What are the 3 stages of whooping cough. The 3 Stages of Whooping Cough: Understanding Pertussis

30.11.202215.07.2023 by alexxlab

What are the key characteristics of pertussis. How does whooping cough progress through its three distinct stages. Why is pertussis still a significant health concern despite vaccination efforts. How can healthcare providers effectively diagnose and treat this highly contagious respiratory infection.

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The Historical Context and Significance of Pertussis

Pertussis, colloquially known as whooping cough, has a rich historical background that dates back to the 16th century. First documented during the Paris epidemic of 1578, this respiratory illness has been a significant cause of infant morbidity and mortality throughout history. The term “pertussis” itself is derived from Latin, literally meaning “a violent cough,” which aptly describes the characteristic symptom of this condition.

The causative agent, Bordetella pertussis, was identified in 1906, marking a crucial milestone in understanding the disease. This discovery paved the way for the development of a vaccine in the 1940s, which dramatically reduced the incidence of pertussis in vaccinated populations. However, despite these advancements, pertussis remains a persistent global health concern.

The Resurgence of Pertussis in Modern Times

In recent years, there has been a notable resurgence of pertussis cases worldwide, including in countries with high vaccination rates. This trend has puzzled healthcare professionals and researchers alike. Several factors contribute to this resurgence:

Waning immunity in adolescents and adults
Improved diagnostic techniques leading to increased detection
Possible genetic changes in the Bordetella pertussis bacterium
Gaps in vaccination coverage

The Centers for Disease Control and Prevention (CDC) reported over 48,000 cases in the United States in 2012, highlighting the ongoing challenge posed by this disease. However, it’s important to note that due to difficulties in diagnosis, actual case numbers may be significantly higher.

The Etiology and Transmission of Whooping Cough

Whooping cough is primarily caused by two species of bacteria: Bordetella pertussis and Bordetella parapertussis. These gram-negative coccobacilli are highly contagious and spread through airborne droplets produced when an infected person coughs or sneezes. The human respiratory tract serves as the sole reservoir for these organisms, making person-to-person transmission the primary mode of spread.

Are there specific risk factors for contracting pertussis? Indeed, several factors can increase an individual’s susceptibility to the disease:

Pregnancy
Exposure during an epidemic
Lack of immunization or incomplete vaccination series
Close contact with an infected individual
Compromised immune system

It’s worth noting that while pertussis is often associated with pediatric populations, adults and adolescents can also contract and spread the disease. This is particularly concerning as these age groups may have milder symptoms, potentially leading to undiagnosed cases and further transmission.

The Pathophysiology of Bordetella Infection

Understanding the pathophysiology of pertussis is crucial for appreciating its clinical presentation and developing effective treatment strategies. When Bordetella pertussis enters the respiratory tract, it adheres to the ciliated epithelial cells lining the airways. This interaction triggers a cascade of local inflammatory changes in the mucosal lining.

The bacteria release several toxins that play key roles in the disease process:

Pertussis toxin
Dermonecrotic toxin
Adenylate cyclase toxin
Tracheal cytotoxin

These toxins act both locally within the respiratory tract and systemically throughout the body. Interestingly, despite the significant symptoms it causes, Bordetella pertussis typically does not fully penetrate the respiratory tract and is rarely found in blood cultures.

The Three Distinct Stages of Whooping Cough

Pertussis infection typically progresses through three well-defined stages, each with its own characteristic features. Understanding these stages is crucial for accurate diagnosis and appropriate management of the disease.

Stage 1: The Catarrhal Phase

The catarrhal phase marks the beginning of the pertussis infection. It typically lasts for 1 to 2 weeks and is characterized by symptoms that closely resemble those of a common cold or upper respiratory tract infection. During this stage, patients may experience:

Low-grade fever
Fatigue
Rhinorrhea (runny nose)
Conjunctival injection (red eyes)
Mild, occasional cough

It’s important to note that the catarrhal phase is the most infectious stage of pertussis. However, because the symptoms are nonspecific, diagnosis during this phase can be challenging, potentially leading to inadvertent spread of the disease.

Stage 2: The Paroxysmal Phase

Following the catarrhal phase, patients enter the paroxysmal phase, which is the most distinctive stage of pertussis. This phase typically lasts for 2 to 6 weeks and is characterized by:

Paroxysms of rapid, staccato coughs followed by a high-pitched inspiratory “whoop”
Resolution of fever
Cyanosis during coughing episodes
Diaphoresis (excessive sweating)
Post-tussive emesis (vomiting after coughing)
Apnea, especially in infants

The characteristic “whoop” sound is caused by forceful inspiration against a narrowed glottis. It’s worth noting that this sound may be absent in very young infants, adults, and those with mild cases. Coughing episodes are often more frequent at night and can be triggered by various stimuli such as cold air or noise.

