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Rapid Responses: Rapid Responses published:
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Whooping cough
- Ada Majd (10 July 2006)
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whooping cough prevalance in schoolchildren
- Stan Bloxham (10 July 2006)
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Is public health action worth-while if we are we missing lots of cases?
- Peter M English (21 July 2006)
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In practice, how are we to assess this?
- Mary G Gibbs, None (22 July 2006)
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Persistent cough – a persisting problem.
- Mark Tighe (23 July 2006)
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What about IgM and PCR?
- Mick A Tarry (25 July 2006)
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Cohort was selected
- Wilfrid Treasure (27 July 2006)
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Whooping cough and vulnerable adults
- Judith H Harvey (30 July 2006)
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Whooping cough – adolescents and adults as preventive targets.
- Patricia GM Bezerra (31 July 2006)
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Whooping cough is quite common and can be diagnosed clinically
- Doug Jenkinson (31 July 2006)
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Ada Majd, general practitioner Tehran - Iran
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Thanks for the perfect article. I just wanted to add that in general practice, presence of conjunctivitis with long lasting cough even in the abscence of vomiting can be a clue toward whooping cough. Competing interests: None declared |
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Stan Bloxham, locum GP DY9-
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During my 30 years in GP I must have missed thousands of such cases! However I am sufficiently old-fashioned to have usually given an antibiotic if after 2-3 weeks the cough and malaise persisted. I would mutter about "2ndary bacterial infection". Most of such illnesses would then clear without any long-term sequelae. Perhaps I was treating correctly?! Competing interests: None declared |
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Peter M English, Consultant in Public Health Medicine Leatherhead, Surrey, KT22 9RX
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Are Harnden et al proposing that we are grossly underestimating the incidence of pertussis?[1] They comment on the relatively low notification rates for pertussis (barely 500 notifications in the last two years according to the Health Protection Agency).[2] 40% of children with persistent cough having pertussis infection sounds like a lot; but this would depend on the prevalence of persistent cough, which cannot be deduced from their article. According to the article, 18 practices in Oxfordshire participated in the study, which ran for 3½ years. 289 children were “eligible for recruitment”: that's only 4 or 5 per practice per year. If 40% of them had pertussis, that would make roughly 110 cases of pertussis, 30 each year, and roughly two cases of pertussis per practice per year, suggesting that the number of notifications might not be such a gross underestimate. Given that the study also showed that children with serological evidence of pertussis infection were also more likely to have had more to have had whooping, vomiting and sputum production, and to have been less likely to wheeze, perhaps most cases of pertussis are actually notified. On the other hand, the methods section does not give sufficient detail for us to be clear whether all children with cough lasting ≥14 days were eligible for the study - maybe chronic cough is far more common than the 289 eligible children would imply? Health Protection Agency guidelines recommend (broadly) that cases are treated and (if appropriate) immunised; and that all incompletely vaccinated members of households containing vulnerable contacts should be treated and/or immunised.[3] The accompanying editorial raises a number of very pertinent questions.[4] If only a small minority of cases is identified, we should add another: is public health action for these few cases is worthwhile? 1. Harnden A, Grant C, Harrison T, Perera R, Brueggemann AB, Mayon- White R, et al. Whooping cough in school age children with persistent cough: prospective cohort study in primary care. British Medical Journal 2006;333(7560):174-177. http://bmj.bmjjournals.com/cgi/content/abstract/333/7560/174 2. Health Protection Agency. Notifications [of whooping cough], England and Wales, by Region, 1991 - 2004, 2005. http://www.hpa.org.uk/infections/topics_az/whoopingcough/data_not_region.htm. Last updated: 29/9/05. Last accessed: 21/7/06. 3. South Yorkshire Health Protection Unit. Guidelines for chemoprophylaxis and immunisation in persons exposed to pertussis: Health Protection Agency, 2005:1-7. http://www.hpa.org.uk/infections/topics_az/whoopingcough/images/SYHPU_pertussis_guidelines.pdf 4. Butler C, Francis N, Dinant G-J. Whooping cough in general practice. British Medical Journal 2006;333(7560):159-160. http://bmj.bmjjournals.com Competing interests: None declared |
