Pertussis, or whooping cough, remains one of the leading causes of vaccine-preventable deaths worldwide, with most deaths occurring in young babies who are either unvaccinated or incompletely vaccinated.
During the COVID-19 pandemic, many of the infection prevention and control measures such as masking, social distancing, and remote learning for children resulted in decreases in reported cases of pertussis. However, in 2023 and 2024 a return to routine activities has resulted in an increase in pertussis cases. Preliminary data from the Centers for Disease Control and Prevention (CDC) show that more than five times as many cases of pertussis have been reported as of October 19, 2024, compared to the same time period in 2023. This is higher than was seen during the same time period in 2019, prior to the pandemic. Compounding this problem are the alarming trends showing lower rates of routine vaccination among adults and children, trends which indicate reduced vaccine confidence and increases in vaccine hesitancy in the U.S. population.
Key points of knowledge and action for nurses
Epidemiology of pertussis
Pertussis is caused by Bordetella pertussis, a gram-negative coccobacillus and is highly contagious and easily spread person-to-person via respiratory droplets or through direct contact with respiratory secretions. It is a respiratory disease and occurs year-round, peaking in the later part of the year.
Adolescents and adults represent more than half of the cases reported to the CDC each year and these individuals can serve as reservoirs for transmission to infants, who are at highest risk for serious complications. When infected, individuals may experience a cough that is sudden onset and recurring (paroxysmal); the cough is often so severe it is difficult to breathe, eat, or sleep, and may even result in cracked ribs, pneumonia, or hospitalization. The ‘whoop’ is a high-pitched sound that occurs after a coughing episode and is caused by vocal cord adduction during inspiration. Whooping cough is most dangerous for infants, particularly those younger than three months.
Symptoms of pertussis include:
- Prolonged cough. Pertussis should be considered in the event a cough lasts longer than one week.
- There are three stages of pertussis:
- The catarrhal is the first stage, lasts one to two weeks, and consists of symptoms common to other respiratory tract infections. This is the most infectious stage. Because it is initially difficult to differentiate from other respiratory illnesses at this stage, pertussis often goes unrecognized, with transmission occurring widely.
- The second stage is paroxysmal and lasts about one week. This stage is where the sudden-onset, rapid, and uncontrolled coughing occurs as well as the characteristic ‘whoop.’ This paroxysmal cough may occur with or without post-tussive vomiting and that characteristic whoop.
- The third stage is the convalescent stage, usually lasting two to three weeks. During this stage there is a gradual improvement in cough frequency and severity.
- Apnea or cyanosis without the characteristic paroxysmal cough may occur, especially in infants.
Testing and treatment of pertussis
Suspected cases of pertussis can be confirmed by culture or polymerase chain reaction (PCR) of respiratory samples or serologic testing. Antimicrobial treatment is given to an individual highly suspected or with a confirmed diagnosis of pertussis and consists of macrolides such as azithromycin, clarithromycin, erythromycin, or trimethoprim-sulfamethoxazole as an alternative. Persons are considered to be infectious until after completion of the fifth day of appropriate treatment but should complete the treatment regimen to avoid bacterial relapse and resistance.
Prevention of pertussis through vaccination
Fortunately, there is a vaccine available for individuals of all ages. Protection against pertussis is included in the pediatric DTaP [diphtheria, tetanus, acellular Pertussis] vaccine and the adult Tdap [Tetanus, diphtheria, acellular pertussis] vaccine. The capital letter in those vaccines indicates that the vaccine contains a standard dose of that component, whereas a lowercase indicates a reduced antigen component. The ‘a’ in both vaccines stands for acellular, which means the vaccine contains only part of the pertussis bacteria. This was an improvement to the original DTP whole cell vaccine.
There is no separate pertussis-only vaccine commercially available in the United States. Neither DTaP or Tdap are live vaccines, and both use noninfectious bacterial components that generate a robust immune response. DTaP was licensed in 1991 and replaced the original whole-cell DTP vaccine that first began use in the United States in 1948.
The current child, adolescent, and and adult immunization schedules can be found at https://www.cdc.gov/vaccines/hcp/imz-schedules/index.html. The CDC’s Advisory Committee on Immunization Practices (ACIP) met on October 23-24, 2024, and approved the 2025 immunization schedules.
Typically, vaccination begins for infants with a 5-dose series consisting of a 3-dose primary series at ages 2, 4, and 6 months, followed by a booster dose at 15-18 months and ages 4-6 years.
Beginning after age 11 years, one dose of Tdap, then Td [no pertussis component] or Tdap is recommended every 10 years. It is important to remember that if Td is given, there is no pertussis component and therefore no pertussis protection is provided. Additionally, repeat doses of Tdap at 5 or 10 year intervals are safe and produce an acceptable immune response.
Vaccine is also recommended for pregnant individuals, given in the early third trimester as a means of inducing antibodies in the mother that can be passed along transplacentally to the developing fetus. These maternal antibodies help protect the newborn during those first few months of life until they are able to begin their own vaccination series.
Key takeaways and implications for nursing practice
- Pertussis (whooping cough) is common in the United States, and rates are on the rise in 2024, rebounding following the return to usual social activities post COVID-19 pandemic phase
- Vaccines effective for pertussis prevention are available, but their acceptance across child and adult populations has declined, resulting in an opportunity for nurse influence.
- Transmission occurs by means of the sharing of respiratory droplets and contact with respiratory secretions (e.g., breathing, coughing, kissing, close social contact).
- People at highest risk for serious illness include infants and children, but disease at any age may have serious health outcomes.
- Treatment includes use of antibiotics, but infectivity remains until the fifth day of completion of appropriate therapy.
- Vaccination is key to prevention. Information regarding vaccination across the lifespan is included in the CDC/ACIP Immunization Schedules.
- Nurses are trusted health professionals and in a position to share information regarding the seriousness of pertussis and the ease of its transmission.
- Following discussion about transmission and resultant illness, there is an opportunity for nurses to remind patients, families, and communities about the importance of prevention through immunization.
- Nurses have expertise in patient conversations and interactions regarding health issues, and immunization is another important area of emphasis.
- Expanding knowledge and competence concerning vaccine confidence and vaccination hesitancy is a critical area for nurses.
For more information about pertussis, the global impact, and vaccination, visit https://www.cdc.gov/pertussis/
Ruth Carrico, PhD, FNP-C, CIC, FSHEA, FNAP, FAAN is an adjunct professor in the Division of Infectious Diseases at the University of Louisville School of Medicine and a board certified family nurse practitioner. She has worked in the field of infection prevention and control for more than 30 years and is also board certified in infection prevention and control. Her research and clinical practice focus on disease prevention in all settings where care is delivered and involves public health and care of vulnerable populations.
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