Pertusiss - “whoop” sound from inspiration of air after cough; Paroxysmal or violent cough without intervening inhalation followed by an

inspiratory whoop

Causes

Pertussis, a respiratory illness commonly known as whooping cough, is a very contagious disease caused by a type of bacteria called Bordetella

pertussis. These bacteria attach to the cilia (tiny, hair-like extensions) that line part of the upper respiratory system. The bacteria release toxins

(poisons), which damage the cilia and cause airways to swell.

Transmission

Pertussis is a very contagious disease only found in humans. Pertussis spreads from person to person. People with pertussis usually spread the disease

to another person by coughing or sneezing or when spending a lot of time near one another where you share breathing space. Many babies who get

pertussis are infected by older siblings, parents, or caregivers who might not even know they have the disease.

Infected people are most contagious up to about 2 weeks after the cough begins. Antibiotics may shorten the amount of time someone is contagious.

While pertussis vaccines are the most effective tool to prevent this disease, no vaccine is 100% effective. When pertussis circulates in the community,

there is a chance that a fully vaccinated person, of any age, can catch this disease. If you have gotten the pertussis vaccine but still get sick, the

infection is usually not as bad.

Pertussis (whooping cough) can cause serious illness in babies, children, teens, and adults. Symptoms of pertussis usually develop within 5 to 10 days
after you are exposed. Sometimes pertussis symptoms do not develop for as long as 3 weeks.

Early Symptoms

The disease usually starts with cold-like symptoms and maybe a mild cough or fever. In babies, the cough can be minimal or not even there. Babies may

have a symptom known as “apnea.” Apnea is a pause in the child’s breathing pattern. Pertussis is most dangerous for babies. About half of babies

younger than 1 year who get the disease need care in the hospital. Learn more about pertussis complications.

In those who have gotten the pertussis vaccine:

 In most cases, the cough won’t last as many days

 Coughing fits, whooping, and vomiting after coughing fits occur less often

 The percentage of children with apnea (long pause in breathing), cyanosis (blue/purplish skin coloration due to lack of oxygen) and vomiting is less

Early symptoms can last for 1 to 2 weeks and usually include:

 Runny nose

 Low-grade fever (generally minimal throughout the course of the disease)

 Mild, occasional cough

 Apnea – a pause in breathing (in babies)

Pertussis in its early stages appears to be nothing more than the common cold. Therefore, healthcare professionals often do not suspect or diagnose it

until the more severe symptoms appear.

Later-stage Symptoms

After 1 to 2 weeks and as the disease progresses, the traditional symptoms of pertussis may appear and include:

 Paroxysms (fits) of many, rapid coughs followed by a high-pitched “whoop” sound

 Vomiting (throwing up) during or after coughing fits

 Exhaustion (very tired) after coughing fits

Pertussis in Babies

It is important to know that many babies with pertussis don’t cough at all. Instead it causes them to stop breathing and turn blue.

Pertussis can cause violent and rapid coughing, over and over, until the air is gone from your lungs. When there is no more air in the lungs, you are

forced to inhale with a loud “whooping” sound. This extreme coughing can cause you to throw up and be very tired. Although you are often exhausted

after a coughing fit, you usually appear fairly well in-between. Coughing fits generally become more common and bad as the illness continues, and can

occur more often at night. The coughing fits can go on for up to 10 weeks or more. In China, pertussis is known as the “100 day cough.”

The “whoop” is often not there if you have milder (less serious) disease. The infection is generally milder in teens and adults, especially those who have

gotten the pertussis vaccine.

Recovery

Recovery from pertussis can happen slowly. The cough becomes milder and less common. However, coughing fits can return with other respiratory

infections for many months after the pertussis infection started.

Diagnosis

Healthcare providers diagnose pertussis (whooping cough) by considering if you have been exposed to pertussis and by doing a:
  History of typical signs and symptoms

 Physical examination

 Laboratory test which involves taking a sample of mucus (with a swab or syringe filled with saline) from the back of the throat through the nose —

see Figure 1 and video demonstrations

 Blood test

Treatment

Tips

 Treat appropriately for pertussis. Because pertussis may progress rapidly in young infants, treat suspected and confirmed cases promptly. However,

treatment is ineffective if started late in the course of illness.

