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Recent Advances in Chest Medicine |

Whooping Cough in 2014 and BeyondPertussis: An Update and Review FREE TO VIEW

Joshua D. Hartzell, MD; Jason M. Blaylock, MD
Author and Funding Information

From the Infectious Diseases Clinic, Walter Reed National Military Medical Center, Bethesda, MD.

CORRESPONDENCE TO: Jason M. Blaylock, MD, Infectious Diseases Clinic, Walter Reed National Military Medical Center, 8960 Brown Dr, Bethesda, MD 20889-5629; e-mail: jason.m.blaylock.mil@mail.mil


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(1):205-214. doi:10.1378/chest.13-2942
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Pertussis, or whooping cough, has had a dramatic resurgence in the past several years and is the most common vaccine-preventable disease in the world. The year 2012 marked the most cases in the United States in > 50 years. Large outbreaks have occurred in multiple states, and infant deaths have drawn the attention of not only health-care providers but also the media. Although the disease is theoretically preventable by vaccination, it remains a challenge to control. New vaccination strategies have been implemented across different age groups and populations of patients, but vaccine coverage remains dismally low. Acellular vaccines, although safe, do not afford the same long-lasting immunity as the previously used whole-cell vaccine. Ultimately, improvements in the development of vaccines and in vaccination coverage will be essential to decrease the burden of pertussis on society. This article provides a review of pertussis infection and discusses advances related to the epidemiology, diagnosis, treatment, and prevention of infection, as well as continued areas of uncertainty.

Pertussis, or whooping cough, is an ancient disease that continues to cause significant morbidity and mortality.1 There has been a dramatic resurgence of pertussis in the past several years. This was most evident in 2012, when the highest number of cases in 50 years was reported in the United States.2 Large outbreaks have occurred in multiple states, and infant deaths have drawn the attention of not only health-care providers but also the media. Despite the advent of polymerase chain reaction (PCR) tests, the disease remains underdiagnosed, likely because of a lack of recognition and consideration for testing. Treatments are mainly aimed at preventing spread and have little impact on the course of the disease. New vaccination strategies have been implemented across different age groups and patient populations, to include pregnant women and the elderly, but vaccine coverage remains dismally low.36 Acellular vaccines, although safe, may not afford the same long-lasting immunity as the previously used whole-cell vaccine. Unless we can improve vaccine efficacy and coverage, pertussis will continue to be a significant health threat worldwide. This article reviews advances in the epidemiology, diagnosis, treatment, and prevention of pertussis infection and highlights areas of uncertainty (Table 1).

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TABLE 1  ] Key Updates for Pertussis

Multiple case definitions for pertussis exist worldwide, making it difficult to define the disease from a clinical perspective and to determine the true epidemiologic burden of disease.7 Most definitions are categorized as confirmed or probable and vary depending on the context in which they are used (ie, vaccine trials, outbreaks, and so forth). The US Centers for Disease Control and Prevention (CDC) definition is provided in Table 2 and can serve as the working case definition at this time.8 Similar to the CDC definition, most definitions worldwide are a decade old and based largely on the clinical presentation in infants and children. With an increasing burden of disease in adolescents and adults, new definitions have been proposed in an attempt to improve the sensitivity and specificity of diagnosis. The increased use of PCR testing and its inclusion in updated definitions is being evaluated, with hope of providing more accurate definitions of clinical disease. Studies are needed to validate these definitions and determine their usefulness. A thorough review of the topic, including the proposed definitions and their scientific basis, was recently published.7

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TABLE 2  ] CDC Case Definition of Pertussis8

CDC = Centers for Disease Control and Prevention; PCR = polymerase chain reaction.

a 

The definition is for endemic or sporadic cases. In outbreak settings, a clinical case may be defined as a cough illness lasting at least 2 wk.

b 

Serologic testing can be used clinically to aid in diagnosis but is not part of the official CDC case definition because serologic testing is not standardized.

