Pertussis ( Whooping Cough ) - Management of

Publication: 14/08/2017  
Next review: 01/01/2025  
Clinical Guideline
CURRENT 
ID: 5128 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management of Pertussis (Whooping Cough)

Pertinent aspects of history and examination
Key diagnostic criteria
Investigations required
Treatment
Management
Staff Who Have come into Contact with Suspected/Confirmed Case of Pertussis

Background

Pertussis is an acute respiratory infection caused by Bordetella pertussis. Pertussis is an exclusively human pathogen that can affect people of all ages however young unimmunised infants are at the highest risk of severe complications and death. Older vaccinated individuals often present with milder symptoms which may go unrecognized. Natural infection or vaccination does NOT confer lifelong immunity.

Pertussis is highly contagious and transmission occurs as a result of close contact with an infected person - up to 90% of household contacts will develop the infection.

Pertussis has an incubation period of between 7-10 days (range 5-21 days) The usual presentation is an initial catarrhal stage with a cough that becomes paroxysmal, (frequent and intense in nature).Paroxysms of cough increase in severity and frequency as the infection progresses and persist for between 2-6 weeks. Paroxysms can end in vomiting, cyanosis and/or a characteristic inspiratory cough. Serious complications include pneumonia, seizures and encephalitis. Patients with pertussis are most infectious in the initial catarrhal stage and during the first 3 weeks after the onset of the cough.

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Diagnosis

Risk assessment should consist of a combination of clinical and epidemiological factors such as clinical presentation, vaccination history and epidemiological links. Management should not be delayed whilst waiting for a laboratory confirmed result.

Case definition
Suspected case of pertussis:

  • any person in whom a clinician suspects pertussis infection or
  • any person with an acute cough lasting for 14 days or more, without an apparent cause plus one or more of the following:
    • paroxysms of coughing
    • post-tussive vomiting
    • inspiratory whoop

AND

  • absence of laboratory confirmation
  • no epidemiological link to a laboratory confirmed case

Confirmed case of pertussis:

  • Any person with signs and symptoms consistent with pertussis with:-
    • B. pertussis isolated from a respiratory sample (typically an NPA or NPS/PNS (or throat swab) or
    • anti-pertussis toxin IgG titre >70 IU/ml from a serum or >70 aU from an OF specimen (19) (in the absence of vaccination within the past yeara) or
    • B. pertussis PCR positive in a respiratory clinical specimen

Epidemiologically linked case of pertussis:

  • a suspected case with signs and symptoms consistent with pertussis, but no laboratory confirmation, who was in contact with a laboratory confirmed case of pertussis in the 21 days before the onset of symptoms

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Investigation

Laboratory confirmation of clinically suspected cases can be made by culture and isolation of the causative organism B. pertussis. Detection of its DNA (from pernasal swabs(PNS) or nasopharyngeal swabs (NPA)) or antibody detection performed on serum or oral fluid (which usually only provide a late or retrospective diagnosis).

Where possible culture should be attempted as isolation of the causative organism is definitive.

B. pertussis is a delicate organism and therefore processing delays may affect the likelihood of a positive culture. Sensitivity is dependent on specimen quality and is affected by increasing patient age, vaccination status and length of illness. Cultures are unlikely to be positive in adolescents and adults with more than 3 weeks of coughing.

PCR has been shown to have improved sensitivity over culture and is a valuable confirmatory test, particularly in young infants. PCR is more sensitive than culture however is less likely to be positive in patients with symptom duration of 21 days or more.

Oral fluid testing was piloted from 2007 to 2009 and showed a 32% increase in confirmation of cases particularly in children aged 5-9. In May 2018 oral fluid testing for notified cases of pertussis was introduced for all children aged 2 to <17 years who have not received a pertussis-containing vaccine in the preceding year.

Serology may confirm the diagnosis of pertussis in older children and adults who have been symptomatic for more than 2 weeks.

