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PRACTICE: Anthony Harnden Whooping cough BMJ 2009; 338: b1772 [Full text]

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More on whooping cough

Gianluca Tornese, Federica Patarino, Federico Marchetti   (1 June 2009)

“Easily” missed? None so blind as he who will not see.

Dr Viera Scheibner   (8 June 2009)

Pertussis infection during infancy

Kelsey D J Jones, David P Inwald, Marianne Nolan, John O Warner   (18 June 2009)

More on whooping cough 1 June 2009
Gianluca Tornese, Resident in Paediatrics Department of Paediatrics, Institute of Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Federica Patarino, Federico Marchetti Send response to journal: Re: More on whooping cough	Dear Editor, we really appreciate the article on whooping cough in “Easily missed?” section with its very practical summary on what a clinician should know about this infection and its management (1). Nevertheless, we think that some clarification should be added. Firstly, we believe that erythromycin cannot be considered any more the first choice in contact prophylaxis. According to the last Cochrane review on antibiotics for whooping cough (2) the best regimens for microbiological clearance and for contact prophylaxis, with fewer side effects are azithromycin (for three days, 10 mg/kg as a single dose, or for five days, 10 mg/kg on the first day and then 5 mg/kg once daily) or clarithromycin (for seven days, 7.5 mg/kg/dose twice daily). The 2002 UK guidelines that Harnden used as reference (3) advised against using newer macrolides since they were not licensed, but nowadays these drugs are included in the BNF for children 2008 for prevention of secondary case of pertussis in non-immune or partially-immune patients. Moreover, it should be underlined that infants exposed to erythromycin (and not to other macrolides) are at greater risk for developing hypertrophic pyloric stenosis (4). Secondly, we consider that within investigations, PCR should be at least mentioned: although it is not a basic test, there is no method as quick as PCR and it may be decisive in specific situations when serology is not useful, such as infants, older persons or cough onset for less that 2 weeks (5). Gianluca Tornese, Federica Patarino, Federico Marchetti Department of Paediatrics, Institute of Child Health, IRCCS Burlo Garofolo, Trieste via dell’Istria 65/1. 34100 Trieste, Italy Corresponding Author: Gianluca Tornese, MD, gianluca.tornese@gmail.com References 1. Harnden A. Whooping cough. BMJ 2009 May 21;338:b1772. 2. Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis). Cochrane Database Syst Rev 2007;(3):CD004404. 3. Dodhia H, Crowcroft NS, Bramley JC, Miller E. UK guidelines for use of erythromycin chemoprophylaxis in persons exposed to pertussis. J Public Health Med 2002;24(3):200-6. 4. Maheshwai N. Are young infants treated with erythromycin at risk for developing hypertrophic pyloric stenosis? Arch Dis Child 2007;92(3):271-3. 5. Wood N, McIntyre P. Pertussis: review of epidemiology, diagnosis, management and prevention. Paediatr Respir Rev 2008;9(3):201-11. Competing interests: None declared
“Easily” missed? None so blind as he who will not see. 8 June 2009
Dr Viera Scheibner, Scientist (Retired)/Author Blackheath NSW Australia Send response to journal: Re: “Easily” missed? None so blind as he who will not see.	Discussion about whooping cough is not going to stop until all and sundry realise that vaccination not only fails to prevent children from getting it, but is keeping the disease alive and kicking at the pre- vaccine era incidence levels. Moreover, the discussion about treatment only revolves around which antibiotic is to be used, rather than stepping out of the vicious circle and realising that administering adequate doses of sodium ascorbate, or even doing nothing, is the safer and more effective way to go. Another serious effect of vaccination is that it damages the transplacentally-transmitted immunity: babies born to mothers who were vaccinated as babies have poor or no TTI which normally protects small babies against any infectious diseases at a very young age (Lennon and Black 1986. Maternally derived measles immunity in era of vaccine- protected mothers. J Pediatrics; 108 (1): 671-676). Hence, small babies are now contracting pertussis, usually from their fully vaccinated mothers and/or siblings who had the diseases around the time of their birth (Med J Australia 1998; 168: 281-283). The rapid responders to the original article by Harnden et al. (BMJ 2006; 333: 174-177) admitted seeing whooping cough rampant among fully vaccinated small children, coughing and spluttering in their surgeries’ waiting rooms, and even contracting it themselves from these children. If they went just a little step further and studied orthodox medical literature on pertussis, they would realise that there is overwhelming published evidence that not only the vaccine does not prevent pertussis, but the incidence of this disease has only increased upon mass use of the vaccine. Nowhere else is this better documented than in the United States: Hutchins et al. (1988. Current epidemiology of pertussis in the United States. Tokai J Exp Clin Med; 13 (Suppl.): 103-109) demonstrated that the incidence of pertussis increased substantially after a 1978 nationwide immunization initiative was begun; “individual states passed legislation requiring proof of immunization for school entry at five to six years of age”. While the incidence and mortality from whooping cough fell steadily between 1922 and 1978, characterised by no, or very low, vaccination rate, immediately after the enactment of mandatory vaccination laws the trend reversed, and ever since then there has been a sustained rise in the overall incidence of pertussis in the US, especially in the age group below six months. That’s the age when whooping cough is at its most dangerous (this is also the age group with the highest mortality from whooping cough). Sutter and Cochi (1992. Pertussis hospitalizations and mortality in the United States. JAMA; 267 (3): 386-390) concluded that based on the rate of hospitalisations, there is a substantial under- reporting of pertussis and the national impact of this disease is