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Waging War With Whooping Cough

Pertussis is highly infectious and potentially fatal, especially for babies.

In early September, the Texas Department of State Health Services (DSHS) issued a health alert urging people to make sure they're vaccinated against life-threatening pertussis, or whooping cough.

That precautionary move was due to projections showing the number of people sick with the disease this year is on course to reach the highest level in more than a half-century.

"This is extremely concerning. Pertussis is highly infectious and can cause serious complications, especially in babies, so people should take it seriously," said Lisa Cornelius, MD, MPH, infectious diseases medical officer, DSHS, said in a prepared statement.

As of Sept. 10, 2013, there were 2,160 cases reported in Texas, and counting. State health officials are predicting by the end of the year, the annual toll will have likely surpassed the recent high of 3,358 cases in 2009.

Two deaths have also been reported in, according to published reports. Both were children too young to be vaccinated.

Whooping is Up

Texas is not alone in the battle to stave off pertussis.

In late September the Associated Press was reporting on nearly 1,500 students in two North Carolina counties who were facing possible suspension unless they received a vaccine or a booster shot against whooping cough. State law allows schools to suspend students who do not have up-to-date vaccines within 30 days of the start of the school year. That deadline was September 25.

North Carolina has had 300 cases of whooping cough so far this year, according to the AP published account.

In California, 1,249 cases with onset in 2013 have been reported to the California Department of Public Health (CDPH). Throughout the state, more cases have been reported in 2013 already than in the entire year of 2012, according to the CDPH.

In 2012, the U.S. Centers for Disease Control and Prevention tracked more than 48,000 cases of pertussis throughout the country, the most since 1955 when 62,786 cases were reported. Worldwide, there are an estimated 30-50 million cases of pertussis and about 300,000 deaths each year.

According to the CDC, incidents of pertussis have been on the rise in the U.S. since the 1980s, and healthcare experts say the highly contagious respiratory illness tends to come in three-to-five-cycles.

Waning Immunity

While pertussis can be especially threatening to infants too young to be vaccinated, it's also a serious health threat for older children, teens and adults whose immunity from vaccinations has waned.

In addition to waning immunity, the CDC cites other reasons for the increase in pertussis cases, including: increased awareness; improved diagnostic tests; more circulation of the bacteria; and better reporting.

According to the CDC, an increase in reported cases among 7-10 year olds was seen in 2010, and similar trends occurred in 2012. There was a slight uptick in cases among children ages as well.

Pertussis used to kill as many as 10,000 people annually in the U.S. Those numbers dropped dramatically after 1949 - when a vaccine was licensed for use.

The most effective way to prevent pertussis is through vaccination with DTaP for infants and children and with Tdap for preteens, teens and adults, according to the CDC. The DTaP and Tdap are both combined vaccinations against tetanus, diphtheria and pertussis.

The vaccination of pregnant women with Tdap is especially important to help protect infants. Approximately half of infants less than 1 year of age who get pertussis are hospitalized, according to the CDC.

Vaccine Labeling Concerns

As the battle against pertussis continues, Michael R. Cohen, RPh, MS, ScD (hon) DPS (hon), president of the Institute for Safe Medical Practices (ISMP), expressed some concern with the similarity in nomenclature DTaP and Tdap.

"Although it's not responsible for the outbreaks of pertussis seen around the country, there is a concern that a type of vaccine administration error might be leaving some children temporarily vulnerable to the disease even though they may have been vaccinated," he said.

The ISMP operates a national vaccine error reporting program (VERP). "The program has hundreds of reports of mix-ups between the adult and pediatric combination forms of the whooping cough vaccine that also immunize against diphtheria and tetanus," he said.

According to Cohen, pediatric patients who have no immunity at birth need more antigen and receive a series of vaccinations with the stronger form, abbreviated DTaP using capital letters to signify the higher antigen content. But that this is confused with the adult form given to already immunized older children and adults, abbreviated Tdap because it has less antigen.

"So kids fail to get adequate immunization and may be at risk," Cohen said. "Adults get the stronger version and often have an intense local action."

Cohen said the situation has been reported to authorities at both CDC and FDA, but so far no substantial product changes have been made, such as improved container labeling or warnings to immunizers.

Education By Clinicians

Health officials had reason to suspect it was coming.

"Historically, pertussis in Texas has occurred in waves, peaking every three to five years," said Stacey Cropley, DNP, RN, CPN, director of practice for the 6,000-member Texas Nurses Association. "We are used to seeing the pattern, a rise and fall in the number of cases. At this point, we're seeing that peak."

Though Cropley is certainly mindful of the seriousness of the disease, she does not think the state has an epidemic on its hands. "It's something we can easily treat with the proper care," she said. "Prevention is the key and education is the key to prevention . This is preventable, this is a choice. It's really contingent on education."

That's where clinicians come into play, according to Cropley.

"As children, we're immunized. As we grow older, immunization decreases, and as the immunization wanes, we tend to become more vulnerable," she noted. "It's important for nurses to make sure teenagers and adults get the boosters at the appropriate time."

Clinicians, too, should be communicating to parents the need to keep an infected child away from schools and other social settings. "The spread of pertussis is aerosolized, and so infected children need to stay home until they complete five days of antibiotic therapy," said Cropley.

Staying Under Control

A cough or sneeze can spread the disease. "When we say 'cover your cough,' it's pretty important, especially when it comes to pertussis," Cropley emphasized.

Looking back on her years as a pediatric nurse in Austin, Cropley said she occasionally saw cases of pertussis.

Like a cold, early symptoms of pertussis include a runny nose, low-grade fever and cough. Without proper treatment, patients develop vomiting, exhaustion and even pneumonia, "because the lung function is so compromised," Cropley said.

"Once you heard it, you knew it," she said of the "whooping" sound resulting when someone gasps for air after a fit of coughing, which can last up to 10 weeks or more.

It was Cropley's experience that most infected children who were admitted to the hospital did not receive the series of childhood immunizations, for any number of reasons.

Cropley reminded that all pertussis cases must be reported within one work day. Strict monitoring, she said, "is our way of keeping control of the disease process."

Rose Quinn is a freelance writer.


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