Pertussis

(Whooping Cough or
Hundred
Day
Cough)
Thein Shwe, MPH, MS, MBBS
VPD & IBD Epidemiologist
DIDE 4th Quarter Training
11/18/2009
1

Objectives

To describe clinical description, diagnosis and

epidemiology of pertussis

To understand
Investigation of a case of pertussis and outbreak of pertussis

To review U. S. and West Virginia pertussis surveillance

data

Disease Description

Pertussis, a cough illness commonly known as

whooping cough (100 Day Cough), is caused by the
bacterium Bordetella pertussis.

Prolonged paroxysmal cough often accompanied by an

inspiratory whoop.

Varies with age and history of previous exposure or

vaccination.

Neither infection nor immunization provides lifelong

immunity
3

Other Bordetella species

Three other Bordetella species:

B. parapertussis,
B. holmesii, and
B. bronchiseptica.

B. pertussis and B. parapertussis coinfection is

not unusual.

Disease with Bordetella species other than B.

pertussis is not reportable.
4

Clinical Description of Pertussis

Stages
(6-10 wks.)

Catarrhal
(1-2 wks.)

Paroxysmal
(1-2 wks.)

Symptoms

mild URT
symptoms,
intermittent
dry cough

Infants <6
mths.

Gagging,
gasping or
apnea

No whoop

Convalescent
(up to 3 mths.)

coughing
spasms
inspiratory
whoop
Post-tussive
vomiting
Prolonged

SOUND OF PERTUSSIS
HTTP://WWW.SOUNDSOFPE
RTUSSIS.COM/SOUND_OF_
PERTUSSIS.CFM
6

Epidemiology of Pertussis
Mode of transmission
Person to person via
Aerosolized droplets from cough or sneeze
Direct contact with secretions from respiratory tract of infectious person

80% - secondary attack rate

Older children and adults are important sources of disease for

infants and young children

Infants <12 months of age greatest risk for complications and

death

Epidemiology of Pertussis cont.

Reservoir - Humans
Incubation period 7-10 days (5-21 days).
Infectious period Most contagious during the
catarrhal stage and the first 2 weeks after
cough onset
Duration of illness:
Children: 6-10 wks.
~ of Adolescents: 10 wks or longer
8

Pertussis Complications

Syncope (temporary loss of consciousness/faint)

Sleep disturbance
Incontinence
Rib fractures
Complications among infants

Pneumonia (22%)
Seizures (2%)
Encephalopathy (<0.5%)

Death
Infants, particularly those who have not received a primary
vaccination series, are at risk for complications and
mortality.

Pertussis Laboratory
Diagnosis

10

Pertussis Laboratory Testing

Culture

PCR

DFA

Serology

Specimen

NP Swabs or
aspirates

NP Swabs or
aspirates

NP Swab

Blood

Advantages

Gold
standard
100%
Specific

Results
available
quickly

Rapid results

Disadvantage
s

Relatively
insensitive
Difficult to
isolate
Most
successful
during the
catarrhal
stage
Takes 7-10
days to get
the result

Sensitivity &
specificity
varies

Not
confirmatory

Comments

Calcium
alginate
swabs cannot
be used to
collect NP
swabs for PCR

Use with

No use for
surveillance

Use with

No
standardized
test available
No use for
Surveillance

Use with 11

Proper Technique for Obtaining a

Nasopharyngeal Specimen for Isolation of B
pertussis

12

Nasopharyngeal
Swab Collection
Procedure
http://content.nejm.org/cgi/c

ontent/full/NEJMe0903992/DC1

13

Why do We do Pertussis
Surveillance?

To assess burden of disease and guide policy and

control strategies
e.g., vaccination of postpartum mothers and adult and
adolescent contacts of infants

To monitor disease trends and identify populations at

risk

To identify clusters of related cases that might

indicate an outbreak

To monitor changes in the B. pertussis organism

14

Pertussis Case
Investigation
&
Outbreak
Investigation
15

CDC/CSTE
PERTUSSIS CASE
DEFINITION
16

Pertussis Clinical Case

Definition
1.
2.

A Cough illness lasting at least 2

weeks
With one of the following:
- paroxysms of coughing, or
- inspiratory whoop, or
- posttussive vomiting;

And
without other apparent cause (as reported
by a healthcare professional)
17

Laboratory Criteria for

Diagnosis
Isolation

of Bordetella pertussis from

a clinical specimen (Culture)

Positive

polymerase chain reaction

(PCR) assay for B. pertussis DNA

18

Case Classification

1.
2.
3.

