Pertussis (Whooping Cough) Dr. Harivansh Chopra, DCH, MD Professor, Professor, Department of...

Pertussis Pertussis (Whooping Cough)(Whooping Cough)

Dr. Harivansh Chopra,Dr. Harivansh Chopra,DCH, MDDCH, MD

Professor,Professor,Department of Community Medicine,Department of Community Medicine,LLRM Medical College,LLRM Medical College,Meerut.Meerut. [email protected]@gmail.com

ObjectivesObjectives

1.1. To study the epidemiology of Pertussis.To study the epidemiology of Pertussis.

2.2. To study prevention and treatment of To study prevention and treatment of Pertussis.Pertussis.

04/21/2304/21/23 22DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

PertussisPertussis

1.1. Syadenham first Syadenham first used the term used the term “Pertussis”“Pertussis” (intense (intense cough) in1960.cough) in1960.

2.2. It is preferable to the It is preferable to the term term “whooping “whooping cough”cough” since most since most infected individuals infected individuals do not whoop. do not whoop.


EPIDEMIOLOGYEPIDEMIOLOGY

1.1. Worldwide Worldwide distribution.distribution.

2.2. Global burden in Global burden in terms of DALYs lost terms of DALYs lost was 12.95 million in was 12.95 million in 2002, and 2.95 lakh 2002, and 2.95 lakh died during the same died during the same year.year.



3.3. Pertussis is endemic with epidemic Pertussis is endemic with epidemic cycles every 2 – 3 years after cycles every 2 – 3 years after accumulation of susceptible cohorts.accumulation of susceptible cohorts.


India – Decline of PertussisIndia – Decline of Pertussis

1,63,000

26,700

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

Per

tuss

is C

ases

1987 2000

83.7%



4.4. Majority of cases Majority of cases occur from July occur from July through October.through October.



5.5. Extremely contagious, Extremely contagious, with attack rate as high with attack rate as high as 100% in susceptible as 100% in susceptible individuals exposed to individuals exposed to aerosol droplets at aerosol droplets at close range. close range.



6.6. Sub clinical Sub clinical infection is 50% in infection is 50% in fully immunized fully immunized and naturally and naturally immune individual.immune individual.


Agent FactorAgent Factor

1.1. Agent is Agent is Bacillus Bacillus pertussispertussis in majority of in majority of cases.cases.

2.2. In 5% cases In 5% cases Bacillus Bacillus parapertussisparapertussis..

3.3. Bacillus pertussisBacillus pertussis does does not survives for prolonged not survives for prolonged periods in the periods in the environmentenvironment


Source of InfectionSource of Infection

1.1. A case of pertussis, which may be mild, A case of pertussis, which may be mild, missed or unrecognized.missed or unrecognized.

2.2. Chronic carriage by humans is not Chronic carriage by humans is not documented.documented.04/21/2304/21/23 1111DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

Infective MaterialInfective Material

1.1. Nasopharyngeal and Nasopharyngeal and bronchial secretions – bronchial secretions – Droplet infection and Droplet infection and Direct contact.Direct contact.

2.2. Freshly contaminated Freshly contaminated fomites.fomites.


Infective PeriodInfective Period

A week after A week after exposure to about exposure to about 3 weeks after the 3 weeks after the onset of the onset of the paroxysmal stage.paroxysmal stage.

Secondary Attack rate is 90%.


Incubation PeriodIncubation Period

Ranges from 7 – 14 Ranges from 7 – 14 days.days.


Host Factor – Age Host Factor – Age

1.1. Primarily a disease of infants and pre-Primarily a disease of infants and pre-school children. school children.

2.2. Higher incidence found below five years Higher incidence found below five years of age.of age.


Host Factor – Age Host Factor – Age

3.3. Median age of infection :Median age of infection :1.1. Developing countries – 20-30 months.Developing countries – 20-30 months.2.2. Developed countries – 50 months.Developed countries – 50 months.

4.4. Infants < 6 months of age have highest mortality.Infants < 6 months of age have highest mortality.


Female children show higher incidence Female children show higher incidence and mortality.and mortality.

