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Whooping Cough: A Stealthy Illness
By Jane E. Brody : NY Times : September 24, 2012
Chances are, you think you have never had whooping cough, the bacterial infection known medically as pertussis. Chances are, you're wrong.
Children get five doses of the DTaP vaccine against diphtheria, pertussis and tetanus before entering school. But even with widespread vaccination, "almost everyone has had pertussis," Dr. James D. Cherry, an expert in whooping cough, told me. "Mild illness is almost always overlooked. More than 90 percent of cases don't get recognized."
Neither the vaccine nor the actual illness confers lifelong immunity, and every three to five years there is an epidemic of this disease in the United States. One is occurring now, and it could turn out to be the largest reported outbreak of pertussis in 50 years, according to the Centers for Disease Control and Prevention.
Dr. Cherry, a professor of pediatrics at the University of California, Los Angeles, explained that in a person who has had the disease or been immunized for it, its symptoms - a runny or stuffy nose, little or no fever and a cough - typically resemble those of a common cold. Most people weather it without ever going to the doctor.
Pertussis is highly contagious, spreading from person to person through coughs and sneezes. If someone with the infection comes in contact with an unprotected infant, the result can be catastrophic. Babies who are not fully immunized may develop pneumonia, severe breathing problems and terrifying seizures; they may even die from pertussis. More than half of the babies who get it must be hospitalized, the C.D.C. reports.
Currently, the vaccine is administered at ages 2, 4 and 6 months, and again at 15 to 18 months and at 4 to 6 years. In 2005, DTaP replaced the old "whole cell" pertussis vaccine, called DTP, which often caused severe side effects, including high fevers, seizures, uncontrollable crying and floppiness. Although the old vaccine was blamed for some cases of sudden infant death, this turned out to not be the case, Dr. Cherry said.
In 2010, 27,550 cases of whooping cough were reported to the C.D.C., which estimates that 10 times as many infections actually occurred but were not recognized or not reported. By the end of August of this year, more than 25,000 cases were reported, including 13 deaths, most in children younger than 1.
A Lingering Problem
Why is this preventable disease still such a problem?
A very thorough new study by researchers at the Kaiser Permanente Vaccine Study Center in Oakland, Calif., documented for the first time how quickly immunity can wear off with the current vaccine.
Dr. Nicola P. Klein and colleagues showed that even after all five doses of the acellular vaccine were properly administered, protection against pertussis waned during the next five years, and the chances of getting the disease rose by an average of 42 percent a year. Furthermore, the infected children were surprisingly young, 8 to 11, not the teenagers who were mainly affected in prior epidemics.
"The old vaccine lasted longer," Dr. Klein, a pediatric vaccinologist, said in an interview. "Originally, we didn't think this vaccine would be substantially different from the old one."
It was known that the current DTaP vaccine does not induce as strong an immune response as did the old vaccine. Children are supposed to get a booster shot, Tdap, at age 11 or 12 to prevent outbreaks in their teens.
The new evidence suggests that the booster vaccine ought to be given earlier, perhaps at 8 or 9, to protect children in their preteens, Dr. Klein said.
The same booster is recommended as a one-time injection for adults through age 64 in lieu of a 10-year tetanus shot. But even though the Food and Drug Administration has approved it for one-time use only, Dr. Cherry expects this will soon change to a recommendation for repeated Tdap boosters to replace the once-a-decade tetanus shot.
"Tdap is a relatively new vaccine, and we don't yet know how long its protection lasts," Dr. Klein said. "We're now studying this at Kaiser Permanente."
Taking Precautions
Whooping cough, caused by the bacterium Bordetella pertussis, gets its popular name from the whoop that can accompany periodic coughing spells in the full-blown illness.
The disease starts innocently enough, much like a cold, and may linger for weeks before morphing into the telltale symptoms of whooping cough. Studies have shown that 13 percent to 20 percent of prolonged illnesses involving coughs in adolescents and adults are caused by pertussis.
This is why Dr. Cherry, among other experts, urges anyone with a cough to stay away from infants who have not yet had at least one or two DTaP shots, unless it is certain that they are immune to pertussis or they have had a definitive lab test - called a polymerase chain reaction assay - that is negative for pertussis.
In infants and others lacking antibody protection, pertussis can cause coughing spells so bad that it is difficult if not impossible to eat, drink, sleep or even inhale. Infants may stop breathing for a spell, a terrifying condition called apnea.
Uncontrolled pertussis can cause vomiting, fainting spells, weight loss and cracked ribs. As many as 2 in 100 adolescents and 5 in 100 adults with pertussis have to be hospitalized or suffer serious complications like pneumonia and death.