Probable:

Meets the clinical case definition,

Not laboratory confirmed, and
Not epidemiologically linked to a laboratory-confirmed
case

Confirmed:
A case of acute cough illness of any duration with
a positive culture for B. pertussis
A case that meets the clinical case definition and
is confirmed by PCR
A case that meets the clinical definition and is
epidemiologically linked directly to a case
confirmed by either culture or PCR
19

Pertussis Case Investigation

EXERCISES

20

What would you do with this

pertussis laboratory report?
Exercise 1 Submitter:
Patient Name: Smith, James
Office of Lab Services
Address: 234 A St
167 11 th Ave.
Charleston, WV 25311
S. Charleston,
WV25303
DOB: 06/12/2005
Attention To: Dr Bloom
Age: 4 yrs
Sex: Male
______________________________________________________
Specimen source: Nasopharyngeal

Collection date: 11/7/09

Culture:
Bordetella pertussis isolated
Reported date: 11/14/09

21

Does it meet the lab

criteria?
- Check lab criteria for diagnosis

22

Exercise 2
Patient Name: Bond, James
Address: Peace Ave.
WV
Star City, WV 26503
DOB: 03/1/1985
Age: 24 yrs
Sex: Male
_____________________________________________
Specimen source: Nasopharyngeal

WVU Hospital
Morgantown,
Attention To:
Dr Moody

Specimen date: 11/10/09

Bordetella by Rapid PCR

Result - Bordetella pertussis DNA detected
Reported date: 11/12/09
23

Does it meet the lab

criteria?
- Check lab criteria for diagnosis

24

Exercise 3

Patient Name: A Pullman Lab Corp of America

DOB: 10/7/1998
Dublin, Ohio
Address: Clarksburg, WV
____________________________________________
Test Name B pertussis IgM Ab, Quantitative
Comment: Positive = >1.1, Negative = <1.0,
Borderline = 1.0 -1.1
B pertussis IgM result = 1.7

25

Does it meet the lab

criteria?
- Check lab criteria for diagnosis

26

PERTUSSIS CASE
INVESTIGATION
REGARDLESS OF TYPE OF TEST
AND RESULT,
ALL PERTUSSIS REPORTS
SHOULD BE INVESTIGATED
IMMEDIATELY
27

Importance of Rapid Case

Identification

Early diagnosis and treatment to limit disease

spread

Identify and provide prophylaxis to close

contacts pending laboratory confirmation

When suspicion of pertussis is low, investigation

can be delayed pending laboratory confirmation
Exception: prophylaxis of infants and their household
contacts should NOT be delayed
28

What is the next step in a

case investigation?

Refer to Pertussis Protocol

Use Pertussis WVEDSS form

Begin your case ascertainment

29

Pertussis Surveillance
Protocol

http://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/PERTUSSIS%20Protocol
%20Sept2007.pdf

30

Pertussis WVEDSS Form

31

How do you ascertain a

case?

Three pieces of information needed

to determine if you have a pertussis
case

1.

Clinical information
Additional laboratory report(s)
Epidemiological information

2.
3.

32

What information would you obtain

from a provider?

33

What information would you

obtain from a provider? contd

34

What would you obtain from

the patient/parent?

35

What Epidemiological
information do you need to
obtain?

36

Contact Tracing of a
Pertussis Case

37

Management for Exposed persons

Type of Contact

Evaluate Vaccinate Prophylaxis/

& Lab
treatment

Asymptomatic
Within 3 weeks

No

Yes

Yes

Asymptomatic
> 3 weeks

No

Yes

Consider for
households with highrisk contacts (infants,
pregnant women,
people who have
contact with infants)

Symptomatic

Yes
Collect
NP
swab

Yes

Yes

Postexposure Prophylaxis for Pertussis in

Infants, Children, Adolescents, and Adults
Source: Red Book 2009 AAP pg. 507

Age

Azithromycin
(Recommende
d)

Erythromycin
Recommende
d

Clarithromycin
(Recommended
)

TMP-SMX
(alternative)