Table 1: Summary of microbiological tests for Pertussis

Test method

Patient criteria

Sample

Access

RVPBRU

Culture

Suspected cases in all age groups with cough<21 days duration

NPS/NPA/PNS

NHS laboratories

Confirmed isolated to be sent to RVPBRU

PCR

Suspected cases in all age groups with cough<21 days duration

NPS/PNS preferred; throat swab acceptable for community patients

Regional PHE laboratories

Positive samples to be referred to RVPBRU

OF

Suspected cases aged 2 to <17 years with cough >14 days* duration

OF kit

OF kit sent to patient upon notification to PHE HPT

Samples tested and reported by RVPBRU

Serology

Suspected cases in older children/adults with cough >14 days* duration

Serum

Charged for service at RVPBRU

Samples tested and reported by RVPBRU

Swabs and transport media are available from the molecular laboratory, ext 28750 Samples should reach the laboratory before 10.00 weekdays. For information on how to take a sample from children/ neonates please refer to the Paediatric Whooping Cough (Pertussis) Guideline. (PHE 2016)

How to take a swab

Sample collection technique is critical in pertussis testing.
For hospitalised cases NPS/PNS/NPA are the recommended specimens

PCR testing can be performed on the following specimens:

Throat swabs
Collected using a swab or dry swab in a sterile container
Pernasal swabs
Use a dry swab with a flexible wire shaft and a rayon/Dacron/nylon bud.
a pernasal swab or nasal aspirate is used. The nasopharyngeal swab is collected by having the patient tip their head back and the swab (like a long Q-tip with a small head) is gently inserted into one of the nostrils until resistance is met. Leave in place for 30 seconds and then rotate several times to collect cells, and withdraw. This is not painful, but it may tickle a bit, cause the person's eyes to tear, and provoke a coughing paroxysm. Staff should wear a surgical mask when undertaking sample collection.

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Treatment / Management

Action needs to take place for all clinically suspected, epidemiologically linked or laboratory confirmed cases associated with healthcare settings Action should not be delayed until the results of laboratory testing are available.

  • Case management including laboratory testing, antibiotic treatment and identification of household contacts should follow the UK Health Security Agency Guidelines
  • Healthcare workers (HCWs) who have been diagnosed with pertussis (either clinically suspected, epidemiologically linked or laboratory confirmed) should be excluded from work until 48 hours of appropriate antibiotic treatment has been completed OR for 21 days from onset of symptoms, if appropriate antibiotic treatment has not been completed
  • Hospitalised patients diagnosed with pertussis (either clinically suspected, epidemiologically linked or laboratory confirmed) should be placed in respiratory isolation during the infectious period.
  • As pertussis is a notifiable disease, all cases should be reported to the local Health Protection Team (HPT) as soon as possible. Cases associated with a healthcare setting should also be reported to Infection Prevention and Control team and for HCW’s to Occupational Health, even if it’s too late for prophylaxis
  • If a woman has confirmed or suspected pertussis during pregnancy she should still be offered the pertussis vaccine as not all women may make sufficiently high levels of antibodies following natural infection that can be passed across the placenta to protect the infant from birth.

Significant exposure in healthcare setting

Unprotected direct face to face contact (<2 meters distance) for greater than a cumulative period of 1 hour with an infectious case.

OR

Direct contact with respiratory secretions from an infectious case e.g. performing an aerosol generating procedure (AGP) or examination of the nose and throat without appropriate personal protective equipment.

A lower threshold should be considered in some circumstances e.g. where unimmunized or partially immunized infants are exposed.

Outbreaks of pertussis can occur in healthcare settings. If outbreaks are detected at an early stage prompt action including chemoprophylaxis and vaccination of close contacts can limit the spread and may also be of benefit in reducing transmission to those individuals in group who are at most risk of severe or complicated infection such as young unimmunized infants born to unvaccinated mothers

The list of priority groups for public health action are either:

Group 1. At increased risk of severe or complicated pertussis (vulnerable)
Group 2. At increased risk of transmitting infection to individuals in group 1

Group 1: Groups at increased risk of severe or complicated pertussis (‘vulnerable’)

In light of the high effectiveness of the maternal pertussis vaccine programme in preventing disease for those infants less than 2 months of age, the definition of vulnerable infants has been amended as follows:

  • unimmunised infants (born ≤32 weeks) less than 2 months of age regardless of maternal vaccine status OR
  • unimmunised infants (born >32 weeks) less than 2 months of age whose mothers did not receive maternal pertussis vaccine after 16 weeks and at least 2 weeks before delivery OR
  • infants aged 2 months or over who are unimmunised or partially immunised (less than three doses of DTaP/IPV/Hib up to 1 year of age) regardless of maternal vaccine status.