Pertussis is primarily caused by the gram-negative coccobacillus, Bordetella pertussis. However, other species of Bordetella, most notably Bordetella parapertussis and Bordetella bronchiseptica, can cause mild or moderate pertussis-like symptoms.911 Of interest to pet owners, B bronchiseptica is the cause of kennel cough. More recently, cases of Bordetella holmesii have been identified during pertussis outbreaks that have particularly affected adolescents. In a community outbreak in Ohio, 60% of B holmesii case patients had received tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine, thus questioning the effectiveness of the vaccine in prevention of illness secondary to this particular species.11,12 The emergence of B holmesii has been observed in other countries as well.1315

Variation in the expression of pertussis virulence factors has been reported in recent years, prompting questions regarding the efficacy of the Tdap vaccine in the presence of these novel strains. Pertactin, a highly immunogenic virulence factor of B pertussis, is currently one of the main components of the acellular vaccine. To our knowledge, pertactin-negative strains were first reported in France,16 and researchers in Philadelphia described pertactin-negative strains in 11 isolates for the first time in the United States in 2013.17 Other countries had previously reported similar results, thus highlighting the need for ongoing research into the different variants of pertussis, in particular those isolated from previously vaccinated patients who develop disease.18 The long-term consequences of these changes are unknown, but a recent study from France reported no clinical difference in infants (aged < 6 months) when comparing pertactin-positive and pertactin-negative isolates.19

Pertussis is an acute airway infection that is localized to the airway and does not commonly enter the circulation and disseminate. Although pertussis harbors a multitude of toxins, including pertussis toxin, adenylate cyclase toxin, and tracheal toxin, the mechanism of the paroxysmal cough is not known. The most accepted explanation is that respiratory cilia are damaged by both the toxins and the resultant host immune response, resulting in irritation and subsequent coughing spells.20 There is no long-term human carriage or animal reservoir, and B pertussis does not survive for long periods in the environment. These characteristics should in theory limit transmission; however, pertussis remains very contagious, affecting 40% to 80% of susceptible contacts.21 It is this highly infectious nature that has contributed in large part to the resurgence of disease in the past several years.

The World Health Organization reported 200,868 cases of pertussis in 2012.22 The majority (approximately 95%) of infections occurred in developing countries, with most deaths attributed to young infants who were either unvaccinated or incompletely vaccinated.23,24 Case fatality rates in developing countries are estimated to be as high as 3% in infants.25 Pertussis burden is underestimated in resource-limited countries because of a number of factors, including misdiagnosis, lack of recognition, and absent reporting requirements. Realistic global disease burden models estimate that there are closer to 30 to 50 million pertussis cases and about 300,000 deaths per year.26 In developed countries, implementation of vaccination programs and contact tracing remains problematic in susceptible populations because of social and cultural differences.27

Before the introduction of the whole-cell pertussis vaccine, B pertussis infection was responsible for > 200,000 cases and nearly 7,000 deaths per year in the United States.28 Beginning in the late 1940s, vaccination markedly reduced the overall incidence and mortality of disease. Pertussis cases reached a historic low in the 1970s following implementation of large-scale vaccination strategies throughout the industrialized world during the 1950s and 1960s. Despite these vaccination strategies, pertussis historically has been endemic and cyclical within the United States, with outbreaks occurring every 3 to 5 years; however, a gradual increase has been observed over the past few decades. There were 48,277 cases of pertussis in the United States in 2012.29 Approximately 50% of the cases were in children > age 11 years and adults, yet 15 of the 18 deaths occurred in children < 1 year of age.2 The US military health-care system has reported a shift in the epidemiologic profile of pertussis to include more members of the adolescent and young adult population. In a report of nearly 3,500 pertussis cases among US military members and their beneficiaries from 2005 to 2012, infants < 1 year and adolescents aged 11 to 15 years accounted for the highest numbers of confirmed cases (16.7% and 16.4%, respectively).30 Although localized outbreaks of pertussis are not uncommon and occur throughout the year, marked rises in outbreak activity were identified in several states in 2012.2,31 Of particular importance is that, over the past several years, schools have been identified as significant venues for transmission of pertussis among the adolescent and young adult age groups.32,33 Mirroring the United States, there is a global increase in the number of cases among adolescents and adults. In New Zealand, 86% of diagnosed pertussis cases in 2007 were in groups > 25 years of age.34 In Australia, 60% of pertussis cases occurred in adults > 20 years of age in 2008.35

Infants too young to have completed their primary vaccination series account for the majority of pertussis-related complications, hospitalizations, and deaths. In a multinational study, approximately 75% of infants hospitalized with pertussis had received less than or equal to one dose of pertussis vaccine.36 In a 2010 epidemic in California, household coughing contacts were reported in 75% of patients with pertussis; the mother was the contact in 42% and siblings in 46% of cases.37 Given the diminished duration of protection afforded by the current childhood acellular pertussis vaccines, it is apparent that adolescents and adults with waning immunity and unrecognized pertussis are the most important source of infection for infants. The concern over adult transmission of pertussis to unprotected infants resulted in the Advisory Committee on Immunization Practices and CDC making successive changes to the Tdap immunization schedule in recent years (Table 3).38

