RUNNING HEADER: PERTUSSIS 1

Morgan Howe
Ferris State University
Nurs 319

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Abstract
Pertussis is the least controlled vaccine preventable disease. It affects 50 million people annually
worldwide. Despite the high rate of immunization against pertussis the number of cases
continues to rise. Multiple theories of why this is occurring exist. Waning immunity from the
vaccine, alterations in the cells protein as well as mutations causing increased production of
toxins are considered possible reasons for the up rise of pertussis.

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Pertussis
The incidence of pertussis in the United States prior to widespread use of a vaccine was
more than 265,000 in 1934 (Winter, Harriman, Zipprich, Schechter, Talerico, Watt, Chavez,
2012). Pearl Kendrick and Grace Eldering invented a vaccine for pertussis that was approved for
use by the American Academy of Pediatrics in 1943. By 1976, the number of cases had dropped
to 1010 (Shapiro-Shapin, 2010). With routine use of the vaccine the incidence of pertussis
dropped from 209 cases/ 100,000 residents to 51 cases/ 100,000 residents in 1948. The death rate
also dropped from 5.9/100,000 to less than 1/100,000 for the same years (Shapiro-Shapin, 2010).
Pertussis affects 50 million people worldwide every year (National Institute of Allergy and
Infectious Diseases NIAID, 2005). Over the past twenty years the number of pertussis cases per
year has continued to rise (Journal of the American Medical Association JAMA, 2012).
Despite the use of an effective vaccine pertussis is the least controlled vaccine
preventable disease in the US. In fact, the incidence of pertussis for 2003 to 2004 more than
doubled the number of cases from 2001 to 2002 with the majority of these cases being adults and
adolescents (Gidengil, Lee, & Sandora, 2008). This paper will examine pertussis, how it is
transmitted, what its clinical presentation is, the diagnosis and treatment, and the evidence
supporting why there is an uprising in the number of cases per year.
Transmission
Bordetella pertussis is a bacterium that causes the disease whooping cough or pertussis.
Pertussis is a respiratory disease that is highly contagious. It is spread from person to person by
either coughing or sneezing (Shea-Lewis, Hill and Soper, 2011) droplets from the respiratory
tract (Heininger, 2001). Pertussis is most severe for infants. The death rate is 1 percent. Infants
contract the pertussis bacterium from adults or other children (NIAID, 2005). Kendrick and
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Eldering found that a childs cough contained enough active bacterium to be contagious for the
first three weeks. They also found that by week four most children were not infectious and 90
percent of children were not contagious by week five (Shapiro-Shapin, 2010).
Clinical presentation
Pertussis has three stages: catarrhal, paroxysmal, and convalescent. In the catarrhal stage,
symptoms are like that of the common cold, such as mild upper respiratory symptoms, a low-
grade fever, runny nose, sneezing, and a cough. These symptoms are common in the first week.
The cough will become worse leading to the next stage, the paroxysmal phase. The paroxysmal
phase can last from one to six weeks; though may remain for as long as ten weeks. The
paroxysmal stage is noted to have a spasmodic cough with the distinct whooping sound when
inhaling. These whooping cough attacks are most common at night and may lead to vomiting and
exhaustion. The final stage, the convalescent phase is the slow and gradual recovery phase. This
phase can last months (Shea-Lewis et al., 2011).
Symptoms may vary by age. Infants may have apnea and seizures. Epidemiologic studies
suggest a link between pertussis and SIDS (NIAID, 2005). Other complications of pertussis
include pneumonia, otitis media, encephalopathy, fractured ribs, inguinal hernias, and severe
weight loss (Heininger, 2001).
Diagnosis and treatment
Diagnosis of pertussis is accomplished through a detailed history with examination of
possible exposure, a physical exam and a nasopharyngeal secretion culture. Cultures should be
taken to determine positive results of pertussis because other pathogens are known to cause
similar symptoms. Atypical symptoms are more common now due to high immunization rates.
Pertussis is often misdiagnosed by primary care providers in adults and adolescents. Regardless
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of the presence of typical pertussis symptoms, it is often diagnosed as an upper respiratory
infection or bronchitis (Heininger, 2001).
Treatment for pertussis is antibiotic therapy, though it is best to prevent transmission of
the disease by vaccination (Shea-Lewis et al., 2011). A macrolide antibiotic is the preferred
medication. Erythromycin is the drug most often used. Studies have shown its ability to eradicate
pertussis from the nasopharynx. A fourteen day course is recommended to ensure complete
eradication of pertussis, though it has been shown to happen within a few days of starting
antibiotic treatment. It may be possible for a strain of pertussis to be resistant to erythromycin.