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Mary G Gibbs, General practitioner City Road Surgery, M15 4EA, None
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I have, over the years, noted children where the symptoms have made me wonder about the possibility of pertussis, despite them being immunised against it. I was aware that the immunisation did not give complete protection (I think I remember reading 70% somewhere?) but tended to modify the illness, but I was not aware that the illness itself did not give lifelong protection - I was taught the reverse. I have rarely notified them, as it was usually no more than a possibility, which I could not confirm (even pernasal swabs, of no use after the first two weeks anyway, have not been available when I have asked for them over the last few years). But how many young children and their parents are actually going to be willing to have a blood test done when there is no treatment available? I assume that there is no more patient-friendly test available in the pipeline? And has the suggestion from around twenty years ago, that Carbocisteine sometimes gave some relief, ever been properly studied? I suspect that using Erythromycin early in a lot of coughs would cause more pathology than it cured! Competing interests: None declared |
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Mark Tighe, Paediatric Specialist Registrar Southampton General Hospital, Tremona Road, SO16 6YD
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Editor - Harnden et al present convincing evidence that a common cause (Bordetella pertussis) of persistent cough in adolescents and adults also extends to school age children. They also confirmed that key symptoms such as paroxysmal coughing, whooping, posttussive vomiting, apnoea and sputum production are more likely to be associated with positive B. pertussis IgG serology. This highlights the clinical differences between this group of children and those presenting with asthma (persistent cough, worse at night and in the cold, associated with wheeze) [2]. Other infectious organisms should also be considered. Hallender et al found that 99 of 155 patients (64%) presenting with persistent cough (<100 days) had at least one of the common respiratory infectious agents (mycoplasma pneumoniae, chlamydia pneumoniae, B. parapertussis and B. pertussis) [3]. From those 99 patients, these organisms were identified 115 times, demonstrating the need to consider coinfection. Evidence of B. pertussis was found in 56%, Mycoplasma was demonstrated in 26%, Chlamydia pneumoniae in 17% and B. parapertussis in 2%. It would have been interesting to assess the incidence of all these infectious agents in the school age study group and the impact of coinfection on the duration of symptoms. While the evidence for a macrolide for persistent cough due to B. pertussis is weak, as reiterated by Harnden et al, an empirical macrolide course for persistent cough has been recommended by the American College of Chest Physicians [4]. Gastro-oesophageal reflux and post-nasal drip secondary to sinusitis, as well as asthma, are also common non-infectious causes of persistent cough; thus this study helps to illustrate that a detailed history can provide many clues to help distinguish between the myriad causes of persistent cough [3]. Further work is also needed to characterise the prevalence of B. pertussis in the pre-school age-group (<5y old). [1] Harnden A, Grant C, Harrison T Perera R et al: Whooping Cough in school age children with persistent cough: prospective cohort study in primary care. BMJ 2006 ; 333:174-7 [2]Wolf RL. Berry CA. Quinn K. Development and validation of a brief pediatric screen for asthma and allergies among children. Annals of Allergy, Asthma, & Immunology. 90(5):500-7, 2003 May. [3] Hallander, H O. Gnarpe, J. Gnarpe, H. Olin, P. Bordetella pertussis, Bordetella parapertussis, Mycoplasma pneumoniae, Chlamydia pneumoniae and persistent cough in children. Scandinavian Journal of Infectious Diseases. 31(3):281-6, 1999. [4] Braman SS. Postinfectious cough: ACCP evidence-based clinical practice guidelines. Chest. 129(1 Suppl):138S-146S, 2006 Jan. Competing interests: None declared |
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Mick A Tarry, GP NZ
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I was curious as to why the parameters of diagnosis were limited to paired titres of IgG, that the IgM was not measured and as to whether consideration for the pernasal PCR (polymerase chain reaction) test for B Pertussis, which I find a very useful adjunct to diagnosis of cough <1 week, when there is a prevalence of cough and pertussis within a community. This would have given an opportunity to compare diagnostic tests. Competing interests: None declared |
