Last month I was ward attending at Miller Children’s Hospital in Long Beach, California, which meant that I made daily rounds with the pediatric residents. I came in early to meet my team one day. The senior resident who was on call smiled and said it wasn’t a bad night. They had only five admissions.
As we started rounds the intern presented the first case. It was a 6-week-old female who had cold symptoms for almost two weeks. It started with a runny nose and mild cough which wasn’t too bad as there was no fever, and the baby continued to eat well. Over the following few days, however, the baby became fussy and didn’t want to nurse as much as before. The mother felt that the baby now had a fever and took her to an urgent care center. They did a chest x-ray, some blood work and told mom it was a virus. Conservative measures were recommended. The cough worsened. Two days prior to admission the baby was brought to the pediatrician who put her on an antibiotic for a possible ear infection. If things worsened mom was instructed to go to the emergency room. Things did in fact get worse and mom brought her to the ER that night.
A chest x-ray showed that there was no pneumonia, and the labs were essentially normal. However, the baby had a number of coughing spells whereby she turned beet red in the face. Normally the pulse oximeter which measures the oxygen in the blood reads above 95%. This reading had dropped to the high 70’s, requiring the nurses to give supplemental oxygen by a mask. A nasal swab was sent to the lab and confirmed that the baby had pertussis, or whooping cough.
The residents and I finished discussing our patients and proceeded to the rooms to meet them. Our 6-week-old was comfortably resting in mom’s arms and was a gorgeous baby. She was bright and alert and had a nice social smile which was early for this age. While I was talking to mom the baby started coughing. Within seconds she was red in the face and coughing non-stop. The monitor began to alarm as the oxygen dipped to 86%. The nurse came running in to suction the baby’s nose and give some extra oxygen. The entire episode lasted 30 seconds, but it seemed like minutes. After it was all over the baby looked perfectly normal and was fine until the next coughing spell. The nurse reported that in the eight hours since the baby was admitted to the room she had seven on these episodes.
I explained to the residents that this was classic pertussis in a young infant. There is no specific treatment for this, other than providing supportive care and closely monitoring them. The criteria for discharge is that they obviously are over the worst part of the illness, are able to eat normally, do not need any supplemental oxygen, are not requiring any suctioning and the family is comfortable in going home. We usually teach them CPR before they leave the hospital.
As it turned out, this baby stayed in the hospital for 18 days before she was ready to go home. For the last week of her stay, each day we were sure she would be ready for discharge. Then in the morning the nurse would say that she had had one or two of these spells that required a little blow by oxygen because she would desaturate to the high 80’s. She finally made it over 24 hours with no such events and was discharged, and did very well.
This vignette played out all month as we had a number of similar admissions, all with pertussis. What is sobering is that this is an entirely preventable disease, yet we are in the midst of a true epidemic as declared by the California Department of Health. In California, there is a fourfold rise in the number of cases compared to this time last year. As of June 15th there have been 910 confirmed cases with another 600 suspected. There have been three deaths, all in infants under three months of age. We are on pace to have over 3000 cases this year. The most ever was in 1958 with 3837 cases. What is pertussis, and why are we in an epidemic?
a bacterial infection of the respiratory tract caused by the bacterium Bordatella pertussis. It is also known as whooping cough. In the old literature, pertussis was known as “the hundred day cough”. This is because toddlers who are infected with this have coughing spells whereby they cough, cough, cough…and then breathe in forcibly which creates a whoop sound as if they are frantically trying to catch their breath. The problem is in infants who aren’t strong enough to generate an actual “whoop”. They may just stop breathing.
Pertussis typically has three stages. The first is the catarrhal phase which lasts around 1-2 weeks. During this phase they have usual cold-like symptoms with runny nose, some sneezing and maybe a low-grade fever. Then comes the paroxysmal phase whereby they have the paroxysms, or coughing spells. This can last for 1-6 weeks. Lastly is the convalescent phase which can last for weeks. During this phase there is residual coughing spells, but not nearly as severe as during the paroxysmal phase.
Pertussis not only causes lengthy hospitalizations, but one-in-ten develop pneumonia, one in fifty develop seizures felt to be due to lack of oxygen to the brain, and one in 250 get encephalopathy. It can be a devastating illness, and as stated above, it is preventable with immunizations.
Why an epidemic now? It is well known that pertussis does cycle from year-to-year. We may be at a cycle whereby the incidence is peaking, but this does not explain the tremendous numbers we are seeing. Infectious experts have suggested that this may in part be explained by the failure of successful immunization practices.
We immunize against pertussis at 2,4,6,18months and 5 years with the DTaP vaccine--the P is for pertussis. The last DTaP at 5 years protects for probably another 5 or 6 years. Then the protection wanes. Pertussis in teenagers and older individuals is not a serious illness. It more likely will cause a lingering, nuisance cough that just won’t go away. However, the problem is that if they have pertussis, they are highly contagious and can infect countless people with one cough or sneeze.
Infants get their DTaP at 2,4 and 6 months of age. With one DTaP, there is very little protection. With two vaccines there is some protection but it is not great. With the third DTaP there is close to 90% protection. This is boosted with the 18-month vaccine, and again at 5 years of age. That is the reason why the young infants are at such risk in getting pertussis. They are not yet fully protected, but are around older individuals who have this lingering cough that won’t go away. They actually have pertussis and are giving it to the infants.
One study showed that 83% of infants that have pertussis get it from a family member. Over 50% get it from a parent. In order to prevent this, it is now recommended that we give a tetanus booster at 12 years that also has pertussis in it to boost the teenagers. Since adults should get a tetanus booster every 10 years, one of these should have a pertussis booster in it to boost their immunity, especially if they work with or around children.
A number of Infectious Disease experts also cite California as the “Mecca of immunization refusal”. They feel that the epidemic is in part due to the poor compliance in this state with fully immunizing children. While schools require documentation of all immunizations before being allowed to enter, parents can, and do refuse on an individual basis in writing. This is honored by the schools. From an epidemiological standpoint it is known that vaccine rates of 93% are needed for herd immunity whereby an entire population will be protected. We are nowhere near this.
As it turned out, while meeting with my residents that day, we had five admissions. After we talked about our 6-week-old with pertussis, the intern went on a present our next case. This was an 8-week-old infant with a cough of two weeks duration that was being admitted from an outside ER. The admitting diagnosis was pertussis, as they had confirmed in the ER.