Stage 3: The Convalescent Phase

The final stage of pertussis is the convalescent phase. During this period, which can last for weeks to months, the severity and frequency of coughing episodes gradually decrease. However, patients may continue to experience occasional paroxysms, especially when exposed to respiratory irritants or during subsequent viral infections.

How long does the convalescent phase typically last? While it varies from person to person, this phase can persist for up to several months, leading to the colloquial name “100-day cough” for pertussis.

Diagnostic Challenges and Approaches in Pertussis

Diagnosing pertussis can be challenging, especially in the early stages or in partially immunized individuals who may present with atypical symptoms. The gold standard for diagnosis is culture of Bordetella pertussis from nasopharyngeal specimens. However, this method has limitations:

It requires specialized media and takes several days to yield results
The sensitivity decreases with disease duration and prior antibiotic use
It may not detect other Bordetella species causing similar symptoms

To overcome these limitations, polymerase chain reaction (PCR) testing has become increasingly popular. PCR offers several advantages:

Rapid results, often within 24 hours
Higher sensitivity, especially later in the course of illness
Ability to detect multiple Bordetella species

Serological testing for pertussis-specific antibodies can be useful in later stages of the disease or for epidemiological studies, but it’s generally not recommended for acute diagnosis due to the delay in antibody production.

Treatment Strategies and Management of Pertussis

The management of pertussis involves a multifaceted approach, focusing on both treating the infected individual and preventing further spread of the disease. The specific treatment strategy depends on the stage of the illness and the severity of symptoms.

Antimicrobial Therapy

Antibiotics play a crucial role in the treatment of pertussis, particularly when administered early in the course of the disease. The primary goals of antibiotic therapy are to:

Eradicate the organism from the nasopharynx
Reduce the duration and severity of symptoms if given early
Decrease the period of communicability

Which antibiotics are most effective against Bordetella pertussis? The macrolide antibiotics are the first-line treatment for pertussis. These include:

Azithromycin
Clarithromycin
Erythromycin

In cases of macrolide allergy or resistance, trimethoprim-sulfamethoxazole can be used as an alternative. It’s important to note that while antibiotics can help control the infection, they may not significantly alter the course of the illness if started late in the disease process.

Supportive Care

Supportive care is a crucial aspect of pertussis management, especially during the paroxysmal phase. This may include:

Ensuring adequate hydration and nutrition
Providing a calm, quiet environment to minimize cough triggers
Using suction to clear secretions, particularly in infants
Monitoring for complications such as pneumonia or encephalopathy

In severe cases, particularly in young infants, hospitalization may be necessary for close monitoring and respiratory support.

Prevention Strategies and Vaccination Protocols

Prevention remains the cornerstone of pertussis control. Vaccination is the most effective strategy for preventing pertussis and its complications. Current recommendations include:

A primary series of DTaP (diphtheria, tetanus, acellular pertussis) vaccine for infants and young children
Tdap booster for adolescents and adults
Tdap vaccination during each pregnancy to provide passive immunity to newborns

How effective is the pertussis vaccine? While not 100% effective, vaccination significantly reduces the risk of contracting pertussis and, if infection does occur, typically results in milder disease.

In addition to vaccination, other preventive measures include:

Prompt identification and treatment of cases
Prophylactic antibiotic treatment for close contacts of confirmed cases
Practicing good respiratory hygiene and hand washing
Isolating infected individuals, particularly from vulnerable populations such as young infants

The Role of Interprofessional Teams in Pertussis Management

Effective management of pertussis requires a coordinated effort from an interprofessional healthcare team. This team typically includes:

Primary care providers
Pediatricians
Infectious disease specialists
Nurses
Respiratory therapists
Public health officials

Each member of the team plays a crucial role in various aspects of pertussis management:

Diagnosis and treatment of individual cases
Implementation of infection control measures
Contact tracing and prophylaxis
Patient and family education
Vaccination promotion and administration

Clear communication and coordination among team members are essential for optimal patient outcomes and effective disease control at the community level.

The Importance of Continuing Education

Given the evolving nature of pertussis epidemiology and management strategies, ongoing education for healthcare providers is crucial. This includes staying up-to-date on:

Current diagnostic techniques
Treatment guidelines
Vaccination recommendations
Emerging research on Bordetella pertussis and its interactions with the human immune system

By maintaining current knowledge and skills, healthcare providers can ensure they are delivering the most effective care to patients with pertussis and contributing to broader public health efforts to control this persistent disease.

