1. Pertussis
Meaghan Mollard

2. Definition “Whooping cough”
Highly contagious, acute respiratory illness cause by Bordetella pertussis bacteria
Most commonly affects children <6 months of age who are not completely vaccinated and children years as childhood vaccination coverage wears off
Inspiratory whoop
Paroxysmal cough
Post-tussive emesis
(CDC, 2014)
Pertussis is also know as whooping cough secondary to the whooping sound that is made when an individual gasps for air after a coughing fit.
Pertussis is a highly contagious, acute respiratory infection caused by the bordetella pertussis bacteria.
Most commonly affects children <6 months of age who are not completely vaccinated and children years as childhood vaccination coverage wears off.
Pertussis is characterized by 3 specific clinical features in children less than 10 years old including an inspiratory whoop, a paroxysmal cough and post tussive emesis. These features can be absent in adolescents and adults.

3. Etiology B. pertussis is caused by gram negative pleomorphic bacillus
Pertussis is highly contagious infecting 80-90% of susceptible individuals that are exposed
3 Species of Bordetella can affect respiratory tract
B. parapertussis, B. bronchiseptica, B. holmesii
(Bocka, 2014)

4. Pathophysiology Pertussis is primarily a toxin-mediated disease.
Bacteria attach to the cilia of the respiratory epithelial cells.
Bacteria produce toxins that paralyze the cilia causing inflammation of the respiratory tract.
Inflammation interferes with the clearing of pulmonary secretions.
Pulmonary secretions are described as a mucopurulosanguineous exudates.
(Bocka, 2014)
Pertussis is primarily a toxin-mediated disease.
Bacteria attach to the cilia of the respiratory epithelial cells.
This bacteria then produce toxins that paralyze the cilia causing inflammation of the respiratory tract.
Inflammation interferes with the clearing of pulmonary secretions.
Pulmonary secretions are described as a mucopurulosanguineous exudates.

5. Transmission
Spread from person to person when coughing, sneezing, talking, and laughing while in close contact.
Inhalation of infected respiratory droplets.
Many infants and children who are not fully vaccinated are infected by older siblings, parents and caregivers.
Contagious from the onset of cold like symptoms through 3rd week, after paroxysmal coughing onset, or until after 5 days of effective antibiotic treatment.
(CDC, 2014)
Pertussis is spread from person to person. Humans are the only reservoirs.
Transmission occurs via respiratory droplets expectorated from infected persons within close contact.
Infants usually contract the bodetella bacteria from infected siblings, parents and caregivers
Individuals are contagious from the onset of cold like symptoms through the 3rd week of symptoms after paroxysmal coughing onset, or until after 5 days of effective antibiotic treatment

6. Incubation
Incubation period can be as short as one week but as long as 3 weeks
Typically 7-10 days
Incubation period is longer than that of the common cold, which is about 1 to 3 days
(Bocka, 2014)
Incubation period can be as short as one week but as long as 3 weeks
Typically 7-10 days
Incubation period is longer than that of most upper respiratory infections like the common cold, which is about 1 to 3 days

7. Incidence 48.5 million yearly cases world wide
4,838 cases of pertussis reported from January 1, 2014 to April 14, 2014
High infant mortality rate prior to whole cell vaccine in the 1940’s.
Cyclical epidemics every two to five years, present in the pre-vaccine era
Most cases occur in late summer and early fall
5-10% of cases are recognized and reported
Most commonly reported vaccine-preventable disease in the United States in children younger than 5 years.
(Bocka, 2014), (CDC, 2014)
Affects 48.5 million individuals every year world wide
With 4,838 cases of pertussis reported from January 1, 2014 to April 14, 2014 showing a 24% increase over the same period in 2013.
There was a high infant mortality rate prior to the introduction of the whole cell vaccine in the U.S. in the 1940’s.
Pertussis is a cyclical epidemic that peaks every 2 to 5 years. These peaks were present prior to the vaccine administration.
Pertussis is seen most often in the late summer to early fall.
Pertussis is a reportable illness , with the CDC estimating only 5-10% of cases actually being recognized and reported.
It is remains the most commonly reported vaccine preventable disease in children younger than 5 years old.

8. Figure 1: reported cases of pertussis from 1922- 2013 (CDC, 2014)
This graph illustrates the number of pertussis cases reported to CDC from 1922 to 2013.
After the introduction of pertussis vaccines in the 1940s when 100,000 cases were reported per year, there was a dramatic drop to fewer than 10,000 by 1965.
During the 1980s pertussis reports began increasing gradually, and by 2013 more than 28,000 cases were reported nationwide.
Several factors have likely contributed to the increase in reported cases, including increased awareness and improved recognition of pertussis among clinicians, along with greater access and use of laboratory diagnostics.

