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Featured topic and speakers
How serious is whooping cough? Is whooping cough going around? How long does whooping cough last? What is the pertussis vaccine? What are the symptoms of whooping cough?
Discussing pertussis in adults, treatment for whooping cough symptoms, pertussis vaccines and more with Alyssa Kuban, MD, associate medical director at Texas Children's Pediatrics Cypress. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Alyssa Kuban, MD, associate medical director, Texas Children's Pediatrics Cypress
Transcript
Dr. Kuban: It's quite contagious. So if you had a group of 10 non-immune people exposed to this bacteria, 8 out of the 10 will get whooping cough.
Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about whooping cough, why it's on the rise and what we can do about it. Our guest today is Dr. Alyssa Kuban, associate medical director at Texas Children's Pediatrics Cypress, who's calling us today from Houston, Texas. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Kuban, welcome.
Dr. Kuban: Thank you so much for having me. This is an important topic, and I'm glad we can discuss it.
Unger: Unfortunately, Texas has been in the news a lot lately, but most of what we've been talking about is measles. We're here to talk about something different today, and that's whooping cough. It might surprise people out there that, according to the CDC, last year in the U.S., there were 35,000 cases of whooping cough, or pertussis, as it's referred to clinically.
And that's the highest number in more than a decade. Why are cases on the rise right now? And is this something you're seeing in your own patients?
Dr. Kuban: Cases are currently on the rise for a couple different reasons. So the first reason is, number one, it turns out masks work. So during the pandemic, everyone was masking and was actually staying home when they were sick. There was less of a spread of a variety of illnesses and whooping cough is one of those. With less masking, we are seeing a return back to prepandemic levels.
The second reason is that immunity from the vaccine does wane over time. We used to give a vaccine called DTP. This was diphtheria, tetanus, pertussis, which is whooping cough. But there were more side effects from the vaccine. So in the mid-1990s, that vaccine was switched to something called DTaP—diphtheria, tetanus, acellular pertussis. There were fewer side effects with it, but the immunity doesn't last as long.
And then the third reason that we're seeing cases rise is that immunization rates are dropping. We saw this in a study that looked at the number of kindergartners who had had all their vaccines, and this number in the United States has dropped by two percentage points from the 2019 school year to the 2021 school year.
Unger: Those are really important reasons. I completely understand. In the post pandemic world, you're kind of saying, we move back to whatever, quote, prepandemic levels were of whooping cough but change to the vaccine itself and waning of its effectiveness and then just overall lower Immunization rates, which seems to be a theme that we're seeing all over the place these days, really having an impact since vaccination is the best way to prevent the spread of pertussis. Can you remind us what the recommended schedule for that looks like?
Dr. Kuban: So vaccination actually starts in pregnancy. So pregnant women should receive the Tdap vaccine between weeks 27 to 36 of pregnancy with each pregnancy. What happens here is that the immunity from the mom crosses the placenta and actually protects the baby from birth and until the baby can be protected with immunization.
Then the baby receives Immunization at two, four and six months of life, again, somewhere between 12 to 15 months of life. Then the child receives a booster around age four to five before kindergarten, and then they receive it again in middle school, around ages 11 to 12. Additionally, if an adult has never received the vaccine, it's recommended in adulthood at any point in time.
Unger: Is that unusual relative to other vaccines, that it happens at those intervals?
Dr. Kuban: We actually give a variety of vaccines at that time. What we found is that small doses repeatedly over time gives a good immune response but that is also really safe for the child.
Unger: All right, that makes sense. You mentioned the waning. So if somebody has been previously vaccinated against pertussis, does that protection—again, how long does that last? And what should patients do?
Dr. Kuban: You're right. Unfortunately, the immunity does wane over time. I actually had one case of a patient with whooping cough at age 10. So this patient had received the infant series, had gotten the dose at age four, and was due for the next dose at age 11, but the child presented in my clinic actually at age 10.
So my first recommendation to families is to receive the series, as we discussed, two, four six months of life, again at 15 months and age four. That's going to provide about 98%—98% kids will be protected after that series, but then five years later, that actually does drop down to 71%. And that is why the recommendation for 11 and 12-year-olds, it used to just be the Td, just the tetanus diphtheria booster, but they changed it to the Tdap to address this waning immunity.
Additionally, women receiving that Tdap vaccine with each pregnancy does protect the baby. And when the pregnant woman receives the vaccine, that has prevented 78% of pertussis cases in infants less than two months and 90% of hospitalizations for infants less than two months with pertussis. And again, when we're talking about whooping cough, it's the babies that tend to get more severely affected.
Unger: Those are really impressive figures. I'm curious, you mentioned about vaccine hesitancy. Do you encounter kind of a different thing when you're trying to encourage someone to get the pertussis vaccine relative to others? How do you navigate that conversation?
Dr. Kuban: I think it's important to address how people are feeling. And so I think a lot of families out there are scared. They're hearing a lot of misinformation, and quite frankly, disinformation on social media and other platforms.
