Whooping Cough: On the Rise

WebMD Live Events Transcript

Pertussis, or whooping cough, seems to be making a comeback. The CDC recently reported the highest number of cases in nearly 40 years, and 39% of those cases are in kids aged 10 to 19. Should vaccines be given to teens? How do you recognize the signs and symptoms? Adolescent medicine expert Amy Middleman, MD, joined us on Nov. 16, 2004, to discuss what you need to know about pertussis.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Dr. Middleman. Why is whooping cough making a comeback - or did it ever really go away?

MIDDLEMAN:
That's a great question, and a complicated question. It appears as though pertussis is on the rise; however, there are other factors to consider. Greater physician awareness, greater uses of diagnostic tests, more complete, and timely reporting all play a role in possible reasons for increased pertussis incidence rates.

What we do know is that pertussis deaths in young infants have increased, so we suspect that disease load in the community has also truly increased. Why it has increased recently is not totally clear.

MODERATOR:
I made sure my children had all of their vaccinations. So why should I be worried about pertussis and my teens?

MIDDLEMAN:
Few people realize that immunity from their pertussis vaccine wanes after five to 10 years. Pertussis vaccination is only currently approved for those under the age of 7 years. The number of cases of pertussis is increasing the most among adolescents and young adults. Pertussis is an incredibly uncomfortable disease that can certainly impact a teenager's life significantly.

However, the highest rates of mortality occur in infants under the age of 3 months. If you look at varying data sets, they all support the fact that in the majority of cases, infant cases can be traced back to an adolescent within the home as the source of transmission. So adolescents are not, in general, protected against pertussis, and it's important to protect them, not only for their own health and safety, but also for our infant population.

In a recent survey conducted by the Society of Adolescent Medicine, we found that 85 percent of parents of adolescents did not know that the duration of pertussis protection is relatively brief. Immunity from childhood pertussis vaccination wanes after five to 10 years.

MODERATOR:
If teens are no longer protected by the vaccinations they received when they were young, what can we do?

MIDDLEMAN:
The FDA is currently considering adding the pertussis component to the current Td booster (tetanus diphtheria) that's given between the ages of 12 and 14. That would be a huge step in preventing disease outbreaks without adding any additional shots to the vaccination schedule.

Because treatment is truly not effective in easing the symptoms of pertussis, then prevention is going to be our best weapon against disease.

"Few people realize that immunity from their pertussis vaccine wanes after five to 10 years. Pertussis vaccination is only currently approved for those under the age of 7 years."

MEMBER QUESTION:
We use teenage babysitters. Should I be worried about them giving whooping cough to my baby?

MIDDLEMAN:
If a teenager has a cough or a cold, it's best for them not to expose young unimmunized or partially immunized babies to that cold. The problem is that pertussis is most contagious at its earliest stage, which is often confused with the common cold or flu. If a cough has lasted more than seven days or has become violent in nature, that person may have pertussis and should be checked.

In general, infants are often more susceptible to getting any sorts of illnesses, and a sick babysitter should probably not be used.

MODERATOR:
Can you please explain the symptoms of pertussis and what causes it?

MIDDLEMAN:
Pertussis is caused by a bacterium called bordetella pertussis.
  • It usually begins with a mild upper respiratory tract infection that's called the catarrhal stage, which can last up to one to two weeks. It's usually mild at that point, but also most contagious then.
  • There can be anywhere from a 1 to 6-week stage called the paroxysmal stage that is characterized by violent paroxysmal cough, often with a characteristic whoop.
  • It can be followed by vomiting, pulled muscles, hemorrhages around the eyes, and, in extreme cases, these violent coughs can result in a broken rib.
  • People are usually fine in between coughing spells. Symptoms wane over weeks to months, and that stage is called the convalescent stage.
  • In infants, apnea (when they stop breathing) is a common problem. This represents a significant danger to infants.
  • It is possible for older children and adults to have a prolonged cough, no real whoop, but in many cases there can be a significant and violent cough that interferes with lifestyle.

MEMBER QUESTION:
How can I tell the difference between whooping cough and bronchitis?