Host Factor – SexHost Factor – Sex


Host Factors - ImmunityHost Factors - Immunity

1.1. Infants are susceptible Infants are susceptible to infection from birth to infection from birth because there is no because there is no protection from maternal protection from maternal antibodies.antibodies.

2.2. Recovery from Pertussis Recovery from Pertussis and Adequate and Adequate Immunisation both lead Immunisation both lead to immunity.to immunity.


Host Factors - ImmunityHost Factors - Immunity

3.3. Neither natural disease nor vaccination Neither natural disease nor vaccination provides complete or lifelong immunity provides complete or lifelong immunity against reinfection or disease.against reinfection or disease.

4.4. Protection begins to wane 3 – 5 yrs after Protection begins to wane 3 – 5 yrs after vaccination; unmeasurable after 12 yrs.vaccination; unmeasurable after 12 yrs.

5.5. Subclinical reinfection contributes Subclinical reinfection contributes significantly to immunity against disease, significantly to immunity against disease, ascribed to vaccine or prior infection.ascribed to vaccine or prior infection.04/21/2304/21/23 1919DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

Catarrhal Stage

Paroxysmal Stage

Convalescent Stage

Due to long duration of the disease,Pertussis is also known as “100 day cough”.


Catarrhal StageCatarrhal Stage

1.1. The stage lasts for 7-14 The stage lasts for 7-14 days.days.

2.2. It is the most infectious It is the most infectious period.period.

3.3. Features:Features:1.1. Low-grade fever.Low-grade fever.2.2. Sneezing.Sneezing.3.3. Lacrimation.Lacrimation.4.4. Conjunctival suffusion.Conjunctival suffusion.


Catarrhal StageCatarrhal Stage

4.4. Cough:Cough:

1.1. Not paroxysmal in early stages, but more Not paroxysmal in early stages, but more annoying and frequent at night.annoying and frequent at night.

2.2. Does not improve with passage of time, Does not improve with passage of time, unlike upper respiratory tract infections.unlike upper respiratory tract infections.

3.3. Paroxysmal nature of cough can be Paroxysmal nature of cough can be suspected towards the later part of this suspected towards the later part of this phase.phase.04/21/2304/21/23 2222DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

Paroxysmal PhaseParoxysmal Phase

1.1. This stage lasts for 2-4 This stage lasts for 2-4 weeks weeks

2.2. Cough:Cough:

1.1. Initially dry, intermittent, Initially dry, intermittent, irritative hack.irritative hack.

2.2. Evolves into inexorable Evolves into inexorable paroxysms.paroxysms.


3.3. The bout of cough terminates with along The bout of cough terminates with along drawn out inspiratory crowing sound or drawn out inspiratory crowing sound or whoop.whoop.


Cough is a forced expiratory effort against closed glottis.

Hear cough, click here04/21/2304/21/23 2424DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

WhoopWhoopThe whoop is produced by the air rushing The whoop is produced by the air rushing in during inspiration through the half open in during inspiration through the half open glottis.glottis.

Hear whoop, click here04/21/2304/21/23 2525DR HARIVANSH CHOPRADR HARIVANSH CHOPRA


4.4. The paroxysms of cough may occur every The paroxysms of cough may occur every hour, or even frequently, and may hour, or even frequently, and may terminate by vomiting.terminate by vomiting.


5.5. The child may appear The child may appear chocked ,is unable to chocked ,is unable to breath, looks anxious breath, looks anxious and has suffused face.and has suffused face.




6.6. The whoop may not always present in The whoop may not always present in infants, who present with apneic or infants, who present with apneic or cyanotic spells.cyanotic spells.


INFANTS <3 MO DO NOT DISPLAY CLASSICAL STAGES. AFTER THE MOST INSIGNIFICANT STARTLE FROM A DRAUGHT, LIGHT, SOUND, SUCKING, OR STRETCHING, A WELL-APPEARING YOUNG INFANT BEGINS TO CHOKE, GASP, AND FLAIL EXTREMITIES, WITH FACE REDDENED. COUGH (EXPIRATORY GRUNT) MAY NOT BE PROMINENT.