Pertussis – StatPearls – NCBI Bookshelf

Continuing Education Activity

Pertussis, literally meaning “a violent cough,” also known as whooping cough or “the cough of 100 days,” was first described in the Paris epidemic of 1578. Bordetella pertussis, the causative organism, was discovered in 1906, and a vaccine was developed in the 1940s. Before the pertussis vaccine was developed, pertussis was a major cause of infant morbidity and mortality. This activity describes the presentation and management of pertussis and highlights the role of the interprofessional team in the treatment of affected patients and families.

Objectives:

Identify the etiology of pertussis.
Describe the typical presentation of a patient with pertussis.
Outline the treatment and management options available for pertussis.
Summarize interprofessional team strategies for improving care coordination and communication to enhance the care of patients with pertussis and improve patient outcomes.

Access free multiple choice questions on this topic.

Introduction

Pertussis, literally meaning “a violent cough,” also known as whooping cough or “the cough of 100 days,” was first described in the Paris epidemic of 1578. Bordetella pertussis, the causative organism, was discovered in 1906, and a vaccine was developed in the 1940s. Before the pertussis vaccine was developed, pertussis was a major cause of infant morbidity and mortality.[1][2][3] Pertussis is a serious illness with very high morbidity and mortality.

Etiology

The causative organisms of pertussis are Bordetella pertussis and Bordetella parapertussis. Bordetella is spread by airborne droplets and is highly contagious. Pertussis often affects 100% of non-immune household contacts. Immunity wanes to 50% 12 years after completing a vaccination series. Immunocompromised persons can also contract Bordetella bronchiseptica, which typically affects animals and is commonly known as “a kennel cough. ”[4][5][6]

Humans are the sole reservoir for Bordetella; the organism is spread via aerosolized droplets produced during a cough. The organism is highly contagious, with the majority of cases occurring during summer.

Risk factors for acquiring pertussis include:

Pregnancy
Epidemic exposure
Lack of immunization
Close contact with an infected individual

Epidemiology

Reported pertussis cases are increasing in the United States and worldwide. The prevalence of pertussis in the United States sharply declined from 150,000 to 250,000 cases per year in the prevaccination era to 1010 cases reported in 1976. Since then, pertussis has been on the rise, which is partially attributed to waning adolescent and adult immunity. Although pertussis largely remains a pediatric disease, with 38% of cases occurring in infants younger than 6 months and 71% of cases occurring in children younger than 5 years, adolescents and adults can also contract the disease and are likely contributing to the increasing number of both adult and pediatric cases seen over the past three decades. Worldwide, there are over 24 million cases annually, with greater than 160,000 deaths. The Center for Disease Control and Prevention (CDC) reported over 48,000 cases in the United States in 2012, the most recent year for which this data is available. Due to difficulty in diagnosis, the CDC estimates likely underreporting.[7]

Pathophysiology

Bordetella is a gram-negative coccobacillus that adheres to ciliated respiratory epithelial cells. Local inflammatory changes occur in the mucosal lining of the respiratory tract. Released toxins (pertussis toxin, dermonecrotic toxin, adenylate cyclase toxin, and tracheal cytotoxin) act locally and systemically, although the organism itself does not fully penetrate the respiratory tract, and almost never is found in blood cultures.

History and Physical

After an incubation period of 1 to 3 weeks, pertussis infection typically progresses through three distinct stages: the catarrhal phase, the paroxysmal phase, and the convalescent phase.

The catarrhal phase presents similarly to other upper respiratory tract infections, with fever, fatigue, rhinorrhea, and conjunctival injection. The catarrhal phase lasts 1 to 2 weeks and is the most infectious stage of the disease.

The paroxysmal phase follows the catarrhal phase and is characterized by paroxysms of a staccato cough and the resolution of fever. The patient typically coughs repeatedly, followed by forceful inspiration, which creates the characteristic “whoop.” These episodes may be triggered by cold or noise and are more common at night. Patients are nontoxic-appearing in between paroxysms, but during coughing episodes, may exhibit cyanosis, diaphoresis, or apnea. Immediately following a paroxysm, patients may develop post-tussive emesis, syncope, or apnea.

Finally, during the convalescent phase, a residual cough persists for weeks to months, usually triggered by exposure to another upper respiratory infection or irritant.