MIDDLEMAN:
It's hard to distinguish in the early stage. In the later stages whooping cough, if mild, can be confused with bronchitis, so it's important to see a health care provider if any cold symptoms last longer than seven days. But in clear-cut cases, the cough of pertussis is violent and often ends up with vomiting. If anyone has a cough that is so violent it ends in vomiting or where they have difficulty catching their breath to the point of vomiting, they definitely need to be checked for pertussis.

From an infection control point of view, all coughs lasting seven to 10 days that are characteristic of pertussis should be checked and identified.

MEMBER QUESTION:
My son has had a cough for several weeks. He had a cold in September. Everything is gone except the cough. He's fine between coughing spells. Could this be pertussis? How would the doctor diagnose it?

MIDDLEMAN:
There are varying ways to diagnose pertussis. The most common way right now is either a culture for pertussis or a naso-pharyngial swab sent for PCR technology testing. Negative cultures are common in the early phase of illness and cultures often test negative after the 4th week. They can also test negative if patients have received antibiotics.

So essentially testing can be problematic, but other things can cause chronic cough, and it's important if a cough does last a long time that a child be evaluated, because it may be something that is more common and even more easily treated.

MODERATOR:
Are they still contagious as long as they are coughing?

MIDDLEMAN:
They may be contagious, but the most contagious time is in the first week or two of illness. When people are diagnosed with pertussis they are put on antibiotics. This rarely affects the disease process significantly; they're still going to be sick, but it does decrease the risk of the contagious aspect significantly.

MEMBER QUESTION:
Is there a chance that it's on the rise again because some parents have been scared off of vaccines?

MIDDLEMAN:
Pertussis is the only disease for which children are routinely vaccinated that's currently on the rise in the U.S. It is possible that lack of vaccination could theoretically play a role, but I'm not sure that it is in this case. It's not fully clear what factors are playing the most significant role in this current rise in pertussis incidence.

MEMBER QUESTION:
Can pertussis lead to anything else?

MIDDLEMAN:
In babies the outcomes can be devastating, including apnea, which we've discussed, seizures, pneumonia, encephalopathy, and death, although complications requiring hospitalization occurs usually in those under 6 months of age.

For teens, complications include most of what we've already discussed: violent coughing, interference in activities, pulled muscles, and vomiting. Serious complications among adolescents are not common.

MODERATOR:
On the web site of the Society of Adolescent Medicine, you can read the stories of two teens who had their lives interrupted by bouts of pertussis. www.adolescenthealth.org/whoopingcough.html

"Recognition of pertussis is going to be important for controlling the disease among adolescents until we have a vaccine that will help us accomplish prevention in a different way."

MEMBER QUESTION:
What is adolescent medicine? Isn't it OK to take the kids to see their pediatrician until they turn 18?

MIDDLEMAN:
Adolescent medicine is a subspecialty that can be done by pediatricians, internal medicine doctors or family practice doctors. It is a subspecialty within those larger specialties.

Pediatricians are trained today to treat patients until they reach adulthood, which is commonly considered the age of 18. Adolescent medicine specialists receive usually three additional years of training to work solely with the age group of approximately 11 to 25 years of age. We address the general medicine concerns of that age group, as well as preventive health care issues for that age group with which other specialties may not have a strong familiarity.

For example, I treat many patients with depression, eating disorders, menstrual disorders, chronic fatigue, and other issues that begin to occur during adolescence. We also are extremely vigilant about addressing preventive health issues, including the risk behaviors that often put adolescents at risk for poor health outcomes.

I believe currently there are 469 board certified pediatric adolescent medicine subspecialists in the U.S.

MODERATOR:
We are almost out of time. Before we wrap things up for today, do you have any final words for us, Dr. Middleman?

MIDDLEMAN:
It's important to know that pertussis is on the rise, among adolescents especially, and to think about pertussis if someone has a chronic cough or cold that is not going away. Recognition of pertussis is going to be important for controlling the disease among adolescents until we have a vaccine that will help us accomplish prevention in a different way.

For additional information I recommend www.adolescenthealth.org, as well as the CDC web site, which is cdc.gov. Also your primary care provider can be an excellent source of information specially geared toward you or your family members.

MODERATOR:
Our thanks to Amy Middleman, MD, for joining us. To learn more about pertussis, please visit the web site of the Society of Adolescent Medicine at www.adolescenthealth.org/whoopingcough.html.



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