1. Pertussis (Whooping Cough)
Dr. Harivansh Chopra,
DCH, MD
Professor,
Department of Community Medicine,
LLRM Medical College,
Meerut.

2. Objectives To study the epidemiology of Pertussis.
To study prevention and treatment of Pertussis.
4/11/2017
DR HARIVANSH CHOPRA

3. Pertussis
Syadenham first used the term “Pertussis” (intense cough) in1960.
It is preferable to the term “whooping cough” since most infected individuals do not whoop.
4/11/2017
DR HARIVANSH CHOPRA

4. EPIDEMIOLOGY Worldwide distribution.
Global burden in terms of DALYs lost was million in 2002, and 2.95 lakh died during the same year.
4/11/2017
DR HARIVANSH CHOPRA

5. EPIDEMIOLOGY
Pertussis is endemic with epidemic cycles every 2 – 3 years after accumulation of susceptible cohorts.
4/11/2017
DR HARIVANSH CHOPRA

6. India – Decline of Pertussis
83.7%
4/11/2017
DR HARIVANSH CHOPRA

7. EPIDEMIOLOGY Majority of cases occur from July through October.
4/11/2017
DR HARIVANSH CHOPRA

8. EPIDEMIOLOGY
Extremely contagious, with attack rate as high as 100% in susceptible individuals exposed to aerosol droplets at close range.
4/11/2017
DR HARIVANSH CHOPRA

9. EPIDEMIOLOGY
Sub clinical infection is 50% in fully immunized and naturally immune individual.
4/11/2017
DR HARIVANSH CHOPRA

10. Agent Factor Agent is Bacillus pertussis in majority of cases.
In 5% cases Bacillus parapertussis.
Bacillus pertussis does not survives for prolonged periods in the environment
4/11/2017
DR HARIVANSH CHOPRA

11. Source of Infection
A case of pertussis, which may be mild, missed or unrecognized.
Chronic carriage by humans is not documented.
4/11/2017
DR HARIVANSH CHOPRA

12. Infective Material
Nasopharyngeal and bronchial secretions – Droplet infection and Direct contact.
Freshly contaminated fomites.
4/11/2017
DR HARIVANSH CHOPRA

13. Secondary Attack rate is 90%.
Infective Period
A week after exposure to about 3 weeks after the onset of the paroxysmal stage.
Secondary Attack rate is 90%.
4/11/2017
DR HARIVANSH CHOPRA

14. Incubation Period Ranges from 7 – 14 days. 4/11/2017
DR HARIVANSH CHOPRA

15. Host Factor – Age
Primarily a disease of infants and pre-school children.
Higher incidence found below five years of age.
4/11/2017
DR HARIVANSH CHOPRA

16. Host Factor – Age Median age of infection :
Developing countries – months.
Developed countries – 50 months.
Infants < 6 months of age have highest mortality.
4/11/2017
DR HARIVANSH CHOPRA

17. Host Factor – Sex Female children show higher incidence and mortality.
4/11/2017
DR HARIVANSH CHOPRA

18. Host Factors - Immunity
Infants are susceptible to infection from birth because there is no protection from maternal antibodies.
Recovery from Pertussis and Adequate Immunisation both lead to immunity.
4/11/2017
DR HARIVANSH CHOPRA

19. Host Factors - Immunity
Neither natural disease nor vaccination provides complete or lifelong immunity against reinfection or disease.
Protection begins to wane 3 – 5 yrs after vaccination; unmeasurable after 12 yrs.
Subclinical reinfection contributes significantly to immunity against disease, ascribed to vaccine or prior infection.
4/11/2017
DR HARIVANSH CHOPRA

20. CLINICAL MANIFESTATIONS
Catarrhal Stage
Paroxysmal Stage
Convalescent Stage
Due to long duration of the disease,
Pertussis is also known as “100 day cough”.
4/11/2017
DR HARIVANSH CHOPRA

21. Catarrhal Stage The stage lasts for 7-14 days.
It is the most infectious period.
Features:
Low-grade fever.
Sneezing.
Lacrimation.
Conjunctival suffusion.
4/11/2017
DR HARIVANSH CHOPRA

22. Catarrhal Stage Cough:
Not paroxysmal in early stages, but more annoying and frequent at night.
Does not improve with passage of time, unlike upper respiratory tract infections.
Paroxysmal nature of cough can be suspected towards the later part of this phase.
4/11/2017
DR HARIVANSH CHOPRA