WHOOP (FORCEFUL INSPIRATORY GASP) INFREQUENTLY OCCURS IN INFANTS <3 MO OF AGE WHO ARE EXHAUSTED OR LACK MUSCULAR STRENGTH TO CREATE SUDDEN NEGATIVE INTRATHORACIC PRESSURE


A WELL-APPEARING, PLAYFUL TODDLER WITH SIMILARLY INSIGNIFICANT PROVOCATION SUDDENLY EXPRESSES AN ANXIOUS AURA AND MAY CLUTCH A PARENT OR COMFORTING ADULT BEFORE BEGINNING A MACHINE-GUN BURST OF UNINTERRUPTED COUGHS, CHIN AND CHEST HELD FORWARD, TONGUE PROTRUDING MAXIMALLY, EYES BULGING AND WATERING, FACE PURPLE, UNTIL COUGHING CEASES AND A LOUD WHOOP FOLLOWS AS INSPIRED AIR TRAVERSES THE STILL PARTIALLY CLOSED AIRWAY.


WhoopWhoopThe whoop is produced by the air rushing The whoop is produced by the air rushing in during inspiration through the half open in during inspiration through the half open glottis.glottis.

Hear whoop, click here04/21/2304/21/23 3232DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

ADULTS DESCRIBE A SUDDEN FEELING OF STRANGULATION FOLLOWED BY UNINTERRUPTED COUGHS, FEELING OF SUFFOCATION, BURSTING HEADACHE, DIMINISHED AWARENESS, AND THEN A GASPING BREATH, USUALLY WITHOUT A WHOOP


Convalescent PhaseConvalescent Phase

1.1. During convalescence, the interval between During convalescence, the interval between the paroxysms of cough increases and the paroxysms of cough increases and severity of episode decreases gradually.severity of episode decreases gradually.

2.2. Paradoxically, in infants, coughs and Paradoxically, in infants, coughs and whoop may become louder and more whoop may become louder and more classic in convalescence. classic in convalescence.


Clinical Manifestations – Clinical Manifestations – Additional notesAdditional notes

1.1. Immunized children Immunized children have foreshortening of have foreshortening of all stages of pertussis.all stages of pertussis.

2.2. Adults have no distinct Adults have no distinct stages.stages.


3.3. In infants < 3months the catarrhal stage In infants < 3months the catarrhal stage is usually a few days or not recognized at is usually a few days or not recognized at all when apnea chocking or gasping all when apnea chocking or gasping cough herald the onset of disease.cough herald the onset of disease.

Clinical Manifestations – Clinical Manifestations – Additional notesAdditional notes


MCQsMCQs

1. Which of the following is not true about Pertussis –

1. The other name is “Whooping cough”.

2. The other name is “Hundred day cough”.

3. Everyone suffering from it must have whoop.

4. It is endemic with superimposed epidemic cycles every 2-3 years.

Ans. – 3.04/21/2304/21/23 3737DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

Diagnosis – ClinicalDiagnosis – Clinical1.1. High suspicion index in High suspicion index in

individual having pure or individual having pure or predominant complaint of cough predominant complaint of cough f/b vomitting, and f/b vomitting, and Absent:

1. Fever.2. Malaise / Myalgia.3. Exanthem / Enanthem.4. Sore throat, Hoarseness.5. Tachypnoea.6. Wheezes, Rales.


Diagnosis – ClinicalDiagnosis – Clinical

2.2. In infants < 3 months In infants < 3 months of age, Apnea or of age, Apnea or Cyanosis (before Cyanosis (before appreciation of cough) appreciation of cough) is the clue – is the clue – occasionally cause of occasionally cause of Sudden Infant Death.Sudden Infant Death.


1.1. Leukocytosis – Leukocytosis – 15,000-100,000cells/mm15,000-100,000cells/mm33..

1.1. Absolute lymphocytosis.Absolute lymphocytosis.

2.2. Absolute increase in neutrophils Absolute increase in neutrophils suggests a differential diagnosis or suggests a differential diagnosis or secondary bacterial infection. secondary bacterial infection.

