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

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Presentation on theme: "Pertussis (Whooping Cough) Dr. Harivansh Chopra, DCH, MD Professor, Professor, Department of Community Medicine, LLRM Medical College, Meerut."— Presentation transcript:

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

3 Objectives 1. To study the epidemiology of Pertussis. 2. To study prevention and treatment of Pertussis. 4/18/20152DR HARIVANSH CHOPRA

4 Pertussis 1. Syadenham first used the term “Pertussis” (intense cough) in It is preferable to the term “whooping cough” since most infected individuals do not whoop. 4/18/20153DR HARIVANSH CHOPRA

5 EPIDEMIOLOGY 1. Worldwide distribution. 2. Global burden in terms of DALYs lost was million in 2002, and 2.95 lakh died during the same year. 4/18/20154DR HARIVANSH CHOPRA

6 EPIDEMIOLOGY 3. Pertussis is endemic with epidemic cycles every 2 – 3 years after accumulation of susceptible cohorts. 4/18/20155DR HARIVANSH CHOPRA

7 India – Decline of Pertussis 83.7% 4/18/20156DR HARIVANSH CHOPRA

8 EPIDEMIOLOGY 4. Majority of cases occur from July through October. 4/18/20157DR HARIVANSH CHOPRA

9 EPIDEMIOLOGY 5. Extremely contagious, with attack rate as high as 100% in susceptible individuals exposed to aerosol droplets at close range. 4/18/20158DR HARIVANSH CHOPRA

10 EPIDEMIOLOGY 6. Sub clinical infection is 50% in fully immunized and naturally immune individual. 4/18/20159DR HARIVANSH CHOPRA

11 Agent Factor 1. Agent is Bacillus pertussis in majority of cases. 2. In 5% cases Bacillus parapertussis. 3. Bacillus pertussis does not survives for prolonged periods in the environment 4/18/201510DR HARIVANSH CHOPRA

12 Source of Infection 1. A case of pertussis, which may be mild, missed or unrecognized. 2. Chronic carriage by humans is not documented. 4/18/201511DR HARIVANSH CHOPRA

13 Infective Material 1. Nasopharyngeal and bronchial secretions – Droplet infection and Direct contact. 2. Freshly contaminated fomites. 4/18/201512DR HARIVANSH CHOPRA

14 Infective Period A week after exposure to about 3 weeks after the onset of the paroxysmal stage. Secondary Attack rate is 90%. 4/18/201513DR HARIVANSH CHOPRA

15 Incubation Period Ranges from 7 – 14 days. 4/18/201514DR HARIVANSH CHOPRA

16 Host Factor – Age 1. Primarily a disease of infants and pre- school children. 2. Higher incidence found below five years of age. 4/18/201515DR HARIVANSH CHOPRA

17 Host Factor – Age 3. Median age of infection : 1. Developing countries – months. 2. Developed countries – 50 months. 4. Infants < 6 months of age have highest mortality. 4/18/201516DR HARIVANSH CHOPRA

18 Female children show higher incidence and mortality. Host Factor – Sex 4/18/201517DR HARIVANSH CHOPRA

19 Host Factors - Immunity 1. Infants are susceptible to infection from birth because there is no protection from maternal antibodies. 2. Recovery from Pertussis and Adequate Immunisation both lead to immunity. 4/18/201518DR HARIVANSH CHOPRA

20 Host Factors - Immunity 3. Neither natural disease nor vaccination provides complete or lifelong immunity against reinfection or disease. 4. Protection begins to wane 3 – 5 yrs after vaccination; unmeasurable after 12 yrs. 5. Subclinical reinfection contributes significantly to immunity against disease, ascribed to vaccine or prior infection. 4/18/201519DR HARIVANSH CHOPRA

21 CLINICAL MANIFESTATIONS Catarrhal Stage Paroxysmal Stage Convalescent Stage Due to long duration of the disease, Pertussis is also known as “100 day cough”. 4/18/201520DR HARIVANSH CHOPRA

22 Catarrhal Stage 1. The stage lasts for 7-14 days. 2. It is the most infectious period. 3. Features: 1. Low-grade fever. 2. Sneezing. 3. Lacrimation. 4. Conjunctival suffusion. 4/18/201521DR HARIVANSH CHOPRA

23 Catarrhal Stage 4. Cough: 1. Not paroxysmal in early stages, but more annoying and frequent at night. 2. Does not improve with passage of time, unlike upper respiratory tract infections. 3. Paroxysmal nature of cough can be suspected towards the later part of this phase. 4/18/201522DR HARIVANSH CHOPRA

24 Paroxysmal Phase 1. This stage lasts for 2-4 weeks 2. Cough: 1. Initially dry, intermittent, irritative hack. 2. Evolves into inexorable paroxysms. 4/18/201523DR HARIVANSH CHOPRA

