Whooping coughBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1772 (Published 21 May 2009) Cite this as: BMJ 2009;338:b1772
All rapid responses
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:
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: No competing interests
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
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
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
Competing interests: No competing interests
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
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,
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
5. Wood N, McIntyre P. Pertussis: review of epidemiology, diagnosis,
management and prevention. Paediatr Respir Rev 2008;9(3):201-11.
Competing interests: No competing interests