Two reports have shown a resistant strain, but there have been no more reports since 1994 and
1997 (Heininger, 2001). The benefit of medication is limited for patients with a cough lasting
more than 21days; except in the high risk populations such as infants (Gidengil, Lee, and
Sandora, 2008).
Prevention of contracting pertussis is ideal. This can be done by avoiding exposure,
prophylactic medication and immunization. Avoiding exposure is unrealistic because it is
commonly spread before diagnosis is made. Prophylactic medication such as erythromycin
should be given to those in close contact with the diagnosed person.
There are two forms of the pertussis vaccine; whole cell and acellular. The acellular
pertussis vaccine is less likely to cause adverse reactions than its whole cell counterpart
(Heininger, 2001). Whole cell vaccine was used until the 1990s. It is made of killed Bordetella
pertussis organisms. It is thought that the acellular vaccine that has three to five different purified
pertussis components may not be as effective as the whole cell vaccine (Friedrich, 2011).
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Immunization for pertussis is done in a series of five vaccinations. Pertussis is included
in the DTaP immunization. The DTaP immunization is a combination injection covering
multiple diseases. DTaP includes immunizations for diphtheria, tetanus and acellular pertussis.
The first three immunizations are given at two, four and six months of age. The next one
is given between 15 and 18 months and the last is given between four and six years of age (Shea-
Lewis et al., 2011). A booster shot is encouraged for people who have completed the course,
ages 11-64. This single dose of Tdap is recommended by the Advisory Committee on
Immunization Practices (ACIP) and contains tetanus, diphtheria and acellular pertussis vaccines
(Shea-Lewis et al., 2011). In a large-scale clinical study, the booster vaccine for adults and
adolescents has shown to be 90 percent effective. The director of the National Institute of
Allergy and Infectious Diseases was quoted as saying, This new study shows that an effective
adult acellular pertussis vaccine is feasible and if routinely used could provide the US population
greater protection against the disease (NIAID, 2005).
Immunized children can still contract pertussis. They are not as infectious. It is also less
likely for them to have severe outcomes, such as hospitalization because symptoms are milder
(JAMA, 2012).
Promoting factors
Veenema (2013) states there are several factors contributing to the spread of infectious
diseases. These factors include, but are not limited to; immune status, climate and weather, risk
behaviors, human demographics and behavior (p. 431). These factors pertain to the pertussis
infection as well.
The immune status of a person refers to their ability to fight off infections. Veenema
(2013, p. 431) states, the wide spread use of vaccines has increased the proportion of the
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population that can successfully ward off many conditions The likelihood of a person
contracting pertussis is low if they are up-to-date on their DTaP immunization and if they have
had the recommended booster Tdap. A risk behavior would be choosing to not be vaccinated for
whatever the reason may be.
According to aarogya.com (2014) climate and weather affect the spread of pertussis.
While it is possible to contract pertussis at any time of the year, it is more common during the
winter and spring months due to overcrowding. Overcrowding is common in the lower socio-
economic class (demographic) and is reflected in the number of pertussis cases among this
group.
Analysis of evidence
According to the Journal of the American Medical Association (2012) there has been a
slow and steady uprising of pertussis cases since the all-time lows in the 1970s in the United
States. The number of cases of pertussis for 2012 exceeded the number of cases from the
previous five years for the same time frame (JAMA, 2012). Documentation on this up-swing of
the number of cases of pertussis is vast. The biggest being that of the number of cases in
California for 2010. The number of cases reported was seven times more than the previous year
including eight infant deaths. Five other states have reported resurgence in pertussis cases as well
(Shea-Lewis et al., 2011).
There are a number of possible explanations for why there is an uprising of pertussis
cases. The high incidence of cases of adolescence in Washington suggests a diminishing
immunity from the vaccine (JAMA, 2012). The number of cases more than doubled for adults
and adolescents in the 1990s supporting the conclusion that protection from earlier childhood
immunization was declining (NIAID, 2005).
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Another study of the incidence rates for Minnesota and Oregon was conducted in the
years following completion of the five doses of DTaP. This study found that the incidence rates
rose each year of the follow-up. After the first year the incidence rate was 15.6/100,000 and at
year six it had risen to 138.4/100,000 in Minnesota. Findings were similar in Oregon as well.