Diagnosis – Blood pictureDiagnosis – Blood picture


Diagnosis – Chest radiographDiagnosis – Chest radiograph

1.1. Only mildly abnormal – Only mildly abnormal – perihilar infiltrate or edema perihilar infiltrate or edema (sometimes butterfly (sometimes butterfly appearance), and variable appearance), and variable atelectasis.atelectasis.

2.2. Parenchymal consolidation Parenchymal consolidation suggests secondary bacterial suggests secondary bacterial infection.infection.

3.3. Occasional Pneumothorax, Occasional Pneumothorax, Pneumomediastinum, and air Pneumomediastinum, and air in soft tissues.in soft tissues.

Pertussis pneumonia with hyperaeration (air trapping)


Diagnosis – Bacteriological testingDiagnosis – Bacteriological testing

1.1. Isolation of Isolation of Bacillus pertussisBacillus pertussis is the gold is the gold standard in diagnosis.standard in diagnosis.

2.2. Positive in catarrhal and paroxysmal Positive in catarrhal and paroxysmal stage.stage.


Diagnosis – SerologyDiagnosis – Serology

1.1. Tests for detection of antibodies in acute Tests for detection of antibodies in acute and convalescent samples are most and convalescent samples are most sensitive tests in immunised individuals.sensitive tests in immunised individuals.

2.2. Antibody to PT raised >2S.D. indicates Antibody to PT raised >2S.D. indicates recent infection.recent infection.

3.3. Useful epidemiologically.Useful epidemiologically.04/21/2304/21/23 4343DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

Differential DiagnosisDifferential Diagnosis

1.1. Adenoviral infections – Adenoviral infections – distinguishable by presence distinguishable by presence of fever, sore throat, and of fever, sore throat, and conjunctivitis.conjunctivitis.

2.2. Mycoplasma – Mycoplasma – distinguishable by history of distinguishable by history of fever, headache, & systemic fever, headache, & systemic symptoms; frequent rales on symptoms; frequent rales on chest auscultation.chest auscultation.


Differential DiagnosisDifferential Diagnosis

3.3. Afebrile pneumonia Afebrile pneumonia ((Chlamydia trachomatisChlamydia trachomatis) – ) – distinguishable by staccato distinguishable by staccato cough (i.e. breath with every cough (i.e. breath with every cough), purulent conjunctivitis, cough), purulent conjunctivitis, tachypnea, rales.tachypnea, rales.

4.4. Afebrile pneumonia (RSV) – Afebrile pneumonia (RSV) – distinguishable by lower distinguishable by lower respiratory tract signs.respiratory tract signs.


MCQsMCQs

3. Which of the following is diagnostic of pertusis

1. Leucocytosis with absolute lymphocytosis.

2. Leucocytosis with relative lymphocytosis.

3. Leucocytosis with neutropenia.

4. Leucocytosis with eosinopenia.


ComplicationsComplications

1.1. Apnea.Apnea.

2.2. Secondary infections :Secondary infections :

a.a. Otitis media.Otitis media.

b.b. Pneumonia.Pneumonia.

3.3. Flaring up of existing Flaring up of existing TB infection.TB infection.

4.4. Malnutrition.Malnutrition.


Complications – Complications – Physical Physical sequel of forceful coughingsequel of forceful coughing

