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1. Adults are whooping, but are internists listening?

   • Gregory D Huhn, MD, MPHTM

   Rush University Medical Center

   Mark S. Dworkin, MD, issues an important “call to action” to all physicians in the May 17 issue of Annals of Internal Medicine (1). Pertussis is a highly contagious disease that is too often missing from the differential diagnosis of physicians evaluating patients with cough illness, especially adults and adolescents with chronic cough. In my own experience, I have seen adults with cough paroxysms so intense that they have fractured ribs and developed subconjunctival hemorrhages, while others have suffered facial lacerations requiring immediate medical attention from cough syncope.

   As Dr. Dworkin illustrates, pertussis in adults is not uncommon; reported cases of pertussis in adults in the United States have increased 490% between 1990-1993 and 2001-2003 (2-4). Adolescents and adults now account for two-thirds of all cases of this disease. Because immunity declines over time, adults – particularly healthcare workers, childcare workers and parents – have become a reservoir of the disease and are transmitting it to infants and young children, who are at greatest risk of complications and death.

   Physicians must accurately diagnose pertussis in adults and report cases to local health departments in order to help contain this public health threat. Booster vaccines for adolescents have recently been licensed by the FDA, and when they become available, physicians should encourage their adult and adolescent patients without contraindications to get vaccinated against pertussis. Through these measures of proper notice and timely action by internists, family physicians and other members of the medical community, we may hope to break the cycle of pertussis transmission.

   References:

   1. Dworkin MS. Adults are whooping, but are internists listening? Ann Intern Med 2005;142: 832-5.

   2. CDC. Morb Mort Weekly Rep 2002;51:73-6.

   3. Huhn GD, Jennings C, Hunt K, et al. Pertussis outbreak among adults at an oil refinery – Illinois, 2002. 43rd Annual Interscience Conference on Antimicrobial Agents and Chemotherapy, abstract L-1583, Chicago, IL, September 16, 2003.

   4. CDC. Pertussis surveillance report, August 6, 2004.

   Conflict of Interest:

   Consultant - Sanofi Pasteur

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   Published June 16, 2005
2. antibiotic prophylaxis for whooping cough

   • eliezer alkalay, MD

   Tel Aviv University, Israel

   M.S. Dworkin should be congratulated for reminding the medical community about the possibility of pertussis occuring in immunized (including adolescents and adults) persons. As a family physician I diagnose (with laboratory confirmation) Pertussis patients from all age groups from time to time, and I guess I miss many more cases.

   The author ststes that "...their close contacts should receive antimicrobial prophylaxis".

   I'm not sure about the author's recommendation for giving antibiotics to the close contacs. According to a recent Cochrane meta-analysis (only 2 studies available for the analysis): "Contact prophylaxis (of contacts older than six months of age) with antibiotics did not significantly improve clinical symptoms or the number of cases that developed culture positive B. pertussis...There is insufficient evidence to determine the benefit of prophylactic treatment of pertussis contacts."

   Source: Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis). The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD004404.pub2. DOI: 10.1002/14651858.CD004404.pub2.(abstract)

   Conflict of Interest:

   None declared

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   Published May 31, 2005