Atypical presentations are common in infants, and fever may not occur. Rather, tachypnea, apnea, cyanosis, and episodic bradycardia may be the presenting features.

Increased intrathoracic pressure from coughing may result in petechiae above the nipple line, subconjunctival hemorrhage, and epistaxis.

Breath sounds are variable; auscultation may reveal clear lungs or rhonchi, while rales suggest superimposed pneumonia. The inspiratory whoop or gasp is usually heard in children between 6 months to 5 years.

Evaluation

Testing for pertussis is not readily available in the emergency department. Nasopharyngeal culture and polymerase chain reaction (PCR) may yield laboratory confirmation, but the fastidious and slow-growing Bordetella organisms require specialized media, and cultures are typically not positive for 3 to 7 days. In adults, by the time the diagnosis is suspected, cultures are typically negative (96%), and overall culture sensitivity is only 20% to 40%. PCR is more sensitive and specific than culture, but testing is not widely available. [8][9][10]

In the emergency department, pertussis should be considered in patients with prolonged cough, especially occurring in paroxysms or with whoops or post-tussive emesis. During the late catarrhal and early paroxysmal phases, leukocytosis (often 25,000 to 60,000 per mL) with lymphocytosis may raise suspicion for pertussis. In a study of 100 infants less than 120 days old and admitted to a pediatric intensive care unit, there was a significantly higher leukocytosis in the five fatal cases. Unfortunately, leukocytosis may be the only laboratory finding useful in the emergency department. Chest x-ray findings are nonspecific and may show peribronchial thickening, atelectasis, or infiltrates. The classic association, though not often seen, is a “shaggy” right heart border.

Treatment / Management

Treatment of pertussis is largely supportive, including oxygen, suctioning, hydration, and avoidance of respiratory irritants. Parenteral nutrition may be necessary as the disease tends to have a prolonged course.

Hospitalization is indicated for patients with superimposed pneumonia, hypoxia, central nervous system (CNS) complications, or who are unable to tolerate nutrition and hydration by mouth. Patients less than 1-year-old are not fully vaccinated and carry the greatest risk of morbidity and mortality; they should be hospitalized regardless of symptoms. Neonates should be admitted to an intensive care setting as life-threatening cardiopulmonary complications and arrest can occur unexpectedly.

Antibiotic effect on the duration or severity of the disease is minimal when started in the catarrhal phase and not proven effective when started in the paroxysmal phase. Rather, the primary goal of antibiotic treatment is to decrease the carriage and spread of disease. Erythromycin (40 to 50 mg/kg per day, maximum 2 g per day, in 2 to 3 divided doses) is the first-line treatment for pertussis. Azithromycin (10 mg/kg per day on day 1 followed by 5 mg/kg on days 2 to 5) and clarithromycin (15 mg/kg per day in two divided doses) are alternative treatments. Trimethoprim-sulfamethoxazole (8 mg/kg per day of trimethoprim) has been used as an alternative in macrolide-allergic patients, but its efficacy has not been proven.

The macrolides are not recommended for infants less than 4 weeks old for fear that this may lead to infantile hypertrophic pyloric stenosis.

Strict isolation is important while the patient remains infectious. Pertussis is contagious throughout the catarrhal phase and for 3 weeks after the onset of the paroxysmal phase. In patients treated with antibiotics, isolation should be continued for at least 5 days after treatment is initiated. Postexposure prophylaxis with erythromycin is recommended for all household contacts.

Corticosteroids have not shown definite benefit in reducing the severity and course of illness but are sometimes given to critically ill infants. Beta2-agonists, pertussis immune globulin, cough suppressants, and antihistamines are not effective. Exchange blood transfusion therapy for leukocytosis with lymphocytosis may be considered.

Close contacts should be treated with azithromycin or erythromycin.

Vaccination is recommended with the acellular vaccine at ages 2,4,6, 15-18 months, and at ages 4 to 6 years. In addition, the CDC recommends a single dose of Tdap for all adults to reduce transmission to children. Adverse effects of the vaccine include crying and febrile seizures, but severe neurological effects are rare. The vaccine can also be administered during the third trimester to pregnant women without causing harm to the fetus.

DTaP is approved during the last 3 months of pregnancy to prevent pertussis in infants under 2 months old.

Differential Diagnosis

Pertussis initially presents similarly to other respiratory infections, such as viral upper respiratory infection, bronchiolitis, pneumonia, and tuberculosis. Key differentiating factors of pertussis include typical progression through the three phases and persistent cough without fever. Foreign body aspiration should be considered in younger patients, and exacerbation of chronic obstructive pulmonary disease should be considered in older patients with the appropriate history. The striking leukocytosis may also be confused with leukemia.

