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January 13, 2006

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Publication Date: Friday, January 13, 2006

The cough that kills The cough that kills (January 13, 2006)

Doctors hope new vaccines will help stop on upsurge in pertussis, better known as whooping cough

By Diana Reynolds Roome

Nobody who's ever heard the sound of full-blown whooping cough ever forgets it. For the sufferer, it's like being seized by a monster from Hieronymus Bosch's sixteenth century paintings of hell, who fits a bellows to your lungs, pumps in air to bursting point, then expels it with a force that makes you throw up everything in your body. The whole process then repeats over again without pause enough to snatch a breath. Fractured ribs, hernias, collapsed lungs and fainting are not uncommon results of these spasms of whooping.

Most adults survive, though whooping cough (also known as pertussis) may seem to go on forever. But for babies or young children who have not yet received the full course of pertussis vaccines -- part of the standard DPT inoculations -- such a cough is too big for their tiny airways to handle, and it can prove fatal.

Though traditionally considered a childhood disease, increasing numbers of adults and adolescents have been coming down with whooping cough in recent years. By the end of 2005, 150 cases had been reported in Santa Clara County -- up almost three times from 2004 and five times more than in 2003 -- and last June, the Santa Clara County Public Health Department sent out an alert to physicians. Pertussis tends to recur in cycles, but recently it has been advancing rapidly nationwide, with 25,827 cases confirmed in 2004, a 30-year high.

Thankfully, whooping cough is not always severe, but its symptoms are so confusing that it is one of the most underreported of all contagious diseases. This is because it is "very, very difficult to diagnose," especially in milder cases, according to Dr. Alan Chausow, a pulmonologist with Camino Medical Group. Throat cultures can fail to confirm its presence and even blood tests are unreliable, says Chausow, because a previous vaccination can cause a false positive. However, because it is so contagious and dangerous to babies and people with weak immune systems, it is essential to detect and treat the disease wherever it shows up, even in mild forms.

At first, pertussis enters by stealth, masquerading as a common cold or cough. It has no particular season during which doctors might be on the alert for a higher incidence.

Unlike most bacterial infections, there's no fever, so during the early stage carriers are at their most contagious yet unaware that they may be spreading a serious infection. According to the Centers for Disease Control, the disease is usually spread from person to person through close contact with respiratory droplets released when a carrier coughs or sneezes. One problem is that patients can appear quite normal between coughing fits. Not everyone develops the whoop, but when they do it seldom actually happens in the doctor's office where it might be recognized.

The usual types of chronic cough -- caused by post-nasal drip, common viruses, mild asthma and even acid reflux -- start with a tickle in the throat and work up to a greater intensity. Instead the whoop (officially known as a paroxysmal cough) seizes its victim out of the blue, sometimes paralyzing them in one position and leaving them exhausted for hours. The lingering respiratory distress can resemble asthma and can affect the voice and swallowing. In China, pertussis is known as 90-day cough because it takes so long to shake off.

Once diagnosed, there are no effective cures for whooping cough, but getting appropriate treatment as soon as possible can alleviate the severity and reduce long-term debilitation. Though antibiotics have limited success, inhalers and decongestants can help manage the distressing symptoms.

The good news is that two new booster vaccines for adolescents and adults, both known as Tdap and combining vaccines for tetanus, diphtheria and pertussis, have been developed and are now becoming available. The National Advisory Committee on Immunological practices has recommended routine use of these, especially for adults who come into contact with infants, including pregnant women and new mothers.

And last week, the Centers for Disease Control, jointly with the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) released their official recommendation that children of 11 and 12 years of age going into 7th and 8th grade should receive Tdap (a booster tetanus, diphtheria and pertussis vaccine) along with other recommended vaccines for meningitis and hepatitis. This can help protect not only them but their infant relatives.

The occurrence of whooping cough was drastically reduced in the 1970s by a widespread 5-stage whole-cell pertussis vaccination program for babies, beginning at around 2 months. This was to combat a disease that, at its peak during the 1920s and 1930s, caused 160,000 cases and up to 9,000 deaths annually. By the mid-1970s, reported cases had decreased by more than 99 percent to just over 1,000 in the U.S.

Though most infants are routinely vaccinated against pertussis, scares about the vaccine's possible link with autism and other serious childhood conditions have caused some parents to opt against it over the past two decades. This has allowed the disease to seep back into the community as the effects of herd immunity wear thin.

Though it is essential for doctors to be on the alert for whooping cough, it's also important for the rest of us to be vigilant. Because the new vaccines are not yet widely used, parents may need to ask their children's pediatricians about it. Here are some reasons to get whooping cough treated quickly if you suspect it in any member of your family or close contacts.
* Pertussis is not just a childhood disease - more than 50 percent of those who catch it are teenagers and adults. * Childhood vaccination only protects up to the early teenage years and wanes rapidly three or four years after the last vaccine dose. * Pertussis is highly contagious -- 70 to 100 percent of household contacts will catch it if exposed. * Pertussis starts off like a regular cold, with catarrh, sniffles and a mild cough for seven to 10 days. During this time, it is at its most contagious and can be spread through schools, offices, and -- worst of all -- from teenage babysitters to their small charges. * Pertussis is not just a winter illness -- it can occur at any time of year. * The effects of pertussis can go on for many weeks, even months. * When pertussis is diagnosed, family members and others with close contact should take erythromycin or another approved antibiotic (even if no symptoms have developed) to help prevent or reduce the severity of the disease. Babies and young children who have not yet completed their course of DPT vaccinations are at highest risk, and their pediatrician should be informed at once if they have been exposed. * Booster vaccines for adolescents (age 10 to 18) and adolescents and adults (age 19 to 64) are now available. These may be almost as important in stopping the disease as the DPT vaccines routinely administered to babies from age 6 months. Families and caregivers of babies and very young children should be vaccinated or given a booster shot.

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