Pertussis, or whooping cough, is being reported in Washington state at much higher levels this year since 2012. They were quite low during COVID-19 but have jumped dramatically this year.
While this is a national and state trend, we are seeing it as a local concern, as well. For Washington, as of Nov. 30 of this year, the total confirmed and probable cases stand at 1665. Notable is that reported “confirmed and probable” cases are lower than the total number of actual cases in our state or community, as only a portion get reported.
The best way we have to prevent the spread of pertussis and protect those at highest risk is to make sure you and your children are up to date with your vaccines. There is a series of vaccines stimulating combined protection against tetanus, diphtheria and pertussis that is recommended for our children as well as boosters for adults every 10 years. While the vaccine will not help protect an unimmunized child this season, completing the series will provide protection for the future.
You should discuss the benefits and risks of the DTaP vaccine with your primary care provider.
When there is an outbreak, key to containing it is to quickly identify, isolate and treat cases as well as their close contacts, until all have been treated for it and are no longer contagious to others.
Pertussis is a respiratory illness caused by the bacterium Bordetella pertussis. The pertussis bacteria are breathed into the airway and, as it grows and multiplies, it releases toxins which wipe out the cilia in the airway and causes inflammation.
This disease is spread through contact with secretions discharged or droplets coughed into the air from an infected person. Initially, a family is unaware of the potential severity of the disease as, at the onset of symptoms, it appears to just be a runny nose from a common cold.
After a person is infected, the non-immune or under-immune person enters an incubation period where the bacteria are growing but not causing symptoms. Then they enter the runny nose (catarrhal) phase, which is followed by the harsh coughing (tussive) phase. This is intermittent and the child can seem normal between bouts of coughing fits. The infected person is contagious starting in the runny nose phase and up to 21 days after the coughing phase starts, and possibly longer. Treatment with a five-day course of antibiotics will stop the coughing person from being contagious upon completion of treatment but, after the cough has started, the antibiotic will not shorten the prolonged coughing phase, because the eradicated cilia in the airway take time to grow back.
The greatest health concern with this illness is the impact it can have on infants under a year of age. While the classic symptom of pertussis is the harsh intermittent cough, an infant may not have a cough, yet become a poor feeder and suddenly stop breathing (known as apnea). This causes a drop in the baby’s oxygen level that can lead to seizures, brain damage or even death.
When an older child or adolescent gets to the tussive (coughing) phase, they can really struggle with the classic, intermittent, staccato-type coughing fit that is prolonged, without taking a breath until they gasp or make the classic whooping sound, only to go back into the staccato cough again. The cough can put you on the floor, causing vomiting, as mucous drains out of your mouth and nose. This harsh, whole-body cough can produce hemorrhages in the white of the eyes, bruising on the face, bruised or torn chest muscles, and rarely even fractured ribs or hernias.
Remember, once the cough develops, treatment with a five-day course of antibiotics will kill the bacteria but will not stop or modify the prolonged cough. This is because the bacteria produce a toxin that destroys the cilia or hair-like projections that are in the larger airways. The cilia’s job is to sweep the mucous and debris up and out of the bronchi and trachea air passages. With the cilia gone, mucous and debris build up until it stimulates a violent cough reflex to clear out the mucous. But the advantage of antibiotic treatment is that it does kill the bacteria in one’s airway so that the person is no longer contagious to others.
All family members exposed to the sick person should be treated prophylactically (preventive antibiotic treatment) before any symptoms are identified, whether they are fully vaccinated or not. Experience shows us that if a person is in the incubation period, and maybe even in the early runny nose phase, and they get the antibiotic treatment, it can prevent toxin production and keep them from losing all or most of their cilia and prevent or moderate the coughing phase.
The good news for those with classic pertussis is that the cilia do eventually grow back, but it will take weeks to months for the number of cilia to grow to where they are functional enough to see the cough resolve.
How can we prevent pertussis and its spread?
1. Immunization against pertussis. This is considered to be the best way to limit this disease and its spread. This is offered as a childhood immunization in the DTaP (diphtheria, tetanus and acellular pertussis) at two months, four months, six months, 15 months, and a fifth dose between 4 and 6 years; a booster Tdap is given at 11 or 12 years of age due to the expected waning of protective antibody levels. Waning immunity occurs in the immunized as well as the unimmunized person who has had the actual disease in the past, so boosters in adolescence and adulthood with the Tdap are recommended every 10 years. This is especially recommended for pregnant mothers so that their boosted protective antibody levels against pertussis are shared with their newborn via placental transfer, before the cord is cut, and thus provides some passive protection in early infancy, when the baby is at highest risk.
2. Isolation of individuals with pertussis. This can be difficult in the home setting, especially with small children, but good hand washing and drying hands with paper towels can help some when it comes to infectious secretions. Older children with the cough can avoid eating with the family at the table and limit their time in common areas until all have been treated with five days of antibiotics. The key is isolating the whole family from others by not leaving home to attend extended family activities or go to public gatherings, or to work, school or daycare, until the completion of five days of antibiotics.
Again, treating those ill with pertussis with antibiotics and giving preventative (prophylactic) antibiotics to close contacts is key to limiting the spread of this contagious illness.
To identify pertussis, a medical provider must suspect the illness by either the classic clinical presentation or obtaining history that there was exposure to someone with pertussis. If not, they may just diagnose it as “bronchitis” and give antibiotics to only that patient and not treat all close contacts. If you suspect that you have pertussis and tell your provider of your concern, the provider is more likely to confirm or rule out pertussis by testing for it. Often, the patient being evaluated may not cough during the exam (since the cough can be intermittent) and if the provider doesn’t hear the cough, they may downplay the parent’s or patient’s concern. Often, a parent of a child or an adult patient will make several trips to the doctor before the provider orders a test for pertussis, delaying the diagnosis and prolonging exposure to others.
Obstacles to this use of antibiotics for all exposed include:
• Testing requires a medical appointment and that can sometimes take days
• The medical provider has to suspect pertussis to test for it
• The testing for many medical offices is a “send out” test and the results could take a day or two before being reported
You are the best advocate for your and your family’s health. I want you to be aware of the increased rates of pertussis in our state and in our county so you can be alert to it and advocate for and protect your family and our community at large, especially the most vulnerable among us.
Learn more at https://lewiscountywa.gov/departments/public-health/community-health/quick-info-series/.
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Joseph Wiley, MD, is the Lewis County health officer.