9. Reduce the Risk Prevention: GET VACCINATED!!!
Recommendations for infants and children:
5 doses of diphtheria, tetanus and pertussis (DTaP) vaccine given between 6 weeks and 7 years of age, usually at 2 months, 4 months, 6 months, between months and 4-6 years. (CDC, 2014), (Cornia & Lipsky, 2014)
DTaP vaccine can be administered at the same time as other recommended vaccines, should not be mixed with other vaccines unless licensed by FDA.

10. Reduce the RISK Vaccine recommendation for children >7 and adults:
Tdap given between years old, preferred administration is between years
Adults 19 and older who have not had Tdap vaccine need a booster shot
Tdap administered to pregnant individuals during each pregnancy between weeks gestation
Td every 10 years
(CDC, 2014), (Cornia & Lipsky, 2014)
Used to protect adolescents and adults against pertussis and prevent spreading to infants and young children
Single dose of tetanus toxoid reduced diphtheria toxoid-acellular pertussis (Tdap) given between years old when childhood vaccines begin to wear off.
Administration is preferable between years
Adults 19 and older who have not had Tdap vaccine need a booster shot, Tdap can be administered regardless of the interval since the previous Td dose was given, especially if in close contact with children
Tdap administered to pregnant women during each pregnancy ideally between weeks gestation
Once Tdap booster given in adult life only need Td which is given every 10 years
Tdap and Td can be administered at the same time as meningococcal conjugate, HPV and Flu vaccines.

11. Risk Factors Young infants born prematurely
Patients with underlying cardiac, pulmonary, neuromuscular, or neurologic disease
Non-vaccinated individuals
Contact with an infected person
Epidemic exposure
Pregnancy
(Cornia & Lipsky, 2014)

12. Screening
Vaccination screening should be done routinely at primary care visits
Screen:
High risk individuals- infants, pregnant women, and non vaccinated children OR
Individuals who have had cough >2 weeks

13. Clinical Findings
Incubation period 7-10 days after exposure to B. pertussis
Followed by the onset of nonspecific symptoms
Total duration of pertussis is about 3 months
“The cough of 100 days.”
3 stages of Pertussis:
Catarrhal
Paroxysmal
Convalescent
(Yeh & Mink, 2014), (CDC, 2014)
The total duration of pertussis typically lasts about 3 months. Classical pertussis has been called “ the cough of 100 days” in china.

14. Clinical Findings- Catarrhal
Lasts 1-2 weeks
Pertussis most infectious during catarrhal phase
Indistinguishable from common upper respiratory infections
Nasal Congestions
Rhinorrhea
Sneezing
Occasional low grade fever
Occasional cough
Red, watery eyes
Apnea in infants
(Yeh & Mink, 2014), (CDC, 2014)
Lasts 1-2 weeks
Pertussis most infectious during catarrhal phase, when live bacteria are viable in the nasopharynx
Indistinguishable from common upper respiratory infections
Nasal Congestions
Rhinorrhea
Sneezing
Occasional low grade fever
Occasional cough
Red, watery eyes
Apnea in infants

15. Clinical Findings- Paroxysmal
Stage lasts 2 to 6 weeks
Paroxysmal attacks
Characteristic “Whoop”
Posttussive emesis
Extreme fatigue
(Yeh & Mink, 2014), (CDC, 2014)
Stage typically last for 2 to 6 weeks.
Cold symptoms improve, but cough worsens
Paroxysmal attacks characterized by long series of coughs where the patient can become cyanotic, gag or grasp for air. Attacks can develop spontaneously or by external stimuli like yawning, stretching, laughing, yelling, exercise, or the inhalation of steam or mist.
The cough is persistent and usually increases in severity throughout this phase.
A whoop can begin in the paroxysmal phase but is not always present, the whoop noise is made from forced inspiratory effort after a paroxysmal fit. This sound is more common in infants and young children due to the small size of the trachea.
Pusttussive emesis is when a coughing fit is followed by an episode of vomiting
Extreme fatigue caused by coughing fits

16. Clinical Findings- Convalescent
3rd and final stage, lasts 1-2 weeks
Gradual reduction in the frequency and severity of cough
Cough usually disappears after 2-3 weeks
Coughing symptoms can reappear with subsequent upper respiratory infections during the convalescence phase
(Yeh & Mink, 2014), (CDC, 2014)
3rd and final stage, lasting 1-2 weeks
Gradual reduction in the frequency and severity of cough
Cough usually disappears after 2-3 weeks
Coughing symptoms can reappear with subsequent upper respiratory infections during the convalescence phase