Group 2: Groups at increased risk of transmitting pertussis to those at risk of severe or complicated infection (Group 1), who have not received a booster dose of pertussis vaccine more than 1 week and less than 5 years ago

  • pregnant women (>32 weeks gestation)
  • healthcare staff working with infants or pregnant women.

Identification of contacts for prophylaxis
Prophylaxis should be offered to those in priority groups WITH a significant exposure to an infectious case within a healthcare setting. However, the time/duration criteria are only a guide and where unimmunised or partially immunised infants are exposed, a lower threshold should be applied e.g. prophylaxis should be considered for these infants in direct contact with an affected HCW regardless of duration of contact.

Action for priority contacts identified with a significant exposure
Contacts in the priority groups defined above who have been identified within 21 days of a significant exposure should be offered chemoprophylaxis/ vaccination as outlined below.

Chemoprophylaxis
Chemoprophylaxis should be offered (based on recommendations in the PHE guidelines) (PHE 2018) to contacts within 21 days of a significant exposure in the following priority groups:

  • vulnerable infant contacts
  • pregnant women (>32 weeks gestation) who have not received a booster dose of pertussis vaccine more than 1 week and less than 5 years ago
  • HCW contacts who have not received a booster dose of pertussis containing vaccine more than 1 week and less than 5 years ago.

Recommended antibiotic treatment and post exposure prophylaxis by age groupb

Age group

Clarithromycin*

Azithromycin*

Erythromycin

Co-trimoxazole*c

Neonates(<1 month)

Preferred in neonates
7.5mg/kg twice a day for 7 days

10mg/kg once a day for 3 days

 

Not recommended due to association with hypertrophic pyloric stenosis

Not licensed for infants below 6 weeks

Infants (1 month – 12 months) & Children(>12 months)

1 month to 11 years:

Under 8kgs 7.5mg/kg twice a day for 7 days

8-11kg
62.5mg twice a day for 7 days

12-19kg
125mg twice a day for 7 days

20-29kg
187.5mg twice a day for 7 days

30-40kg
250mg twice a day for 7 days

12 to 17 years:
500mg twice a day for 7 days

1 to 6 months: 10mg/kg once a day for 3 days

> 6 months:
10mg/kg (max 500mg) once a day for 3 days

1 to 23 months:
125mg every 6 hours for 7 days ≠

2 to 7 years:
250mg every 6 hours for 7 days≠

8 to 17 years:
500mg every 6 hours for 7 days≠

6 weeks to 5 months:
120mg twice a day for 7 days

6 months to 5 years:
240mg twice a day for 7 days

6 to 11 years:
480mg twice a day for 7 days

12 to 17 years:
960mg twice a day for 7 days

Adults

500mg twice a day for 7 days

500mg once a day for 3 days

500mg every 6 hours for 7 days ≠

960mg twice a day for 7 days

Pregnant womend

Not recommended

Not recommended

Preferred antibiotic -not known to be harmful

Contraindicated in pregnancy

Doses can be doubled in severe infections

* Please note that the doses for treatment and prophylaxis are the same

b The above information has been taken from BNF 75 (March 2018) and BNF for Children 2017-18. The recommendation to use azithromycin for infants less than six months of age is based on advice from experts on the Pertussis Guidelines Group and CDC Guidelines. Azithromycin and co-trimoxazole doses are extrapolated from treatment of respiratory tract infections.

c Consider if macrolides contra-indicated or not tolerated.

d For pregnant contacts, a risk assessment would need to be done to looks at the risk and benefits of antibiotic therapy/prophylaxis. The aim of treating/prophylaxing women in pregnancy is to prevent transmission to the newborn infant, and should be considered in those who have not received a pertussis containing vaccine more than one week and less than five years prior. Where possible, pregnant women should begin treatment at least three days prior to delivery.

Vaccination
Immunisation should be considered for those who have been offered

chemoprophylaxis:

  • vulnerable infants should complete the primary course with the appropriate vaccine according to the recommended schedule
  • a booster dose of pertussis containing vaccine is recommended for pregnant women (> 32 weeks gestation) and HCW contacts who have not received a dose of pertussis containing vaccine in the preceding 5 years and no Td-IPV in the preceding month.

Communication
“Inform and advise” letters should be provided along with the offer of prophylaxis (Appendix 2).

Action for contacts with significant exposure NOT in priority groups

Contacts with significant exposure who are not in priority groups should be informed and advised to seek medical attention if symptoms develop (template letters included in Appendix 2).

