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.
- What Is the Typical Presentation and Progression of Pertussis?
- Can Pertussis Be Diagnosed with Clinical Signs and Symptoms Alone, or Is Laboratory Testing Required?
- What Is the Preferred Diagnostic Laboratory Test for Pertussis?
- Why Does Pertussis Remain a Common Disease Despite High Vaccination Rates?
- Why Did the Vaccine Recommendations Change for Adolescents in 2005 and Pregnant Patients in 2012?
- Should Nonmaternal Caretakers of Infants or Close Contacts of Health Care Workers Be Given Tdap Boosters?
- If a Patient Has a Seizure After Administration of Any Dose of DTaP or Tdap, Are Additional Doses Contraindicated?
- What Antibiotic Should Be Used to Treat Patients with Pertussis?
- Should Pertussis-Related Cough Be Treated with Adjunct Therapies?
- Who Should Receive Antibiotic Prophylaxis?
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
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.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
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
Inconclusive results from trials and a meta-analysis; recommended by Centers for Disease Control and Prevention guidelines
Consistent findings from a meta-analysis; recommended by guidelines
Recommended by guidelines; vaccines have limited long-term effectiveness
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
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