23. Paroxysmal Phase This stage lasts for 2-4 weeks Cough:
Initially dry, intermittent, irritative hack.
Evolves into inexorable paroxysms.
4/11/2017
DR HARIVANSH CHOPRA

24. Paroxysmal Phase What is cough?
The bout of cough terminates with along drawn out inspiratory crowing sound or whoop.
What is cough?
Cough is a forced expiratory effort
against closed glottis.
4/11/2017
DR HARIVANSH CHOPRA
Hear cough, click here

25. Whoop
The whoop is produced by the air rushing in during inspiration through the half open glottis.
4/11/2017
DR HARIVANSH CHOPRA
Hear whoop, click here

26. Paroxysmal Phase
The paroxysms of cough may occur every hour, or even frequently, and may terminate by vomiting.
4/11/2017
DR HARIVANSH CHOPRA

27. Paroxysmal Phase
The child may appear chocked ,is unable to breath, looks anxious and has suffused face.
4/11/2017
DR HARIVANSH CHOPRA

28. Paroxysmal Phase
The whoop may not always present in infants, who present with apneic or cyanotic spells.
4/11/2017
DR HARIVANSH CHOPRA

29. Infants <3 mo do not display classical stages
Infants <3 mo do not display classical stages. After the most insignificant startle from a draught, light, sound, sucking, or stretching, a well-appearing young infant begins to choke, gasp, and flail extremities, with face reddened. Cough (expiratory grunt) may not be prominent.
4/11/2017
DR HARIVANSH CHOPRA

30. Whoop (forceful inspiratory gasp) infrequently occurs in infants <3 mo of age who are exhausted or lack muscular strength to create sudden negative intrathoracic pressure
4/11/2017
DR HARIVANSH CHOPRA

31. A well-appearing, playful toddler with similarly insignificant provocation suddenly expresses an anxious aura and may clutch a parent or comforting adult before beginning a machine-gun burst of uninterrupted coughs, chin and chest held forward, tongue protruding maximally, eyes bulging and watering, face purple, until coughing ceases and a loud whoop follows as inspired air traverses the still partially closed airway.
4/11/2017
DR HARIVANSH CHOPRA

32. Whoop
The whoop is produced by the air rushing in during inspiration through the half open glottis.
4/11/2017
DR HARIVANSH CHOPRA
Hear whoop, click here

33. Adults describe a sudden feeling of strangulation followed by uninterrupted coughs, feeling of suffocation, bursting headache, diminished awareness, and then a gasping breath, usually without a whoop
4/11/2017
DR HARIVANSH CHOPRA

34. Convalescent Phase
During convalescence, the interval between the paroxysms of cough increases and severity of episode decreases gradually.
Paradoxically, in infants, coughs and whoop may become louder and more classic in convalescence.
4/11/2017
DR HARIVANSH CHOPRA

35. Clinical Manifestations – Additional notes
Immunized children have foreshortening of all stages of pertussis.
Adults have no distinct stages.
4/11/2017
DR HARIVANSH CHOPRA

36. Clinical Manifestations – Additional notes
In infants < 3months the catarrhal stage is usually a few days or not recognized at all when apnea chocking or gasping cough herald the onset of disease.
4/11/2017
DR HARIVANSH CHOPRA

37. MCQs Which of the following is not true about Pertussis –
The other name is “Whooping cough”.
The other name is “Hundred day cough”.
Everyone suffering from it must have whoop.
It is endemic with superimposed epidemic cycles every 2-3 years.
Ans. – 3.
4/11/2017
DR HARIVANSH CHOPRA

38. Diagnosis – Clinical
High suspicion index in individual having pure or predominant complaint of cough f/b vomitting, and Absent:
Fever.
Malaise / Myalgia.
Exanthem / Enanthem.
Sore throat, Hoarseness.
Tachypnoea.
Wheezes, Rales.
4/11/2017
DR HARIVANSH CHOPRA

39. Diagnosis – Clinical
In infants < 3 months of age, Apnea or Cyanosis (before appreciation of cough) is the clue – occasionally cause of Sudden Infant Death.
4/11/2017
DR HARIVANSH CHOPRA

40. Diagnosis – Blood picture
Leukocytosis – 15, ,000cells/mm3.
Absolute lymphocytosis.
Absolute increase in neutrophils suggests a differential diagnosis or secondary bacterial infection.
4/11/2017
DR HARIVANSH CHOPRA