1.1. Conjuctival and Conjuctival and Scleral hemorrhage.Scleral hemorrhage.

2.2. Petechiae in upper Petechiae in upper body.body.

1.1. Conjuctival and Conjuctival and Scleral hemorrhage.Scleral hemorrhage.

2.2. Petechiae in upper Petechiae in upper body.body.


3.3. Epistaxis.Epistaxis.

4.4. Hemorrhage in Hemorrhage in CNS and Retina.CNS and Retina.

3.3. Epistaxis.Epistaxis.

4.4. Hemorrhage in Hemorrhage in CNS and Retina.CNS and Retina.



5.5. Pneunomothorax.Pneunomothorax.

6.6. Subcutaneous emphysema.Subcutaneous emphysema.

7.7. Umbilical and inguinal Umbilical and inguinal hernia.hernia.

5.5. Pneunomothorax.Pneunomothorax.

6.6. Subcutaneous emphysema.Subcutaneous emphysema.

7.7. Umbilical and inguinal Umbilical and inguinal hernia.hernia.



TreatmentTreatment

1.1. Antibiotics are useful only in the catarrhal Antibiotics are useful only in the catarrhal stage.stage.

2.2. Once the child goes in paroxysmal stage it Once the child goes in paroxysmal stage it is very difficult to abort the attack.is very difficult to abort the attack.


TreatmentTreatment

1.1. Erythromycin 40-50 mg/kg/day in 4 divided Erythromycin 40-50 mg/kg/day in 4 divided doses X 14days. (Maximum 2 gm / 24 doses X 14days. (Maximum 2 gm / 24 hrs.)hrs.)

2.2. Respiratory Isolation for Respiratory Isolation for ≥ 5 days after ≥ 5 days after start of Erythromycin therapy.start of Erythromycin therapy.04/21/2304/21/23 5252DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

Alternative drugsAlternative drugs

1.1. Clarithromycin 15-20 mg/kg/day in 2 div Clarithromycin 15-20 mg/kg/day in 2 div doses X 7 days. (Maximum 1 gm/24 hrs.)doses X 7 days. (Maximum 1 gm/24 hrs.)

2.2. Azithromycin 10 mg/kg/day once daily X 5 Azithromycin 10 mg/kg/day once daily X 5 days.days.


Alternative drugsAlternative drugs

3.3. Ampicillin, Rifampicin and Cotrimoxazole Ampicillin, Rifampicin and Cotrimoxazole are modestly active against pertussis.are modestly active against pertussis.

4.4. The 1The 1stst and 2 and 2ndnd generation Cephalosporins generation Cephalosporins are not active against pertussis.are not active against pertussis.


MCQsMCQs

2. The attack of pertussis can be aborted with the help of antibiotics only if the is treated :

1. In catarrhal stage.

2. In paroxysmal stage.

3. In convalescent stage.

4. In all the above stages.


MCQsMCQs

5. The drug of choice for the treatment of Pertusis & its dose is

1. Erythromycin 40-50 mg/kg/day

2. Cephalexin 50-100 mg/kg/day

3. Cotrimoxazole 5-8 mg/kg/day

4. Tetracyclin 20-40 mg/kg/day


Care of Household and Close Care of Household and Close Contacts – ChemoprophylaxisContacts – Chemoprophylaxis

Erythromycin 40-50 Erythromycin 40-50 mg/kg/day in 4 mg/kg/day in 4 divided doses X 14 divided doses X 14 days regardless of days regardless of age, history of age, history of immuinisation, and immuinisation, and symptoms.symptoms.


Care of Household and Close Care of Household and Close Contacts – ImmunisationContacts – Immunisation

Situation for contact < 7 yearsSituation for contact < 7 years Recommendation Recommendation

Not vaccinated against pertussisNot vaccinated against pertussis Initiate Initiate vaccinationvaccination

Partially vaccinated against Partially vaccinated against pertussispertussis

Complete the Complete the recommended recommended scheduleschedule

Received 3Received 3rdrd dose > 6 mths. back dose > 6 mths. back Booster doseBooster dose

Received 4Received 4thth dose dose ≥ 3 years back≥ 3 years back Booster doseBooster dose


PREVENTIONPREVENTIONVACCINES

PurifiedAcellularVaccine

Whole CellVaccine


Whole cell vaccine (DTP) Whole cell vaccine (DTP)

1. Developed in late 1940s.

2. Bacteria killed by heat or formalin.

3. Controversial because of local and systemic side effects:

1. Redness, Pain, Swelling.

2. Fever (30-70%).04/21/2304/21/23 6060DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

Whole cell vaccine (DTP) Whole cell vaccine (DTP)

4. National Childhood Encephalopathy Study (Britain) :

1. Infantile Spasms.

2. Sudden Infant Death Syndrome (SIDS).

5. Efficacy :1. Three doses.

2. 80 - 90% effective.


