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Whooping cough, also known as pertussis, is a highly infectious disease…
Whooping cough, also known as pertussis, is a highly infectious disease usually caused by the bacterium Bordetella pertussis, an exclusively human pathogen that can affect people of all ages
The infection is transmitted via respiratory secretions generated by coughing and sneezing, or via objects contaminated with respiratory secretions.
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If untreated, people typically remain infectious for 21 days from the onset of symptoms.
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The maternal whooping cough vaccination programme was introduced to protect infants (through the intrauterine transfer of maternal antibodies) from birth until they can be actively protected by the routine infant vaccination programme. The programme offers vaccination to pregnant women, ideally between 16–32 weeks (but up to 38 weeks) of pregnancy. For more information, see the CKS topic on Antenatal care - uncomplicated pregnancy.
The whooping cough vaccine is given as part of the 6-in-1 vaccine offered to children aged 8, 12, and 16 weeks, and as part of the 4-in-1 pre-school booster offered to children at the age of 3 years and 4 months old. For more information, see the CKS topic on Immunizations - childhood. There is currently no single whooping cough vaccine available.
CLINICAL FEATURES
Whooping cough has 3 phases of symptoms: catarrhal, paroxysmal, and convalescent.
The catarrhal phase typically begins 7–10 days (and ranges from 4–21 days) after exposure and lasts for 1–2 weeks.
Symptoms are often difficult to distinguish from those of other upper respiratory tract infections and include rhinorrhoea, malaise, mild cough, sore throat, and conjunctivitis.
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It is characterized by rapid, violent, and uncontrolled coughing fits (paroxysms) due to difficulty expelling thick mucus from the tracheobronchial tree.
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Typically consist of a short expiratory burst followed by an inspiratory gasp (causing the characteristic 'whoop' sound). The ‘whoop’ is less common in adults, and in children younger than 3 months of age (who may present with apnoea alone).
Occur frequently at night, with an average of 15 attacks per 24 hours.
May be triggered by external stimuli, such as cold or noise.
Are frequently associated with post-tussive vomiting and may be severe enough to cause cyanosis in children. Adults may experience sweating attacks with facial flushing, and rarely, cough syncope.
Increase in frequency during the first 1–2 weeks, remain at the same frequency for 2–3 weeks, and then gradually decrease.
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The convalescent phase usually lasts 2–3 weeks, during which there is a gradual improvement in cough frequency and severity. However, paroxysms can recur with subsequent respiratory infections for many months after the initial infection.
DIAGNOSIS
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A person presents with an acute cough lasting for 14 days or more without an apparent cause plus one or more of the following:
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Is known to be part of an ongoing outbreak investigation in a specific group of people; for example, children attending a school where whooping cough is known to be circulating.
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If suspected, complete a notification form within 3 days and send it to the local Public Health England (PHE) centre.
The local health protection team will advise on appropriate tests for confirmation and surveillance. This will depend on the person's age, duration of symptoms, and local laboratory facilities.
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In young infants, the characteristic ‘whoop’ may never develop and coughing spasms may be followed by periods of apnoea.
In older children and adults, whooping cough may present as a persistent cough without the classic symptoms.
People who have some immunity (due to prior infection or vaccination) may present with milder illness.
LAB TESTS
Laboratory confirmation of clinically suspected cases of whooping cough can be made by culture, polymerase chain reaction (PCR), serological testing, or oral fluid testing (OFT).
The local health protection team will advise on appropriate tests for confirmation and surveillance, this will depend on the person's age, duration of symptoms, and local laboratory facilities. The following tests are available from Public Health England (PHE) laboratories:
Culture and isolation of Bordetella pertussis (from nasopharyngeal aspirate [NPA] or nasopharyngeal swab [NPS]/pernasal swab [PNS]) is suitable for people of all age groups with a cough duration of less than 21 days.
PCR, a molecular technique used to detect DNA sequences of B. pertussis, is suitable for people of all age groups with a cough duration of less than 21 days. PCR is usually more sensitive than culture as the organism does not need to be viable; however, PCR is less likely to be positive in people with a symptom duration of 21 days or more.