41. Diagnosis – Chest radiograph
Only mildly abnormal – perihilar infiltrate or edema (sometimes butterfly appearance), and variable atelectasis.
Parenchymal consolidation suggests secondary bacterial infection.
Occasional Pneumothorax, Pneumomediastinum, and air in soft tissues.
Pertussis pneumonia with
hyperaeration (air trapping)
4/11/2017
DR HARIVANSH CHOPRA

42. Diagnosis – Bacteriological testing
Isolation of Bacillus pertussis is the gold standard in diagnosis.
Positive in catarrhal and paroxysmal stage.
4/11/2017
DR HARIVANSH CHOPRA

43. Diagnosis – Serology
Tests for detection of antibodies in acute and convalescent samples are most sensitive tests in immunised individuals.
Antibody to PT raised >2S.D. indicates recent infection.
Useful epidemiologically.
4/11/2017
DR HARIVANSH CHOPRA

44. Differential Diagnosis
Adenoviral infections – distinguishable by presence of fever, sore throat, and conjunctivitis.
Mycoplasma – distinguishable by history of fever, headache, & systemic symptoms; frequent rales on chest auscultation.
4/11/2017
DR HARIVANSH CHOPRA

45. Differential Diagnosis
Afebrile pneumonia (Chlamydia trachomatis) – distinguishable by staccato cough (i.e. breath with every cough), purulent conjunctivitis, tachypnea, rales.
Afebrile pneumonia (RSV) – distinguishable by lower respiratory tract signs.
4/11/2017
DR HARIVANSH CHOPRA

46. MCQs Which of the following is diagnostic of pertusis
Leucocytosis with absolute lymphocytosis.
Leucocytosis with relative lymphocytosis.
Leucocytosis with neutropenia.
Leucocytosis with eosinopenia.
Ans. – 1.
4/11/2017
DR HARIVANSH CHOPRA

47. Complications Apnea. Secondary infections : Otitis media. Pneumonia.
Flaring up of existing TB infection.
Malnutrition.
4/11/2017
DR HARIVANSH CHOPRA

48. Complications – Physical sequel of forceful coughing
Conjuctival and Scleral hemorrhage.
Petechiae in upper body.
4/11/2017
DR HARIVANSH CHOPRA

49. Complications – Physical sequel of forceful coughing
Epistaxis.
Hemorrhage in CNS and Retina.
4/11/2017
DR HARIVANSH CHOPRA

50. Complications – Physical sequel of forceful coughing
Pneunomothorax.
Subcutaneous emphysema.
Umbilical and inguinal hernia.
4/11/2017
DR HARIVANSH CHOPRA

51. Treatment Antibiotics are useful only in the catarrhal stage.
Once the child goes in paroxysmal stage it is very difficult to abort the attack.
4/11/2017
DR HARIVANSH CHOPRA

52. Treatment
Erythromycin mg/kg/day in 4 divided doses X 14days. (Maximum 2 gm / 24 hrs.)
Respiratory Isolation for ≥ 5 days after start of Erythromycin therapy.
4/11/2017
DR HARIVANSH CHOPRA

53. Alternative drugs
Clarithromycin mg/kg/day in 2 div doses X 7 days. (Maximum 1 gm/24 hrs.)
Azithromycin 10 mg/kg/day once daily X 5 days.
4/11/2017
DR HARIVANSH CHOPRA

54. Alternative drugs
Ampicillin, Rifampicin and Cotrimoxazole are modestly active against pertussis.
The 1st and 2nd generation Cephalosporins are not active against pertussis.
4/11/2017
DR HARIVANSH CHOPRA

55. MCQs
The attack of pertussis can be aborted with the help of antibiotics only if the is treated :
In catarrhal stage.
In paroxysmal stage.
In convalescent stage.
In all the above stages.
Ans. – 1.
4/11/2017
DR HARIVANSH CHOPRA

56. MCQs The drug of choice for the treatment of Pertusis & its dose is
Erythromycin mg/kg/day
Cephalexin mg/kg/day
Cotrimoxazole mg/kg/day
Tetracyclin mg/kg/day
Ans. – 1.
4/11/2017
DR HARIVANSH CHOPRA

57. Care of Household and Close Contacts – Chemoprophylaxis
Erythromycin mg/kg/day in 4 divided doses X 14 days regardless of age, history of immuinisation, and symptoms.
4/11/2017
DR HARIVANSH CHOPRA

