Authors: Nikki Abela / Editor: Liz Herrieven / Codes: ResC5, SLO5 / Published: 25/06/2024

It’s happening again. Paediatrics – moving from one infectious disease to the next. It feels like we are only just peeling down the posters from the measles outbreak, when we are putting up the pertussis one.

If only there was a vaccine. Oh yes, there is, so why is this happening?

Well, I suspect it’s due to a number of reasons but, according to UKHSA, a pertussis (a.k.a. whooping cough) spike happens every few years. The last recorded was in 2016, with low case numbers of this infectious disease being even more prolonged by the social restrictions of the COVID-19 outbreak.

Pertussis is a highly contagious, airborne disease, caused by Bordetella pertussis, a gram-negative coccobacillus, that is spread by droplets, so once it is active again, it is difficult to stop the spread.

What does this mean for me, the medic on the shop floor? – Well, it means that pertussis screening, treating, contact tracing and notifying need to be on the agenda more.

What does it look like? – In infants and neonates, it should be one of those red flags that goes up when they present with periods of apnoea. It may also present as feeding difficulties and a normal (although likely intractable) cough. Don’t forget that, in the UK, pregnant women are offered the pertussis vaccine at around 16 weeks gestation which can reduce the risk of pertussis until the child gets their own vaccine at around 8 weeks of age. According to UKHSA, studies in England found maternal vaccination offers around 90% vaccine effectiveness against confirmed disease and 97% protection against death from pertussis in infants under 3 months of age.

Infants under six months have the highest mortality rate of pertussis (around 1%), with most of these deaths happening in infants younger than 2 months of age.

In older children, it tends to follow three stages:

  1. The catarrhal phase with one to two weeks of non-specific snottiness/coryzal symptoms, commonly without fever – this is the most infectious period
  2. The paroxysmal phase where the classic “whoop” is heard but this isn’t always present. Bouts of coughing tend to be uncontrolled due to difficulty expectorating mucus. Bouts are frequently followed by vomiting, infrequently by cough syncope – in infants there may be apnoeas. Tends to be worse at night and can be triggered by cold or noise. This phase usually lasts about six weeks with the first couple of weeks being the worst. It can sometimes last up to ten weeks.
  3. The convalescent phase – where the coughing spells become less frequent and less severe, but paroxysms may recur with subsequent respiratory infections.

Immunised children can still get whooping cough, but they tend to get a milder illness than the unimmunised ones.

Testing for pertussis varies from Trust to Trust but generally is recommended for those with suspected pertussis who are at risk of severe or complicated illness i.e. infants <6months, immunosuppressed, patients with diabetes, neurological, hepatic, renal, pulmonary and chronic cardiac disease, morbidly obese or pregnant. If you suspect pertussis in someone who lives with someone from this patient group or is exposed to them regularly, then swabbing will be important. Rules also apply for health care workers who work with these contact groups here.

Testing may be done by culture, PCR or serology (culture is mainly indicated to check for antibiotic sensitivity in resistant/allergy cases). The type of test will vary depending on where you work, so check what your Trust is doing. (ID will invariably know the answer).

Don’t forget that whooping cough is a notifiable disease and all the forms and numbers can be found here.

For us, the spike has meant tracing those exposed in the waiting room as it is difficult to identify whooping cough from other respiratory illnesses at triage.

Contact tracing is important to give prophylaxis to close contacts who are in priority groups according to UKHSA (those at increased risk or those who come into contact with those at increased risk – the full list is here).

Treatment for whooping cough is with a macrolide first line or co-trimoxazole as a second line (although co-trimoxazole should not be given to pregnant patients or those under 6 weeks old). It should be given if they present within 21 days after the start of their symptoms and they should isolate until they have had 48 hours of treatment (or 21 days from the onset of symptoms if they do not want antibiotics). However, due to the high outbreak, antibiotics should be given within 14 days as per updated guidance.

Antibiotics will not make the symptoms go away, but they may make the course of the illness less severe and reduce shedding (and spreading) of the disease.

Those having apnoeas or significant complications will obviously need admission and isolation. You will need to have a low threshold for admitting children under 6 months with pertussis due to the high mortality rate in this age group.

Once the illness has subsided, the patient should have their vaccinations updated. Health care workers would also be eligible for booster vaccines if they qualify (guidance here).

References

  1. Whooping cough (pertussis): immunisation of healthcare workers. Public Health England, 2013. Updated: 2019.
  2. Notifiable diseases and causative organisms: how to report. Guidance, UK Health Security Agency, 2010. Updated: 2024.
  3. National Institute for Health and Care Excellence (NICE). Scenario: Management of whooping cough. CKS, Last revised: May 2024.
  4. Pertussis: occupational vaccination of health care workers. Guidance, UK Health Security Agency, 2024.