 Quickly report cases of pertussis to the local public health department to assist with preventing additional cases.

Early treatment of pertussis is very important. The earlier a person, especially an infant, starts treatment the better. If a patient starts treatment for

pertussis early in the course of illness, during the first 1 to 2 weeks before coughing paroxysms occur, symptoms may be lessened. Clinicians should

strongly consider treating prior to test results if clinical history is strongly suggestive or patient is at risk for severe or complicated disease (e.g., infants).

If a clinician diagnoses the patient late, antibiotics will not alter the course of the illness and, even without antibiotics, the patient should no longer be

spreading pertussis.

Persons with pertussis are infectious from the beginning of the catarrhal stage (runny nose, sneezing, low-grade fever, symptoms of the common cold)

through the third week after the onset of paroxysms (multiple, rapid coughs) or until 5 days after the start of effective antimicrobial treatment.

Postexposure Antimicrobial Prophylaxis (PEP)

CDC supports targeting postexposure antibiotic use to persons at high risk of developing severe pertussis and to persons who will have close contact

with those at high risk of developing severe pertussis. A reasonable guideline is to treat persons older than 1 year of age within 3 weeks of cough onset

and infants younger than 1 year of age and pregnant women (especially near term) within 6 weeks of cough onset.

Administer a course of antibiotics to close contacts within 3 weeks of exposure, especially in high-risk settings. Use the same doses as in the treatment

schedule.

Antimicrobial Choice

The recommended antimicrobial agents for treatment or chemoprophylaxis of pertussis are azithromycin*, clarithromycin, and erythromycin. Clinicians

can also use Trimethoprim-sulfamethoxasole. Clinicians should choose the antimicrobial after consideration of the:

 Potential for adverse events and drug interactions

 Tolerability

 Ease of adherence to the regimen prescribed

 Cost
Infants

Macrolides erythromycin, clarithromycin, and azithromycin are preferred for the treatment of pertussis in persons 1 month of age and older. For infants

younger than 1 month of age, azithromycin is preferred for post exposure prophylaxis and treatment because azithromycin has not been associated with

infantile hypertrophic pyloric stenosis (IHPS), whereas erythromycin has. For infants younger than 1 month of age, the risk of developing severe

pertussis and life-threatening complications outweighs the potential risk of IHPS that has been associated with macrolide use. Clinicians should monitor

infants younger than 1 month of age who receive a macrolide for the development of IHPS and for other serious adverse events. For persons 2 months

of age and older, an alternative to macrolides is trimethoprim-sulfamethoxazole.

Footnote

On March 12, 2013, the Food and Drug Administration (FDA) issued a warning that azithromycin can cause abnormal changes in the electrical activity of

the heart that may lead to a potentially fatal irregular heart rhythm in some patients. Azithromycin remains one of the recommended drugs for treatment

and chemoprophylaxis of pertussis, but consider using an alternative drug in those who have known cardiovascular disease, including:

 Patients with known prolongation of the QT interval, a history of torsades de pointes, congenital long QT syndrome, bradyarrhythmias, or

uncompensated heart failure

 Patients on drugs known to prolong the QT interval

 Patients with ongoing proarrhythmic conditions such as uncorrected hypokalemia or hypomagnesemia, clinically significant bradycardia, and in

patients receiving Class IA (quinidine, procainamide) or Class III (dofetilide, amiodarone, sotalol) antiarrhythmic agents.

Elderly patients and patients with cardiac disease may be more susceptible to the effects of arrhythmogenic drugs on the QT interval

Prevention
DTaP vaccination, one of the recommended childhood immunizations, protects children against pertussis infection. DTaP vaccine can be safely given to
infants. Five DTaP vaccines are recommended. They are most often given to children at ages 2 months, 4 months, 6 months, 15 to 18 months, and 4 to
6 years.
The TdaP vaccine should be given at age 11 or 12.
During a pertussis outbreak, unimmunized children under age 7 should not attend school or public gatherings. They should also be isolated from anyone
known or suspected to be infected. This should last until 14 days after the last reported case.

It is also recommended that adults age 19 and older receive 1 dose of the TdaP vaccine against pertussis.