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TABLE 3  ] CDC DTaP and Tdap Recommendations38

DTaP = diphtheria-tetanus toxoids, acellular pertussis; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis. See Table 2 legend for expansion of other abbreviation.

a 

Catch-up schedule should be followed if not fully vaccinated.

b 

Five doses of DTaP or four doses of DTaP if the fourth dose was administered on or after the fourth birthday.

c 

Administer as soon as possible regardless of when tetanus- or diphtheria toxoid-containing vaccine was last given. Tdap is only given once currently (either as an adolescent or an adult).

There are several proposed reasons for the changes in the epidemiology of pertussis infection. More press reports and recent published scientific literature, as well as reports of pertussis vaccine trials and subsequent licensures of acellular vaccines for use in adults, have all contributed to increased clinician awareness and reporting.39,40 Growing use of PCR testing for B pertussis has improved the ability to make the diagnosis.41 It has been hypothesized that genetic changes in circulating strains of B pertussis might be contributing to vaccine failures.42 A diminished duration of protection afforded by the acellular vaccine compared with the whole-cell pertussis vaccine is also contributing to the increase in pertussis cases and is discussed in further detail in the Vaccination section.4347

The incubation period for B pertussis is longer (approximately 7-10 days) than most viral upper respiratory tract infections (1-3 days); therefore, exposure to a person with a cough illness 1 to 2 weeks prior to the development of upper respiratory symptoms may be more suggestive of pertussis. Classic infection with B pertussis is characterized by three stages: catarrhal, paroxysmal, and convalescent. The catarrhal stage is marked by a 1- to 2-week period of generalized malaise, rhinorrhea, and mild cough. Fevers, if present, are generally low grade and not incapacitating. Symptoms during this stage are nonspecific and overlap with other more common viral infections. A diagnosis of pertussis is rarely considered unless there is a clear contact. It is important to ask if other family members have had a prolonged cough, as this increases the odds of pertussis.21 The presence of nonpurulent conjunctival injection or excessive lacrimation might prompt the astute clinician to consider a diagnosis of pertussis during this stage.48

The paroxysmal stage usually commences during the second week of illness and consists of paroxysms, or a series of coughs during a single expiration. In severe cases, patients may have 30 or more paroxysms per day. Low lung volumes caused by the paroxysmal cough lead to vigorous inspiration that, particularly in infants and children with a smaller caliber trachea, can result in the classically described “whoop.”49 Examples of the cough are available online.50,51 Paroxysms occur most frequently at night and may be incited by cold air, loud noises, or other stressors. The presence of posttussive emesis and inspiratory whoop is associated with an increased likelihood of pertussis infection.48 Patients are often asymptomatic between paroxysms, which should point toward the diagnosis, as few other respiratory infections present in this manner. A recent study suggested that cyanosis and a lack of fever and congestion can be predictive of pertussis in infants.37 The presence of wheezing in children should not dissuade providers from including pertussis in the differential, as this might ultimately delay the diagnosis.52 Sweating between episodes of paroxysms has also been indicative of a diagnosis of pertussis in adults.7 At the end of the catarrhal stage or beginning of the paroxysmal stage, patients may exhibit signs of systemic disease, such as leukocytosis with predominant lymphocytosis, which portend a worse clinical outcome.53

Severe paroxysms have led to complications including syncope, subconjunctival hemorrhages, rib fractures, urinary incontinence, hernias, intracranial hemorrhage, and stroke from vertebral artery dissection.54 Older adults with asthma and obesity are at increased risk of more severe disease and hospitalization.55 Complications are more common in nonimmune infants and include pneumonia, failure to thrive, seizures, encephalopathy, cerebral hypoxia, secondary bacterial infections, pulmonary hypertension, and rectal prolapse.56

Patients are most infectious during the catarrhal period and for the first 2 weeks of spasmodic cough; however, they can remain infective for up to 6 weeks, especially in the case of nonimmune infants. A gradual transition to the convalescent stage (1-6 weeks) occurs after 1 to 2 months and is characterized by a persistent but decreasing frequency and severity of cough. It is important to note that children who have had pertussis may have a recurrence of coughing paroxysms when exposed to new respiratory viral infections.49

