Pertussis Infection in the United States: Role for Vaccination of Adolescents and Adults

Dennis A. Brooks, MD; Richard Clover, MD

J Am Board Fam Med. 2006;19(6):603-611.

Complications of Pertussis

Life-threatening complications are most common in infants <3 months of age,^[19,21] but infection can also be severe in some adult cases. Secondary bacterial pneumonia is diagnosed in up to one quarter of young infants with pertussis^[21,25] and is the most common complication and the cause of most pertussis-related deaths across age groups. Data from 1997 to 2000 indicate that pneumonia occurred in up to 5.2% of all reported pertussis cases, and 11.8% of infants <6 months of age.^[7] Other complications include seizures (0.8% of all cases, 1.4% of infants <6 months of age) and encephalopathy (0.1% of all cases, 0.2% of infants <6 months of age).

Death due to pertussis is rare (0.2%). The vast majority (90%) occurs in children younger than 6 months of age with no predisposing conditions.^[2] Risk factors for death among infants include premature birth, Hispanic ethnicity, and having a young mother.^[2,26] Pertussis has also been linked to sudden infant death (3% to 5%).^[27,28] Other less severe complications in infants include otitis media, anorexia, and dehydration. Pressure effects of severe paroxysms may lead to pneumothorax, epistaxis, subdural hematomas, hernias, and rectal prolapse. Additional complications identified in adolescents and adults include urinary incontinence, rib fracture, unilateral hearing loss, herniated disk, and precipitation of angina pectoris.^[5,24]

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Cite this: Pertussis Infection in the United States: Role for Vaccination of Adolescents and Adults - Medscape - Dec 01, 2006.

Abstract and Introduction
Epidemiology and Transmission of Disease
Pathogenesis of Infection
Clinical Manifestations and Complications of Infection
Complications of Pertussis
Diagnosis of Pertussis
Management of Pertussis
Conclusions
References

Table 1. CDC Definitions of Clinical, Confirmed, and Probable Cases of Pertussis
A clinical case is defined as an acute cough illness lasting 14 days in a person with at least one pertussis-associated symptom (ie, paroxysmal cough, post-tussive vomiting without other apparent cause, or inspiratory whoop) or, in an outbreak setting, ≥ 14 days of cough with no other symptoms.
A confirmed case is defined as a cough illness of any duration in a person from whom B. pertussis is isolated, or a case that meets the clinical case definition and is confirmed by polymerase chain reaction (PCR) or by epidemiologic linkage to a culture- or PCR-confirmed case.
A probable case meets the clinical case definition but is neither laboratory confirmed nor epidemiologically linked to a laboratory-confirmed case.
Confirmed and probable cases of pertussis should be reported to the National Notifiable Disease Surveillance System (NNDSS) of the US Centers for Disease Control and Prevention.

Table 2. Stages of Pertussis Infection ^[24]
	Duration	Characteristic Signs and Symptoms
Incubation period	7 to 10 days (range, 4 to 21 days)	--
Catarrhal stage	7 to 14 days	Insidious onset of coryza, sneezing, and a mild, nonspecific cough that gradually becomes more severe
Catarrhal stage	7 to 14 days	In infants: excessive sneezing or 'throat clearing'
Paroxysmal stage	1 to 6 weeks (up to 10 weeks)	Bursts, or paroxysms, of numerous, rapid coughs followed by a long inspiratory effort often associated with a high-pitched whoop; post-tussive vomiting.
Paroxysmal stage	1 to 6 weeks (up to 10 weeks)	In infants: paroxysms of coughing, but may not have sufficient musculature to develop a whoop. In addition, they may experience gagging, gasping, or eye bulging, and occasionally bradycardia or cyanosis.
Convalescent stage	Weeks to months	Recovery gradual, with cough becoming less paroxysmal and then disappearing. Fever is generally minimal

Table 3. DTaP/Tdap Vaccination: Recommendations of the Advisory Committee on Immunization Practices ^[37,38,39]
Dose	Age	Minimum Interval
Routine Primary Immunization of Infants
1	2 months	-
2	4 months	4 weeks
3	6 months	4 weeks
4	15 to 18 months*	6 months
5	4 to 6 years
Booster dosing of adolescents:	11 to 12 years	-
Booster dosing of adolescents:	13 to 19 years	-
Dosing of Adults^§
All adults who expect to be in close contact with a vulnerable infant	19 to 64 years
Health care personnel	19 to 64 years

*May be given at 12 months.
If 4th dose given before age 4 years.
Catch-up vaccination recommended if Td not received at 11 to 12 years; vaccination with Tdap encouraged for those who received Td at 11 to 12 years with a 5-year interval between Td and Tdap.
^§A single dose of Tdap booster to replace the next scheduled dose of tetanus diphtheria vaccine.
^¶Infant who has not received 2 to 3 doses of DTaP.

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