Prognosis

Most people infected with pertussis will fully recover, albeit usually after a prolonged illness of months. Infants and older adults tend to have the highest mortality and morbidity, respectively. The infant death rate is about 2% of cases and accounts for 96% of deaths related to pertussis. Older adults tend to have increased morbidity due to other chronic medical conditions, as well as an increased rate of complications, such as pneumonia.[11][12][13]

Secondary complications like pneumonia, seizures, and encephalopathy may occur in some patients.

Complications

Secondary pneumonia or otitis media may occur. Superimposed pneumonia is a major cause of mortality in infants and young children and may be caused by aspiration of gastric contents during paroxysms of cough or because of decreased respiratory clearance of pathogens. Fever should subside during the catarrhal phase, and its presence during the paroxysmal phase should raise suspicion for pneumonia. The most common causes of secondary bacterial pneumonia are Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae, and Staphylococcus aureus; although viral infections with the respiratory syncytial virus, cytomegalovirus, and adenovirus superinfections are also common.

Rarely (less than 2% of cases), CNS complications such as seizures and encephalopathy can occur, likely secondary to hypoxia, hypoglycemia, toxins, secondary infections, or cerebral bleeding from increased pressure during coughing. Sudden increases in intrathoracic and intraabdominal pressures can also result in periorbital edema, pneumothorax, pneumomediastinum, subcutaneous emphysema, diaphragmatic rupture, umbilical and inguinal hernias, and rectal prolapse.

Pertussis toxin also causes histamine hypersensitivity and increased insulin secretion.

Infants are particularly prone to bradycardia, hypotension, and cardiac arrest from pertussis. The development of pulmonary hypertension has been increasingly recognized as a factor contributing to infantile mortality, as it may lead to worsening systemic hypotension and hypoxia.

Deterrence and Patient Education

Pertussis vaccine exists in both whole-cell (DPT) and acellular (DTaP) forms. In 1991, the acellular formulation largely replaced the whole-cell vaccine, which had been associated with acute encephalopathy and prolonged seizures. The acellular form has fewer adverse effects and is as effective as the whole-cell formulation. As a result, the whole-cell preparation is only recommended when the acellular form is not available. Common adverse effects are mild and include fever, irritability, behavioral changes, and pain at the injection site. Less commonly, moderately severe reactions, including fever over 40 C, persistent and high-pitched crying, and seizures may occur. A recent study of over 50,000 patients vaccinated from 1981 to 2016 did not detect any new or unexpected adverse effects.

Pearls and Other Issues

Laboratory and radiographic confirmation of pertussis is a challenge in the emergency department setting. It is important to maintain a low threshold of suspicion for pertussis in any patient presenting with prolonged cough, regardless of immunization status. A complete blood count with attention to leukocytosis and lymphocytosis may be the best diagnostic screening tool in the emergency department.

Enhancing Healthcare Team Outcomes

The management of pertussis is best done with an interprofessional team that includes the pharmacist and nurses. With a strong anti-vaccine movement, patient education is key. Parents and caregivers have to be informed that the adverse effects of the vaccine are rare. In an era of anti-vaccination sentiments, clinicians should educate the public that the vaccine is safe and effective.

Pertussis immunity wanes significantly about seven years after vaccination and about 15 years after natural infection. As a result, the CDC Advisory Committee on Immunization Practices recommends routine booster immunization, starting at ages 11 to 18 years. A study of almost 70,000 patients showed no significant adverse effects for patients receiving Tdap instead of Td as a tetanus booster; in patients requiring a tetanus booster in the emergency department, adding the acellular pertussis component could be considered, especially in pregnant women. Mothers are often identified as the source of pertussis infection in newborns who have not completed their vaccination series, and preliminary data suggest that infants of mothers vaccinated against both influenza and pertussis may be at lower risk for contracting pertussis.

Pertussis is a reportable infection in the US, and even one case must be reported immediately, and control measures to prevent transmission should be in place. Open communication between the interprofessional team is vital to ensure that patients are treated with optimal care and that vaccination protocols are in place.