Anyone who has routine contact with infants should be immunized against pertussis. If pregnant women have not recently had a booster shot, the C.D.C. recommends that it be given late in the second trimester or early in the third trimester. Trickier to deal with are fathers, who should also get the booster vaccine, Dr. Cherry said. He said that in a study of Hispanic families, 75 percent of pertussis infections in infants came from a family member, all of whom had cough illnesses not recognized as pertussis.
Certainly, all day care workers, nannies and baby sitters should be immunized. Still, uncontrolled exposure to pertussis may come innocently enough from relatives and friends who visit with or care for infants.
How might the vaccine be improved? One possibility would be to increase the number of antibody-inducing proteins from the bacterium in the acellular vaccine. Another, Dr. Cherry said, would be to add an attenuated form of the bacterium's toxin, which causes the disease's symptoms, or return to a whole-cell vaccine with an attenuated toxin.
Meanwhile, Dr. Klein said, "although a better vaccine is needed, the current vaccine is safe and effective, and some protection is better than no protection."
Whooping Cough Makes a Comeback
By Paula Span : NY Times : August 1, 2012
When last we discussed the Tdap vaccine, which protects against tetanus, diphtheria and pertussis, the Centers for Disease Control and Prevention had recommended it for adults over 65 who had contact with small children.
But after an advisory committee meeting last winter, the CDC has revised its recommendation and now urges all adults to get a single dose - and just in time.
Diphtheria has been nearly eliminated in the United States, and tetanus has become fairly rare, with about 30 or 40 documented cases a year. But pertussis, a k a whooping cough, is surging in most states, an unwelcome comeback that makes vaccination much more urgent.
Washington State, whose health officials declared pertussis to be an epidemic in April, has recorded more than 3,000 cases this year, a rate not seen since the early 1940s. Wisconsin, Montana, Vermont, Minnesota and Iowa have also reported particularly high rates of disease.
Nationally, the CDC has tracked nearly 18,000 cases this year, more than twice as many as last year at this time, said Dr. Anne Schuchat, director of the agency's National Center for Immunization and Respiratory Diseases, at a recent news briefing. "We may need to go back to 1959 to find a year with as many cases reported by this time," she said, adding, "I think there may be more coming to a place near you."
Even adults who had whooping cough as children (vaccinations began in the 1940) or who were previously vaccinated should get a dose of Tdap, said Dr. Tom Clark, a CDC medical epidemiologist. Officials' concern is not only for older adults themselves, but for the very young, for whom the disease is particularly perilous. Grandparents, take heed.
"Because babies are too young to be vaccinated themselves, we rely on everyone around them to be vaccinated," said Dr. Clark. As of mid-July, pertussis had killed nine infants this year, according to the CDC, which has also noticed a spike among 13- and 14-year-olds, perhaps because a switch to a different form of vaccine in the late '90s means that immunity wears off more quickly than it used to. That, along with normal cycles in which the disease ebbs and then spreads, may be contributing to the current increase.
Though close to 70 percent of adolescents are vaccinated, a 2010 survey found, only 8 percent of adults have gotten a Tdap booster. "I know we can do better than this," Dr. Schuchat said at the briefing.
Tdap - sold under the brand names Boostrix and Adacel - is covered under Medicare Part D, which means that patients who go to doctors' offices may have to pay for it out of pocket (it's in the $40 to $65 range) and then file for reimbursement. The simpler way for many will be to get vaccinated at a pharmacy, where the bill can go directly to Medicare.
Getting vaccinated when you're older is responsible citizenship, but it's not pure altruism. Thought the CDC says an average of 318 adults over age 65 have reported pertussis each year, it believes the true number is at least 100 times higher. The disease can have different symptoms in adults (they may not whoop), and non-pediatricians often don't recognize them. "Doctors who take care of adults don't think about whooping cough," Dr. Clark said. "They see it as a childhood disease."
By Paula Span : NY Times : August 1, 2012
When last we discussed the Tdap vaccine, which protects against tetanus, diphtheria and pertussis, the Centers for Disease Control and Prevention had recommended it for adults over 65 who had contact with small children.
But after an advisory committee meeting last winter, the CDC has revised its recommendation and now urges all adults to get a single dose - and just in time.
Diphtheria has been nearly eliminated in the United States, and tetanus has become fairly rare, with about 30 or 40 documented cases a year. But pertussis, a k a whooping cough, is surging in most states, an unwelcome comeback that makes vaccination much more urgent.
Washington State, whose health officials declared pertussis to be an epidemic in April, has recorded more than 3,000 cases this year, a rate not seen since the early 1940s. Wisconsin, Montana, Vermont, Minnesota and Iowa have also reported particularly high rates of disease.
Nationally, the CDC has tracked nearly 18,000 cases this year, more than twice as many as last year at this time, said Dr. Anne Schuchat, director of the agency's National Center for Immunization and Respiratory Diseases, at a recent news briefing. "We may need to go back to 1959 to find a year with as many cases reported by this time," she said, adding, "I think there may be more coming to a place near you."
