Purpose and Goal: CEARP # 1100

  • Describe the multifactorial causes of pertussis outbreaks.
  • Describe the risks of pertussis infection in the neonate.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored.

Requirements for Successful Completion

  • Successfully complete the post-test.
  • Complete the evaluation form.

Date

  • July 2014-July 2016

Learning Objectives

  • Describe the multifactorial causes of pertussis outbreaks.
  • Describe the risks of pertussis infection in the neonate.

Introduction

  • Bordatella pertussis is a gram-negative bacillus.
  • Pertussis is also known as whooping cough.
  • Humans are the only known hosts.
  • It was first recognized and named in 1679.
  • It is a highly contagious respiratory infection.
  • Infants are at highest risk of severe infection.

Epidemiology

  • Transmission
    • Spread rapidly via aerosolized droplets
      • Easily spread during coughing
    • Incubation period ranges from 1-3 weeks.
      • Most typically 7-10 days
    • Asymptomatic infection is common.
    • As many as 80% of household contacts develop infection.
    • Infected individuals are contagious until treated for five days.
  • Incidence
    • Illness can occur all year round.
      • Typically peaks in late summer-early fall
    • Devastating disease prior to development of vaccines
      • Relatively high rate of infant mortality
    • First vaccine available in the U.S. in 1940
    • Widespread vaccination led to a dramatic decline.
      • >250,000 reported illness in 1934.
      • 1,010 reported illness in 1976.
  • Evolving epidemiology
    • There has been a steady rise in reported illness.
      • 27,550 reported illness in 2010.
      • >41,000 reported illness in 2012.
    • Outbreaks have occurred in several states.
      • Washington state has seen a significant increase.
      • Reported illness has increased 1,300% since 2011.
    • Pertussis is underdiagnosed in adults.
      • The incidence may be higher.

Etiology

  • Etiology is multifactorial.
  • Lack of vaccination
    • Older adults without proper immunization
    • Older children with waning immunization
    • Young children without any immunization
  • Diminished herd immunity
    • Lack of immunized individuals in the community
    • Increased incidence of exposure to infection
  • Lack of booster vaccinations
    • Immunization does not provide lifelong protection.
    • Booster immunizations are required.
  • Celebrity anti-vaccine campaigns
    • Inaccurate fear over link to autism
  • Waning community immunity
    • Increased incidence of exposure to infection

Clinical Presentation

  • Classical clinical features
    • Prolonged respiratory illness
    • Increased inspiratory effort ("whooping")
    • Paroxysmal coughing
  • Classical presentation
    • Illness can be divided into three stages.
      • Catarrhal
      • Paroxysmal
      • Convalescent
    • Catarrhal stage
      • Similar to the common cold
      • Mild cough lasts one to two weeks.
      • Fever is uncommon.
      • Cough gradually increases.
    • Paroxysmal stage
      • Coughing severely increases.
      • Occurs in paroxysmal attacks
      • Lasts two to six weeks
      • Gagging and cyanosis may occur.
      • Whooping may follow an attack.
      • Post-coughing vomiting is frequent.
      • Complications most frequent during this stage
    • Convalescent stage
      • Coughing begins to subside.
      • Lasts several weeks to months
      • Episodic coughing is common.
  • Atypical presentations
    • May occur in young infants
    • May occur in vaccinated individuals
    • Catarrhal stage very short or absent
    • Paroxysms of cough are common.
      • Gagging
      • Apnea
      • Cyanosis
      • Bradycardia
    • Infants may appear well in between episodes.
    • Infants may not develop whooping.

Complications

  • Apnea
    • Occurs exclusively in infants.
      • Primarily in infants <6 months
      • Usually associated with coughing
  • Pneumonia
    • Most frequent complication
    • May be primary pertussis infection.
      • Extreme leukocytosis
      • Pulmonary hypertension
      • Increased mortality
  • Weight loss due to feeding difficulties
  • Post-coughing vomiting
    • Common in 50% of infants <1 year
  • Seizures
    • Occur in 1-2% of infants <6 months
    • Occur in 2% of infants <2 years
  • Death
    • Most common in infants <6 months
      • Incidence is 1% of infected infants.
      • Majority of deaths occur in infants <2 months.
      • Also occurs in unvaccinated young children.

Treatment

  • Supportive care is the mainstay of treatment.
  • Avoidance of known triggers for coughing paroxysms
    • Exercise
    • Cold temperatures
    • Nasopharyngeal suctioning
  • Hospitalization may be indicated.
    • Respiratory distress
    • Evidence of pneumonia
    • Inability to feed
    • Cyanosis or apnea
    • Seizures
    • <3 months of age
      • Severity of illness is unpredictable.
      • Clinical decline may occur rapidly without warning.
  • Adjunctive treatments
    • Bronchodilators
    • Corticosteroids
    • Antitussives
    • Pertussis immunoglobulin
    • ECMO
    • Leukodepletion
  • Antimicrobial therapy
    • May shorten the duration of illness
    • Decreases incidence of spread of infection
    • Erythromycin should be administered for 14 days.
    • Clarithromycin should be administered for seven days.
    • Azithromycin should be administered for five days.
    • Trimethoprim-sulfamethoxazole should be administered for 14 days.

Antimicrobial Prophylaxis

  • Post-exposure prophylaxis can prevent illness.
  • American Academy of Pediatrics recommendations
    • All close contacts should be treated.
      • Family members and all caregivers
      • Regardless of immunization status
      • Should be treated within 21 days of exposure

Prevention

  • Immunization is the most effective strategy.
  • Current standard for infant immunization
    • Acellular combination vaccine (DTap)
    • Four doses before 2 years
      • 2, 4, and 6 months of age
      • Between 15-18 months
    • Immunity is not present before the 6-month vaccine
  • Children should receive a booster DTap between 4-6 years.
  • Adolescents should receive a booster DTap >18 years.
  • Adults should receive a booster DTap >65 years.
  • Pregnant women should receive a DTap in the third trimester.
    • Regardless of immunization status
    • With every pregnancy (between 27-36 weeks)
    • Provides protection to the fetus and neonate

Summary

  • Pertussis infection is dramatically on the rise in the U.S.
  • Immunization or infection do not provide lifelong protection.
  • Parents need to be well informed about the risks of pertussis.
    • Infants are at high risk of infection and severe illness.
    • Family members and caregivers should be immunized.
    • Post-exposure prophylaxis can help prevent illness.

References

  1. Snapp, B. & Fischetti, D. 2013. Bordatella Pertussis Infection in the Neonate: A Reemerging Disease. Advances in Neonatal Care, 13 (2), p. 103-107.
  2. Rust, C. 2014. A Cocooning Project to Protect Newborns from Pertussis. Nursing for Women's Health, 18 (3), p. 204-211.
  3. Pickering, L.K. 2012. Pertussis .
  4. Yeh, Sylvia. 2014. UpToDate: Bordatella Pertussis Infection in Infants and Children: Treatment and Prevention

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