17. Differential Diagnosis
Mycoplasma pneumoniae
Chlamydia pneumoniae
Adenoviruses
Respiratory syncytial virus infection
(Bocka, 2014)
Illness that mimic clinical pertussis:
Mycoplasma pneumonia- patients with mycoplasma infections have more pronounced system symptoms, fever, headache and relented on auscultation.
Chlamydial pneumonia - Young infants with chlamydial infections present with a staccato cough, purulent conjunctival discharge, tachypnea, rales, and wheezing
Adenoviral respiratory infection - Children present with fever, sore throat, and conjunctivitis
RSV- Patients present with predominantly lower respiratory tract signs (Wheezing and rales)

18. Differential Diagnosis
Common cold
Febrile Seizures
Influenza
Fever
Interstitial pneumonitis
Gastroenteritis
Bronchiolitis
Tachycardia
Croup
Tuberculosis
Dehydration
(Bocka, 2014)
Aspiration pneumonia
Bacterial pneumonia
Viral pneumonia
Conditions that should be considered in the differential diagnosis of pertussis include:

19. Social/Environmental Considerations
Get vaccinated
High risk patients like infants and immuno-compromised individuals should avoid potential exposure
Drink plenty of fluids
Adequate rest
Environmental:
Be aware of stimuli that can trigger coughing fits, ie: laughing, talking
Keep air clean and free from triggers, ie: tobacco smoke

20. Diagnosis Detailed history Physical exam
potential exposure to pertussis from infected individuals
common signs and symptoms associated with pertussis
Duration of symptoms
Physical exam
Rule out other potential causes of signs and symptoms
Most common physical findings include:
conjunctival hemorrhage
facial petechiae
(Bocka, 2014)
Detailed history
potential exposure to pertussis from infected individuals
common signs and symptoms associated with pertussis
Duration of symptoms
Physical exam
Rule out other potential causes of signs and symptoms
Most common physical findings include:
conjunctival hemorrhage
facial petechiae related to coughing fits

21. Laboratory Tests Nasopharyngeal culture PCR and Elisa Serology Testing
CBC trend
The CDC recommends a combination of a culture and PCR assay if a patient has a cough lasting longer than 3 weeks. (CDC, 2014)
Nasal aspirate culture to check for the evidence of the bordetella bacteria, ideally collect specimen within first 2 weeks of symptoms when bacteria is viable.
Gold standard for diagnosis of B. Pertussis as it is 100% specific
PCR is also a nasopharyngeal specimen collected within the first 3 weeks for most accurate results, High sensitivity, low specificity with high false positive. CDC recommends confirmation of PCR with the ELISA test
Serology testing: useful for diagnosis in later phases
CBC tend to assess leukocytosis with lymphocytosis occurring in the late catarrhal and paroxysmal phases
The CDC recommends a combination of a culture and PCR assay if a patient has a cough lasting longer than 3 weeks.

22. Management Goals of treatment
Limit the number of paroxysms
Maximize nutrition, rest, and recovery
Practice good hand hygiene to prevent the spread of respiratory illnesses

23. Treatment
Starting treatment within first 1-2 weeks of symptom onset before paroxysmal cough starts might decrease the severity of symptoms. (Bocka, 2014)
CDC suggests treating prior to test results if clinical history strongly suggestive or if high risk patient, ie: infants. (CDC, 2014)
If patient diagnosed late, ABX will not change course of illness and should only be treated with an ABX if still contagious. (Bocka, 2014)

24. Treatment Treatment indications:
Antimicrobial tx with B.Pertussis isolated from culture or + PCR
Patient with a clinical diagnosis who has had symptoms for less than 21 days
Antimicrobial therapy for pt.’s who have >21 days of symptoms, especially those in contact with high risk individuals.
The Committee on Infectious Diseases (COID) of the American Academy of Pediatrics (Red Book Committee) recommends treating household members of infected individuals to limit secondary infection.
(CDC, 2014)
Treatment indications:
Antimicrobial tx with B.Pertussis isolated from culture or + PCR
Patient with a clinical diagnosis who have had symptoms for less than 21 days
Antimicrobial therapy for pt.’s who have >21 days of symptoms, especially those in contact with high risk individuals.
The Committee on Infectious Diseases (COID) of the American Academy of Pediatrics (Red Book Committee) currently recommends promptly treating all household and other close contacts (e.g., children and staff at daycare centers) to limit secondary transmission