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Wilfrid Treasure, GP principal Muirhouse Medical Group, EH4 4PL
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The cohort in this paper comprised 179 children recruited over 3.5 years from 18 practices, the equivalent I estimate of only one child per general practitioner per year. Given that coughs are common and often last at least two weeks I suspect that general practitioners selected patients in a way not described in the paper. I would not conclude that of children aged 5-16y whom I see with cough lasting 2w as many as 37% will have pertussis. Wilfrid Treasure Competing interests: None declared |
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Judith H Harvey, Salaried GP Caversham Group Practice NW5 2UP
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Twelve years ago I developed whooping cough. As the illness started after a week notable for the number of coughing and sputtering children brought to the surgery, I have since supposed that at least some of the coughs we see every winter are likely to be due to pertussis, the clinical picture being attenuated by immunisation. I am interested to find this hypothesis given support in this paper. i wonder how many of the children in the study with whooping cough passed it on to vulnerable adults. Competing interests: None declared |
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Patricia GM Bezerra, Pediatric Pneumologist Instituto Materno Infantil Professor Fernando Figueira Recife PE Brazil 50070-550
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In Brazil there has been complete vaccine coverage for three doses of pertussis vaccine in infants since the late nineties. However, in a study conducted in the Pediatric Infectious Diseases Service School, Hospital University of Pernambuco Recife, Brazil by Baptista, Paulo Neves and colleagues, it was found that subjects older than 11 years and six months were the sources for the majority of secondary cases of whooping cough. The problem consists of convincing people beyond this age to get new shots of vaccines, since the majority of adults in our country thinks that vaccines are only for children. Competing interests: None declared |
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Doug Jenkinson, GP principal Keyworth Health Centre, Bunny Lane, Keyworth, Nottingham NG12 5JU
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The authors, with the help of a recently available blood test, have gone some way to confirm that whooping cough is still about, as several other studies have done in the last few years. Whooping cough can be diagnosed fairly easily clinically, once one has heard it and been made aware of its characteristics. It is a notifiable disease because it can be distinguished from other coughing illnesses and therefore provide a guide to incidence. The sad fact is that most health professionals are totally unfamiliar with it. The consequence is that notifications have gone down as those older doctors who remember it well have retired. This make people think there is less of it, and so it seems less important, continuing the downward spiral of knowledge of whooping cough. Since 1977, I have, with the help of my practice colleagues, been recording every clinically diagnosable case of whooping cough (based on a minimum of 3 weeks of paroxysmal coughing). This year so far we have seen 6 cases in a practice of 11,000. In 2002 we recorded 44 cases. Ten had blood specimens tested, 9 were positive, the tenth was lost. 23 had pernasal swabs taken, 14 were positive. This small practice was responsible for 5% of all whooping cough notifications in England and Wales in 2002. This surely cannot be because there is more whooping cough where I work. I have been fortunate to have had four papers published in this Journal as a result of this study. I have decided to publish the incidence data on the web. Some years ago I set up a website to help patients diagnose their own whooping cough, and I can confirm from the feedback that doctors the world over appear to be equally poor at diagnosing it. I have published the Keyworth figures at www.whoopingcough.net/keyworth. Basic data on all cases are available, as well as year by year figures compared with national notifications. The graph of both is a bit of an eye opener if I may be immodest. Whooping cough is a distressing illness, especially when bearing it with failure to be diagnosed. I am hopeful that this paper will start to wake us up about this disease, which, if my data are correct, is just as common as it was 25 years ago after the vaccine scare settled. Competing interests: I have a website on whooping cough that charges a fee for personal advice. The fees have so far never covered the site expenses |
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