TdaP is especially important for health care professionals and anyone having close contact with a baby younger than 12 months old.

Pregnant women should get a dose of TdaP during every pregnancy between 27 and 36 weeks of pregnancy, to protect the newborn from pertussis.
Diptheria - Pseudomembrane on tonsils, pharynx, and nasal cavity

What causes diphtheria?

A type of bacteria called Corynebacterium diphtheriae causes diphtheria. The condition is typically spread through person-to-person contact or through

contact with objects that have the bacteria on them, such as a cup or used tissue. You may also get diphtheria if you’re around an infected person when

they sneeze, cough, or blow their nose.

Even if an infected person doesn’t show any signs or symptoms of diphtheria, they’re still able to transmit the bacterial infection for up to six weeks after

the initial infection.

The bacteria most commonly infect your nose and throat. Once you’re infected, the bacteria release dangerous substances called toxins. The toxins

spread through your bloodstream and often cause a thick, gray coating to form in these areas of the body:

 nose

 throat

 tongue

 airway

In some cases, these toxins can also damage other organs, including the heart, brain, and kidneys. This can lead to potentially life-threatening

complications, such as:

 myocarditis, or inflammation of the heart muscle

 paralysis

 kidney failure

What are the risk factors for diphtheria?

Children in the United States and Europe are routinely vaccinated against diphtheria, so the condition is rare in these places. However, diphtheria is still

fairly common in developing countries where immunization rates are low. In these countries, children under age 5 and people over age 60 are

particularly at risk of getting diphtheria.

People are also at an increased risk of contracting diphtheria if they:

 aren’t up to date on their vaccinations

 visit a country that doesn’t provide immunizations

 have an immune system disorder, such as AIDS

 live in unsanitary or crowded conditions

What are the symptoms of diphtheria?

Signs of diphtheria often appear within two to five days of the infection occurring. Some people don’t experience any symptoms, while others have mild

symptoms that are similar to those of the common cold.

The most visible and common symptom of diphtheria is a thick, gray coating on the throat and tonsils. Other common symptoms include:

 a fever

 chills

 swollen glands in the neck

 a loud, barking cough

 a sore throat

 bluish skin

 drooling

 a general feeling of uneasiness or discomfort

Additional symptoms may occur as the infection progresses, including:

 difficulty breathing or swallowing

 changes in vision

 slurred speech

 signs of shock, such as pale and cold skin, sweating, and a rapid heartbeat

If you have poor hygiene or live in a tropical area, you may also develop cutaneous diphtheria, or diphtheria of the skin. Diphtheria of the skin usually

causes ulcers and redness in the affected area.

How is diphtheria diagnosed?

Your doctor will likely perform a physical exam to check for swollen lymph nodes. They’ll also ask you about your medical history and the symptoms

you’ve been having.

Your doctor may believe that you have diphtheria if they see a gray coating on your throat or tonsils. If your doctor needs to confirm the diagnosis, they’ll

take a sample of the affected tissue and send it to a laboratory for testing. A throat culture may also be taken if your doctor suspects diphtheria of the

skin.

How is diphtheria treated?

Diphtheria is a serious condition, so your doctor will want to treat you quickly and aggressively.

The first step of treatment is an antitoxin injection. This is used to counteract the toxin produced by the bacteria. Make sure to tell your doctor if you

suspect you might be allergic to the antitoxin. They may be able to give you small doses of the antitoxin and gradually build up to higher amounts. Your

doctor will also prescribe antibiotics, such as erythromycin or penicillin, to help clear up the infection.

During treatment, your doctor may have you stay in the hospital so you can avoid passing your infection on to others. They may also prescribe

antibiotics for those close to you.

How is diphtheria prevented?

Diphtheria is preventable with the use of antibiotics and vaccines.

The vaccine for diphtheria is called DTaP. It’s usually given in a single shot along with vaccines for pertussis and tetanus. The DTaP vaccine is

administered in a series of five shots. It’s given to children at the following ages:

 2 months

 4 months

 6 months

 15 to 18 months

 4 to 6 years

In rare cases, a child might have an allergic reaction to the vaccine. This can result in seizuresor hives, which will later go away.