Serology is suitable for older children (aged over 16 years old) and adults with more than 14 days history of cough and at least one year after the most recent dose of whooping cough vaccine (including any dose administered in pregnancy). Serology detects antibodies to the whooping cough toxin. It may be suitable in people with a cough duration of 21 days or more, when culture and PCR are unlikely to yield positive results.
OFT is suitable for people aged between 2–16 years (that is, aged 2 to under 17 years) with a history of more than 14 days of cough and at least one year after the most recent dose of whooping cough vaccine. It is tested for anti-pertussis toxin immunoglobulin G (IgG).
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B. pertussis isolated from a respiratory sample, typically an NPA or NPS/PNS (or throat swab).
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IgG titre greater than 70 International Units per millilitre (IU/ml) from a serum specimen, or greater than 70 arbitrary units (aU) from an oral fluid specimen (in the absence of vaccination within the past year).
DIFFERENTIALS
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Cough due to these causes is usually less severe as pertussis toxin is not produced. For more information, see the CKS topics on Chest infections - adult, Common cold, Cough, and Cough - acute with chest signs in children.
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Asthma — for more information, see the CKS topic on Asthma.
Chronic obstructive pulmonary disease (in adults) — for more information, see the CKS topic on Chronic obstructive pulmonary disease.
Post-infectious cough — for more information, see the CKS topic on Cough.
Upper-airway cough syndrome — for more information, see the CKS topic on Cough.
Gastro-oesophageal reflux disease — for more information, see the CKS topics on Dyspepsia - proven GORD and GORD in children.
Underlying lung malignancy — for more information, see the CKS topic on Lung and pleural cancers - recognition and referral.
MANAGEMENT
Arrange hospital admission for people with significant breathing difficulties (for example apnoea episodes, severe paroxysms, or cyanosis) or significant complications (for example seizures or pneumonia).
Have a low threshold for admitting children aged 6 months or younger, as they are at increased risk of severe illness and death.
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If admission is not necessary and the onset of the cough is within the previous 21 days, prescribe antibiotic treatment.
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For infants aged under 1 month, clarithromycin is preferred. Azithromycin may be used although there are limited data in this age group.
For children aged over 1 year, prescribe azithromycin or clarithromycin.
For non-pregnant adults, prescribe azithromycin or clarithromycin.
For pregnant women, prescribe erythromycin.
If macrolides are contraindicated or not tolerated, prescribe co-trimoxazole.
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For information on dosing regimens, contraindications, cautions, adverse effects, and drug interactions of these antibiotics, see the section on Prescribing information.
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On self-care measures including rest, adequate fluid intake, and the use of paracetamol or ibuprofen for symptomatic relief. For more information, see the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues.
That even with antibiotic treatment, whooping cough is likely to cause a protracted non-infectious cough that may take several weeks to completely resolve.
Symptoms are likely to be less severe and resolve more quickly if the person has been immunized or has had whooping cough before.
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That exclusion from nursery, school, or work is required.
Children and healthcare workers who have suspected or confirmed whooping cough should stay off nursery, school, or work until they have completed 48 hours of appropriate antibiotic treatment, or for 21 days from the onset of symptoms if not treated.
People who work in other settings should avoid contact with infants under one year who are unvaccinated or partially vaccinated until 48 hours of appropriate antibiotic treatment, or for 21 days after the onset of symptoms if not treated.
Arrange for the person to have any outstanding vaccinations after they have recovered from the acute illness.
The whooping cough vaccination programme for pregnant women offers vaccination to pregnant women, ideally between 16–32 weeks (but up to 38 weeks) of pregnancy. If a pregnant woman is diagnosed with whooping cough before 16 weeks gestation, she should wait until she reaches 16 weeks of pregnancy (and ideally following the detailed ultrasound scan) to have the vaccine. For more information, see the CKS topic on Antenatal care - uncomplicated pregnancy.
The whooping cough vaccine is given as part of the 6-in-1 vaccine offered to children aged 8, 12, and 16 weeks and as part of the 4-in-1 pre-school booster offered to children at the age of 3 years and 4 months old. For more information, see the CKS topic on Immunizations - childhood.
PRESCRIBING
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) or the British National Formulary (BNF).
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