Whooping cough cases on the rise in Midwest

The News-Sentinel (Fort Wayne, Ind.) (MCT) - An underreported, often misdiagnosed disease that people think affects only young children is drawing concern from national health officials and has recently struck hospital workers, closed schools in the Midwest and kept multiple health departments busy sending out alerts.

It is whooping cough, known medically as pertussis, a highly communicable bacterial infection that affects the respiratory tract, producing a cough that will last weeks, even months, if untreated. The spasmodic cough can take on the characteristic of a whooping sound as it ends _ thus the name.

"We do see pertussis tends to be cyclic. One year we'll have more cases. Other years we'll have less, but the baseline has gone up over time," said Dr. Joan Duwve, medical director for Public Health and Preparedness at the Indiana State Department of Health. "We have been concerned with decreasing immunity in adolescent and adult populations."

Because of increased outbreaks across the country and growing concern about waning immunity for older children and adults, McMahan has asked local doctors to be on the alert for patients with long-lasting coughs.

"We are seeing some increase in pertussis activity compared to last year at this same time," said Kristin Ryker, an epidemiologist with the state health department.

A few recent examples of national cases: On Nov. 11, the health department of Evanston, Ill., a Chicago suburb, declared an outbreak of whooping cough after five cases were confirmed.

Nearby Winnebago County, Ill., health officials the week before confirmed 38 cases of whooping cough, with 28 of them in one private school.

An outbreak of whooping cough was declared in South Dakota in late October after 10 students at an elementary school in Huron developed the disease and seven other cases were confirmed in Lake Preston.

The Minnesota Department of Health also reported a whooping cough outbreak earlier this month, after at least 30 cases were confirmed in a group of upper-elementary and high school students in two counties.

Other outbreaks in California, South Carolina, Pennsylvania and Iowa have been declared this year, most in recent weeks. The disease struck students at a South Carolina college and more recently was diagnosed in 11 employees at a veteran's hospital in Pittsburgh.

"There's a lot more pertussis out there than we recognized," said Allen County Health Commissioner Dr. Deborah McMahan. To date, 87 pertussis cases have been reported by ISDH to the U.S. Centers for Disease Control and Prevention.

"We are seeing some increase in pertussis activity compared to last year at this same time," said Kristin Ryker, an epidemiologist with ISDH.

In 2005, the most recent year data is available, the U.S. Centers for Disease Control and Prevention reported 8,000 confirmed cases of pertussis that year, "but the estimated true disease incidence was 600,000 cases. That's how underreported this is," Duwve said.

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People, including health care providers, think of this as a pediatric disease, McMahan said. Doctors may be diagnosing bronchitis and giving an antibiotic, which is the treatment for pertussis. But pertussis can be fatal to infants and young children who have not completed their series of immunizations. Grandparents or child-care workers may be spreading the disease unknowingly to babies or other adults.

While the burden of pertussis means missed work days or several trips to the doctor for an adult, "The true hospitalization burden of disease lies with the very old and very young," Duwve said.

Infants get their first dose of pertussis vaccine, in combination with diphtheria and tetanus (DTaP), at 2 months, 4 months and 6 months. Boosters are given at 12 to 15 months and then around age 4 or 5.

Between 2000 and 2004, 92 infants under 6 months of age died from pertussis-related illness, according to the CDC. Pneumonia associated with pertussis is often the cause of death.

The disease can be spread even before the cough develops, and if no antibiotics are taken, it can be transmitted to others for up to 21 days, said Ryker. Older children, college students and adults are more likely to self-medicate with over-the-counter cough medicine for that "nagging cough" for weeks before finally seeing a doctor. By then, many people will have been exposed.

People ages 10-64 should get a pertussis booster now "The ability of the immune system to fight off pertussis decreases as we get older," Duwve said. That is why in 2006 the CDC began recommending that children get a pertussis booster before entering middle school. The CDC now also recommends adults up through age 64 get the Tdap vaccine, the adult combination vaccine version.

Most adults know they are to get a flu shot every year and a tetanus booster every 10 years, McMahan said, but few primary health care providers are reminding adults to get the pertussis vaccine. The CDC suggests that the every-10-years tetanus booster be substituted one time with the Tdap, to ensure the person is getting both the tetanus and pertussis vaccine. But if someone gets the pertussis booster at age 15 will they still have immunity at age 50? "That's the $6 million question," Duwve said.

One of the challenges adults face is where to get the pertussis vaccine. Fewer family practice and other primary care doctors are keeping vaccine in stock for even children, let alone adults, because of need to store the vaccine under certain temperatures and short shelf life.

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More and more Allen County doctors are referring children to Super Shot or the health department. But the health department does not routinely give adult vaccinations, and Super Shot is only for children and teens to age 18.

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If a doctor doesn't have the vaccine, a prescription can be written and some pharmacies stock it or obtain it with advance notice. Pharmacists in all states but Maine and the District of Columbia can now give shots. Some urgent care clinics may also have the adult vaccine.

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McMahan agrees availability of the vaccine for adults is a problem and said the health department might consider, if they can obtain enough vaccine, holding a mass immunization clinic for pertussis and other vaccines now recommended for adults, such as Zostavax for shingles.

Another option is that the health department, which has been recently approved to be a Medicaid provider to help cover refugee and low-income clients' health care services, could begin offering shots to adults and bill insurance companies.

Both ideas are not likely to happen soon, however.

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COUGH

The facts

Diagnosing pertussis, or whooping cough: a quick test called polymerase chain reaction (PCR); or by culturing the bacteria.

Symptoms: at onset similar to those of a bad cold or viral upper-respiratory infection and can include fever, runny nose, congestion and sneezing. The pertussis cough is a dry cough, however, and the fits of coughing worsen and continue for more than two weeks.

See a doctor: adults with a severe cough should seek medical care if little relief is found from over-the-counter cough medicine and the cough has lasted two weeks or more, sooner if you are immuno-compromised or have contact with infants or elderly; because infants face the greatest risk of dying from pertussis, seek medical advice for a baby with a cough and flu-like symptoms who has not yet been fully immunized.

Sources: CDC and ISDH

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© 2008, The News-Sentinel (Fort Wayne, Ind.).