Even adults who had whooping cough as children (vaccinations began in the 1940) or who were previously vaccinated should get a dose of Tdap, said Dr. Tom Clark, a CDC medical epidemiologist. Officials' concern is not only for older adults themselves, but for the very young, for whom the disease is particularly perilous. Grandparents, take heed.
"Because babies are too young to be vaccinated themselves, we rely on everyone around them to be vaccinated," said Dr. Clark. As of mid-July, pertussis had killed nine infants this year, according to the CDC, which has also noticed a spike among 13- and 14-year-olds, perhaps because a switch to a different form of vaccine in the late '90s means that immunity wears off more quickly than it used to. That, along with normal cycles in which the disease ebbs and then spreads, may be contributing to the current increase.
Though close to 70 percent of adolescents are vaccinated, a 2010 survey found, only 8 percent of adults have gotten a Tdap booster. "I know we can do better than this," Dr. Schuchat said at the briefing.
Tdap - sold under the brand names Boostrix and Adacel - is covered under Medicare Part D, which means that patients who go to doctors' offices may have to pay for it out of pocket (it's in the $40 to $65 range) and then file for reimbursement. The simpler way for many will be to get vaccinated at a pharmacy, where the bill can go directly to Medicare.
Getting vaccinated when you're older is responsible citizenship, but it's not pure altruism. Thought the CDC says an average of 318 adults over age 65 have reported pertussis each year, it believes the true number is at least 100 times higher. The disease can have different symptoms in adults (they may not whoop), and non-pediatricians often don't recognize them. "Doctors who take care of adults don't think about whooping cough," Dr. Clark said. "They see it as a childhood disease."
Neglected Vaccine
By Paula Span : NY Times : November 9, 2011
Like many other grown-ups, I hadn't given any thought to what we used to call the D.P.T. vaccine -- for diphtheria, pertussis and tetanus -- for decades. I got the shots when I was a child, and I made sure my daughter got them during her childhood immunizations. Every now and then, my doctor tells me it's time for a tetanus booster, so I get one. That's enough, right?
The Centers for Disease Control and Prevention is advising otherwise. In recent years, the federal agency been steadily expanding its recommendations for the age groups that should receive a single dose of what's now known as T.D.A.P., short for tetanus, diphtheria and acellular pertussis.
First its advisory committee on immunization recommended the vaccine for adolescents, then for all adults through age 64. (In this case, as in others, older adults were initially excluded from clinical trials. This practice really has to stop.)
Now the Food and Drug Administration has approved one brand of T.D.A.P., called Boostrix, for adults over age 65. Accordingly, the C.D.C. has issued guidelines recommending the vaccine for those older adults "who have or who anticipate having close contact with an infant aged less than 12 months," as well as for all health care providers.
Doting grandparents of newborns and about-to-become-grandparents: This means you. When the C.D.C. advisers next meet in February, they may recommend vaccination for all older adults.
We've managed to virtually eliminate diphtheria in the United States, Tom Clark, a C.D.C. epidemiologist, told me in an interview; the last confirmed case was in 2003. Tetanus has also become rare: 30 to 50 cases a year, mostly in adults over 65 who didn't complete their vaccinations or haven't kept up with boosters.
While we all want to continue holding those once-lethal diseases at bay, the real worry here is pertussis, a k a whooping cough. "Anyone can get pertussis. It's not just a childhood disease," Dr. Clark said. Last year, the C.D.C. recorded 27,550 cases, and that probably is an underestimate.
This illness, characterized by extreme coughing fits that recur for four to six weeks, is among those that are milder in older people but more dangerous to the very young. Older people can crack a rib or rupture a blood vessel from coughing; babies usually are hospitalized, and last year 25 infants died.
"When very young infants get pertussis, it's usually from someone in their own households," Dr. Clark said. Public health specialists are hoping that concern for their grandchildren will lead a lot of older adults to get vaccinated, which keeps everyone safer.
As often happens with new vaccination guidelines, it takes some time for the word to spread. Physicians may not mention vaccination for us or our parents, but we can raise the subject ourselves. The vaccine's only common side effect: "It gives a lot of people sore arms," Dr. Clark said. But the pain at the injection site ebbs in two or three days.
Another potential problem: T.D.A.P. vaccine is covered by Medicare Part D, which means doctors can't simply add it to their bills under Part B. Either people have to pay out of pocket and await reimbursement, or they can go to pharmacies that will bill Medicare directly. At least T.D.A.P. isn't a terribly expensive vaccine; it retails for $35 to $40, plus the cost of the injection.
That sets it apart from Zostavax, the shingles vaccine, which goes for about $200 and is also covered under Part D.
As for T.D.A.P., it can be administered at the same time as a flu shot, which most older adults get at this time of year. So there's an opportunity.