Special settings;
For a child admitted to NICU/ SCBU/Paediatric HDU or ITU with pertussis, a risk assessment needs to be undertaken to determine the need for wider prophylaxis. This will include identifying whether the case was ventilated, if this was a closed or an open circuit and if there is a possibility of breaks in the ventilatory circuit leading to exposure risk. Also consider any teams used to transport babies. E.g. Embrace

If a risk is identified, given the vulnerability of the patient population, prophylaxis is recommended for infants specified in the vulnerable group above in the same bay as the case -regardless of the time/duration of exposure.

Chemoprophylaxis should be offered to those identified as recommended

Household contacts - (followed up by UK Health Security Agency)
Household contacts of cases who have symptoms suggestive of pertussis should be advised to seek medical attention and to avoid visiting the case in hospital until they have been assessed and managed appropriately.

Stopping isolation precautions.

Isolation of the patient with Pertussis can be stopped when the patient has received 48 hours or more of appropriate antibiotic treatment or 21 days from onset, if symptoms have subsided-

Case finding and surveillance

Occupational Health and Infection Prevention should be informed of any cases of pertussis occurring in healthcare settings. All contacts identified with significant exposure should be informed and advised of symptoms to enable early detection of illness. See Appendix 3 for contact list.

The IPCT and OH will need to undertake passive surveillance amongst staff and patients to ensure early detection and management of any further cases. This would normally be for a period of 42 days (two incubation periods) from onset of symptoms in the index case.

Two or more epidemiologically linked cases of pertussis in a healthcare setting

If two or more confirmed or epidemiologically linked cases of pertussis occur in a healthcare setting an outbreak control team should be convened and the cases investigated. See LTHT outbreak guideline.

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Provenance

Record: 5128
Objective:

To provide evidence-based recommendations for appropriate diagnosis, investigation and management of Pertussis.

Clinical condition:

Pertussis (whooping cough)

Target patient group: All LTHT Inpatients
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1: Flow Chart for HCW Index Case

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Appendix 2: Flow Chart for Hospitalised Patient Index Case

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Appendix 3: Letters for contacts

3.1 Letter for parents/guardians whose child has been in contact with a case and does not require chemoprophylaxis

Dear Parent/Guardian,
Your child has been identified as a contact of a case of whooping cough (pertussis) at XXX hospital/centre/practice.

Whooping cough is a lung infection caused by Bordetella pertussis bacteria. Whooping cough usually begins like a common cold with a runny nose, low fever, sneezing and mild occasional coughing. Over the next one to two weeks, this progresses to fits of coughing which may be followed by choking and/or vomiting. The cough often comes in short bursts followed by a gasp for air (when the characteristic whooping noise may be made) and the feeling of not being able to catch your breath. Whooping cough doesn’t always cause the typical whoop or vomiting after coughing.

As your child has been in contact with a case, there is a small possibility that your child may develop whooping cough.

If your child is well and has been fully immunised/ is over 1 year old (DELETE AS APPROPRIATE), the risk from the recent contact is low and, we would not recommend antibiotics at this stage based on the national guidance. Please check that their immunisations are up to date (if unsure, check in their red book or with your GP or health visitor).

If your child is unwell or develops a cough illness in the next 3 weeks, please contact your general practitioner. They will arrange appropriate testing for whooping cough and management.

Further information on pertussis is available from:

http://www.nhs.uk/Conditions/Whooping-cough/Pages/Introduction.aspx
or
https://www.gov.uk/government/collections/pertussis-guidance-data-and-analysis

Yours faithfully,

XXX


3.2 Letter for parents/guardians whose infant has been in contact with a case and requires immunisation/chemoprophylaxis

Dear Parent/Guardian,

Your child has been identified as a contact of a case of whooping cough (pertussis) at XXX hospital/centre/practice.

Whooping cough is a lung infection caused by Bordetella pertussis bacteria. Whooping cough usually begins like a common cold with a runny nose, low fever, sneezing and mild occasional coughing. Over the next one to two weeks, this progresses to fits of coughing which may be followed by choking and/or vomiting. The cough often comes in short bursts followed by a gasp for air (when the characteristic whooping noise may be made) and the feeling of not being able to catch your breath. Whooping cough doesn’t always cause the typical whoop or vomiting after coughing.

As your child has been in contact with a case, there is a possibility that your child may develop whooping cough.

