Question from practice: Isn't whooping cough a thing of the past?
A. Many lung infections can cause choking attacks, as can other inflammatory conditions such as asthma. Lung cancer can trigger one, as well as reflux oesophagitis. Choking coughs that come out of the blue and disappear within three weeks will almost invariably be the result of minor conditions that do not require medical intervention or assessment but may require symptomatic treatment that a community pharmacist is best placed to provide.
However, a prime cause of a choking type of cough is Bordetella pertussis infection — whooping cough. Sufferers are almost certain to visit a pharmacy for relief because the cough is so bad.
Although whooping cough is a notifiable disease, it is believed that the true number of cases could be 100 times the notified number. For a decade or so only about 500 to 1,000 cases have been notified annually in England and Wales. Historically, clinical diagnosis has been the basis for notification but this is difficult nowadays because few doctors are familiar with the sound of the disease — a far cry from 60 years ago when most babies would get it and everyone could recognise it.
Immunisation against whooping cough was introduced in the 1950s, combined with the tetanus and diphtheria vaccine already in use.
Infection numbers tend to cycle, with peaks about every four years (2011/12 was a peak year). There are trends in the official figures which indicate a changing pattern of incidence. The first is an increase in numbers over previous outbreaks, despite a 94 per cent vaccination rate. The second is that adolescents and adults are affected as much as children. Immunity can decrease over time. Incidence appears to be rising because there has been a widely available blood test since 2006. Nevertheless some doctors will fail to diagnose whooping cough even when a case is clear.
Whooping cough starts off indistinguishable from any other respiratory infection and early symptoms (these may include sneezing, runny eyes, fever and tickly cough) last about two weeks. Then the tickly cough condenses into concentrated attacks of coughing that can last up to a minute without being able to breathe in. For the patient the attack can be terrifying, with a feeling of suffocation and drooling or vomiting, followed by a breath in and relief, but sometimes immediately followed by another attack. Patients often go blue, which frightens those around them. Sometimes when taking breath again the eponymous “whoop” sound occurs. Only about half sufferers will sometimes whoop.
These intense episodes, which usually occur five to 20 times a day, are separated by hours of complete absence of coughing. This phase of the infection will last from four weeks to four months.
The reason whooping cough is little diagnosed is because healthcare professionals do not usually get to see the coughing fit. And we might assume that a patient giving a description such as the one above is exaggerating because he or she looks well. It is important to note, however, that some cases are less severe and will be more difficult to diagnose.
Sound recordings and videos of whooping cough can be seen at www.whoopingcough.net, a site I set up to help patients diagnose whooping cough.
Listen to the patient’s story. If you hear mention of “choking attacks” or equivalent this should alert you to the possibility of whooping cough, expecially if the cough has been going on for weeks in an otherwise healthy person who has already been checked by a doctor and cleared. People with these symptoms and who have not seen a doctor need to be referred for clinical examination and possible investigation, but a tentative diagnosis of whooping cough could likely help all concerned. A high-tech solution would be to record a choking attack on a smartphone and show it to a doctor.
Blood tests to confirm pertussis can be done from two weeks from the start of the illness.
Whooping cough kills one in 50 infants, hence the vital importance of the immunisation programme. The vaccine is given at two, three and four months of age, with a preschool booster. Infants under three months are only protected if older siblings are immunised, although nowadays the source of the infection is often the parent. The cough is most infective in the non-specific early stages but infectivity lasts up to three weeks after the onset of coughing.
Infected infants are likely to need hospital admission. For older children and adults whooping cough is an unpleasant and prolonged, but rarely serious illness (which is made more difficult to bear without a diagnosis). Pneumonia is the most common complication.
There is no effective treatment for uncomplicated whooping cough. Macrolide antibiotics will eradicate the organism and render patients non-infectious. They can prevent the disease if given within the incubation period (about 10 days). The Health Protection Agency considers azithromycin to be the most satisfactory option — a three to five day course will render the patient non-infectious, although the cough itself can continue.
Cough syrups have not been shown to help whooping cough, although pharmacists may still choose to recommend them. In this case, the man has had the cough for a while and may no longer be infectious. Patients with suspected whooping cough can be advised to avoid contact with others until they have finished the course of antibiotics or they have had the cough for over three weeks.
The pharmacist could recommend this man suggests whooping cough to his GP. Only confirmed cases count towards official statistics. Protection and containment will involve isolation, antibiotics and immunisation. The management of cases in communities where there are vulnerable patients should be undertaken by the HPA.
About the author
Doug Jenkinson is a retired GP
Citation: The Pharmaceutical Journal URI: 11104085
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