25 3. The bout of cough terminates with along drawn out inspiratory crowing sound or whoop. Paroxysmal Phase Cough is a forced expiratory effort against closed glottis. Hear cough, click here 4/18/201524DR HARIVANSH CHOPRA

26 Whoop The whoop is produced by the air rushing in during inspiration through the half open glottis. Hear whoop, click here 4/18/201525DR HARIVANSH CHOPRA

27 Paroxysmal Phase 4. The paroxysms of cough may occur every hour, or even frequently, and may terminate by vomiting. 4/18/201526DR HARIVANSH CHOPRA

28 5. The child may appear chocked,is unable to breath, looks anxious and has suffused face. Paroxysmal Phase 4/18/201527DR HARIVANSH CHOPRA

29 Paroxysmal Phase 6. The whoop may not always present in infants, who present with apneic or cyanotic spells. 4/18/201528DR HARIVANSH CHOPRA

30 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. 4/18/201529DR HARIVANSH CHOPRA

31 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 4/18/201530DR HARIVANSH CHOPRA

32 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. 4/18/201531DR HARIVANSH CHOPRA

33 Whoop The whoop is produced by the air rushing in during inspiration through the half open glottis. Hear whoop, click here 4/18/201532DR HARIVANSH CHOPRA

34 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 4/18/201533DR HARIVANSH CHOPRA

35 Convalescent Phase 1. During convalescence, the interval between the paroxysms of cough increases and severity of episode decreases gradually. 2. Paradoxically, in infants, coughs and whoop may become louder and more classic in convalescence. 4/18/201534DR HARIVANSH CHOPRA

36 Clinical Manifestations – Additional notes 1. Immunized children have foreshortening of all stages of pertussis. 2. Adults have no distinct stages. 4/18/201535DR HARIVANSH CHOPRA

37 3. 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. Clinical Manifestations – Additional notes 4/18/201536DR HARIVANSH CHOPRA

38 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. 4/18/201537DR HARIVANSH CHOPRA

39 Diagnosis – Clinical 1. High suspicion index in individual having pure or predominant complaint of cough f/b vomitting, and 1. 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. 4/18/201538DR HARIVANSH CHOPRA

40 Diagnosis – Clinical 2. In infants < 3 months of age, Apnea or Cyanosis (before appreciation of cough) is the clue – occasionally cause of Sudden Infant Death. 4/18/201539DR HARIVANSH CHOPRA

41 1. Leukocytosis – 15, ,000cells/mm Absolute lymphocytosis. 2. Absolute increase in neutrophils suggests a differential diagnosis or secondary bacterial infection. Diagnosis – Blood picture 4/18/201540DR HARIVANSH CHOPRA

42 Diagnosis – Chest radiograph 1. Only mildly abnormal – perihilar infiltrate or edema (sometimes butterfly appearance), and variable atelectasis. 2. Parenchymal consolidation suggests secondary bacterial infection. 3. Occasional Pneumothorax, Pneumomediastinum, and air in soft tissues. Pertussis pneumonia with hyperaeration (air trapping) 4/18/201541DR HARIVANSH CHOPRA

43 Diagnosis – Bacteriological testing 1. Isolation of Bacillus pertussis is the gold standard in diagnosis. 2. Positive in catarrhal and paroxysmal stage. 4/18/201542DR HARIVANSH CHOPRA

44 Diagnosis – Serology 1. Tests for detection of antibodies in acute and convalescent samples are most sensitive tests in immunised individuals. 2. Antibody to PT raised >2S.D. indicates recent infection. 3. Useful epidemiologically. 4/18/201543DR HARIVANSH CHOPRA

45 Differential Diagnosis 1. Adenoviral infections – distinguishable by presence of fever, sore throat, and conjunctivitis. 2. Mycoplasma – distinguishable by history of fever, headache, & systemic symptoms; frequent rales on chest auscultation. 4/18/201544DR HARIVANSH CHOPRA

46 Differential Diagnosis 3. Afebrile pneumonia (Chlamydia trachomatis) – distinguishable by staccato cough (i.e. breath with every cough), purulent conjunctivitis, tachypnea, rales. 4. Afebrile pneumonia (RSV) – distinguishable by lower respiratory tract signs. 4/18/201545DR HARIVANSH CHOPRA

47 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. 4/18/201546DR HARIVANSH CHOPRA

48 Complications 1. Apnea. 2. Secondary infections : a. Otitis media. b. Pneumonia. 3. Flaring up of existing TB infection. 4. Malnutrition. 4/18/201547DR HARIVANSH CHOPRA

49 Complications – Physical sequel of forceful coughing 1. Conjuctival and Scleral hemorrhage. 2. Petechiae in upper body. 4/18/201548DR HARIVANSH CHOPRA

50 3. Epistaxis. 4. Hemorrhage in CNS and Retina. Complications – Physical sequel of forceful coughing 4/18/201549DR HARIVANSH CHOPRA