So the parents that I talked to of my patient families just feel bombarded with negative information about vaccination. They see it on social media. It's being talked about at the bus stop. Family members are sending them clips and snapshots of information that they see online.
So as a physician, my first job is to listen. I don't think it's productive to immediately dismiss their concerns. With that being said, after I listen, I like to echo that it is scary when you hear all of this information constantly about that vaccines can be dangerous and it can make it very hard to know what to believe.
But then I guide them in the conversation with science and data and that we make our decisions about vaccines not from fear, but from strong data over decades about their safety and efficacy. And we have all of that data for these immunizations. I also like to end with a personal note to my patient families, and I tell them I would never offer something to their kid that I wouldn't do for my own two children. And both my kids are fully vaccinated.
Unger: Do you think people have a sense of the downside of getting whooping cough relative to what they might perceive as the risk of getting vaccinated?
Dr. Kuban: No. I think that vaccines are a victim of their own success. I had one patient that previously had been completely unimmunized, got whooping cough. And I'll never forget the parents looked at me, and they actually said, I didn't know it was going to be this bad.
Unger: Describe that for people. What's bad look like?
Dr. Kuban: Sure. So I think it depends on the age. So there's a little bit of different presentation in infants and in children. But for children, teens and adults, it starts out as a cold. You have a cough, runny nose, maybe a low grade fever.
But then as you go on from end of week 1, somewhere between week 2 to 3 of illness, they start with these coughing fits. And they are coughing so hard that they're throwing up. Sometimes they will break the blood vessels in their eyes, a subconjunctival hemorrhage.
And a third of kids will have the classic whoop, which is they have a coughing fit. And then as they're trying to take a big breath, they're gasping for air. And that's where you'll hear the classic whoop. That stage of having coughing fits lasts two to eight weeks—
Unger: Oh my god.
Dr. Kuban: And then it slowly fades time over time. This is called the 100-day cough for a reason. For infants, they may not even have the runny nose and cough stage. Some of them will go straight into the coughing fits.
Or they'll have apneic episodes. These are episodes where they stop breathing for 20 seconds or more. Their oxygen levels can go low, and they can get severely dehydrated because they're coughing so much they can't even eat or drink.
Unger: I got to tell you, that just sounds horrifying. I think being sick longer than a week in and of itself is a lot, and you're saying 100 days. And that kind of coughing, I don't even know, as a parent, I could take listening to my child do that. That's really tough.
One of the things we hear about, especially in regard to measles is just a contagiousness. I just read today fear about an outbreak at O'Hare Airport here in Chicago because measles is so contagious. How does whooping cough stack up?
Dr. Kuban: It's quite contagious. So if you had a group of 10 non-immune people exposed to this bacteria, 8 out of the 10 will get whooping cough. And part of the problem is it's spread through coughing and sneezing. And the droplets, it can go as far as six feet away and it can survive on surfaces for two days.
With that being said, most people are not getting it from touching surfaces but instead the droplets from people coughing and sneezing. And the transmission is highest before they get the classic whoop. The transmission is highest in weeks 1 and 2, and that's really when it kind of looks like a cold.
Unger: And is there anything you can do once that cycle starts? You're in week 2, and you're starting to cough. What can be done about it?
Dr. Kuban: That's a great question. So I think one of the challenging parts for whooping cough is there is a medicine to treat it, but it's most effective when starting in the first seven days of symptoms. But most people don't present with classic whooping cough until that phase is over.
There's still a recommendation to treat people during that second stage, not because it's going to help their symptoms, but because it will decrease transmission. There isn't really a lot of data that over-the-counter cough and cold medications help this cough a lot either.
Unger: That is tough because you could present in that first week. It sounds like it's just a cold, and who would know that it might progress? Dr. Kuban, any other advice for physicians out there on how to address misconceptions about pertussis or how to talk to patients about preventing it with vaccination?
Dr. Kuban: So I think another misconception that I hear from parents is they say, well, my baby isn't as at much risk because they're not in daycare. But the truth is, most babies get this from adults. And so that's why I stress to families of newborns that they need to make sure that everyone around them—this is like this cocooning method—is up to date on their vaccinations. When I had my first child, I politely asked my in-laws and my own parents, please make sure you go get your flu shot and you're up to date on your Tdap before coming over to see their new grandson.
I also think when we're addressing vaccine hesitancy, I would think about equipping families. So I think it helps to say to them that in this world, where we don't have a lot of control over so many things, Immunization is one way we can actively protect our children to keep them safe. And sometimes the best offense is defense. Teach our bodies how to fight this so that, if it does encounter it, our body can clear this infection, and we can get on with our lives quicker.
Unger: That's a great way to think about it. Dr. Kuban, that was really helpful. Thank you so much for joining us today and sharing your experience with us.
If you found this discussion valuable can support more programming like it by becoming an AMA member at ama-assn.org/joinnow. That wraps up today's episode. We'll be back soon with another AMA Update.
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Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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