Dear Dr. Lanny:
My 15-year-old son just got a diagnosis of whooping cough from his pediatrician. How is this possible? I thought the Dtap vaccine he got as a kid protected him. Not only that, I've since heard Onondaga County is a hotbed of whooping cough cases. Now I'm wondering if I need to have my 8-year-old son vaccinated. What do you think?
A: Before you go storming your pediatrician's office--or home--let me just say that I feel your pain. You believe, not unreasonably, that you agreed to all those needle sticks because they would prevent your baby from getting some terrible illnesses. And now I, representing the medical profession in this discussion, have not held up my end of the deal.
Not so. Although your 15-year-old son, zits and all, will always be your "baby," when he was truly a baby, and at greatest risk of severe or fatal whooping cough (pertussis), he did not get the disease. I (we) did my job.
I'm not trying to weasel out of responsibility here, as there really is a very significant difference between whooping cough in infancy and adolescence. Whooping cough in the first year of life can cause terrible complications such as pneumonia, seizures or death. The same illness in older children, adolescents and adults, can be quite uncomfortable, have occasional complications, and is known in some areas as the "Hundred Days Cough"!
Unpleasant as this is, fatalities after infancy are almost unheard of. It is quite remarkable that even today, worldwide there are an estimated 300,000 deaths annually due to whooping cough. That is not a typo. Pertussis clearly remains a serious problem in many parts of the world.
Incidence in the United States was approximately 175,000 cases per year prior to the "whole cell" vaccine, which was licensed in the 1940s. By 1976 the incidence had decreased to only 1,000 cases per year. The story, however, didn't come to a fairy-tale ending, and by 2004 more than 25,000 cases were reported. Present-day figures are felt to be quite inaccurate as many cases in adolescents and adults are milder and not recognized as whooping cough and therefore not reported to health departments. The classic whoop, as the patient desperately pulls in a breath, is mostly a symptom of infancy.
The original "whole cell" vaccine, although a life saver, often caused fevers to 104 degrees, inconsolable crying, and occasional seizures. Grandparents' anxiety about side effects of childhood shots largely comes from this vaccine. In the early 1990s, the acellular pertussis vaccine came on the market, replacing the "whole cell" vaccine, and side effects became minimal. Ask recent parents whose little ones have four shots at 2 and 4 months of age, and they will confirm today's mild-mannered shots.
Unfortunately, there is a tendency for immunity to decrease with time, resulting in adolescents and adults again becoming susceptible. Although such older victims are exceedingly unlikely to become seriously ill, they have the potential to transmit pertussis to infants they come in close contact with. The early stage of the illness, when it is very contagious, looks like your average cold. Testing all adolescents and adults with colds for pertussis would be impractical, and exceedingly expensive. The present standard test costs nearly $100 and involves a swab up the nose. And it is also easy to do inadequately, leading to inaccurate results.
Treatment for pertussis is brief and simple, just five days of antibiotics. Treatment does little for the patient and is largely done to decrease transmission to others. As always, antibiotics should not be used without strong evidence that the patient has, or has been exposed to, pertussis. Always remember that overuse of antibiotics will come back to haunt us all.
So this brings us back to your two boys. The most recent recommendation is that the pertussis vaccine be given four times in the first two years of life, and then a booster between 4 and 6 years, and again at 11 years. The shot at 11 years is the newest requirement and will generally be prior to sixth grade. As of this year, it is mandatory, due to outbreaks of whooping cough in this state in 2006. In your family's case, this means your 15-year-old is due for a booster, and your 8-year-old still has adequate immunity and is OK for a few more years.
Remember that humans, bacteria, viruses and the rest of our environment are a dynamic and ever-evolving landscape. The recommendations from your doctor represent the state of knowledge at this point in time. We rely on the best efforts of our research scientists and alter our treatments as new knowledge is gained.
Dr. Alan Freshman, father of two grown boys, practices at Syracuse Pediatrics. Consult your own physician before making decisions about your family's health care. Send e-mail to him at firstname.lastname@example.org.