Vaccines only last for 10 years, so your child will need to be vaccinated again around age 12. For adults, it’s recommended that you get a combined

diphtheria-tetanus-pertussis booster shot once. Every 10 years afterward, you’ll receive the tetanus-diphtheria (Td) vaccine. Taking these steps can help

prevent you or your child from getting diphtheria in the future.

Tetanus - Risus sardonicus (abnormal sustained spasm of the facial muscles--lockjawed). Chvostek sign (muscle twitching face), Torsseau's
sign (Jerky movements)

Tetanus is a serious bacterial disease that affects your nervous system, leading to painful muscle contractions, particularly of your jaw and neck

muscles. Tetanus can interfere with your ability to breathe and can threaten your life. Tetanus is commonly known as "lockjaw."

Thanks to the tetanus vaccine, cases of tetanus are rare in the United States and other parts of the developed world. However, the disease remains a

threat to those who aren't up to date on their vaccinations, and is more common in developing countries.

There's no cure for tetanus. Treatment focuses on managing complications until the effects of the tetanus toxin resolve.

Symptoms

Signs and symptoms of tetanus appear anytime from a few days to several weeks after tetanus bacteria enter your body through a wound. The average

incubation period is seven to 10 days.

Common signs and symptoms of tetanus include:

 Spasms and stiffness in your jaw muscles (trismus)

 Stiffness of your neck muscles

 Difficulty swallowing

 Stiffness of your abdominal muscles

 Painful body spasms lasting for several minutes, typically triggered by minor occurrences, such as a draft, loud noise, physical touch or light

Possible other signs and symptoms include:

 Fever

 Sweating

 Elevated blood pressure

 Rapid heart rate

When to see a doctor

See your doctor for a tetanus booster shot if you have a deep or dirty wound and you haven't had a booster shot in five years. If you aren't sure of when

your last booster was, get a booster.

Or see your doctor about a tetanus booster for any wound — especially if it might have been contaminated with dirt, animal feces or manure — if you

haven't had a booster shot within the past 10 years or aren't sure of when you were last vaccinated.

Causes
Spores of the bacteria that cause tetanus, Clostridium tetani, are found in soil, dust and animal feces. When they enter a deep flesh wound, spores grow

into bacteria that can produce a powerful toxin, tetanospasmin, which impairs the nerves that control your muscles (motor neurons). The toxin can cause

muscle stiffness and spasms — the major signs of tetanus.

Nearly all cases of tetanus occur in people who have never been vaccinated or adults who haven't kept up with their 10-year booster shots. You can't

catch tetanus from a person who has it.

Risk factors

The following increase your likelihood of getting tetanus:

 Failure to get vaccinated or to keep up to date with booster shots against tetanus

 An injury that lets tetanus spores into the wound

 A foreign body, such as a nail or splinter

Tetanus cases have developed from the following:

 Puncture wounds — including from splinters, body piercings, tattoos, injection drugs

 Gunshot wounds

 Compound fractures

 Burns

 Surgical wounds

 Injection drug use

 Animal or insect bites

 Infected foot ulcers

 Dental infections

 Infected umbilical stumps in newborns born of inadequately immunized mothers

Complications

Once tetanus toxin has bonded to your nerve endings it is impossible to remove. Complete recovery from a tetanus infection requires new nerve endings

to grow, which can take up to several months.

Complications of tetanus infection may include:

 Broken bones. The severity of spasms may cause the spine and other bones to break.
  Blockage of a lung artery (pulmonary embolism). A blood clot that has traveled from elsewhere in your body can block the main artery of the

lung or one of its branches.

 Death. Severe tetanus-induced (tetanic) muscle spasms can interfere with or stop your breathing. Respiratory failure is the most common cause

of death. Lack of oxygen may also induce cardiac arrest and death. Pneumonia is another cause of death.

Prevention

You can easily prevent tetanus by being immunized.

The primary vaccine series

The tetanus vaccine usually is given to children as part of the diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. This vaccination

provides protection against three diseases: a throat and respiratory infection (diphtheria), whooping cough (pertussis) and tetanus.