<1mo

10mg/kg/day as a
single dose for 5
days

40mg/kg/day in 4
divided
dosesx14days

Not recommended

CI at <2 mo of
age

1-5 mo

See above

See above

15mg/kg/day in 2
divided doses x 7 days

2mo of
age:TMP,8mg/kg/
day;SMX,40mg/kg
/day in 2 doses x
14 days

6 mo
or older
&
children

10mg/kg/day as a
single dose on day
1(maximum 500
mg); then 5
mg/kg/day as a
single dose on days
2-5(maximum 250
mg/day)

40 mg/kg/day in 4
divided doses for 14
days (maximum
2g/day)

15mg/kg/day in 2
divided doses x 7 days
(maximum 1 g/day)

See above

Adolesc
ents &
adults

500 mg as a single
dose on day 1, then
250 mg as a single

2g/day in 4 divided
doses for 14 days

1g/day in 2 divided
doses for 7 days

TMP, 200 mg/day;

SMX,1600 mg/day
in 2 divided39
doses

Once the investigation is

completed:

Document public health action

Check case classification
Print the report for your files or per your
LHD policy & procedure
Send lab report(s) to DIDE
Submit completed WVEDSS report
electronically to your regional
epidemiologist and DIDE
40

Pertussis Outbreak Case

Definition
Outbreak is defined as:

Two or more cases

Involving two or more households
Clustered in time & space AND
One case must be confirmed by
positive culture

41

Pertussis Outbreak Line List Form

http://www.wvidep.org/Portals/31/PDFs/IDEP/Pertussis/Pertussis%20Outbreak%20Linelisting
%20Form.pdf

42

Outbreak Notification and

Control

Notify your regional epidemiologist &

DIDE
immediately

Evaluate case status & manage close

contacts

Obtain nasopharyngeal swabs for culture

(confirmation) and PCR
43

Outbreak Control in Any Settings

Treat/Prophylax with recommended antibiotic

Isolate 5 days after starting antibiotic

treatment
or 21 days from cough onset if no treatment

Bring immunizations up-to-date

Accelerated vaccination if cases are occurring
young infants

44

Alert your providers and notify the

parents

Healthcare Providers
Send Health alert letter
Provider information sheet

Parent/Guardian
Send notification letter
Public information sheet

45

Exposures in Child Care

Exposed Children (especially incompletely

immunized) and childcare providers should be
Observed for respiratory tract symptoms for 21 days
after contact with an infectious person has been
terminated

Administer vaccine and antibiotics

Exclude:
Symptomatic or confirmed pertussis until
completion of 5 days of the recommended
course of antimicrobial therapy or 21 days if
untreated
46

Follow up & Reporting

Check for the status of the outbreak control

Document and update your regional

epidemiologist and DIDE when the outbreak is
controlled completely

Forward report with lab results to DIDE

47

PERTUSSIS
SURVEILLANCE DATA
WEST VIRGINIA
&
U.S.A
48

Number of Reported Pertussis Cases, by Year,

United States, 1922-2005
Source: MMWR December 15, 2006 / 55(RR17);1-33

49

Number of Reported Pertussis Cases,

by Year, United States, 1922-2006
Source: MMWR May 30, 2008 / 57 (04);1-47,51

50

51

52

53

Summary
Discussed

Disease description including clinical

characteristics, laboratory diagnosis and
epidemiology
Pertussis case investigation and
outbreak investigation
National and state surveillance data

54

Resources

IDEP Pertussis site:

http://www.wvdhhr.org/idep/a-z/a-z-pertuss
is.asp
CDC Pertussis Surveillance Investigation:

http://www.cdc.gov/nip/publications/sur-m
anual/chpt08_pertussis.pdf
Guideline for Control of Pertussis
Outbreak:
http://www.cdc.gov/nip/publications/pertus
sis/guide.htm
55

References

CDC VPD Surveillance Manual, 4th Edition, 2008

Pertussis: Chapter 10
Pertussis (Whooping Cough) Pg. 504-519, Red
Book, 2009 Report of the Committee on Infectious
Diseases American Academy of Pediatrics, 28th
Edition
http://www.cdc.gov/vaccines/recs/schedules/adult
-schedule.htm
Pertussis Pg. 455-461, Control of Communicable
Diseases Manual, APHA & WHO, 19th Edition,
David Heymann, MD, Editor
56

Thank you!
Questions
?

57

59

60

61

62

63