considerably higher than previously published reports have suggested. Between 1985 and 1988, 187,867 to 515,930 cases of pertussis may have occurred instead of only 14,057 cases reported to the CDC (the reporting efficacy being only 2.7% to 7.5%). Marchant et al. (1994. Pertussis in Massachusetts, 1981-1991: incidence, serologic diagnosis, and vaccine effectiveness. J Infect Diseases; 169: 1297-1305) demonstrated that 90% of whooping cough cases in the US occur below the age of one year, however, a breakdown in months actually demonstrated that this is in fact a very high incidence between 6-8 weeks and 4 months, right after the first and second doses of DPT. They wrote that most children with pertussis received less or equal to 3 doses of DPT while 87% of adolescents with pertussis received more or equal to 4 doses, forgetting that all these rates simply reflect “correct for age full vaccination”. They also confirmed a very high incidence below 6-8 weeks, this, no doubt in my mind, confirming the effect of poor or no TTI in the mothers of these babies. Even though they failed to recognise it, Marchant et al. (1994) nevertheless in fact confirmed that the highest incidence was indeed after the first and second doses as also observed in poliomyelitis and other so called “vaccine-preventable” (whatever that means) disease. Even the latest information on whooping cough in the United States (MMWR 2009; 55(53): 1-104), demonstrates the ever increasing pertussis incidence with a major epidemic flareup in 2004, the highest level since 1963, with the level in the subsequent cyclical trough still higher than it ever reached in the latter half of the 1960s. The age distribution still shows the high incidence in 1 month old infants (lack of TTI) and increased incidence in teenagers; all these ages being the most vulnerable. To quote: “Pertussis is an acute, infectious cough illness that remains endemic in the United States despite longstanding routine childhood pertussis vaccination.” The same inversion of the age distribution of pertussis (and measles) has occurred in all countries with mass vaccination. The acellular pertussis vaccines failed to make any inroads into pertussis, as witnessed in Sweden: already during the trials of this vaccine, the infant recipients contracted whooping cough which prompted discontinuation of the trial well before the planned date (Olin 1995. Acellular pertussis vaccines – a question of efficacy. J Hospital Practice; 30 (Supplement): 503-507). This is particularly instructive, since during the eleven years of no usage at all of pertussis vaccine (1979-1990), babies under 1 year of age did not contract whooping cough and 90% of cases occurred in the ideal age group of between 5-10 years (Isacson et al. 1993. How common is whooping cough in a nonvaccinating country? Pediatr Infect Dis J; 12 (4): 284-288). England has its own exemplary study of whooping cough: Ditchburn (1979. Whooping cough after stopping pertussis immunisation. BMJ; 1: 1601-1603) considered it interesting that the outbreak in rural Shetland started among the older children, in whom the vaccination rate was 94%. He reasoned that if the vaccination were effective this high vaccination rate should have produced herd immunity and prevented the outbreak. It did not and almost half of the children under 16 and some adults were affected. No child suffered permanent damage and there were no hospital admissions, however the disease was unpleasant and prolonged. Ditchburn concluded that there was no evidence to support routine vaccination in rural Shetland. Competing interests: None declared
Pertussis infection during infancy 18 June 2009
Kelsey D J Jones, NIHR Academic Clinical Fellow in Paediatrics Imperial College, London, W2 1PG, David P Inwald, Marianne Nolan, John O Warner Send response to journal: Re: Pertussis infection during infancy	Harnden’s practice point on Whooping Cough usefully highlights the importance of this condition (1). Despite vaccination strategies, Bordetella pertussis remains an important cause of infant mortality, and is significantly underdiagnosed (2). Clinical identification is challenging as infection in infancy often presents without the characteristic cough. Post-tussive emesis and apnoeic or cyanotic episodes are clinically suggestive (3). The youngest and most severely unwell infants can develop a rapidly progressive form of the disease with pneumonia and atypical lymphocytosis associated with cardiorespiratory failure, pulmonary hypertension, seizures and sometimes death (4-6). Older infants more often require ventilatory support for single organ respiratory failure. A high index of suspicion is critical to facilitate early intervention and PICU referral. Treatment is supportive and with macrolide antibiotics, but erythromycin is no longer first choice as azithromycin at 10mg/kg for three days is better tolerated in children (note: maximum dose of 500mg once daily). There is now good evidence that azithromycin is safe in the early neonatal period (7,8). 1. Harnden A (2009) Whooping cough. BMJ 338: b1772. 2. Crowcroft NS, Andrews N, Rooney C, Brisson M, Miller E (2002) Deaths from pertussis are underestimated in England. Arch Dis Child 86: 336-338. 3. Cosnes-Lambe C, Raymond J, Chalumeau M, Pons-Catalano C, Moulin F et al. (2008) Pertussis and Respiratory Syncytial Virus infections. Eur J Pediatr 167: 1017-1019. 4. Pierce C, Klein N, Peters M (2000) Is leukocytosis a predictor of mortality in severe pertussis infection? Intensive Care Med 26: 1512-4. 5. Inwald D, Brown K, Gensini F, Malone M, Goldman A (2004) Open lung biopsy in neonatal and paediatric patients referred for extracorporeal membrane oxygenation (ECMO). Thorax 59: 328-333. 6. Namachivayam P, Shimizu K, Butt W (2007) Pertussis: severe clinical presentation in pediatric intensive care and its relation to outcome. Pediatr Crit Care Med 8: 207-211. 7. Tiwari T, Murphy TV, Moran J (2005) Recommended antimicrobial agents for the treatment and postexposure prophylaxis of Pertussis: 2005 CDC guidelines. MMWR Recomm Rep 54: 1-16. 8. Altunaiji S, Kukuruzovic R, Curtis N, Massie J (2007) Antibiotics for whooping cough (Pertussis). Cochrane Database Syst Rev : CD004404. Competing interests: None declared