51 5. Pneunomothorax. 6. Subcutaneous emphysema. 7. Umbilical and inguinal hernia. Complications – Physical sequel of forceful coughing 4/18/201550DR HARIVANSH CHOPRA

52 Treatment 1. Antibiotics are useful only in the catarrhal stage. 2. Once the child goes in paroxysmal stage it is very difficult to abort the attack. 4/18/201551DR HARIVANSH CHOPRA

53 Treatment 1. Erythromycin mg/kg/day in 4 divided doses X 14days. (Maximum 2 gm / 24 hrs.) 2. Respiratory Isolation for ≥ 5 days after start of Erythromycin therapy. 4/18/201552DR HARIVANSH CHOPRA

54 Alternative drugs 1. Clarithromycin mg/kg/day in 2 div doses X 7 days. (Maximum 1 gm/24 hrs.) 2. Azithromycin 10 mg/kg/day once daily X 5 days. 4/18/201553DR HARIVANSH CHOPRA

55 Alternative drugs 3. Ampicillin, Rifampicin and Cotrimoxazole are modestly active against pertussis. 4. The 1 st and 2 nd generation Cephalosporins are not active against pertussis. 4/18/201554DR HARIVANSH CHOPRA

56 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. 4/18/201555DR HARIVANSH CHOPRA

57 MCQs The drug of choice for the treatment of Pertusis & its dose is Erythromycin mg/kg/day Cephalexin mg/kg/day Cotrimoxazole 5-8 mg/kg/day Tetracyclin mg/kg/day Ans. – 1. 4/18/201556DR HARIVANSH CHOPRA

58 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. 4/18/201557DR HARIVANSH CHOPRA

59 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 3 rd dose > 6 mths. back Booster dose Received 4 th dose ≥ 3 years back Booster dose 4/18/201558DR HARIVANSH CHOPRA

60 PREVENTION VACCINESVACCINES Purified Acellular Vaccine Whole Cell Vaccine 4/18/201559DR HARIVANSH CHOPRA

61 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%). 4/18/201560DR HARIVANSH CHOPRA

62 Whole cell vaccine (DTP) National Childhood Encephalopathy Study (Britain) : Infantile Spasms Sudden Infant Death Syndrome (SIDS) Efficacy : Three doses % effective. 4/18/201561DR HARIVANSH CHOPRA

63 Purified acellular vaccine (DTaP) Introduced in 1981 by Japan Contains subcomponents of bacteria: Filamentous Hemagglutinin (Fha) Pertussis Toxin (PT). 4/18/201562DR HARIVANSH CHOPRA

64 Purified acellular vaccine (DTaP) Efficacy Two doses % protection against culture confirmed infection % protection against severe whopping cough. 4/18/201563DR HARIVANSH CHOPRA

65 DTP Vaccine Content (BE ltd.): Diptheria toxoid ≥20Lf to ≤30Lf Pertussis ≥4 IU Tetanus toxoid ≥5Lf to ≤25Lf. 2. Dose – 0.5 ml. 3. Route – Deep intramuscular. 4. Recommended site – Antero-lateral part of thigh. 4/18/201564DR HARIVANSH CHOPRA

66 Vaccination Schedule Immunization Policy : DPT doses during first year of life EPI recommendation 6, 10, 14 weeks Booster Policy : th DPT vaccine at 12 to 24 months th DPT vaccine used by some countries (In India, given 3 years after 4 th dose). 4/18/201565DR HARIVANSH CHOPRA

67 Contraindications to vaccination 1. Personal or strong family history of epilepsy, convulsions or similar CNS disorders. 2. Any febrile upset until fully recovered. 3. Reaction to one of the previously given triple vaccines. 4/18/201566DR HARIVANSH CHOPRA

68 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. 4/18/201567DR HARIVANSH CHOPRA

69 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), 4/18/201568DR HARIVANSH CHOPRA

70 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 4/18/201569DR HARIVANSH CHOPRA

71 Conclusions 1. Pertussis is a vaccine preventable disease caused by Bacillus pertussis. 2. It is characterised by intensive cough and whoop, and absence of other systemic features. 3. Highly contagious disease – prophylaxis of all contacts recommended. 4/18/201570DR HARIVANSH CHOPRA

72 4/18/201571DR HARIVANSH CHOPRA

73 4/18/201572DR HARIVANSH CHOPRA

74 TABLE 3 COMPOSITION OF DPT VACCINES CONTENTSGLAXO (PER 0.5ML)KASAULI DIPHTHERIA TOXOID TETANUS TOXOID B. PERTUSSIS (MILLIONS) AI. PHOSPHATE THIOMERSAL, B.P. 25LF 5LF MG 0.01% 30 LF 10 LF MG 0.01% 4/18/201573DR HARIVANSH CHOPRA


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