25. Pharmacological Management
Antimicrobial agents and antibiotics help to eradicate B pertussis and prevent spreading
Macrolides: Erythromycin, Azithromycin, Clarithromycin
Azithromycin preferred for infants <1 month
Erythromycin administered for 14 days
Azithromycin administered for 5 days
Clarithromycin administered for 7 days
Trimethoprim-sulfamethoxazole alternative agent for persons >2months who can not tolerate macrolides
Bactrim is administered for 14 days
(Yeh, 2014), (CDC, 2014), (Bocka, 2014)
Medication chosen in regard to tolerability, potential for interaction, cost and ease of adherence to regime
Azithromycin and Clarithromycin recommended, better tolerated and has more convenient dosing compared to erythromycin
Erythromycin recommended treatment for household and close contacts
Caution use of azithromycin in patients with cardiovascular disease for potential QT prolongation
trimethoprim 8 mg/kg per day, sulfamethoxazole 40 mg/kg per day in 2 divided doses for 14 days.
Adults: trimethoprim 320 mg per day, sulfamethoxazole 1,600 mg per day in 2 divided doses for 14 days.
Bronchodilators, corticosteroids, and antitussives have not been proven to be beneficial for patients with pertussis

26. NON-Pharmacological Rest Drink plenty of fluids
Eat smaller, more frequent meals
Vaporize the room
Keep the air clean
Prevent transmission
(CDC, 2014)
Get plenty of rest
Drink plenty of fluids, monitoring for dehydration like dry lips, crying without tears, and infrequent urination
Small meals to avoid vomiting after coughing
Vaporize the room, a mist vaporizer can help soothe the throat and lungs, helping to loosen respiratory secretions
Keeping the air clean, avoiding irritants like tobacco smoke
Prevent transmission, cover mouth when coughing, and wash hands frequently

27. Complications Related the infection: Sequelae of severe cough:
Pneumonia
Otitis Media
Reintroduction of paroxysmal coughing with upper respiratory infections
Sequelae of severe cough:
Subconjunctival hemorrhage
Development or exacerbation of abdominal wall hernia
Rib fractures
Loss of bladder control
Weight loss, loss of appetite
Dehydration
Bloody nose
Hemoptysis
Cerebral hemorrhage,
Encephalopathy
Seizures
(Bocka, 2014), (CDC, 2014),
Typically life threatening complications are seen in infants and young children that are not fully vaccinated, infants less than 1 year old who get pertussis, ½ of those infants are hospitalized.
Adolescents and adults have less serious complications, with only 5 % of infected individuals being hospitalized.
Pneumonia is most common complication occurring in at least 1 out if 20 cases decreased ability to mobilize secretions causing pneumonia and atelectasis
Seizures and encephalopathy common in infants related to the decrease in oxygen supply to the brain

28. Follow-up
Most patients older than 1 year can be treated on an outpatient basis if they do not fulfill the criteria for hospital admission
Hospital admission is warranted for respiratory distress, pneumonia, inability to feed, apnea, and seizures
Frequent outpatient re-evaluations are required
frequency based on the patient's age, disease severity, and presence of comorbid conditions.
(Bocka, 2014)

29. Counseling/Education
Education regarding importance of vaccination administration *key to prevention*
Review risks associated with vaccine
Provide information regarding the infectious and contagious potential of pertussis
Seek medical attention if exposed for preventative antibiotics
Practice good hand hygiene
Avoid contact with high risk patients for at least 5 days after treatment initiation if diagnosed with B. pertussis

30. Consultation/Referral
Consultation with subspecialists is usually not indicated
Unless….
The diagnosis is unclear
Infectious disease consultation
(Bocka, 2014)

31. Question 1 What is the macrolide used in infants <1 month?
A. Erythromycin
B. Azithromycin
C. Clarithromycin

32. Answer
B: Azithromycin is preferred in infants <1 month of age, unknown reaction with erythromycin and clarithromycin. Increased potential of pyloric stenosis with the use of erythromycin. Less side effects noted with azithromycin (Cornia & Lipsky, 2014)

33. Question 2
What antibiotic can be used in the treatment of pertussis instead of a macrolide?
A. Azithromycin
B. Amoxicillin
C. TMP-SMZ
D. Ceftriaxone

34. Answer
C: TMP-SMZ: trimethoprim-sulfamethoxazole is an alternative agent for persons >2months who can not tolerate macrolides Infants: trimethoprim 8 mg/kg per day, sulfamethoxazole 40 mg/kg per day in 2 divided doses for 14 days. Adults: trimethoprim 320 mg per day, sulfamethoxazole 1,600 mg per day in 2 divided doses for 14 days. (Bocka, 2014)

