaction of the bacteria with the host epithelium
Pertactin (PRN), or p.69, was also initially described for its role in attachment of B.
pertussis to epithelial cells. PRN is exposed at the surface of the bacteria and
belongs to the autotransporter family. On the other hand, a PRN-deficient B.
bronchiseptica strain was shown to be impaired in colonization of the mouse
respiratory tract due to a reduced resistance to neutrophil-mediated clearance.
Therefore, PRN might not contribute significantly to B. pertussis adherence to
epithelial cells but rather play a role in survival of the bacteria in the host respiratory
tract.

Indirect contribution of toxins such as pertussis toxin (PTX), adenylate cyclase

toxin (ACT), and tracheal cytotoxin (TCT) in the early steps of B. pertussis
infection has also been established
PTX is a complex multimeric protein belonging to the ADP ribosylating toxins family.
This major toxin, exclusively produced by B. pertussis, is composed of 5 different
subunits, named S1 to S5, with S1 being responsible for the enzymatic and toxic
activities of the protein. PTX is actively secreted through the bacterial outer membrane
using a type IV secretion system called the Ptl machinery.
Whereas certain B. parapertussis strains have been isolated from sheep and B.
bronchiseptica has a broad mammalian host spectrum, B. pertussis is a strictly
human pathogen, although anecdotal reports of zoo outbreaks also suggest that
chimpanzees can be naturally infected with B. pertussis.
The most convenient animal model used so far is the mouse model. However,
mice do not cough and do not transmit the disease to other mice, and therefore,
B. pertussis infection of mice does not reflect the typical human disease.
mice have been useful to study several aspects of whooping cough, similar to
humans, infant mice are more susceptible to B. pertussis infection than adult
mice and can die from the infection. Furthermore, the duration of B. pertussis
colonization in the respiratory tract is similar between mice and humans.
Unlike mice, rats do cough when inoculated with B. pertussis. This led to the
coughing rat model as a potentially useful system to study the full pathogenesis of
pertussis. In this model, B. pertussis is embedded in agarose beads and
intrabronchially administered under anesthesia to Sprague–Dawley rats, which
induces coughing episodes at 9–14 days after infection that can be monitored
using sound activated tape recorders with microphones above the rat cages in
sound-insulated booths. However, the administration of simple suspensions of B.
pertussis without beads does not induce significant coughing

It was instrumental to show that pertussis toxin is required for cough induction,
as a pertussis toxin-deficient mutant strain was inactive as a cough inducer . In
addition, the model has been used to assess pertussis vaccines.
In the pre-vaccination era, typical childhood pertussis could easily be recognized
by the specific paroxysmal cough with the classic whoop, which is much less the
case in vaccinated populations (Yaari et al. 1999). Although quite specific,
diagnosing pertussis on the whoop alone is thus not sensitive enough. The
marked lymphocytosis during pertussis is also a classical marker and can be a
useful indicator of the disease, especially when combined with other diagnostic
methods
Traditional laboratory methods to diagnose pertussis were based on B. pertussis
identification after culturing nasopharyngeal
secretions. The secretions can be collected by swabbing or aspiration. The swabs or
aspirations are plated onto selective media after an enrichment step, and after
several days of incubation, B. pertussis can be identified with high specificity

As an alternative, direct fluorescent-antibody tests have been developed, using

polyclonal fluorescein-labeled antibodies against B. pertussis to directly identify the
organism in the nasopharyngeal specimens This method appears to be more sensitive
and provides results more rapidly than culture. However, results may sometimes be
difficult to interpret and are prone to a high percentage of false-positives
Serology has also been extensively used to diagnose pertussis. Initially, the
most widespread method was based on the ability of anti–B. pertussis antisera
to agglutinate the bacteria (Evans and Maitland 1939).With the advent of
enzyme-linked immunosorbent assays (ELISA), more sensitive tests were
designed. A handful of antigens have been used to determine seroconversion
by ELISA. They include pertussis toxin, FHA, pertactin, or whole-cell extracts
However, seroconversion may be influenced by vaccination prior to infection,
as the antigens used for serology are also included in most pertussis vaccines.