The clinical presentation of pertussis in previously immunized or infected adolescents and adults is variable and often atypical. The predominant, and sometimes sole, symptom is persistent cough. Pertussis was the cause of 12% to 32% of prolonged cough illnesses in adolescents and adults in one study.57 The mean duration of cough in adults is 36 to 48 days. Recurrences of paroxysmal cough are not uncommon and may occur up to 1 year following infection.58 In a recent outbreak of pertussis infection in Ohio, paroxysmal cough was noted in 82% of infections, but posttussive vomiting and a whooping cough were only noted in 42% and 20% of cases, respectively.11 These atypical presentations and subsequent lack of recognition often lead to delays in diagnosis, thus eliminating the chance to initiate timely and effective treatment.

Clinical suspicion is paramount in the diagnosis of pertussis. If a case meets the clinical case definition criteria as defined in Table 2, then it should be confirmed via either an epidemiologic link or with appropriate laboratory testing (ie, culture or PCR assay). Even during influenza season, pertussis should be considered in the differential for a patient presenting with a chronic cough. Timely diagnosis prevents unnecessary evaluations and allows for early treatment to prevent spread. Current recommendations from the CDC support a combination of diagnostic tests based on the duration of symptoms (Table 4).59

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TABLE 4  ] Clinical Stages of Pertussis and Diagnostic Approach Over Time58

See Table 2 legend for expansion of abbreviation.

a 

PCR sensitivity decreases markedly after 2 wk; 64% and 56% in the third and fourth weeks after symptom onset, respectively.

Culture is the gold standard because it is 100% specific for identification of B pertussis and allows for specific strain identification and antimicrobial resistance testing. Sensitivity has ranged from 10% to 60% depending upon the timing of specimen collection as it relates to symptom onset.60,61 Sensitivity markedly decreases when culture is obtained > 2 weeks after symptom onset.61,62 Various factors contribute to this low sensitivity, including the fastidious nature of the organism, recent antibiotic use, the type of specimen collected, the method of collection, prolonged transport to the laboratory and delayed specimen plating, and the specific collection media.63 The CDC provides an overview for providers on testing strategies as well as sample collection.64 Specimens for culture should be obtained via nasopharyngeal aspirate or posterior nasopharyngeal swab, as these specimens contain the ciliated respiratory epithelial cells for which the organism has an affinity. The specimens should be collected via calcium alginate or Dacron swabs; however, Dacron is optimal, as calcium alginate may interfere with PCR assays. Cotton or rayon swabs should not be used, as they contain fatty acids that are toxic to B pertussis. Specimens should be immediately placed in Regan-Lowe media for transport or directly onto Regan-Lowe agar or Bordet-Gengou agar, which usually reveals growth in 7 to 10 days.49 Sample collection is variable and should be discussed with your local laboratory.

PCR is the most sensitive method for rapid detection of pertussis. PCR is generally not affected by previous antibiotic use, and results are available within 1 to 2 days. Compared with culture, PCR may increase the diagnostic yield threefold to fivefold and can detect very small numbers of viable and nonviable organisms.11 PCR is most sensitive during the first 3 weeks of cough, when bacterial DNA is still present in the nasopharynx.65 Thereafter, sensitivity markedly declines. A recent study during a pertussis outbreak found that PCR sensitivity was 64% and 56% in the third and fourth weeks after symptom onset, respectively.41 PCR testing is not without its flaws. PCR is costly, not available in all settings, and can produce both false-negative and false-positive results (especially during outbreaks). It is not recommended after 5 days of antibiotic use.66 Pseudo-outbreaks due to false-positive results of assays have highlighted the need for defined cutoff values based on analytical sensitivity and clinical relevance.67 There is no standardized or US Food and Drug Administration-approved, commercially available PCR test for B pertussis. PCR methodologies and results may vary significantly between laboratories. Among several chromosomal regions used for real-time PCR detection of B pertussis, the multicopy insertion sequence IS481 is often the target of choice because it is found in multiple copies in B pertussis. However, IS481 is found in other Bordetella species, to include B holmesii and B bronchiseptica.68 Novel real-time PCR assays that include multiple targets for speciation among Bordetella species have improved the specificity of diagnosis in pertussis-like illnesses.69

