Pertussis

Dr Sudhir Joshi
Pertussis
Latin: violent cough
 Outline of the presentation

Aetiopathogenesis
Transmission and communicability
Occurrence and reservoir
Clinical features and complications
Laboratory diagnosis
Case selection
Management
 Aetiopathogenesis

Bacterial disease caused by Bordetella pertussis

Aerobic, gram negative, coccobacilli

Three other species cause milder disease

B. parapertussis, B. holmesii, B. bronchisepta
 Transmission and communicability
Highly infectious:
spread by aerosolised droplets

Incubation period:
9-10 days (range; 6-20 days)

Secondary attack rate:

80-100% for susceptible household contacts

Period of infectivity:
3 weeks from onset
Antibiotics therapy reduces the period
 Occurrence and reservoir
Occurs worldwide
continues to be a public health concern even in
countries with high vaccination coverage
important cause of death in infants
~ 12-32% of chronic cough in adults
Human specific disease
no animal or insect source/ vector
no prolonged carrier state
adolescents and adults are an important reservoir
and source of transmission to unvaccinated infants
 Pertussis

Clinical features and complications

0 day
Catarrhal
Non specific symptoms- cough, rhinorrhoea, sore
throat and conjunctivitis

2 weeks

Spasmodic
Paroxysm of cough ending in characteristic whoop,
post tussive vomiting, symptoms severe at night

4-8 weeks

Convalescent
Coughing gradually subsides, relapse if another
respiratory infection is acquired
Months
 Clinical features and complications
Other common presenting features-
Infants: apnoea, cyanotic episodes, poor feeding
Adults: prolonged cough, phlegm, intracranial
haemorrhages
Partially immunised: reduced duration of catarrhal
phase, whoop may not occur

Complications-
Secondary bacterial pneumonia
Neurological complications: seizures, encephalopathy
 Laboratory diagnosis
Culture of nasopharyngeal secretions considered
best
fastidious growth requirements makes it difficult to isolate
chances of isolation maximum during catarrhal phase and
declines rapidly after two weeks
small window of opportunity for culture proven diagnosis
PCR
detects DNA sequence of the bacteria
sensitivity decreases after 4 weeks of onset
Serology
useful for diagnosis in convalescent phase
 Case definition
A suspected case of pertussis is defined as:
A person with a cough lasting at least two weeks with at least one
of the following:
Paroxysms (i.e. fits) of coughing

Inspiratory whooping

Post-tussive vomiting

Without other apparent causes

OR
Apnoea (with or without cyanosis) in infants (age <1 year old) with
cough of any duration
OR
If a specialist physician strongly suspects pertussis in a patient with
cough of any duration.
 Case definition
Paroxysms of cough:
Cough becomes more frequent and spasmodic
Repetitive bursts of five to ten coughs, often within a
single expiration
During paroxysm there may be a visible vein distension,
bulging eyes, tongue protrusion and cyanosis
Frequency of paroxysmal episodes varies from several
per hour to 5-10 per day
Episodes are often worse at night and interfere with
sleep
 Case definition
Whoop:
Sound produced due to rapid inspiration against closed
glottis at the end of cough paroxysm
Post tussive vomiting:
Vomiting immediately after coughing occasionally with a
mucous plug expelled at the end of an episode
Without other apparent causes:
Exclude other causes of chronic cough like tuberculosis,
asthamatic episodes, chronic bronchitis etc.
Other associated signs and symptoms
In young infants: apnoea and cyanosis may be the
only presenting symptoms
Paroxysms of cough lead to increased intra
thoracic pressure
Subconjunctival haemorrhage
Intracranial haemorrhage
Rectal prolapse
Hernias
Pneumothorax
Petechiae
Rib fracture
 Demonstration of whooping cough: child

Source: https://www.youtube.com/watch?v=KZV4IAHbC48
 Demonstration of whoop: infant

Source: https://www.youtube.com/watch?v=S3oZrMGDMMw
Case management
 General principles
Treatment is most effective if offered early
First two weeks before coughing paroxysms occur
But during early stage pertussis is most difficult to
diagnose
Treatment in later stages prevents transmission
The period of communicability is reduced to 5 days
after treatment with antibiotics
No proven treatment exist for pertussis induced
cough
Steroids and beta agonists are not effective
 General principles
Coughing (symptomatic) household members of a
pertussis patient should be treated as pertussis cases
Earlier treatment and prevention of transmission may
reduce the considerable burden of adult pertussis
loss of work
prolonged symptoms
multiple hospital visits
Suspected pertussis cases should not be allowed to
go for work/school until completion of at least 5 days
of antimicrobial therapy
 Case management
Macrolide antibiotics eradicate B. pertussis
within 5 days
Azithromycin for 5 days
Clarithromycin for 7 days
Erythromycin for 14 days
E estolate is preferred over stearate/ethyl succinate
because esteolate achieves higher serum levels with
equal doses
Alternate agent
Trimethoprim/ sulfamethoxazole for 14 days
 Case management
Azithromycin is drug of choice for infants less
than 1 month
Erythromycin is associated with idiopathic
hypertrophic pyloric stenosis
Cotrimoxazole is associated with risk of
kernicterus
Cotrimoxazole is contraindicated in pregnancy
and lactation
Recommended doses in table provided
 Public health intervention
Single dose of DPT to children less than 7
years of age
Persons aged more than 7 years can be given
Tdap if available
Tdap - contains low dose of Diphtheria toxoid and
acellular pertussis along with Tetanus Toxoid
Post exposure microbial prophylaxis to
contacts
Post exposure antimicrobial prophylaxis (PEP)

PEP to all pertussis contacts is not cost

effective measure
No data available on effectiveness of widespread
use of PEP for pertussis outbreak control
Serious complications and deaths are primarily
limited to infants
Antibiotic prophylaxis should be given to all infants
and their contacts
Recommended treatment and post-exposure prophylaxis, by
age group

Alternate agent: TMP-

Age group Azithromycin Erythromycin Clarithromycin
SMX
Recommended
4050 mg/kg per Contraindicated in
drug; 10 mg/kg Not
<1 month day in 4 divided infants <2 months of
per day in a single recommended.
doses x 14 days age
dose x 5 days
For infants aged >2
months of age, TMP 8
10 mg/kg per day 15 mg/kg per day
15 mg/kg per day; SMX 40
in a single dose x 5 As above in 2 divided doses
months mg/kg per day in 2
days. x 7 days.
divided doses x 14
days.
Recommended treatment and post-exposure prophylaxis, by
age group
Age group Azithromycin Erythromycin Clarithromyci Alternate agent:
n TMP-SMX
Children aged 10 mg/kg as a single 40 mg/kg per Maximum TMP 8 mg/kg
more than 6 dose on day 1 day in 4 divided 1g/day per day; SMX 40
months (maximum 500 mg); doses for 7-14 mg/kg per day
then 5 mg/kg per days (maximum in 2 divided
day as a single dose 1-2 g per day) doses x 14 days
on days 25
(maximum 250
mg/day)

Adolescents 500 mg as a single 2g/day in 4 1g/day in 2 TMP 320

and adults dose on day 1 then divided doses x divided doses mg/day, SMX
250 mg as a single 14 days x 7 days 1600mg/day in
dose on days 25 2 divided doses
x 14 days
THANK YOU