35. Question 3
How many vaccines are included in the diphtheria, tetanus, and pertussis (DTaP) series and at what ages are they administered?
A. 5 injections at birth, 6 months, 1 year, 18 months, and 2 years
B. 5 injections at 2, 4, 6 months, between months and 4-6 years
C. 3 injections at birth, 1 year, and 2 years
D. 3 injections at 2, 6, 12 months

36. Answer 3
B: DTaP is given in a series of 5 injections between 6 weeks and 7 years of age. Given at 2 months, 4 months, 6 months, between months and between 4-6 years of age. (CDC, 2014)

37. Question 4
How long should individuals with Pertussis avoid contact with other individuals after starting antibiotics?
A. 24 hours
B. 3 days
C. 5 days
D. 7 days

38. Answer
C. Patients with B. pertussis should avoid contact with young children and infants until after they have completed 5 days of antibiotics. (Cornia & Lipsky, 2014)

39. Question 5
Pregnant women can not get vaccinated with Tdap during pregnancy.
True or false?

40. Answer
False
It is recommended that women get vaccinated with Tdap during each pregnancy preferably between weeks gestation (CDC, 2014)

41. Question 6
What test is the gold standard used by clinician’s to diagnose B. pertussis
A. PCR
B. Blood culture
C. Nasopharyngeal culture
D. Serology Testing

42. Answer
C: Nasopharyngeal culture is the gold standard for identifying pertussis because it is a 100% specific. Results take 5-7 days. (CDC, 2014)
Best to collect sample within two weeks of symptom onset when viable bacteria are still present in the nasopharynx. After 2 weeks sensitivity is decreased and the risk of false-negatives increases. (CDC, 2014)

43. Question 7 What is true about B. pertussis?
A. It does not affect adults over the age of 65.
B. Parents don’t need to get vaccinated if they vaccinate their children
C. It is the most commonly reported vaccine preventable illness in individuals less than 5 years old.

44. Answer
C: Pertussis can affect individuals over the age of 65, they more frequently hospitalized than individuals between 11 and 64.
Parents who are in close contact with children need to get vaccinated despite vaccination status of other individuals. Adolescents and adults usually infect infants unknowingly.
Pertussis is a nationally reported illness, and the CDC states that is it the most commonly reported vaccine preventable illness in children less than 5. (CDC, 2014)

45. Question 8 What is the best way to prevent B pertussis?
A. Avoid contact with potentially infected individuals
B. Vaccination
C. Stay away from children
D. Wash hands routinely

46. Answer
B: The CDC states, “The best way to prevent pertussis (whooping cough) among infants, children, teens, and adults is to get vaccinated.” (CDC, 2014)

47. Question 9
What is the most significant clinical finding in the second phase of B. pertussis?
A. Fever
B. Malaise
C. Runny nose
D. Paroxysmal cough

48. Answer
D: Fever and runny nose are both clinical findings in the catarrhal phase
Malaise is a finding in the second phase but the malaise is typically a side effect related to the paroxysmal coughing fits(Cornia & Lipsky, 2014)

49. Question 10 What is the most common complication of B. Pertussis?
A. Pneumonia
B. Rib Fractures
C. Seizure
D. Dehydration

50. Answer
A: Pneumonia is the most common complication of B. pertussis, affecting about 1 in 20 individuals who are infected (CDC, 2014), (Bocka, 2014)

51. References
Bocka, J. (2014). Pertussis. Retrieved on October 6, 2014 from
Cornia, P. & Lipsky, B.A. (2014 April 9). Treatment and prevention of bordetella pertussis infection in adolescents and adults. Retrieved October 3, 2014, from
Cornia, P. & Lipsky, B.A. (2014 February 4). Microbiology, epidemiology, and pathogenesis of bardetella pertussi infection. Retrieved October 3, 2014, from
Cornia, P., & Lipsky, B.A. (2014 March 13). Clinical manifestations and diagnosis of bardetlla pertussi infections in adolescents and adults. Retrieved October 3, 2014, from
Drutz, J.E.(2014, July14). Diphtheria, tetanus, and pertussis immunization in infacts and children 0 through 6 years of age. Retrieved on October 3, 2014 from
Centers for Disease Control and Prevention. (2014). Pertussis, whooping cough. Retrieved on October 3, 2014 from
MayoClinic. (2013). Whooping cough. Retrieved on October 6, 2014 from
Yeh, S. & Mink, C.M. (2014, June 17). Bordetella pertussis infection in infants and children: Clinical features and diagnosis. Retrieved October 3, 2014, from
Yeh, S. (2014, April 9). Treatment and prevention of bordetella pertussis in adolescents and adults. Retrieved October 3, 2014, from