"Down in the Valley
And not far off
A blue jay died of a whooping cough
He whooped and he whooped
And he whooped some more
He whooped his head and tail right off"
-- Children's Camp Song (Author Unknown)
It's really not much of an exaggeration. The force of the cough is so hard it can break a rib. The common name for pertussis, whooping cough, comes from the sound victims make when they struggle to breathe between fits of hacking and choking. However, it is a disease that most people thought had faded into the past, only to be remembered playfully in a children's song. That couldn't be further from the truth -- and those who are most seriously affected are babies, too young yet to sing.
Maggie Hopkins struggled from the moment she was born. She is four months old and has spent most of her life in Children's Hospital. Born eight weeks premature, she was put in the intensive care unit for a month before going to her new home in River Ridge. Her mother, Margaret Hopkins, thought it best not to expose her baby too much to the outside world, so she took Maggie directly home and there she stayed. Nevertheless, two weeks later, Maggie began having flu-like symptoms along with a nasty cough.
After several visits to her pediatrician, Maggie returned to Children's Hospital, where she was diagnosed with parainfluenza, a respiratory viral infection. She went home with a regimen of medications, and within a week almost all of the symptoms had faded. But the cough, loud and frightening, only became worse.
"It petrified me -- she would become blue," Hopkins says. "Every little part of her body was shaking and she was gasping for air. She couldn't breathe."
Returning to the pediatrician, Hopkins told the doctor that she suspected that Maggie had pertussis. She had looked up the symptoms in the popular parent's reference book What to Expect in the First Year. She says the doctor told her it was possible, but she hadn't seen cases of whooping cough in years. She sent Maggie back to Children's Hospital, where the infant tested positive for the disease.
Nobody knows when whooping cough first manifested itself, but the recorded history of the disease dates to the 16th century, when it was described as an epidemic. Up until the 1940s, when a vaccine was developed, it was one of the most common of childhood illnesses and a leading cause of death in young children in the United States. Prior to the vaccine, from 1940 to 1945, there were 175,000 cases per year. After the vaccine's introduction, those statistics progressively fell; from 1980 to 1990, about 2,900 cases were recorded annually.
But whooping cough continues to flourish in developing countries, where vaccines are underused or not available. Worldwide, 50 million cases of pertussis are reported each year, with 300,000 deaths. Now, numbers are again increasing in the United States. In 2002, there were 9,771 reported cases across the country, the highest total since 1964. Preliminary figures for 2003 indicate more than 11,000 occurrences.
PERTUSSIS IS AN ACUTE RESPIRATORY INFECTION caused by the bacteria bordetella pertussis. When someone contracts the disease, usually from droplets produced from an infected person's sneeze or cough, it will progress through three stages before it is over. The first, or catarrhal stage, is fairly mild. The sufferer exhibits the symptoms of a cold: a runny nose, sneezing, a low-grade fever and an occasional cough. Due to these similarities to the common cold, pertussis is rarely diagnosed at this stage when, unfortunately, it is also most contagious. If a person without immunity to pertussis comes in contact with it, the chances of contracting the disease are as high as 80 percent. And the number of non-immune people is higher than you think.
Most children in the United States begin immunization against pertussis at two months of age. Doses of the vaccine are given every 4 to 8 weeks. By six months, after the third shot, they will have up to 80 percent immunity to the disease. Booster shots are administered to kids prior to pre-school and kindergarten. Because the severity of the illness decreases significantly as kids get older, no booster shots are given after the age of five. However, as researchers began to discover in the 1980s, the vaccine-produced immunity begins to wane at 11 to 15 years of age.
"The rise in pertussis incidences is thought to be a manifestation of the waning immunity in older children and young adults, that is the parents of young children," says Dr. Russell Steele, a professor and vice chair of pediatrics at Louisiana State University Medical School and head of the Infectious Disease Division at Children's Hospital. "The real rise in occurrences is in this unique group: teenagers and young adults. They represent the source of infecting young children."
From 1997 to 2000, the incidences of pertussis rose in the adult population and young adult population by 60 percent and 62 percent respectively, according to the Centers for Disease Control. The disease is fairly mild in these age groups, but when the disease is transmitted to infants who are only partially immunized -- or not at all -- the situation can become critical.
In the second, or paroxysmal, stage, pertussis makes itself known. For an adult, the symptom is a persistent, annoying cough. Infants can have sudden and intense coughing attacks, or paroxysms, during which they can become apneic or breathless. The child "whoops" when they try to resume breathing. The paroxysmal stage usually lasts one to six weeks and most infants younger than six months will be hospitalized like Maggie. Erythromycin is the drug of choice for treatment, but it is used only to eliminate the bacteria, making patients non-contagious. The disease must run its course; all a hospital staff can do is provide comfort and surveillance, making sure that the baby is breathing.
Even then it helps for parents to prepare for possible emergencies. For Margaret Hopkins, this meant taking CPR courses and staying by her daughter's side as much as possible. "You can't just leave her in that room because a lot of the time the nurses won't hear the monitor," she says. "Sometimes when she was sleeping, I'd look and she was blue and gasping. The staff at Children's Hospital is great, but someone has to be there all the time. If you don't get to them on time, you have to perform CPR. People need to realize that this can kill their babies."
STEELE IS VERY AWARE of this possibility. In his article "Pertussis: Is Eradication Possible?" scheduled for publication this month in Pediatric Annals, he elaborates on some of chilling results surrounding the disease. It has a .8 percent mortality rate in the United States for sufferers younger than two months, and is much more dangerous in developing countries. Furthermore, he writes, pertussis is a "well-described cause of sudden infant death syndrome (SIDS)."
Armed with statistical evidence, Steele advocates the need for booster shots for older children and adults to combat the disease in this country. As for the rest of the world, Steele stresses that the vaccine should be provided everywhere and sadly notes that "pertussis is currently the fifth leading cause of vaccine-preventable deaths."
As of the week of July 23, 2004, there were 5,043 provisionally reported cases of pertussis across the United States, with a wide variance among states. For instance, there have been 571 cases in Massachusetts, but only 3 recorded cases in Nebraska. In Louisiana, there have been 7 reported cases. Two possible factors are at work. First, states with a high number of cases have had large localized community outbreaks. In other words, once the disease starts spreading, the numbers will rise exponentially. Second, the statistics reflect reported cases. State epidemiologist Dr. Raolt Ratard believes that the actual figures could be much higher, because adults might not know they have pertussis at all.
Many believe that the rise in whooping cough points to the need for booster shots for young adults and, eventually, adults. In the past month, the pharmaceutical company GlaxoSmithKline has applied to the Food and Drug Administration (FDA) for approval of a booster shot for 11 to 18 year olds. Studies funded by GlaxoSmithKline have shown vaccines to be safe and effective, and Steele says FDA approval typically takes about seven months. Researchers are now studying a booster shot that would be available for all adults, particularly new parents, infant caregivers and health workers.
Meanwhile, it's important to remember that seeing a doctor and taking care of that nagging cough will not only help you, but it could save a child. "The numbers are going to rise," Ratard says. "For a chronic cough, more than three weeks, go see your doctor." If not sooner. As for Maggie, three and a half weeks after her admittance, the child came home. She was still coughing, but she's a tough little girl. "It's been a struggle with my baby from day one with all of these problems," says her proud mother, "but she's pulling herself through."
- "Every little part of her body was shaking and she was gasping for air," remembers Margaret Hopkins about her infant daughter Maggie's battle with whooping cough.