Pertussis: Common Questions and Answers

 

Am Fam Physician. 2021 Aug ;104(2):186-192.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/whooping-cough.

Pertussis, also known as whooping cough, remains a public health concern despite expanded immunization recommendations over the past three decades. The presentation of pertussis, which is variable and evolves over the course of the disease, includes nonspecific symptoms in the catarrhal stage, coughing with the classic whooping in the paroxysmal stage, and persistent cough in the convalescent stage. When there is clinical suspicion for pertussis, the diagnosis should be confirmed using polymerase chain reaction testing, which has replaced culture as the preferred confirmatory test. Recent evidence has confirmed a waning of acquired immunity following pertussis immunization or infection, leading to changes in tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) immunization recommendations. Patients 11 years or older should receive at least one dose of Tdap, although Tdap may replace any dose of the tetanus and diphtheria toxoids (Td) vaccine. All pregnant patients should receive Tdap between 27 and 36 weeks' gestation with each pregnancy to convey immunity to the newborn. Cocooning (vaccinating close contacts of high-risk individuals) is no longer recommended because immunized patients can still contract and transmit pertussis. A history of seizure or hypotonic-hyporesponsive episodes after a prior pertussis vaccination is no longer a contraindication to immunization. Antibiotic treatment is intended to prevent transmission of pertussis to others and does not shorten the disease course or improve symptoms. Antibiotic prophylaxis is recommended for household contacts of someone with pertussis and for those exposed to pertussis who are at high risk of severe illness (e.g., infants, people who are immunocompromised or in the third trimester of pregnancy) or in close contact with someone at high risk. Azithromycin is the preferred antibiotic for treatment or prophylaxis.

Pertussis, or whooping cough, is an acute respiratory tract infection that continues to affect a significant portion of the global population, with more than 24 million estimated cases in 2014.1 Pertussis, a Centers for Disease Control and Prevention (CDC) reportable disease, is caused by Bordetella pertussis. The disease can lead to substantial complications in infants, such as apnea, pneumonia, seizures, other hypoxic complications, hospitalization, or death.2,3 Bordetella parapertussis and rarely Bordetella bronchiseptica can also cause a pertussis-like syndrome.

WHAT'S NEW ON THIS TOPIC

Pertussis

Cocooning (vaccinating close contacts of infants and others at high risk) is no longer a recommended strategy because immunized persons can still contract and transmit pertussis.

Patients who receive the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during each pregnancy to provide passive immunity to their infants in periods shorter than five years do not experience increased adverse effects with multiple doses.

A 2014 Cochrane review found that symptomatic treatments for pertussis do not reduce coughing episodes or length of hospitalization.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

To diagnose acute pertussis, a polymerase chain reaction test using a nasopharyngeal swab should be performed, rather than culture, other testing, or symptomatic diagnosis.13,16,18

B

Consistent finding in a meta-analysis; guideline recommendations

Consider antibiotic prophylaxis within 21 days of exposure for household contacts of patients with pertussis and for those exposed to pertussis who are at high risk of severe illness or in close contact with someone at high risk.38,39

C

Inconclusive results from trials and a meta-analysis; recommended by Centers for Disease Control and Prevention guidelines

Prescribe azithromycin (Zithromax) as the preferred agent for the treatment and prophylaxis of pertussis.2,33

A

Consistent findings from a meta-analysis; recommended by guidelines

Administer Tdap in children seven to 10 years of age if the DTaP series is incomplete or if the patient's immunization status is unknown.4,28

C

Recommended by guidelines; vaccines have limited long-term effectiveness

Administer Tdap, rather than Td, in adolescents and in adults if not previously administered. For convenience, Tdap may replace any dose of Td that is otherwise due.4,28

C

Recommended by guidelines; vaccines have limited long-term effectiveness


DTaP = diphtheria and tetanus toxoids and acellular pertussis; Td = tetanus and diphtheria toxoids; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort

The Authors

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JONATHAN M. KLINE, PharmD, is the director of pharmacy and the director of the Pharmacy Residency Program at Jefferson Medical Center, Ranson, W.Va. He is also a clinical associate professor at West Virginia University Schools of Pharmacy and Medicine, Eastern Campus, Martinsburg....

ELEANOR A. SMITH, MD, is the pediatric clerkship director at Harpers Ferry (W.Va.) Family Medicine and an assistant professor at West Virginia University School of Medicine, Eastern Campus.

ADRIENNE ZAVALA, MD, is a physician at Harpers Ferry Family Medicine and an assistant professor at West Virginia University School of Medicine, Eastern Campus.

Address correspondence to Jonathan M. Kline, PharmD, West Virginia University Schools of Pharmacy and Medicine, Eastern Campus, 171 Taylor St., Harpers Ferry, WV, 25425 (email: klinejo@wvumedicine.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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