FW: Even With Vaccination, the 'Whoop' Is Back

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From: Rex Warren [mailto:gladston@...]

So much for vaccination.

Rex

http://www.nytimes.com/2004/03/02/health/02BROD.html

Even With Vaccination, the 'Whoop' Is Back

By JANE E. BRODY

et used to it. Pertussis, better known as whooping cough, is here to

stay.

So are pertussis-related deaths among vulnerable infants, unless steps

are taken to stem the increasing number of cases of the highly

contagious disease.

" Pertussis is the only vaccine-preventable disease that is still

increasing in this country, " said Pascual, a public health

specialist at the Centers for Disease Control and Prevention. The

increase is occurring even though vaccination rates are considerably

higher today than they were a decade or two ago, Mr. Pascual said.

So far this year, five states have reported pertussis outbreaks to the

centers, and that number is expected to increase greatly. Cases and

outbreaks tend to peak in the fall, when adolescents whose immunity has

worn off return to school.

In 2002, the most current year with full statistics, nearly 9,771 cases

were reported - the most since 1964. Fifteen children are known to have

died of pertussis complications, mostly those who had not been

vaccinated. The number of reported cases last year, 8,483, will continue

to grow as states finish filing their year-end reports, Mr. Pascual

said.

But these reported numbers are believed to be far below the actual

cases. Even among hospitalized and fatal cases, one-third are reported.

The rate of reported cases among those not hospitalized is believed to

be much lower, perhaps under 10 percent.

The Stealth Factor

Pertussis is a bacterial infection of the air passages leading to the

lungs, plugging them with thick mucus. The organism, Bordetella

pertussis, has a number of weapons, including toxins that attack and

destroy the protective hair cells that line the respiratory tract.

Even though the infection is bacterial, it rarely causes a fever, and

certainly not the raging fever that prompts someone to seek immediate

medical care.

The classic symptom of pertussis is, as the common name implies, a

whooping cough - 5 to 15 consecutive forceful coughs on a single breath

followed by a high-pitched whoop as the victim rapidly and deeply

inhales. Moments later, another round of coughing occurs, sometimes

accompanied by gagging and vomiting.

Unfortunately, in the most contagious stage of the disease, the

characteristic coughing spells have not yet started. Rather, the illness

begins insidiously, more or less like a common cold, with sneezing, a

runny nose, the loss of appetite, listlessness and an annoying cough

that can interfere with sleep. No fever and no whoops that might warn a

person to see a doctor.

Furthermore, adults with the infection may never experience the classic

cough, although persistent coughing lasts for weeks and can take its

toll on stamina and quality of life. With or without treatment, the

illness persists for three weeks to three months (seven weeks on

average), long after the bacteria are no longer present. Even after

recovery, classic coughing fits may recur for months afterward whenever

the person develops an upper respiratory infection that irritates the

damaged airways.

Rarely is pertussis more than a debilitating annoyance for adolescents

and adults. Most carry on with their usual lives, unwittingly spreading

the disease to others at school, work or home, including those who are

most vulnerable to serious, even life-threatening, complications -

mainly infants, the elderly and people with weakened immunity.

The bacteria are transmitted to others through coughs or sneezes -

rarely through contact with contaminated articles - and invade the nose,

throat, trachea and bronchial tubes. The typical incubation period is

one to two weeks before symptoms appear in a newly infected person.

About two-thirds of infants who contract pertussis become seriously ill,

and many have to be hospitalized. It is not uncommon for infected

infants to choke, turn blue and develop convulsions or life-threatening

pneumonia. Ear infections often accompany pertussis in children.

Other possible complications from severe coughing include hemorrhages

into the brain, eyes, skin, mucous membranes and even fractured ribs and

hernias. In addition, swelling of the brain and encephalitis can cause

spastic paralysis, mental retardation or other neurological disorders.

About 1 to 2 percent of infants with pertussis die.

It is clear that even though few adults become seriously ill, this is

not an illness to be taken lightly. Though parents are believed to be

the main source of infection among infants, anyone can spread pertussis

to highly vulnerable infants.

Path to Prevention

A vaccine to prevent pertussis in infants and young children has been

available since the 1940's. It was a whole-bacteria vaccine administered

along with the vaccines for diphtheria and tetanus as the D.P.T. series

of immunizations given at 2, 4 and 6 months of age, with booster shots

at 18 months and 6 years.

But in the 1980's, many parents became aware of a high incidence of side

effects with the old shots, and some refused to have them given to their

infants. As health officials predicted then, the incidence of pertussis

in young children began to rise, along with serious and sometimes fatal

complications.

Parents who refused immunization were counting on the fact that because

most children were vaccinated, the chances that their unprotected

children would be exposed to pertussis were slim. But what many failed

to realize is that the pertussis vaccine offers just short-lived

protection. By the time children reach adolescence, and certainly by

adulthood, they are no longer protected.

Pertussis has never gone away and perhaps never will. A constant

undercurrent of it lies in the population, with outbreaks occurring

every three to five years among unvaccinated and once-vaccinated

teenagers and adults.

In one study, 26 percent of students at the University of California,

Los Angeles, evaluated over 30 months had evidence of recent pertussis

infections.

Medical researchers responded to parental concerns about the vaccine

safety by creating a new one that does not rely on whole cells and

causes far fewer side effects. Since this safer vaccine became available

in 1996, pertussis vaccination rates have risen.

But a major problem remains, according to Dr. Masahiro Tanaka, an

epidemiologist at the disease control centers. That is the failure of

parents to be sure that their babies receive the vaccine in a timely

fashion. Two shots are believed to offer nearly full protection, and

even one shot offers some protection, Dr. Tanaka said.

But no shots or a delay in timing can leave an infant highly

susceptible. Even " full protection " is not 100 percent, because the

vaccine is not perfect, and 10 to 15 percent of immunized children

remain susceptible.

Dr. Cherry, a pertussis expert at U.C.L.A., said he expected that

by next year, two good vaccines for adults would be approved. Meanwhile,

to protect vulnerable infants, Dr. Cherry and other experts in pediatric

infectious disease recommend that adolescents and adults with coughs

avoid exposing babies who have not been fully immunized. Only with an

early diagnosis, which rarely occurs among adults, will antibiotic

therapy diminish the risk of spreading pertussis to others.

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