To reduce the risk, we recommend that your child has a short course of antibiotics. Your child should attend for their routine immunisations as usual as the vaccines offer long term protection for your child against whooping cough. If your child is over 4 months and has not received 3 doses of a pertussis containing vaccine (the normal schedule includes pertussis vaccines at 2, 3 and 4 months), we will arrange for your child to complete this schedule/ please contact your GP or health visitor. ADD DETAILS OF ARRANGEMENTS.

If your child is unwell or develops a cough illness in the next 3 weeks, please contact your general practitioner. They will arrange appropriate testing for pertussis and management.

Further information on pertussis is available from:

http://www.nhs.uk/Conditions/Whooping-cough/Pages/Introduction.aspx
or
https://www.gov.uk/government/collections/pertussis-guidance-data-and-analysis

Yours faithfully,

XXX


3.3 Letter for HCWs that have been in contact with a case but do not require immunisation/chemoprophylaxis

Dear,

You have been identified as a contact of a case of whooping cough (pertussis). Although the risk that you will develop whooping cough is low, we are writing to you to provide information about whooping cough and what you should do in the unlikely event that you develop symptoms.

Whooping cough is a respiratory infection caused by Bordetella pertussis bacteria. Whooping cough usually begins like a common cold with a runny nose, low fever, sneezing and mild occasional coughing. Over the next one to two weeks, this progresses to fits of coughing which may be followed by choking and/or vomiting. The cough often comes in short bursts (paroxysms) followed by a gasp for air (when the characteristic whooping noise may be made) and the feeling of not being able to catch your breath. Whooping cough doesn’t always cause the typical whoop or vomiting after coughing.

Whooping cough most commonly affects infants and is most serious in this group. Whooping cough does, however, also occur in older children, adolescents and adults. Across the UK, the number of cases of whooping cough in these older age groups is currently high.

If a healthcare worker develops whooping cough, they may transmit whooping cough to vulnerable patients, particularly young children and pregnant women.

In line with national guidance, antibiotics and immunisation is being offered to those with close contact with the case and who are due to work with children or pregnant women in the next 3 weeks. Based on the information available to us, you are not part of this group and thus do not require antibiotics or immunisation as a result of the recent contact.

If you develop a cough illness in the next 3 weeks, please contact occupational health on XXXXXXXXXXX to ensure appropriate testing for whooping cough and management.

Further information on pertussis is available from:

http://www.nhs.uk/Conditions/Whooping-cough/Pages/Introduction.aspx
or
https://www.gov.uk/government/collections/pertussis-guidance-data-and-analysis

Yours faithfully,

XXX


3.4 Letter for HCWs that have been in contact with a case and require immunisation/chemoprophylaxis

Dear,

You have been identified as a contact of a case of whooping cough (pertussis). Although the risk that you will develop whooping cough is low, we are writing to provide you with information about the infection and how you can protect yourself and your patients.

Whooping cough is a respiratory infection caused by Bordetella pertussis bacteria. Whooping cough usually begins like a common cold with a runny nose, low fever, sneezing and mild occasional coughing. Over the next one to two weeks, this progresses to fits of coughing which may be followed by choking and/or vomiting. The cough often comes in short bursts (paroxysms) followed by a gasp for air (when the characteristic whooping noise may be made) and the feeling of not being able to catch your breath. Whooping cough doesn’t always cause the typical whoop or vomiting after coughing.

Whooping cough most commonly affects infants and is most serious in this group. Whooping cough does, however, also occur in older children, adolescents and adults. Across the UK, the number of cases of whooping cough in these older age groups is currently high.

If a healthcare worker develops whooping cough, they may transmit whooping cough to patients, particularly young children and pregnant women.

As you have been in close contact with a case and you are due to work with infants or pregnant women in the next 3 weeks, we recommend that you have a short course of antibiotics and a booster dose of vaccine (if you have not had a pertussis vaccine in the last 5 years) . ADD DETAILS OF ARRANGEMENTS.

If you develop a cough illness in the next 3 weeks, please contact occupational health on XXXXXXXXXXX to ensure appropriate testing for whooping cough and management.

Further information on pertussis is available from:

http://www.nhs.uk/Conditions/Whooping-cough/Pages/Introduction.aspx
or
https://www.gov.uk/government/collections/pertussis-guidance-data-and-analysis

Yours faithfully,

XXX

Staff Who Have come into Contact with Suspected/Confirmed Case of Pertussis

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