brand logo

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

Patient information: A handout on this topic is available at

This clinical content conforms to AAFP criteria for CME.

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.



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.

The incidence of pertussis in the United States decreased with universal childhood immunization, but it has rebounded steadily in recent years, from a low of 1,010 reported cases in 1976 to a peak of 48,277 cases in 2012.4 The most recent available data show 15,609 reported cases in 2018.5

What Is the Typical Presentation and Progression of Pertussis?

There are three stages of pertussis (catarrhal, paroxysmal, and convalescent), each with a different clinical presentation (Table 1).68 However, clinical presentation varies widely depending on age and immunization status, and not every patient has the classic stage progression.9

StageDurationSigns and symptoms
Catarrhal1 to 2 weeksHighly contagious
Insidious onset with gradual progression
Malaise, rhinorrhea, dry cough, and lacrimation
No or mild fever
Paroxysmal1 to 6 (sometimes up to 10) weeksApnea associated with paroxysms
Chest and abdominal soreness
Leukocytosis, lymphocytosis, and weight loss
Paroxysmal coughing (periods of rapid succession coughing during one exhalation)
Posttussive emesis, cyanosis, and exhaustion
Scleral hemorrhage
Whooping on inspiration after coughing
Convalescent2 to 4 weeksCoughing lessens
Susceptibility to respiratory infections


The key clinical features of the initial catarrhal stage are difficult to distinguish from a viral upper respiratory tract infection and include malaise, rhinorrhea, dry cough, and lacrimation. Fever is usually mild or absent. After one to two weeks, the paroxysmal stage may manifest. Typical features of this stage include paroxysmal coughing, whooping on inspiration after coughing, and posttussive emesis.

Other common features of the paroxysmal stage include periods of apnea associated with paroxysms, chest and abdominal soreness from prolonged coughing, and scleral hemorrhage. In between paroxysms, the patient may be asymptomatic. The paroxysmal stage typically lasts up to six weeks before transitioning to the convalescent stage. In this stage, the coughing lessens but typically persists for an additional two to four weeks, with some patients experiencing symptoms for a longer period (e.g., “100-day cough”).7,1012

Can Pertussis Be Diagnosed with Clinical Signs and Symptoms Alone, or Is Laboratory Testing Required?

The diagnosis of pertussis requires laboratory confirmation. Because early detection and treatment are critical to reducing transmission, accurate identification of the clinical features of pertussis is important to prompt testing.


No validated, accepted clinical decision rule has been established for diagnosing pertussis.13 However, the key clinical features of the infection are included in CDC and World Health Organization (WHO) case definitions. The CDC case definition of pertussis includes coughing of any duration and at least one sign or symptom (i.e., paroxysmal coughing, inspiratory whooping, posttussive emesis, or apnea) and contact with a laboratory-confirmed case of pertussis, or at least two weeks of coughing and one of these signs or symptoms.14 The WHO definition adds the clinical suspicion of pertussis and specifies that apnea is a criterion only in infants younger than one year.15 Although sensitive, the CDC and WHO criteria lack specificity.13

Two 2017 systematic reviews evaluated the clinical features used in the diagnosis of pertussis (Table 2).13,16 One found that the best clinical predictors of pertussis in adults were the presence of whooping (positive likelihood ratio [LR+] = 1.45) and posttussive emesis (LR+ = 1.46), and the best negative predictors were a lack of paroxysmal coughing (negative likelihood ratio [LR−] = 0.33) and presence of fever (LR− = 0.97).16 However, the second systematic review reported minimal value of individual signs and symptoms, with the clinician's overall impression having the highest likelihood ratio out of both reviews (LR+ = 3.3).13

Already a member/subscriber?  Log In


From $145
  • Immediate, unlimited access to all AFP content
  • More than 130 CME credits/year
  • AAFP app access
  • Print delivery available

Issue Access

  • Immediate, unlimited access to this issue's content
  • CME credits
  • AAFP app access
  • Print delivery available

Article Only

  • Immediate, unlimited access to just this article
  • CME credits
  • AAFP app access
  • Print delivery available
Purchase Access:  Learn More

Continue Reading

More in AFP

More in Pubmed

Copyright © 2021 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.