Oregon incidence rates at one year post-vaccination were 6.2/100,000 and increased to
24.4/100,000 after six years (Tartof, Lewis, Kenyon, White, Osborn, Liko, Zell, Martin,
Messonnier, Clark, & Skoff, 2013).
Gidengil, Lee, and Sandora (2008) found the majority of pertussis cases were among
adults and adolescents. Adults and adolescents accounted for 60 percent of cases. The group
having the highest number of cases for 2004 was people age 10-18 years with 6,500 reported
cases. Infants six months and under came in second with 2,200 reported cases (NIAID, 2005).
A study of the seroprevalence for pertussis and other vaccinated diseases was conducted
in Singapore. The study examined children ages 1-17 years. The study found that an overall
seroprevalence for pertussis antibodies was only 60.8 percent. It also revealed that within a year,
those who had the three recommended doses by age two had 85.0 percent seroprevalence for
pertussis antibodies. This percentage decreased to 75.0 percent in those who had the vaccine just
one year before the study. In those who had received the vaccine two years before the study were
found to have a seroprevalence of 63.1 percent. The seroprevalence for those who were four
years or more post vaccine had about a 50 percent seroprevalence of pertussis antibodies.
Because of decreasing immunity shown by this study suggest routine boosters should be
administered to ensure continued immunity (Laia, Thoonb, Anga, Teya, Henga, Cuttera, Phoonc,
& Chowc, 2012).
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Another possible theory for the uprising of pertussis cases is an antigenic shift due to
immunization against pertussis. This is believed to be a possible explanation because of the
increase in the number of pertussis cases during the 1990s with a high vaccination rate. These
trends were also observed in other countries such as Australia, Canada, and the Netherlands
(Gidengil, Lee, and Sandora, 2008).
In an article by Friedrich (2011) it was found that there were small alterations to proteins
of pertussis that were different than the current strains of pertussis. The senior scientist at the
National Institute for Public Health and the Environment in Bilthoven, Netherlands, Fritz Mooi,
PhD. says, the differences are small, but we think they are immunologically relevant. This
difference may make the current vaccine less effective due to mismatched antigens.
Mooi also believes that another reason may be a mutation causing more pertussis toxin to
be produced by the cell. This toxin suppresses the immune system. This increased toxin
production and the alterations to the proteins may contribute to the increase in cases of pertussis.
According to Winter, Harriman, Zipprich, Schechter, Talarico, Watt, and Chavez (2010)
other possible explanations for the resurgence of pertussis include more susceptible babies being
born, use of acellular vaccine instead of the whole cell version, and better detection of infection.
Winter et al (2010) suggest the protection provided by acellular vaccine diminishes from the
immune system faster than that of the whole cell vaccine that was previously used. This may
suggest a need to use the whole cell vaccine (Gidengil, Lee, & Sandora, 2008).
Dr. James Cherry has a similar opinion of why pertussis is on the rise. He believes the
increase in cases is due to better awareness and detection of pertussis. He also believes that the
effectiveness of the acellular vaccine is less than the whole cell vaccine that was used in the early
1990s (Friedrich, 2011).
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To combat the rising number of pertussis cases among adolescents, Dr. Thomas Clark a
medical epidemiologist at the CDCs National Center for Immunization and Respiratory
Diseases suggests a booster dose for 11 to 12 year olds. He is quoted as saying, We still have a
ways to go since were at about 65% coverage. Theres room for improvement, but weve seen
less of an increase in this age group during this most recent outbreak (Friedrich, 2011).
Clark found that with the booster dose for ages 11 to 12 year olds there was then an
increase in cases of 7 to 10 year olds. This supports the conclusion that immunity is diminishing
sooner after the childhood series. Clarks position is that the problem does not have to do with
children not getting vaccinated. He believes that the problem is decreasing immunity. He plans to
focus on determining the length of time children will have protection after they complete the
series and have had the boosters. This will ensure doses are given at appropriate times to provide
protection (Friedrich, 2011).
Conclusion
Pertussis is a major problem for not only the United States, but other countries as well.
The exact reason is unknown. The various reasons are decreased effectiveness of the acellular
vaccine, antigenic shift or alterations in the proteins and genetic mutation causing increased
production of toxin. The only suggestion to help decrease the number of pertussis cases is to
administer booster doses of pertussis, but at this time the exact time frame for these boosters is
not known. Pertussis remains the least controlled vaccine preventable disease.

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