The DTaP vaccine is a series of five shots, typically given in the arm or thigh to children at ages:

 2 months

 4 months

 6 months

 15 to 18 months

 4 to 6 years

The booster

A booster of the tetanus vaccine is typically given in combination with a booster of diphtheria vaccine (Td). In 2005, a tetanus, diphtheria and pertussis

(Tdap) vaccine was approved for use in teens and adults under age 65 to ensure continuing protection against pertussis, too.

It's recommended that adolescents get a dose of Tdap, preferably between the ages of 11 and 12, and a Td booster every 10 years thereafter. If you've

never received a dose of Tdap, substitute it for your next Td booster dose and then continue with Td boosters.

If you're traveling internationally, particularly to a developing country where tetanus might be common, make sure your immunity is current.

To stay up to date with all of your vaccinations, ask your doctor to review your vaccination status regularly.

If you weren't vaccinated against tetanus as a child, see your doctor about getting the Tdap vaccine.

Diagnosis

Doctors diagnose tetanus based on a physical exam, medical and immunization history, and the signs and symptoms of muscle spasms, stiffness and

pain. Laboratory tests generally aren't helpful for diagnosing tetanus.

Treatment

Since there's no cure for tetanus, treatment consists of wound care, medications to ease symptoms and supportive care.

Wound care

Cleaning the wound is essential to preventing growth of tetanus spores. This involves removing dirt, foreign objects and dead tissue from the wound.

Medications

 Antitoxin. Your doctor may give you a tetanus antitoxin, such as tetanus immune globulin. However, the antitoxin can neutralize only toxin that

hasn't yet bonded to nerve tissue.

 Antibiotics. Your doctor may also give you antibiotics, either orally or by injection, to fight tetanus bacteria.

 Vaccine. All people with tetanus should receive the tetanus vaccine as soon as they're diagnosed with the condition.

 Sedatives. Doctors generally use powerful sedatives to control muscle spasms.

 Other drugs. Other medications, such as magnesium sulfate and certain beta blockers, might be used to regulate involuntary muscle activity,

such as your heartbeat and breathing. Morphine might be used for this purpose as well as sedation.

Supportive therapies

Severe tetanus infection often requires a long stay in an intensive care setting. Since sedatives can inhibit breathing, you might temporarily need a

ventilator.

Lifestyle and home remedies

Puncture wounds or other deep cuts, animal bites, or particularly dirty wounds put you at increased risk of tetanus infection. Get medical attention if the

wound is deep and dirty, and particularly if you're unsure of when you were last vaccinated. Leave unclean wounds open to avoid trapping bacteria in

the wound with a bandage.

Your doctor may need to clean the wound, prescribe an antibiotic and give you a booster shot of the tetanus toxoid vaccine. If you've previously been

immunized, your body should quickly make the needed antibodies to protect you against tetanus.

If you have a minor wound, these steps will help prevent tetanus:

 Control bleeding. Apply direct pressure to control bleeding.

 Keep the wound clean. After the bleeding stops, rinse the wound thoroughly with clean running water. Clean the area around the wound with

soap and a washcloth. If something is embedded in a wound, see your doctor.

 Use an antibiotic. After you clean the wound, apply a thin layer of an antibiotic cream or ointment, such as the multi-ingredient antibiotics

Neosporin and Polysporin. These antibiotics won't make the wound heal faster, but they can discourage bacterial growth and infection.
 Certain ingredients in some ointments can cause a mild rash in some people. If a rash appears, stop using the ointment.

 Cover the wound. Exposure to the air might speed healing, but bandages can keep the wound clean and keep harmful bacteria out. Blisters that

are draining are vulnerable. Keep them covered until a scab forms.

 Change the dressing. Apply a new dressing at least once a day or whenever the dressing becomes wet or dirty to help prevent infection. If

you're allergic to the adhesive used in most bandages, switch to adhesive-free dressings or sterile gauze and paper tape.

Preparing for your appointment

If your wound is small and clean but you're concerned about infection or whether you're immune from tetanus, start by seeing your primary care

provider. If your wound is severe or you or your child has symptoms of tetanus infection, seek emergency care.

What you can do

If possible, let your doctor know the following information:

 When, where and how you were injured

 Your immunization status, including when you received your last tetanus booster shot

 How you've been caring for the wound

 Any chronic illness or condition you have, such as diabetes, heart disease or pregnancy

If seeking care for an infant other than your own, let the doctor know the mother's country of origin, her immune status and how long she's been in the

United States.

