This document provides information on pertussis (whooping cough), including its causative agents, epidemiology, pathogenesis, clinical manifestations, diagnosis, treatment, prevention, and references. Pertussis is caused by Bordetella pertussis and related bacteria. It is highly contagious and while vaccination has reduced cases and deaths, it remains endemic. Presentation varies by age but commonly involves paroxysmal coughing fits. Treatment involves antibiotics in early stages and supportive care. Prevention centers on vaccination with DPT or DTaP.

1. PERTUSSIS
K.R POKHREL
MBBS,KUSMS

2. Pertussis
-whooping cough ,100 days cough
-pertussis=intense cough(most individuals don’t
whoop)
Causative agent:
-Bordetella Pertussis
-Bordetella Parapertussis
-Bordetella Holmessi,Bordetella Bronchiseptica

3. • Small,ovoid,fastidious,Gram negative
coccobacilli,0.5 microns length
• Nonmotile,non sporing,capsulated,aerobic
• Colonize only ciliated epithelium

4. Epidemiology
• Worldwide
• 1922-1948 leading cause of death
• 2008(WHO)-16 million cases;195000
childhood deaths esp in developing countries
• U.S-leading cause of death <14 yrs(10000
deaths/yr)before vaccines were available
• After the advent of pertussis vaccine->99%
decline on cases and shift of disease burden to
adolescents and adults

5. • Extremely contagious-attack rates 80-100%
• Source of infection=cases
• Chronic carriers not known
• Immunity never complete(waning protection following
vaccination)
• Adolescents and adults are major reservoir but
unrecognized
• Age:any age, most prevalent(<5 yrs )most severe(<6
months)
• Incubation Period:3-12 days
• Infectivity:first 4 weeks
• Transmission by droplets and direct contact

6. • Nepal 2015 A.D
-4416 cases of pertussis reported
-DTP3 coverage of 91%
2016 A.D
-4890 cases of pertussis reported
-DTP3 coverage 87%

7. Pathogenesis(toxin mediated)
Aerosol acquisition
colonize ciliated epithelium of respiratory tract(via
adhesins)
Expression of toxins (Pertussis toxin,Tracheal
cytotoxin,Adenylate cyclase,Dermonecrotic factor)
Paralyze cilia,Increase in cAMP(mucus
hypersecretion,inflammation) and inhibit clearance
of organisms-interferes with clearing of secretions

8. modifies host defences(lymphocytosis+impaired
chemotaxis)
local epithelial damage causing respiratory
symptoms and invasion into tissues(macrophages)
Immune response by body
Neutralization the toxins

9. Clinical Manifestations
• 3 Stages
1)Catarrhal Stage
• 1-2 weeks
• Congestion,rhinorrhea,
• low grade fever
• sneezing,lacrimation,conjunctival suffusion
• Most contagious at this stage

10. 2)Paroxysmal Stage
• 2-6 weeks
• Coughing marks its onset
• Initially dry,irritant,intermittent hack
• Progresses to inexorable paroxysm(hallmarks
of pertussis)
• Machine gun burst of uninterrupted cough on
a single exhalation

11. • Chin and chest held forward
• Tongue maximally protruded
• Eyes bulging ,watering
• Face red then blue
• Loud whoop(high pitched inspiration) at the end
of paroxysm
• Posttussive emesis and exhaustion
• Number and severity progresses over days to
weeks then plateau for days to week(peak >1
episodes/hr)

12. • 3)Convalescent Stage(>/=2 weeks)
• Number,severity and duration of episodes
diminishes
• Upto months
• Risk of developing secondary infections
common in this stage

13. Infants <3 months
• No classical stages
• Well appearing infant suddenly
chokes,gasps,gags,flail extremities,reddened
face
• Cough not prominent,whoop infrequent
• Apnea and cyanosis
• Young infants-paroxysmal and convalescent
stage longer
• Immunized children-foreshortened stages

14. • Adolescents and adults-no distinct stage,milder
-sudden feeling of strangulation
-suffocation,headache,diminished
awareness
-gasping without whoop
-post tussive emesis and intermittent
paroxysms separated by hours of well being
-non specific cough>21 days
• Physical examination not informative
-signs of LRT involvement,conjunctival
hemorrhages and petechiae

15. Diagnosis
• Clinical Diagnosis-Paroxysmal stage
• Suspect if predominant cough with absent
-fever,malaise,myalgia,rash,sorethroat,
hoarseness,tachypnea,wheeze,crepitations
• Cough>/=14 days+symptoms of paroxysm,whoop
or post tussive emesis
• Older children=escalating intermittent cough for
7-10 days
• <3 months=gagging,gasping,apnea,cyanosis

