Tuesday, November 07, 2006

The Hundred Day Cough

Author's note: the accompanying photo is not the patient described in this story. The story is fiction.

The latest epidemic of whooping cough to hit southwest Alaska started about two months ago in one of the coastal villages. An eight-week old girl, scheduled to have her first round of immunizations in a week, was brought to the village clinic by her mother because "sometimes she just stops breathing." Mom had noticed two episodes of apnea with peri-oral cyanosis; both times she responded to direct stimulation and started breathing again, but Mom was worried. Mom reported that the infant had a slight cough which seemed worse at night.

On physical exam by the health aide, the baby looked fine. She had normal vitals, was breathing well, and had no runny nose or watery eyes. Her cough was minimal. But as the health aide watched her lying on the exam table, she simply stopped breathing. Again, she responded to stimulation.

The baby was medevac'd to the Alaska Native Medical Center in Anchorage, where she was diagnosed with pertussis. She was treated with antibiotics and admitted for supportive care for a few days, and then discharged home with her parents.

Within two weeks there were four more cases of pertussis in her village, two in kids less than one year of age, and two in teenagers. Soon cases showed up in a neighboring village. By the time the epidemic ended there were 24 cases in four villages. Health aides became very adept at performing nasopharyngeal swabs.

Whooping cough is an infection of the respiratory system caused by a bacterium, Bordetella pertussis. Its close cousin, Bordetella bronchiseptica, causes kennel cough in dogs. When untreated, whooping cough is an illness with three stages. The early stage, or catarrhal phase, is much like any viral upper respiratory illness; it produces runny nose, watery eyes, dry cough and sometimes low-grade fever. It lasts for one to two weeks. The middle, or paroxismal phase, causes the characteristic coughing paroxisms that end in a sudden whooping inspiration, and can end in vomiting. This phase may last several weeks. The final or convalescent phase is a gradual decline of all symptoms; though a persistent cough may last for many more weeks, it will not be as intense or paroxysmal as earlier in the illness.

Pertussis is highly contagious and is spread by droplet transmission of respiratory secretions. The biggest risk factor for getting it is being coughed on by someone with active disease. In most village homes in southwest Alaska, crowding is the norm; from five to twelve people often live in a rather small home, which increases the likelihood of disease transmission.

The population at biggest risk from the infection is very young babies, who do not usually have the characteristic whoop. Neither immunization nor disease confers immunity for more than a few years, and children are not routinely immunized for it after age 5 years. In adults, it typically causes minimal illness, and boosters have not been routinely recommended. Adults are recognized as a potential reservoir of bacteria which can be transmitted to children.

When the epidemic was recognized in the coastal villages, a public health effort was quickly put into place. The physician assistant/nurse practitioner team from the closest subregional center traveled to each village with identified cases. They addressed a "town hall" type meeting of the entire village and educated the villagers about pertussis with handouts, videos, and an audio tape of the sound of the cough. Villagers were asked to identify themselves to their health aides, or to the PA and NP if they felt they had symptoms consistent with pertussis. Many came forward. All were tested. Those the mid-levels felt had symptoms truly consistent with the disease were treated prophalactically with macrolide antibiotics (erythromycin, azithromycin); and all positives were treated.

The educational sessions were also an opportunity to get immunizations updated on those who were behind. Over a hundred DTaPs were given during the four educational sessions. Adults are also now being immunized with TDaP to see if boosting them with pertussis vaccine will decrease the burden of disease in young children.



Anonymous Anonymous said...

What kind of a swab do you use? Alginate, dacron or cotton, how far do you do up the nose, just past the nares? & what do you order when you send to the lab?--Thanks

Wednesday, November 08, 2006 3:20:00 PM  
Blogger #1 Dinosaur said...

Quest Diagnostics culture and PCR requirements (including instructions for obtaining the NP specimen.) They supply the NP swabs and media. I have received them but haven't had the opportunity to use them yet. (Watch: probably today.)

I've been using antibody testing, mainly because I haven't wanted to submit my patients to NP swabs. But after several recent cases where I've been very certain of pertussis clinically but have come back negative (negative IgM with positive IgG; I think I caught the IgM on the way down, so it was just under the "positive" cutoff limit) my friendly local health department has been nudging me towards more definitive testing.

Thursday, November 09, 2006 2:59:00 AM  
Blogger The Tundra PA said...

CC--see #1's comment below about the swabs. They go straight in at the bottom of the naris (parallel to the floor, not aimed at the patient's brain)all the way to the back wall, then twirl for 10 seconds. Ummmmm, patients love it! Makes their eyes water. Order "pertussis culture" on the labslip.

#1--thanks for responding to the first comment; I wasn't at the hospital yesterday to find out what kind of swab we use. As far as I know, we only do cultures.

And, BTW, I loved your rules for good blogging! I'm going to refer/link to that post on your blog in an upcoming post on mine. And how do you put links in a comment? I'm so impressed! You're awesome... (http://dinosaurmusings.blogspot.com/2006/11/blogging-101.html)

Thursday, November 09, 2006 7:40:00 AM  
Anonymous Anonymous said...

I'll never forget the first 28 day old baby I saw with pertussis. She almost died. Please, please immunize!

Your photos are again amazing. I'm really getting addicted to your blog. I may have to link to it.

Thursday, November 09, 2006 7:44:00 AM  
Blogger Mary Sue said...

Oh, poor kidlets!

I lived in a upper-middle class suburb of San Francisco as a teenager, and my mother, my sister and I all had pertussis in 1993 (Mom because her vaccinations had run out and she worked with migrant worker populations, Sister and I were never vaccinated because they didn't vaccinate for it over a three year period in the 1980s). I still remember the pain involved from stressing your diaprham so much, and the frightening inability to catch a breath. And that swab sucks SO MUCH. It activated my gag reflex-- don't ever try to cough and throw up at the same time. It's not fun.

My mother and sister also contracted Fifth's Disease about a year later, I managed to escape that one.

Thursday, November 09, 2006 12:22:00 PM  
Anonymous Anonymous said...

Well, you just made me appreciate the DTap I got last month a lot more!

Haven't seen any whooping cough in the ER, yet....but I know it's been in the community...

Tuesday, November 14, 2006 11:01:00 AM  
Blogger Milliner's Dream, a woman of many "hats"... said...

Such sad kiddles.



Wednesday, November 15, 2006 2:06:00 AM  
Anonymous Anonymous said...

My kids were fully immunised when they got whooping cough and no, the vacine didn't mean they didn't have as severe symptoms.

Thursday, November 16, 2006 8:26:00 PM  
Blogger Frank Morgan said...

joking aside - it is no laughing matter


Friday, November 07, 2008 6:00:00 AM  
Anonymous Anonymous said...

Rather cool site you've got here. Thanx for it. I like such themes and everything connected to them. I definitely want to read more soon.

Sincerely yours
Steave Markson

Monday, February 08, 2010 6:11:00 AM  

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