For tetanus, some basic questions to ask your doctor include:

 What is the best course of action?

 What are the alternatives to the primary approach you're suggesting?

 I have these other health conditions. How can I manage them together?

 Do I need to see a specialist?

 Are there restrictions I need to follow?

 Are there brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions.

Dtap and Tdap

DTaP is a vaccine that helps children younger than age 7 develop immunity to three deadly diseases caused by bacteria: diphtheria, tetanus, and whooping
cough (pertussis). Tdap is a booster immunizationgiven at age 11 that offers continued protection from those diseases for adolescents and adults.

What's the Difference Between DTaP and Tdap?

Both vaccines contain inactivated forms of the toxin produced by the bacteria that cause the three diseases. Inactivated means the substance no longer produces
disease, but does trigger the body to create antibodies that give it immunity against the toxins. DTaP is approved for children under age 7. Tdap, which has a
reduced dose of the diphtheria and pertussis vaccines, is approved for adolescents starting at age 11 and adults ages 19 to 64. It is often called a booster dose
because it boosts the immunity that wanes from vaccines given at ages 4 to 6.

Immunity wears off over time. So, the current recommendation is that everyone needs a booster shot for tetanus and diphtheria every 10 years after first being
immunized. That booster comes in the form of a vaccine called Td. But since immunity to pertussis also wears off during childhood, a weaker form of
the pertussis vaccine has been added to the booster to make the vaccine Tdap. The current recommendation is that one dose of the Tdap vaccine be substituted
for one dose of the Td vaccine between the ages of 11 and 64. Pregnant women are also advised to get the Tdap vaccine, preferably between 27 and 36 weeks'
gestation.

Children ages 7 through 10 who aren't fully vaccinated against pertussis, including children never vaccinated or with an unknown vaccination status, should get a
single dose of the Tdap vaccine. Teens ages 13 through 18 who haven't gotten the Tdap vaccine yet should get a dose, followed by a booster of tetanus and
diphtheria (Td) every 10 years.

When Should Children Be Vaccinated With the DTaP Vaccine?

Children should receive five doses of the DTaP vaccine according to the following schedule:

 One dose at 2 months of age

 One dose at 4 months of age
 One dose at 6 months of age
 One dose at 15 to 18 months of age
 One dose at 4 to 6 years of age

Are there any children who should not get DTaP vaccine?

The CDC recommends that children who are moderately or severely ill at the time they are scheduled to receive the vaccine should wait until they recover before
getting it. Minor illnesses like a cold or low-grade fever, however, should not prevent a child from receiving a dose of the vaccine.

If a child has a life-threatening allergic reaction after receiving a dose of the vaccine, that child should not be given another dose.

A child who suffered a brain or nervous system disease within seven days of receiving the vaccine should not be given another dose.

Some children may have a bad reaction to the pertussis vaccine in DTaP and should not take another dose. There is, however, a vaccine called DT that will
protect them from diphtheria and tetanus. Talk with your doctor if your child experienced any of the following reactions:

 Had a seizure or collapsed after a dose of DTaP

 Cried nonstop for 3 hours or more after a dose of DTaP
 Had a fever over 105 F after a dose of DTaP

Are There Dangers Associated With DTaP and Tdap?

Like any medicine, vaccines can have side effects. But the risk of experiencing a serious problem to DTaP or Tdap is extremely small. On the other hand, the risk
of your child contracting a major illness like diphtheria or pertussis is extremely high without the vaccine.

One of the most serious problems that can come from getting the vaccine is an allergic reaction. That happens in less than one out of a million doses. If it were
going to happen it would most likely happen within a few minutes to a couple of hours after taking the vaccine. And even though it's rare, it's important to be alert
for an allergic reaction with any medicine and get medical help at once if it occurs. Symptoms might include any of the following:

 difficulty breathing
 hoarseness
 wheezing
 hives
 paleness
 weakness
 rapid heart beat
 dizziness

Other very rare problems that have been reported include long-term seizures, coma or lowered consciousness, and brain damage. These problems have
occurred so rarely that the CDC says it's impossible to tell whether they were actually related to the vaccine or caused by something else.