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References

1.: Leong RNF, Wood JG, Turner RM, Newall AT. Estimating seasonal variation in Australian pertussis notifications from 1991 to 2016: evidence of spring to summer peaks. Epidemiol Infect. 2019 Jan;147:e155. [PMC free article: PMC6518527] [PubMed: 31063086]
2.: Hotez PJ. Immunizations and vaccines: a decade of successes and reversals, and a call for ‘vaccine diplomacy’. Int Health. 2019 Sep 02;11(5):331-333. [PubMed: 31034023]
3.: Xu J, Liu S, Liu Q, Rong R, Tang W, Wang Q, Kuang S, Zhou C. The effectiveness and safety of pertussis booster vaccination for adolescents and adults: A systematic review and meta-analysis. Medicine (Baltimore). 2019 Apr;98(16):e15281. [PMC free article: PMC6494346] [PubMed: 31008974]
4.: Dou M, Macias N, Shen F, Bard JD, Domínguez DC, Li X. Rapid and Accurate Diagnosis of the Respiratory Disease Pertussis on a Point-of-Care Biochip. EClinicalMedicine. 2019 Feb;8:72-77. [PMC free article: PMC6469871] [PubMed: 31008450]
5.: Dou M, Sanchez J, Tavakoli H, Gonzalez JE, Sun J, Dien Bard J, Li X. A low-cost microfluidic platform for rapid and instrument-free detection of whooping cough. Anal Chim Acta. 2019 Aug 13;1065:71-78. [PMC free article: PMC6481316] [PubMed: 31005153]
6.: Etskovitz H, Anastasio N, Green E, May M. Role of Evolutionary Selection Acting on Vaccine Antigens in the Re-Emergence of Bordetella Pertussis. Diseases. 2019 Apr 16;7(2) [PMC free article: PMC6630436] [PubMed: 30995764]
7.: Jenkinson D. Pertussis (whooping cough) is common in teens and adults. BMJ. 2019 Apr 09;365:l1623. [PubMed: 30967372]
8.: Toubiana J, Azarnoush S, Bouchez V, Landier A, Guillot S, Matczak S, Bonacorsi S, Brisse S. Bordetella parapertussis Bacteremia: Clinical Expression and Bacterial Genomics. Open Forum Infect Dis. 2019 Apr;6(4):ofz122. [PMC free article: PMC6453521] [PubMed: 30976607]
9.: Kandeil W, Atanasov P, Avramioti D, Fu J, Demarteau N, Li X. The burden of pertussis in older adults: what is the role of vaccination? A systematic literature review. Expert Rev Vaccines. 2019 May;18(5):439-455. [PubMed: 30887849]
10.: Argondizo-Correia C, Rodrigues AKS, de Brito CA. Neonatal Immunity to Bordetella pertussis Infection and Current Prevention Strategies. J Immunol Res. 2019;2019:7134168. [PMC free article: PMC6387735] [PubMed: 30882004]
11.: Forsyth KD, Tan T, von König CW, Heininger U, Chitkara AJ, Plotkin S. Recommendations to control pertussis prioritized relative to economies: A Global Pertussis Initiative update. Vaccine. 2018 Nov 19;36(48):7270-7275. [PubMed: 30337176]
12.: Campbell H, Gupta S, Dolan GP, Kapadia SJ, Kumar Singh A, Andrews N, Amirthalingam G. Review of vaccination in pregnancy to prevent pertussis in early infancy. J Med Microbiol. 2018 Oct;67(10):1426-1456. [PubMed: 30222536]
13.: Lumbreras Areta M, Martinez De Tejada B. [Preventing whooping cough in infants : vaccinated mother, protected newborn]. Rev Med Suisse. 2018 Oct 24;14(624):1884-1886. [PubMed: 30375788]

: Disclosure: Ashley Lauria declares no relevant financial relationships with ineligible companies.
: Disclosure: Christopher Zabbo declares no relevant financial relationships with ineligible companies.

Whooping Cough | Pertussis | 3 Stages, Severity, & Spread

Infection & Disease

Whooping Cough

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Written by

Laura Henry, MD.

Resident in the Department of Otolaryngology-Head & Neck Surgery at the University of Pennsylvania

Medically reviewed by

Jeffrey M. Rothschild, MD, MPH.

Associate Professor of Medicine, Brigham and Women’s Hospital

Last updated May 23, 2023

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What is whooping cough?

Symptoms

Causes

Treatment & prevention

When to see a doctor

References

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Written by

Laura Henry, MD.

Resident in the Department of Otolaryngology-Head & Neck Surgery at the University of Pennsylvania

Medically reviewed by

Jeffrey M. Rothschild, MD, MPH.

Associate Professor of Medicine, Brigham and Women’s Hospital

Last updated May 23, 2023

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This article will discuss the respiratory illness whooping cough that can occur in children, adolescents, and adults. Symptoms include fatigue and malaise, a low-grade fever, excessive tearing, red eyes, severe coughing, a “whooping” sound on inspiration, and vomiting after coughing.

