Impact of whooping cough on patients and their families

Occupying 'in-hospitable' spaces: Parental/primary-caregiver perceptions of the impact of repeated hospitalisation in children under two years of age

The experience of having a child hospitalised is stressful and disrupts families in myriad ways; however, the experiences of parents/caregivers who encounter repeated admissions of a child with acute lower respiratory infections are under-researched. This project aims to explore these experiences, from a qualitative perspective, using the philosophical tenets of reflective lifeworld research. The research included 14 face-to-face interviews with parents, grandparents, or primary caregivers, of children who, whilst under two years of age, were admitted to hospital multiple times with a lower respiratory infection diagnosis. Many of the participants were from Māori or Samoan ethnic backgrounds. The findings of this single site study revealed that these parents/caregivers' experiences were characterised by feelings of powerlessness, offering descriptions of hospitals as harsh and difficult places to reside, they are 'in-hospitable'. The findings suggest that repeated hospitalisations created a cycle of stressful experiences that impacted both familial relationships and interactions with society. This study draws attention to this previously obscured population group, and calls health care practitioners and policy advisors to engage differently over issues involving families in similar positions.

When to discharge children hospitalized with pertussis?

OBJECTIVE

It is difficult to know when children hospitalized with pertussis can be safely discharged. We sought to identify clinical features of children hospitalized with pertussis that are associated with readmission.

METHODS

A case series of 207 children hospitalized with pertussis was studied. The 33 children readmitted with pertussis were compared with the 174 who did not require readmission.

RESULTS

Demographic characteristics and immunization status of the children with pertussis requiring readmission did not differ from the children who were not readmitted. Median duration of initial hospital stay was 4 days for both groups (P=.11). The children who were readmitted had more cyanotic episodes per day (0.8 vs 0.0 episodes, P=.03) and on greater proportion of hospital days (0.5 vs 0.1, P=.01). On the last day of admission, the children subsequently readmitted had more coughing episodes (4 vs 0, P < .001), and a larger proportion had a cyanotic episode (30% vs 10%, P=.003). The risk of readmission was increased in children who had > or =1 cyanotic episode per day (relative risk [RR]=2.5, 95% confidence interval [95% CI] 1.3-4.6); cyanosis on > or =50% of days (RR=2.6, 95% CI 1.4-4.8);> or =2 coughing paroxysms on the last hospital day (RR=2.4, 95% CI 1.3-4.4); or any cyanosis on the last day (RR=2.9, 95% CI 1.5-5.2).

CONCLUSIONS

Paroxysmal cough and cyanosis are clinical signs that can be used in children hospitalized with pertussis to help decide when to discharge them from hospital.

Rationale for use of Tdap booster vaccines for adolescent immunization: overview of efficacy, safety, and clinical use

Pertussis is one of the only vaccine-preventable diseases with increasing incidence in the United States. The incidence of pertussis infection in adolescents is a growing concern; it can be a severe disease that may lead to significant morbidity and mortality when transmitted to susceptible populations (eg, infants). Experts have conceded that booster vaccination of adolescents may considerably decrease the incidence of pertussis infections in previously immunized, partially immunized, and nonimmunized populations. Studies in 2 tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccines licensed by the Food and Drug Administration (FDA) have shown efficacy against pertussis disease and have demonstrated a safety profile comparable to tetanus and diphtheria vaccine (Td) in adolescents. Immunization schedules now include use of Tdap vaccines for preadolescent and adolescent populations to counter the increase in pertussis outbreaks. Challenges for clinicians include prompt recognition of pertussis symptoms, proper diagnosis using appropriate tools, and timely reporting of pertussis infections to surveillance bodies. Additional studies are needed to monitor trends of pertussis incidence after implementing the new vaccination schedule for adolescents.

Overview of pertussis: focus on epidemiology, sources of infection, and long term protection after infant vaccination

BACKGROUND

Pertussis, or whooping cough, is a bacterial disease characterized by paroxysmal cough often accompanied by inspiratory whoop and posttussive emesis. Although the introduction of whole-cell pertussis vaccine in the 1940s led to a significant decline in the incidence of pertussis, there has been a gradual increase in reported pertussis cases since 1980. Some of these cases are in infants too young to have received routine pertussis vaccination, and many are in adolescents immunized previously as young children.