The evaluation of antibody isotypes other than IgG may be helpful to partially
solve this problem, as the production of IgA is mainly induced by infection and
not by vaccination However, these antibodies appear relatively late after the
onset of the infection. Anti-B. pertussis IgA can also be detected in
nasopharyngeal secretions, where they appear somewhat earlier than in the
serum
Perhaps today, the most sensitive methods to diagnose pertussis are based on
polymerase chain reaction (PCR). Sensitivities of up to 100 % have been reported
More than 100 protocols have been described, which differ in DNA isolation
techniques, PCR primer selection, reaction conditions, and amplicon detection
methods. PCR assays require specially equipped laboratory environments and well-
trained personnel, as the risk of false-positives is high due to the high sensitivity of
the technology. Owing to its specificity, PCR has become the test of choice for the
diagnosis of pertussis

More recently, rapid and sensitive genotyping assays and microarrays have been
developed to identify pathogens responsible for upper respiratory tract infections,
including B. Pertussis. This technology has the potential to increase speed of
diagnosis at relatively low cost.
TREATMENT

B. pertussis is sensitive to a variety of antibiotics, and treatment given during the

catarrhal phase of the disease may decrease the symptom severity. Erythromycin is
the drug of choice for pertussis. Its minimal inhibitory and minimal bactericidal
concentrations range from 0.02 to 2 mg/ml and 0.04 to 8 mg/ml, respectively and at
a dosage of 50 mg/kg/day given for 7–8 days, it is able to clear B. pertussis from the
nasopharynx
 PREVENTION

Pertussis vaccination usually begins at 2 or 3 months of age, and optimal protection

requires at least three immunizations at 1- to 2-month intervals. A booster dose is
commonly given 1–6 years later. This schedule implies that children are not optimally
protected before the age of 6 months where they are the most vulnerable to the severe
forms of the disease (Bisgard et al. 2005). Two types of vaccines, the whole-cell (wPv) and
the acellular (aPv) pertussis vaccines, are currently available. They are combined with
diphtheria (D) and tetanus (T) toxoids and often also include inactivated polio vaccine
(IPV), Haemophilus influenza b (Hib), and hepatitis B (HepB) vaccines (Storsaeter et al.
2007).
 Whole-cell Pertussis Vaccines

First attempts to develop a vaccine against whooping cough began soon after discovery of B.
pertussis bacteria in 1906 at Pasteur Institute in Brussels, Belgium, by J. Bordet and O. Gengou
. In 1913, C. Nicolle produced several batches of wPv but they produced inconsistent results In
the 1920s, LW Sauer, an American pediatrician, visited the Pasteur Institute in Brussels and
worked on the improvement of wPv when he came back to the USA
By the 1930s, wPv were introduced in many countries and were rapidly combined with
diphtheria and tetanus toxoids to produce the DTP vaccines still in use in routine vaccinations
today. Production process of wPv may vary between manufacturers and explain the relative
heterogeneity between the vaccines, especially the lipopolysaccharides content which
contributes to the reactogenicity of the vaccines
 Acellular Pertussis Vaccines
first demonstrated the protective effect of FHA and PTX in this mouse model. All currently
commercially available aPv contain inactivated PTX usually in combination with FHA.
Additional components such as PRN and fimbriae can also be part of the aPv (Storsaeter et
al. 2007). Differences between current aP vaccines are mainly based on bacterial strains,
numbers, and quantities of each antigen and adjuvant. It was shown during clinical trials
that aPv has a better safety profile than wPv and that aPv needs to contain at least three
components (detoxified PTX, FHA, and PRN) to have similar efficacy and be comparable
to good wPv (Jefferson et al. 2003).
 New Vaccination Strategies
• Maternal Vaccination
Indirect evidences suggest that maternal antibodies might provide passive
protection against B. pertussis infection early in life (Van Rie et al. 2005).
Moreover, the administration of wPv (Kendrick et al. 1945) or aPv (Lewis
2011) late in pregnancy was shown to be safe for the mother and the baby
and resulted in high levels of B. pertussis-specific antibodies in the infants.
The Cocoon Strategy

This strategy targets the parents as well as all persons in

close contact with a newborn to prevent adult-to-child
transmission (DeMaria and Lett 2010). A successful cocoon
strategy implies therefore a very high number of
individuals to be vaccinated in order to significantly
reduce incidence and severity of infant pertussis. A recent
study showed that such a number would to be too high
in low-incidence countries and the strategy too
resource intensive to be efficient for the prevention of
severe pertussis in early infancy
CONCLUSION

Pertussis epidemiology has profoundly changed with the

introduction of the different generations of vaccines.
However, pertussis still remains a major public health issue
especially in very young children, despite the availability of
effective vaccines and high vaccine coverage worldwide. The
limits of the current strategies could be overcome by
developing new approaches, and it is likely that a
combination of several innovative strategies will be needed
to successfully fight against severe pertussis in the very
young.
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