Primary prevention
Pertussis is a preventable disease for which effective vaccines exist.[17]
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Most pertussis vaccines are combined with diphtheria and tetanus toxoids, and some are formulated as combination vaccines containing hepatitis B, poliovirus, and/or Haemophilus influenzae type b antigens. Combination vaccines may be used if these additional components are indicated and no contraindications to their administration exist. Most pertussis vaccines are adjuvanted with alum and are administered intramuscularly. Vaccines for children contain increased quantities of some pertussis antigens and diphtheria toxoid compared with vaccines for adolescents and adults, and are recommended only for children aged <7 years.[4]
In the UK, pertussis vaccination is recommended at aged 2, 3, and 4 months, as part of the DTaP/IPV/Hib/HepB vaccine (diphtheria, tetanus, pertussis/polio/H influenzae b/hepatitis B vaccine), with one booster given at age 3 years 4 months (as part of the DTaP/IPV pre-school booster). Pertussis vaccine is also offered to all household contacts of a clinically suspected or confirmed case where contacts are over aged 10 years and have not received a pertussis vaccine in the last 5 years.[18] NHS Choice: vaccinations Opens in new window A single dose of dTaP/IPV is recommended for women during each pregnancy from 16 weeks' gestation onwards.[18][19] Booster doses for other non-pregnant adults are not recommended in the UK.[18]
In the US, the CDC's Advisory Committee on Immunization Practices (ACIP) recommends a five-dose series of diphtheria, tetanus, and acellular pertussis (DTaP) administered at 2, 4, 6, and 15-18 months, and 4-6 years.[20][21] The series may be started as early as 6 weeks and the fourth dose administered as early as 12 months if at least 6 months have elapsed since the third dose. If the fourth dose of DTaP vaccine is inadvertently administered early, the ACIP recommends that it does not need to be repeated if it was administered at least 4 months after the third dose, and the child was aged 12 months or older. The fifth dose of DTaP is not considered necessary if the fourth dose was administered at age 4 years or older and at least 6 months after the third dose.[21] Pentavalent DTaP-inactivated poliovirus (IPV)-HepB may be used for the first three usual doses and the series completed with DTaP.[20] Pentavalent DTaP-IPV/Hib may be used for the first four doses in the series.[20] The hexavalent DTaP-IPV-Hib-HepB vaccine is licensed for use in children aged 6 weeks to 4 years and is indicated for the primary vaccination series in infants at aged 2, 4, and 6 months.[22] DTaP-IPV may be used as the fifth dose of DTaP and fourth dose of IPV.[20]
Adolescents aged >10 years should receive a single dose of Tdap, preferably at aged 11-12 years.[20][21] Adults should receive one dose of Tdap if they did not receive this booster in adolescence, then a Tdap or tetanus-diphtheria (Td) booster every 10 years. The ACIP and American College of Obstetrics and Gynecology recommend that pregnant women should receive a dose of Tdap during each pregnancy, preferably between 27 and 36 weeks gestation.[23][24] Women who do not receive Tdap during their pregnancy should receive a dose as soon as possible after delivery.[20][24] During the management of wounds, Tdap may be used for tetanus prophylaxis if Td is not available and the individual has not received a Td-containing vaccine in the past 10 years (clean, minor wounds) or 5 years (all other wounds); Tdap is preferred for individuals who have not previously received this vaccine or whose vaccination history is uncertain.[23][25]
Unvaccinated or under-vaccinated close contacts of patients with pertussis should be vaccinated according to recommended schedules as soon as feasible.[18][21][23] Post-exposure antimicrobial prophylaxis is also recommended for all household contacts and for other close contacts judged to be at high risk of severe pertussis or who live in households that include people at high risk of severe pertussis.[26]
Mild-to-moderate local reactions, including redness, swelling, low-grade fever, induration, and injection site tenderness, may occur in children and adults following vaccination.[10][20] These typically resolve within 48 hours without sequelae. Children younger than 7 years may also experience drowsiness. Limb swelling has been reported in 2% to 3% of children aged under 7 years, after receipt of fourth and fifth doses of DTaP.[10] The risk of simple febrile seizures in children may be increased when DTaP is co-administered with inactivated influenza vaccine. Very rarely, brachial neuritis may complicate immunisation with tetanus-toxoid-containing vaccines in children.[10]
Contraindications to DTaP and Tdap include a serious reaction to a previous dose of vaccine, including: 1) a serious allergic reaction (anaphylaxis) after a previous dose of a vaccine containing pertussis, diphtheria toxoid, or tetanus toxoid, and 2) encephalopathy that is not attributable to another cause with an onset within 7 days of a previous dose of vaccine.[10] Precautions for immunisation include: 1) the presence of an evolving neurological disorder (until a treatment regimen has been established and the condition stabilised), 2) Guillain-Barre syndrome within 6 weeks of a previous dose of vaccine, 3) a history of an Arthus-type hypersensitivity reaction after a previous dose of vaccine, or 4) moderate or severe acute illness with or without fever.[10]
Secondary prevention
Pertussis is nationally notifiable in the US and in many other areas, and clinicians should notify the appropriate health department of all patients with suspected infection.[18][39] Close contacts who are unimmunised or under-immunised should begin or continue pertussis vaccinations as soon as feasible (see Primary prevention, above).
Administration of post-exposure antibiotic prophylaxis to contacts within 21 days of the onset of cough in the index case can prevent symptomatic disease in close contacts.[10][27][30] Prophylaxis is indicated for all household contacts and other people at high risk of developing severe pertussis, or who have close contact with those at high risk of developing severe pertussis, including infants aged <1 year, pregnant women, and patients with underlying medical conditions that may be worsened by pertussis, irrespective of their immunisation status. US guidelines recommend prophylaxis for all healthcare staff, regardless of vaccination status, who have an exposure to pertussis, even if they are unlikely to interact with people at increased risk for severe pertussis.[38] UK guidelines differ, only recommending prophylaxis for healthcare workers who work with infants or pregnant women and who have not received a booster dose of pertussis-containing vaccine more than 1 week and less than 5 years ago.[40]
Doses and regimens used for post-exposure prophylaxis are the same as those for treatment. Contacts of patients with pertussis should be monitored for at least 21 days after their last contact with the index case for signs and symptoms of pertussis.[38] The US public health guidelines, including the Centers for Disease Control and Prevention (CDC) Pink Book and recommendations from the American Academy of Pediatrics (AAP), continue to recommend that people with known or suspected pertussis should be excluded from healthcare, childcare, and school settings until they have completed at least 5 days of antimicrobial treatment, or for 21 days from the onset of their cough if untreated.[1][10][38] Work restrictions are not necessary for asymptomatic healthcare personnel who have an exposure to pertussis and receive post-exposure prophylaxis, regardless of their risk for interaction with persons at increased risk for severe pertussis.[38] The UK guidelines specify a shorter exclusion period of 48 hours from initiation of antibiotic therapy (or 21 days from the onset of cough if untreated).[18][40] It is important to refer to the specific public health recommendations in your area to confirm the required time for returning to work, school, or childcare, as guidance may vary.
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