58. Care of Household and Close Contacts – Immunisation
Situation for contact < 7 years
Recommendation
Not vaccinated against pertussis
Initiate vaccination
Partially vaccinated against pertussis
Complete the recommended schedule
Received 3rd dose > 6 mths. back
Booster dose
Received 4th dose ≥ 3 years back
4/11/2017
DR HARIVANSH CHOPRA

59. PREVENTION V A C I Purified N Whole Cell Acellular E Vaccine Vaccine S
4/11/2017
DR HARIVANSH CHOPRA

60. Whole cell vaccine (DTP)
Developed in late 1940s.
Bacteria killed by heat or formalin.
Controversial because of local and systemic side effects:
Redness, Pain, Swelling.
Fever (30-70%).
4/11/2017
DR HARIVANSH CHOPRA

61. Whole cell vaccine (DTP)
National Childhood Encephalopathy Study (Britain) :
Infantile Spasms.
Sudden Infant Death Syndrome (SIDS).
Efficacy :
Three doses.
% effective.
4/11/2017
DR HARIVANSH CHOPRA

62. Purified acellular vaccine (DTaP)
Introduced in 1981 by Japan.
Contains subcomponents of bacteria:
Filamentous Hemagglutinin (Fha).
Pertussis Toxin (PT).
4/11/2017
DR HARIVANSH CHOPRA

63. Purified acellular vaccine (DTaP)
Efficacy
Two doses.
70% protection against culture confirmed infection.
80% protection against severe whopping cough.
4/11/2017
DR HARIVANSH CHOPRA

64. DTP Vaccine Content (BE ltd.): Dose – 0.5 ml.
Diptheria toxoid ≥20Lf to ≤30Lf.
Pertussis ≥4 IU.
Tetanus toxoid ≥5Lf to ≤25Lf.
Dose – 0.5 ml.
Route – Deep intramuscular.
Recommended site – Antero-lateral part of thigh.
4/11/2017
DR HARIVANSH CHOPRA

65. Vaccination Schedule Immunization Policy : Booster Policy :
3 DPT doses during first year of life.
EPI recommendation 6, 10, 14 weeks.
Booster Policy :
4th DPT vaccine at 12 to 24 months.
5th DPT vaccine used by some countries (In India, given 3 years after 4th dose).
4/11/2017
DR HARIVANSH CHOPRA

66. Contraindications to vaccination
Personal or strong family history of epilepsy, convulsions or similar CNS disorders.
Any febrile upset until fully recovered.
Reaction to one of the previously given triple vaccines.
4/11/2017
DR HARIVANSH CHOPRA

67. MCQs What is the correct composition of DPT vaccine
D ≥40Lf; P ≥4 IU; T ≥5Lf to ≤25Lf.
D ≥20Lf to ≤30Lf; P ≥10 IU; T ≥5Lf to ≤25Lf.
D ≥20Lf to ≤30Lf; P ≥4 IU; T ≥5Lf to ≤25Lf.
D ≥20Lf to ≤30Lf; P ≥4 IU; T ≤25Lf.
Ans. – 3.
4/11/2017
DR HARIVANSH CHOPRA

68. Diphtheria toxoid; Tetanus toxoid; Pertussis vaccine; Diphtheria toxoid 25 Lf, tetanus toxoid 10 Lf, purified Bordetella pertussis antigens (pertussis toxoid 25 mcg, filamentous haemagglutinin 25 mcg, 69 kDA outer membrane protein 8 mcg) per 0.5 mL; aluminium hydroxide (adsorbant),
4/11/2017
DR HARIVANSH CHOPRA

69. Dose: 0.5 mL IMI.
Primary course: 3 doses at 2, 4 and 6 months, then 4th dose at 18 months, 5th dose at 4-5 years
4/11/2017
DR HARIVANSH CHOPRA

70. Conclusions
Pertussis is a vaccine preventable disease caused by Bacillus pertussis.
It is characterised by intensive cough and whoop, and absence of other systemic features.
Highly contagious disease – prophylaxis of all contacts recommended.
4/11/2017
DR HARIVANSH CHOPRA

71. 4/11/2017
DR HARIVANSH CHOPRA

72. 4/11/2017
DR HARIVANSH CHOPRA

73. TABLE 3 Composition of DPT vaccines
Contents
Glaxo (per 0.5ml)
Kasauli
Diphtheria toxoid
Tetanus toxoid
B. pertussis (millions)
AI. phosphate
Thiomersal, B.P.
25Lf
5Lf
20 000
2.5 mg
0.01%
30 Lf
10 Lf
32 000
3.0 mg
4/11/2017
DR HARIVANSH CHOPRA