Purified acellular vaccine Purified acellular vaccine (DTaP)(DTaP)

1. Introduced in 1981 by Japan.

2. Contains subcomponents of bacteria:

1. Filamentous Hemagglutinin (Fha).

2. Pertussis Toxin (PT).04/21/2304/21/23 6262DR HARIVANSH CHOPRADR HARIVANSH CHOPRA

Purified acellular vaccine (DTaP)Purified acellular vaccine (DTaP)

3. Efficacy1. Two doses.

2. 70% protection against culture confirmed infection.

3. 80% protection against severe whopping cough.


DTP VaccineDTP Vaccine1. Content (BE ltd.):

1. Diptheria toxoid ≥20Lf to ≤30Lf.

2. Pertussis ≥4 IU.

3. Tetanus toxoid ≥5Lf to ≤25Lf.

2.2. Dose – 0.5 ml.Dose – 0.5 ml.

3.3. Route – Deep Route – Deep intramuscular.intramuscular.

4.4. Recommended site – Recommended site – Antero-lateral part of thigh.Antero-lateral part of thigh.


Vaccination Schedule Vaccination Schedule

1. Immunization Policy :1. 3 DPT doses during first year of life.

2. EPI recommendation 6, 10, 14 weeks.

2. Booster Policy :1. 4th DPT vaccine at 12 to 24 months.

2. 5th DPT vaccine used by some countries (In India, given 3 years after 4th dose).


Contraindications to vaccinationContraindications to vaccination

1.1. Personal or strong family history of Personal or strong family history of epilepsy, convulsions or similar CNS epilepsy, convulsions or similar CNS disorders.disorders.

2.2. Any febrile upset until fully recovered.Any febrile upset until fully recovered.

3.3. Reaction to one of the previously given Reaction to one of the previously given triple vaccines. triple vaccines.


MCQsMCQs

4. What is the correct composition of DPT vaccine

1. D ≥40Lf; P ≥4 IU; T ≥5Lf to ≤25Lf.

2. D ≥20Lf to ≤30Lf; P ≥10 IU; T ≥5Lf to ≤25Lf.

3. D ≥20Lf to ≤30Lf; P ≥4 IU; T ≥5Lf to ≤25Lf.

4. D ≥20Lf to ≤30Lf; P ≥4 IU; T ≤25Lf.


Diphtheria toxoid; Tetanus toxoid; Pertussis vaccine; Diphtheria toxoid 25 Lf, tetanus toxoid 10 Lf, purified Bordetella pertussis antigens (pertussis toxoid 25 mcg, filamentous haemagglutinin 25 mcg, 69 kDA outer membrane protein 8 mcg) per 0.5 mL; aluminium hydroxide (adsorbant),


Dose: 0.5 mL IMI. Primary course: 3 doses at 2, 4 and 6 months, then 4th dose at 18 months, 5th dose at 4-5 years


ConclusionsConclusions

1.1. Pertussis is a vaccine preventable Pertussis is a vaccine preventable disease caused by disease caused by Bacillus pertussis.Bacillus pertussis.

2.2. It is characterised by intensive cough It is characterised by intensive cough and whoop, and absence of other and whoop, and absence of other systemic features.systemic features.

3.3. Highly contagious disease – prophylaxis Highly contagious disease – prophylaxis of all contacts recommended.of all contacts recommended.


TABLE 3 COMPOSITION OF DPT VACCINES

CONTENTS GLAXO (PER 0.5ML) KASAULI

DIPHTHERIA TOXOID

TETANUS TOXOID

B. PERTUSSIS (MILLIONS)

AI. PHOSPHATE

THIOMERSAL, B.P.

25LF

5LF

20 000

2.5 MG

0.01%

30 LF

10 LF

32 000

3.0 MG

0.01%


Pertussis (Whooping Cough) Dr. Harivansh Chopra, DCH, MD Professor, Professor, Department of...

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