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Staying Ahead of Pertussis

Clinician Reviews. 2014 November;24(11):658-659,666-669

References

1. Orenstein WA. Pertussis in adults: epidemiology, signs, symptoms, and implications for vaccination. Clin Infect Dis. 1999;28 suppl 2:S147-S150.

2. Tanaka M, Vitek CR, Pascual FB, et al. Trends in pertussis among infants in the United States, 1980-1999. JAMA. 2003;290:2968-2975.

3. Vitek CR, Pascual FB, Baughman AL, et al. Increase in deaths from pertussis among young infants in the United States in the 1990s. Pediatr Infect Dis J. 2003;22:628-634.

4. Centers for Disease Control and Prevention. Pertussis outbreak trends. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/pertussis/outbreaks/trends.html. Accessed October 10, 2014.

5. Shapiro ED. Acellular vaccines and resurgence of pertussis. JAMA. 2012;308:2149-2150.

6. Centers for Disease Control and Prevention. Pertussis. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book. 2012. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/pert.html. Accessed October 10, 2014.

7. Centers for Disease Control and Prevention. Pertussis: Summary of vaccine recommendations. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/vaccines/vpd-vac/pertussis/recs-summary.htm. Accessed October 10, 2014.

8. Lee GM, Murphy TV, Lett S, et al. Cost effectiveness of pertussis vaccination in adults. Am J Prev Med. 2007;32:186-193.

9. Pertussis vaccines: WHO position paper. Wkly Epidemiol Rec. 2010;85:385-400.

10. Kretsinger K, Broder KR, Cortese MM, et al; Centers for Disease Control and Prevention; Advisory Committee on Immunization Practices; Healthcare Infection Control Practices Advisory Committee. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among healthcare personnel. MMWR Recomm Rep. 2006;55(RR-17):1-37.

11. English P. Pertussis vaccination in pregnant women will protect neonates. Practitioner. 2012;256:5.

12. Winter K, Harriman K, Zipprich J, et al. California pertussis epidemic, 2010. J Pediatr. 2012;161:1091-1096.

13. Centers for Disease Control and Prevention (CDC). Pertussis epidemic—Washington, 2012. MMWR Morb Mortal Wkly Rep. 2012;61:517-522.

14. Klein NP, Bartlett J, Rowhani-Rahbar A, et al. Waning protection after fifth dose of acellular pertussis vaccine in children. N Engl J Med. 2012;367:1012-1019.

15. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older - Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep. 2012;61:468-470.

16. Cherry JD, Tan T, Wirsing von Konig C, et al. Clinical definitions of pertussis: Summary of a global pertussis initiative roundtable meeting, February 2011. Clin Infect Dis. 2012;54:1756-1764.

17. Zouari A, Smaoui H, Kechrid A. The diagnosis of pertussis: which method to choose?. Crit Rev Microbiol. 2012;38:111-121.

18. Loeffelholz MJ, Thompson CJ, Long KS, et al. Comparison of PCR, culture, and direct fluorescent-antibody testing for detection of Bordetella pertussis. J Clin Microbiol. 1999;37:2872-2876.

19. Tozzi A, Celentano L, Ciofi degli Atti ML, et al. Diagnosis and management of pertussis. CMAJ. 2005;172:509-515.

20.  von König CH, Halperin S, Riffelmann M, et al. Pertussis of adults and infants. Lancet Infect Dis. 2002;2:744-750.

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23. Bass JW. Erythromycin for treatment and prevention of pertussis. Pediatr Infect Dis. 1986;5:154-157.

24. Health Protection Surveillance Centre. Guidelines for the Public Health Management of Pertussis: Public Health Medicine Communicable Disease Group HSE—October 2013. Health Protection Surveillance Centre Web site. Available at: http://www.hpsc.ie/A-Z/VaccinePreventable/PertussisWhoopingCough/InformationforHealthcareWorkers/File,13577,en.pdf. Accessed October 2, 2014.

25. Dodhia H, Miller E. Review of the evidence for the use of erythromycin in the management of persons exposed to pertussis. Epidemiol Infect. 1998;120:143-149.

26. Altunaiji S, Kukuruzovic R, Curtis N, et al. Antibiotics for whooping cough (pertussis). Cochrane Database Syst Rev. 2007;(3):CD004404.

27. Prophylactic erythromycin for whooping-cough contacts. Lancet. 1981;1:772.

28. Halperin SA, Bortolussi R, Langley JM, et al. A randomized, placebo-controlled trial of erythromycin estolate chemoprophylaxis for household contacts of children with culture-positive bordetella pertussis infection. Pediatrics. 1999;104:e42.

29. Langley JM, Halperin SA, Boucher FD, et al; Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC). Azithromycin is as effective as and better tolerated than erythromycin estolate for the treatment of pertussis. Pediatrics. 2004;114:e96-e101.

30. Tiwari T, Murphy TV, Moran J; National Immunization Program, CDC. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines. MMWR Recomm Rep. 2005;54(RR-14):1-16.

Four methods of lab testing for pertussis infection are polymerase chain reaction (PCR), direct fluorescent antibody (DFA) testing, serologic testing, and culture (TABLE 3).^17-19The sensitivity of these tests is as follows: PCR, 90% to 95%; DFA, 50% to 60%; serologic testing, 70% to 80%; and culture, 50% to 70%. The specificity is: PCR, 95% to 98%; DFA, 90% to 100%; serologic testing, 90% to 100%; and culture, 100%.

PCR is the preferred method because of its rapid turnaround and fairly high sensitivity. The reliability of PCR decreases, however, for a patient who’s had a cough for more than 2 weeks because the individual may have transitioned to the convalescent phase, when less bacterial DNA remain.

Results from DFA testing also are rapidly available, but the need for specialized equipment and a well-trained examiner of the specimen limits widespread use of this test. It also is not particularly sensitive for pertussis.

Serologic testing is less reliable in patients who have received an acellular pertussis vaccine and is not helpful in the first few weeks of infection.

The sensitivity of culture is best if the sample is collected appropriately (more on this in a bit) and within the first 2 weeks of symptoms (catarrhal stage). Culture is also very specific.

Given the strengths and weakness of the different tests, an acceptable method of laboratory confirmation is to obtain PCR and/or culture within the first 2 weeks of symptoms in all age groups.^17-20Testing after 2 weeks should include a combination of PCR and serology.¹⁷It is essential that the clinical specimen used for PCR or culture testing for pertussis is properly collected. (See “Collecting a swab for pertussis testing” below.²¹)

COLLECTING A SWAB FOR PERTUSSIS TESTING
The illustration below shows the correct swab and sampling method. Swab tips may be polyester (such as Dacron or rayon) or they may be nylon-flocked. Cotton-tipped or calcium alginate swabs are not acceptable because the residue will inhibit DNA assays.²¹ The specimen must be obtained from the posterior nasopharynx and not the nares or oropharynx. The Centers for Disease Control and Prevention offers a video that demonstrates how to properly collect a specimen for testing at http://www.cdc.gov/pertussis/clinical/diagnostic-testing/specimen-collection.html.

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