Serological testing is primarily used for epidemiologic or research purposes but is being incorporated into the diagnostic approach. Both the CDC and the US Food and Drug Administration have developed a useful serologic assay for confirming diagnosis during suspected outbreaks.59 Many state public health laboratories have included this assay as part of their pertussis testing algorithm. Commercial assays should be used cautiously, as they have different antigen composition and quality without proven clinical accuracy. Serologic diagnosis is useful for adults and adolescents who present late in the course of their illness, when both culture and PCR are likely to be negative. Paired sera demonstrating a twofold rise is the gold standard for serological diagnosis, but in clinical practice a probable diagnosis of pertussis can be based on single-sample serology.70 For the CDC single-point serology, the optimal timing for specimen collection is 2 to 8 weeks following cough onset, when antibody titers are at their peak; however, serology may be performed on specimens collected up to 12 weeks following cough onset.59 Importantly, a recent study demonstrated that antibody responses to the vaccine will not affect serologic results if the vaccine was given at least 6 months prior to the testing.71

Direct fluorescent antibody testing of nasopharyngeal specimens is inexpensive and provides rapid results but is not recommended based on its poor sensitivity and specificity. In addition, cross-reactivity has been demonstrated with other organisms, such as B bronchiseptica, Haemophilus influenza, and diphtheroids.72 Pulse-field gel electrophoresis is a DNA fingerprinting technique that may be useful for epidemiologic purposes; however, availability is limited.

The treatment of pertussis consists of treating the bacterial infection and, maybe more importantly to the patient, the symptoms. Treatment efficacy is largely based on the immediacy of treatment. Unfortunately, treatment is rarely given early enough to impact the clinical course of the disease. A recent Cochrane Review concluded that short-term treatment with macrolides was as effective as long-term treatment in eradication of B pertussis, with fewer side effects.73 Azithromycin for 3 to 5 days is the preferred treatment based on ease of administration and side effect profile. Resistance to macrolides is rare but has been reported.74 Trimethoprim/sulfamethoxazole for 7 days is an alternative. It is always important to consider both the age of the patient and possible antibiotic side effects when initiating treatment.

The most distressing issue for patients is the paroxysmal cough; unfortunately, antibiotics have no benefit on symptoms in this stage. No proven treatments exist to decrease the severity or frequency of symptoms. A Cochrane Review on the topic concluded that there is insufficient evidence to make conclusions regarding treatments for the cough.75 The majority of studies were of poor quality, and in general symptomatic treatment was not beneficial. Steroids, pertussis immunoglobulin, and exchange transfusion may provide benefit in severe cases but should not be used routinely.75,76

Prevention remains the key in controlling pertussis, as delays in recognition and treatment significantly hamper providers’ ability to otherwise impact the course of the illness and transmission. Multiple strategies have been used to control pertussis, with the main efforts focusing on vaccination. Antibiotics have a minimal role in preventing disease and should be limited to those who are identified as having close contact (within 91 cm [3 feet] or direct contact with oral/nasal secretions) of someone with pertussis. Prophylactic treatment of contacts has not been demonstrated to have a meaningful impact on the number of cases that occur or the severity of symptoms if disease does develop.77 The CDC is expected to publish a new set of recommendations on prevention within the year. Currently, each case should be considered individually and take into account past guidance.77 Important considerations include degree of exposure, vaccination status, immune status of the patient, and the risks of antibiotic use. Special consideration for antibiotic prophylaxis should be given to pregnant women, infants, and immunosuppressed patients, given the increased risk of morbidity in these populations.

Vaccination for pertussis was introduced in the 1950s and dramatically reduced the incidence of disease, but success was moderated by side effects. Whole-cell pertussis vaccines (ie, diphtheria-tetanus toxoids, whole-cell pertussis [DTwP]) were associated with fever (including febrile seizures), local reactions, and hypotonic episodes.78 These concerns resulted in their replacement with acellular vaccines (ie, diphtheria-tetanus toxoids, acellular pertussis [DTaP]; Tdap; and so forth) in the 1990s. Although acellular vaccines have an improved safety profile, their effectiveness has been called into question. A Cochrane Review demonstrated that the effectiveness of acellular vaccines in preventing typical whooping cough ranges from 59% to 85%.79 Furthermore, studies demonstrated that having a whole-cell vaccine as any part of the vaccination series improved immunity.43,80 A case-control study of children done by Kaiser Permanente Northern California reported that following the fifth dose of DTaP, children were 46% more likely to develop pertussis in each subsequent year.46 Studies in Minnesota children and from 15 California counties reported similar results of waning immunity with DTaP.47,81 These recent reports highlight a clear concern of waning immunity with use of the current acellular vaccines.