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What is whooping cough?

Whooping cough is caused by the bacteria Bordetella pertussis, which affects the respiratory systems of children, adolescents, and adults. Whooping cough has also been called the “100-day cough” because of its extended time course. The symptoms classically associated with whooping cough are a sudden, uncontrollable coughing spell (“paroxysmal cough”), a “whooping” sound on inspiration, and throwing up after a coughing fit. The course of the condition is generally divided up into three phases — catarrhal, paroxysmal, and convalescent phases. The symptoms of the condition generally change over the course of these phases. Whooping cough is highly contagious and generally spread through respiratory droplets. The DTaP or Tdap vaccines are used to prevent the spread of whooping cough.

You should visit your primary care physician within the next 24 hours. This disease is managed with prescription antibiotics, and it is important to get treated as soon as possible to avoid spreading the infection to others.

Whooping cough symptoms

Main symptoms

While whooping cough predominantly affects the respiratory system, the symptoms vary throughout the course of the illness. As previously discussed, the condition is generally divided into the catarrhal, paroxysmal, and convalescent stages. The catarrhal stage is the earliest and usually lasts one to two weeks. The paroxysmal stage is the longest portion, lasting about two months. The convalescent stage is when the condition is resolving and usually lasts one to two weeks. Symptoms of whooping cough are listed below.

Fatigue and malaise: These begin within the first one to two weeks of the condition in the catarrhal phase.
Low-grade fever: This often develops as the bacteria infect the individual and occurs during the catarrhal phase.
Excessive tearing
Red eyes
Severe, uncontrollable coughing: This is the hallmark symptom of whooping cough. It begins during the paroxysmal phase.
“Whooping” sound on inspiration: This sound, giving the condition its name, is generally heard after episodes of intense coughing fits as an individual forcefully breathes in. This sound is heard during the paroxysmal phase and is even more prominent in children with whooping cough due to the small size of their windpipes.
Vomiting after coughing: Also known as post-tussive emesis, this can occur due to the forceful nature of the coughing fits. The intense contraction of the muscles of the thorax (the part of the body where the lungs are found) and the abdomen can cause you to vomit after a coughing fit.

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Other symptoms

Other symptoms seen in whooping cough are not directly caused by the pertussis bacteria but by the extended period of time you experience intense coughing fits:

Subconjunctival hemorrhage: “Subconjunctival” describes the source of the bleeding, located beneath the conjunctiva, the thin membrane covering the surface of the eye. The increased force during coughing fits can lead to rupture of the very small, delicate blood vessels of the eye and cause this symptom.
Development or worsening of an abdominal hernia: The contraction of abdominal muscles used in coughing increases the overall pressure within the abdomen. This increase in intra-abdominal pressure can force movement of organs through membranes within the abdomen. Hernias can be seen around the belly button, lower abdomen, or groin regions.
Urinary incontinence: Involuntary leakage of urine may occur as the abdominal muscles are contracting during coughing fits. This contraction puts stress on the bladder which can cause the release of urine. This occurs when the force from coughing overcomes the force of the pelvic floor muscles and urinary sphincters working to keep urine from expelling.

Diagnosis

It is important to make the diagnosis of whooping cough as early as possible to help you manage your symptoms as well as prevent the spread of infection. According to the CDC, whooping cough can be diagnosed clinically by the presence of a cough not explained by another condition that lasts at least two weeks along with the presence of one of the following: coughing fits, throwing up after coughing fits, or a “whooping” sound on inspiration. Other laboratory tests can also be used for the definitive diagnosis depending on what point of the illness you are experiencing:

Respiratory culture: Respiratory secretions may be swabbed and cultured to look for the presence of the Bordetella bacteria during the first two weeks of the cough.
Polymerase Chain Reaction: Also called PCR, this test is used alongside a culture from the respiratory system if the cough has been present for two to four weeks.
Serology: Serology is a blood test used to detect antibodies, or the body’s natural defense mechanism, to the bacteria causing the infection. This test is used if the cough has been present for greater than four weeks.

Whooping cough causes

Whooping cough is caused by the bacteria Bordetella pertussis. The bacteria multiply in the respiratory tract over the course of seven to 10 days after the bug has lodged itself on the throat and nasal mucosa. This infection is highly contagious and is spread from person-to-person through the respiratory droplets expelled with the vigorous coughing spells that are characteristic of the condition. Prior to the introduction of vaccination in the 1940s, whooping cough often leads to death, especially among infants with the infection. The vaccine has significantly decreased the incidence and severity of pertussis in the U.S.

