Dr. Reddy's Pediatric Office on the Web TM

Whooping Cough (Pertussis)

(with information on the new adult/adolescent whooping cough vaccine
and the recent death of an infant from pertussis in Michigan)

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Whooping cough is caused by a bacteria called Bordetella pertussis, which lives only in human throats. Vaccine-induced immunity to B. pertussis wears off eventually, but for adults the bug usually produces nothing more than a very bad cough. In small children the cough, which comes in bouts or "paroxysms", can make someone literally breathless, and they usually have to take a quick deep breath or "whoop" at the end of the paroxysm -- thus the term "whooping cough". B. pertussis can be grown in culture, but it takes a few days and special culture media; it can also be detected by the polymerase chain reaction (PCR) test, which looks for the bacteria's genetic material and is much faster than culture.

The danger of whooping cough is that in small babies (usually under six months, definitely under two months, and especially ex-premies) the paroxysms may leave them not just breathless but without oxygen. Because of this danger we often have to intubate small babies and put them on ventilators until they get over the infection -- and this is made harder because the cough can be so forceful that a baby can cough the tube right out of the windpipe. (I have seen this happen -- three times in one hour.)

B. pertussis can be treated readily with several antibiotics, usually one of the macrolides (erythromycin, azithromycin, or clarithromycin), or trimethoprim and sulfamethoxazole (TMP-SMX). We usually treat everyone in the family at the same time when one family member is sick so that people don't pass the bug back and forth; we also treat anyone who has has close or prolonged contact with the sick patient, from children (and adults!) in the same classroom or day-care center to someone who sat next to the patient on an airliner for more than 4 hours. (If you have pertussis, you stop being contagious after 5 full days of antibiotics, although you may need a longer course of antibiotics for complete treatment.) We can also immunize against B. pertussis, which is much better since the treatment for an active infection takes a while to work, during which the coughing persists. Students (and teachers and other staff) who have pertussis should stay home from school until they have had at least 5 days of antibiotics; if they do not take antibiotics they need to stay away from school (and from small babies or their families) for 21 days after symptoms begin.

The first four doses of vaccine for whooping cough are given at 2, 4, 6, and 12-18 months of age. Unfortunately, although babies younger than 2 months can get whooping cough, the vaccine isn't effective before about 2 months. However, keeping older kids immune (the last dose of whooping cough vaccine is given at 5 years of age) helps prevent them from bringing the bug home from school. Immunity after vaccination seems to wear off after 5-10 years. Side effects of the previous vaccine prevented us from immunizing adults routinely. However, there are now two new vaccines, known as Tdap>. which combine a modified pertussis vaccine suitable for and effective in adults with the adult vaccines against tetanus and diphtheria. Although there is some debate among infectious-disease experts, many believe that someone who has full-blown B. pertussis infection will be immune to B. pertussis for life. The CDC and its Advisory Committee on Immunization Practices now recommend that everyone receive Tdap in their teens.

The whooping-cough vaccines are made from inactivated B. pertussis. For many years the vaccine was prepared from whole bacterial cells (killed chemically). This induced immunity quite well. However, it also produced many side effects, from fever (up to 103 or 104, and lasting 1-2 days) and pain at the injection site, to seizures (fortunately very rare). When I give whooping-cough vaccine I usually give Tylenol just before the shot and tell parents to continue giving Tylenol regularly for two days, whether or not the child seems to need it. The side effects of the whooping-cough vaccine are a definite problem, but I and most other pediatricians feel that the risk of having whooping cough far outweighs the risks of getting the vaccine. We are now starting to use vaccines from which the parts of the B. pertussis cells have been removed; in clinical trials these "acellular" vaccines seem to produce fewer side effects than the older vaccines -- although I still usually give Tylenol for two days with every dose of pertussis vaccine.

The whooping-cough vaccine is usually combined with the diphtheria and tetanus vaccines and given as a single shot; this is often referred to as DTaP (the a stands for "acellular"). We now have a single vaccine which combines DTaP, the injectable polio vaccine, and the hepatitis B vaccine into one shot; this can be given at ages 2, 4, and 6 months, eliminating six pokes while still giving immunity to all five diseases. The new Tdap vaccine (see above) is recommended for teenagers and for adults. As always, ask your doctor for complete details.

Recent Deaths From Whooping Cough in Michigan and Other States

There have been hundreds of deaths from pertussis, confirmed (by PCR or by culture) or probable (by the definition of "probable" during a pertussis outbreak, as defined by the CDC, in recent years. (Contrast this with 1976, when there were only 1,010 cases in the entire United States; in the 1920's and 1930's there were up to 250,000 cases in the US per year and up to 9,000 deaths.) Many of these cases have been in preteens and teenagers, but there have been several infants with confirmed pertussis. I have seen and cared for a few myself.

Several days ago a 3-month-old girl died in Michigan of complications from pertussis. Earlier this month a 2-month-old died in New Mexico due to pertussis -- the first pertussis-related death in New Mexico in about 7 years.

These children reportedly had received their first doses of DTaP when they were 2 months old. That was good. Unfortunately, it takes three doses of DTaP to provide immunity to a baby -- before that, they are at the mercy of everyone they come in contact with who might expose them to pertussis. If they were exposed to unvaccinated children, those children's parents have a great deal to answer for.

We have been seeing increasing numbers of patients with whooping cough over the past few years. One reason may be that, with the wider use of the PCR test, we are diagnosing B. pertussis infection in people who would have been diagnosed with bad colds a few years ago. Since older children and adults are usually not fully immune to B. pertussis even if they were immunized as kids, there are always older kids and adults who carry the bacteria and can give it to smaller children. (Remember that a baby may not be completely immunized until after all of the first 3 doses.) Another reason may be that, because of scares about side effects and especially about seizures, many parents in the early 1990's avoided having their children vaccinated -- which might explain why so many teens and young adults are susceptible. (This may be hard to prove, but it would explain a few things.)

What can we do about this? For one thing, we can -- and, right now, we do -- treat anyone with a cough lasting more than 2 weeks as if they have pertussis. We also give prophylactic antibiotics to anyone who has been in contact with a possible pertussis patient. And we do this whether or not the patient has been recently immunized; the patient may be able to fight off the infection, but may be able to pass it on to someone who can't fight it off (like a baby).

The other thing we -- actually, you -- can do is to make sure that your children, and you yourself, are vaccinated against pertussis. As I mentioned above, one reason why we are seeing more cases of whooping cough is that many children have not been vaccinated. The risk of side effects from the vaccine are much rarer than the risk of complications from full-blown whooping cough.

For more information on whooping cough, see the CDC page on pertussis. Another useful source of information on whooping cough is whoopingcough.net, maintained by Douglas Jenkinson, MB ChB, an English family practitioner who has considerable experience (both as clinician and as researcher) in the diagnosis and treatment of whooping cough.

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PLEASE NOTE: As with all of this Web site, I try to give general answers to common questions my patients and their parents ask me in my (real) office. If you have specific questions about your child you must ask your child's regular doctor. No doctor can give completely accurate advice about a particular child without knowing and examining that child. I will be happy to try and answer general questions about children's health, but unless your child is a regular patient of mine I cannot give you specific advice.

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Copyright © 1997, 1999, 2003, 2004, 2005, 2006, 2012 Vinay N. Reddy, M.D. All rights reserved.
Written 07/29/97; major revision 04/24/05; major revision 08/23/05; major revision 09/26/06; last revised 05/23/12 counter