METHODS

Based on a literature review, an overview of pertussis is provided, focusing on epidemiology, sources of infection, and trends in incidence patterns, particularly among adolescents. Issues surrounding long-term protection after infant vaccination are also discussed.

RESULTS

The most dramatic increase in pertussis incidence has been among adolescents and young adults. Waning vaccine-induced immunity and refinements in the diagnosis of pertussis have contributed to the rise in the occurrence of pertussis in older age groups. Disease rates in infants have also increased. Determining the source of infection in infants can be challenging, but studies have demonstrated that many infant cases are attributable to infections in adolescent or adult family members.

CONCLUSIONS

Pertussis is on the rise, particularly in adolescents. Booster vaccination of adolescents with less-reactogenic acellular pertussis vaccines appears to be the most logical approach to disease prevention in adolescents and reduced transmission to young infants.

Health burden of pertussis in infants and children

In countries with high rates of vaccination against pertussis, the incidence of this disease has decreased dramatically compared with the prevaccine era. However, pertussis still occurs in these countries, and severe morbidity and mortality are greatest among infants, particularly those who are unimmunized or incompletely immunized. Pertussis in older children and adults is perceived by many as being a mild disease, but it is a significant health burden in persons of all ages. Infants with pertussis experience the highest rates of hospitalization, complications and death. Severe complications include pneumonia, encephalopathy and meningoencephalitis. In addition, infants may experience weight loss, bronchitis, otitis media, apnea, cyanosis, inguinal hernia and rectal prolapse. It is essential to explore methods to prevent disease transmission to infants in the months before they complete their primary immunization series. The Global Pertussis Initiative was established to assess the true health burden of pertussis in infants and to suggest strategies to combat transmission and infection with Bordetella pertussis, which remains a significant public health concern.

Severe hypoxaemia in pertussis

Overnight tape recordings of breathing movements, airflow, and arterial oxygen saturation from six infants aged 3 weeks to 7 months, who had cyanotic episodes associated with pertussis, were compared with recordings from 12 age matched healthy controls. In all patients clinically apparent apnoeic episodes were associated with the rapid onset and progression of central cyanosis. When overnight recordings were compared, patients with pertussis had a greater frequency of apnoeic pauses (particularly those greater than or equal to 12.0 seconds duration) and a greater frequency of episodes of hypoxaemia (oxygen saturation less than or equal to 80% for greater than or equal to 0.5 seconds) associated with apnoeic pauses. In addition to episodes of hypoxaemia associated with a prolonged absence of breathing movements, patients with pertussis had frequent dips in oxygen saturation in association with continued breathing movements with and without continued inspiratory airflow. These episodes of hypoxaemia during continued breathing movements were more common in patients with pertussis. These findings suggest that episodes of abnormal apnoea accompanied by evidence of a mismatch between ventilation and perfusion of the lungs may produce the rapid onset of severe hypoxaemia in infants with pertussis.

Long term respiratory sequelae of whooping cough in a nationally representative sample

The long term respiratory consequences of whooping cough in childhood were sought among members of the National Survey of Health and Development. Peak expiratory flow rate was measured when the survey members were 36 years old and seven respiratory symptoms were reported at the same time. Peak expiratory flow rate was slightly reduced in those who had had whooping cough as a child, and this difference became non-significant when other factors were taken into account. Unexpectedly, chronic cough was significantly less likely to be reported by those who had had whooping cough, and this difference remained significant only among men after other factors had been taken into account. This study failed to show a long term detrimental effect of whooping cough on the respiratory system.

Reading attainment and physical development after whooping cough

Anthropometric measurements were made on 360 primary school children with a history of whooping cough and on 711 controls. Altogether 245 (68%) cases and 469 (66%) controls had taken tests of reading attainment and a smaller number had taken tests of intelligence. No significant differences were found between cases and controls in any of the anthropometric measurements nor in reading age or intelligence quotient after controlling for social class and parental smoking. Whooping cough is, in general, unlikely to cause subsequent deficiency in physical or mental development.