16. Investigations
1.Blood Count
-leukocytosis(15000-100000/mm3)with absolute
lymphocytosis(>/=50%)
2.Culture
-Nasopharyngeal aspirate(dacron/calcium alginate swabs)
-Bordet Gengou Potato Infusion media,Regan Lowe
charcoal media
3.Fluorescent Antibody staining,Serology
4.PCR
5.Chest Xray
-perihilar infiltrates,atelectasis

17. • Gram negative coccobacilli
• B.G media-small,white domed pearls
• R.L media-mercury droplets

18. Differential Diagnosis
• Viral infections(Adenovirus,Respiratory
Syncytial Virus)-
fever,sorethroat,conjunctivitis,LRT signs
• Chlamydial Infections-
conjunctivitis,tachypnea,rales
• Mycoplasma infection-
fever,headache,rales,continous cough
• Pulmonary tuberculosis-fever,weight
loss,night sweats

19. Complications
1.Respiratory
-Apnea,Respiratory failure
-Bronchopneumonia
-Atelectasis
-Bronchiectasis
-Pneumothorax,Emphysema
-Pulmonary Hypertension
-Reactivation of quiescient TB
Others -Otitis media

20. 2.Sequelae of forceful cough
-Epistaxis,Sub conjunctival and scleral
hemorrhage
-petechia on upper body
-Intracranial bleeding
-Retinal hemorrhage
-Umbilical and inguinal hernia
-Rectal prolpase
-Dehydration,malnutrition
3.CNS
-convulsions,encephalopathy

21. Treatment
Specific(antibiotics)
• Effective in early catarrhal phase
• Late phases-reduce transmission but doesn’t alter the
course of disease(>3 wks and not pregnant=no role)
• Primary agents
-Azithromycin-DOC(10mg/kg/day once daily for 5 days)
-Erythromycin(40-50 mg/kg/day in 4 divided doses for 14
days)
-substantial risk for infantile hypertrophic pyloric stenosis
with erythromycin

22. • Secondary agents
-Clarithromycin 15mg/kg/day in 2 divided doses for
7 days
-Cotrimoxazole(TMP 8mg/kg/day + SMZ 40mg/kg
day)in 2divided doses for 14 days
• CI in <2 months
No role for adjunct therapies(B2 agonists,
corticosteriods)

23. General Measures
• Young infants should be hospitalised
• Adequate hydration and nutrition
• Oxygen,Mechanical ventilation
• Quiet environment
Paroxysms-not life threatening
-<45 secs,red but not blue color change
-tachycardia,bradycardia or oxygen desaturation with
spontaneous resolution after paroxysm
-whooping,self expectoration of mucus plug
-post tussive exhaustion but not unresponsiveness

24. Criteria for Discharge
• Disease severity unchanged/diminished over
48 hr period
• No intervention required during paroxysm
• Adequate nutrition
• No complications
• Parents prepared for care at home

25. Care of household and close contacts
• Macrolides given(irrespective of
age,immunization status,symptoms)-dose same
as for treatment
• Vaccination
-close contacts <7 yrs , < 4 doses then complete the
series
-< 7 yrs,3rd dose >6months before exposure
-<7 yrs,4th dose>/=3 yrs before exposure
->9 yrs give if not previously received
• If contacts develop cough-evaluate for pertussis
booster

26. Prevention
• Vaccination
-2 types:DPT(whole cell) and DTaP(acellular)
-DPT vaccine in Nepal(Since 2009 A.D,component of
pentavalent)
-0.5ml IM in anterolateral thigh at 6,10 and 14
weeks included in National EPI schedule of Nepal
-recommendation:5 doses:4 in 1st 2yrs of life,6
months gap between 3rd and 4th
5th dose-4-6 yrs;not required if 4th dose acquired at
or after 4th birthday
-only acellular vaccines for older children and adults

27. • Adverse effects-fever,pain,redness,swelling
• Rarely abscess formation,inconsolable
screaming,seizures,hypotonic
hyporesponsiveness,anaphylaxis
• Contraindications
-Progressive neurological disease
-anaphylaxis after previous dose
-encephalopathy within 7 days of previous dose
• Tdap-in pregnant??
-passive immunity to child until vaccinated
• Continues to be endemic despite high vaccination coverage

28. References
• Nelson Textbook of Pediatrics 20th Edition
• Park’s Textbook of Preventive and Social Medicine
22nd Edition
• http://www.searo.who.int/immunization/data/ne
pal
• UPTODATE
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