There are multiple possible reasons for the decreased efficacy of acellular vaccines, and a full discussion is beyond the scope of this paper. A recent review by Cherry42 highlights several of these potential explanations. Others have discussed the importance of antigenic divergence and how it may be affecting memory recall and antibody efficacy.82 It is clear from the available data that there is a need for newer more immunogenic pertussis vaccines. A recent review suggested that including new virulence factors might be the most appropriate approach.83 Unfortunately, the development and approval of new vaccine products will take time. In the meantime, the use of the vaccines that we do have could be improved.

Vaccination timing is an important component of eliciting immunity. A study of pregnant women reported that passive protection of infants requires vaccination during the third trimester, and it is short-lived.84 As a result, the current Advisory Committee on Immunization Practices recommendation for pregnant women is that vaccination occur between 27 and 36 weeks’ gestation during each pregnancy to maximize the maternal antibody response and passive antibody transfer to the infant.6 Future studies should examine the timing of other patient populations (including infants) to determine if different schedules or more frequent boosters may improve outcomes.

Ensuring adequate vaccination coverage remains a challenge. Several studies have demonstrated that there are gaps in coverage (Tdap coverage ranged from 5.9% to 45.5%) and adherence to recommendations, including patients with free access to care and those with adequate insurance coverage.8590 There are multiple barriers to vaccination, including cost, inadequate coordination of adult vaccination activities, lack of provider recommendation for vaccination, health literacy, and concern about adverse events.91 The problem is amplified worldwide, where an estimated 22.6 million children are not completing the appropriate pertussis vaccination series (three doses in first year of life).92 Unfortunately, this leaves the most vulnerable patients at risk.85,86,88 Disappointingly, health-care workers have low rates of vaccination as well (26.9% in one study).93 To improve vaccination, health-care organizations need to think outside the box and consider a multipronged approach to vaccination (Table 5).88,94,95 The cost of such strategies is a barrier in many settings, but a growing body of evidence suggests that these approaches may ultimately be cost effective.9699

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TABLE 5  ] Multipronged Approach to Improve Pertussis Vaccination

See Table 3 legend for expansion of abbreviation.

Pertussis continues to be a significant health problem worldwide. There are tremendous needs in terms of improved recognition, diagnosis, treatment of symptoms and severe disease, and, most importantly, prevention. Ultimately, the development of new vaccines as well as improvement in vaccination coverage will be essential to decreasing the burden of pertussis on society. Without a comprehensive approach to the disease, it is likely that pertussis will be just as, if not more, prevalent in another 100 years.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Uniformed Services University, Department of Defense, nor the US Government. This work was prepared as part of our official duties. Title 17 U.S.C. 101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties. Reviewed by the WRNMMC public affairs office in February 2014.

CDC

Centers for Disease Control and Prevention

DTaP

diphtheria-tetanus toxoids, acellular pertussis

PCR

polymerase chain reaction

Tdap

tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis

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Figures

Tables

Table Graphic Jump Location
TABLE 1  ] Key Updates for Pertussis
Table Graphic Jump Location
TABLE 2  ] CDC Case Definition of Pertussis8

CDC = Centers for Disease Control and Prevention; PCR = polymerase chain reaction.

a 

The definition is for endemic or sporadic cases. In outbreak settings, a clinical case may be defined as a cough illness lasting at least 2 wk.

b 

Serologic testing can be used clinically to aid in diagnosis but is not part of the official CDC case definition because serologic testing is not standardized.

Table Graphic Jump Location
TABLE 3  ] CDC DTaP and Tdap Recommendations38

DTaP = diphtheria-tetanus toxoids, acellular pertussis; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis. See Table 2 legend for expansion of other abbreviation.

a 

Catch-up schedule should be followed if not fully vaccinated.

b 

Five doses of DTaP or four doses of DTaP if the fourth dose was administered on or after the fourth birthday.

c 

Administer as soon as possible regardless of when tetanus- or diphtheria toxoid-containing vaccine was last given. Tdap is only given once currently (either as an adolescent or an adult).

Table Graphic Jump Location
TABLE 4  ] Clinical Stages of Pertussis and Diagnostic Approach Over Time58

See Table 2 legend for expansion of abbreviation.

a 

PCR sensitivity decreases markedly after 2 wk; 64% and 56% in the third and fourth weeks after symptom onset, respectively.

Table Graphic Jump Location
TABLE 5  ] Multipronged Approach to Improve Pertussis Vaccination

See Table 3 legend for expansion of abbreviation.

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