Treatment options and prevention for whooping cough

Treatment

Despite having the name “100-day cough,” studies show that most people with whooping cough experience a resolution of the infection in three to six weeks without any treatment. The CDC has provided recommendations with regards to administering antibiotics for people with whooping cough. These recommendations state that any person presenting with whooping cough within three weeks of the onset of the cough should receive treatment with antibiotics. The CDC also states that pregnant women, healthcare workers, and individuals with close contact to infants should receive antibiotic treatment if they present with cough suspicious for whooping cough. The preferred antibiotics for treatment are azithromycin or clarithromycin, both in the macrolide class of drugs.

Prevention

The most significant intervention for the prevention of whooping cough is the vaccine. The modern-day form of the vaccine, called the “acellular” vaccine, was introduced in 1991. This form of the vaccine is given along with immunity for tetanus in diphtheria in the vaccine Tdap (tetanus, diphtheria, acellular pertussis). Most people do not have any side effects from this vaccine, however, 25 percent of children will experience redness where the shot was given or a short course of fever.

Infants/children and vaccination: The vaccine schedule for Tdap starts at age 2 months and a total of 5 vaccines given in total and ending around age 6.
Adolescents and vaccination: Adolescents 11 to 18 years of age should receive a booster vaccine for Tdap.
Pregnant women and vaccination: Pregnant women should also receive the vaccination at 27 to 36 weeks as this immunity can be transferred to the developing baby.

Even if an individual has been vaccinated against whooping cough, he or she should receive prophylactic antibiotics after coming in direct contact with someone who has an active pertussis vaccine.

Ready to treat your whooping cough?

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Whooping cough quiz

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When to seek further consultation for whooping cough

An important aspect of preventing the spread of whooping cough is early detection. Any individual who is experiencing a persistent cough, fever, or a whooping sound on inspiration should consult his or her healthcare provider as soon as possible. Infants and elderly are particularly at risk of complications from the condition and should be under the careful care of a physician.

Questions your doctor may ask to determine whooping cough

How severe is your fever?
Has your cough gotten better or worse?
Is your cough constant or come-and-go?
How severe is your cough?
How long has your cough been going on?

Self-diagnose with our free Buoy Assistant if you answer yes on any of these questions.

Jeffrey M. Rothschild, MD, MPH.

Associate Professor of Medicine, Brigham and Women’s Hospital

Dr. Rothschild has been a faculty member at Brigham and Women’s Hospital where he is an Associate Professor of Medicine at Harvard Medical School. He currently practices as a hospitalist at Newton Wellesley Hospital. In 1978, Dr. Rothschild received his MD at the Medical College of Wisconsin and trained in internal medicine followed by a fellowship in critical care medicine. He also received an MP…

Read full bio

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What are the 3 stages of whooping cough. The 3 Stages of Whooping Cough: Understanding Pertussis

The Historical Context and Significance of Pertussis

The Resurgence of Pertussis in Modern Times

The Etiology and Transmission of Whooping Cough

The Pathophysiology of Bordetella Infection

The Three Distinct Stages of Whooping Cough

Stage 1: The Catarrhal Phase

Stage 2: The Paroxysmal Phase

Stage 3: The Convalescent Phase

Diagnostic Challenges and Approaches in Pertussis

Treatment Strategies and Management of Pertussis

Antimicrobial Therapy

Supportive Care

Prevention Strategies and Vaccination Protocols

The Role of Interprofessional Teams in Pertussis Management

The Importance of Continuing Education

Pertussis – StatPearls – NCBI Bookshelf

Continuing Education Activity

Introduction

Etiology

Epidemiology

Pathophysiology

History and Physical

Evaluation

Treatment / Management

Differential Diagnosis

Prognosis

Complications

Deterrence and Patient Education

Pearls and Other Issues

Enhancing Healthcare Team Outcomes

Review Questions

References

Whooping Cough | Pertussis | 3 Stages, Severity, & Spread

Whooping cough quiz

What is whooping cough?

Whooping cough symptoms

Main symptoms

Whooping cough quiz

Other symptoms

Diagnosis

Whooping cough causes

Treatment options and prevention for whooping cough

Treatment

Prevention

Ready to treat your whooping cough?

Whooping cough quiz

When to seek further consultation for whooping cough

Questions your doctor may ask to determine whooping cough

References

Diseases – blog of pediatricians of the children’s clinic “RebenOK”

Diseases – blog of pediatricians of the children’s clinic “RebenOK”

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