Pertussis  

1. DISEASE REPORTING
A. Purpose of Reporting and Surveillance
1. To prevent illness and death among high-risk persons and among persons who may
transmit pertussis to high-risk persons.
2. To identify and evaluate contacts and recommend appropriate preventive measures,
including exclusion, antibiotic prophylaxis and/or immunization.
3. To educate exposed persons about signs and symptoms of disease, thereby facilitating
early diagnosis and treatment and preventing further spread.
4. To vaccinate exposed, underimmunized children.
5. To monitor the epidemiology of pertussis in Washington state.
B. Legal Reporting Requirements
1. Health care providers: notifiable to local health jurisdiction within 24 hours.
2. Health care facilities: notifiable to local health jurisdiction within 24 hours.
3. Laboratories: Bordetella pertussis notifiable to local health jurisdiction within 24 hours -
culture, when available (2 business days).
4. Local health jurisdictions: notifiable to the Washington State Department of Health
(DOH) Communicable Disease Epidemiology Section (CDES) within 7 days of case
investigation completion or summary information required within 21 days.
C. Local Health Jurisdiction Investigation Responsibilities
1. Begin routine case investigation within one working day.
2. Make sure the case is appropriately treated and recommend measures to prevent further
spread from the case.
3. Identify and evaluate contacts; educate and recommend measures to prevent further
spread from potentially infected contacts.
4. Facilitate the transport of specimens to assist with the diagnosis of other cases.

5. Report all confirmed and probable cases (see Section 3C) to CDES. Complete the
pertussis case report form (at http://www.doh.wa.gov/Notify/forms/pert.pdf) and enter the
data in the Public Health Information Management System (PHIMS). Remember to ask
and enter the vaccination history for all patients.
2. THE DISEASE AND ITS EPIDEMIOLOGY
A. Etiologic Agent:
Bordetella pertussis, a fastidious pleomorphic gram-negative bacillus.

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B. Description of Illness
Classic pertussis, whooping cough, is characterized by spasms of severe coughing
(paroxysms) lasting from 6 to 10 weeks. Pertussis should be suspected when any cough
is paroxysmal or lasts more than a week. Pertussis typically lacks fever and classically
progresses through three stages:
1. Catarrhal (1–2 weeks): mild, upper respiratory tract symptoms gradually develop with an
intermittent non-productive cough.
2. Paroxysmal (1–2 weeks or longer): spasms of cough end with a gasp, whoop, or vomiting
(post-tussive emesis). Adolescents and adults may have less dramatic symptoms.
3. Convalescent (2–6 weeks or longer): gradual resolution of the paroxysmal coughing.
Pertussis can occur at any age, regardless of vaccination history. Apnea rather than
cough may be the initial or most important symptom in infants less than 6 months of age.
A clue to the diagnosis in infants only is an elevated white blood count (over
15,000/mm³) with a predominance of lymphocytes. Pertussis among older children,
adults, and those previously immunized can be milder than classic whooping cough; the
symptoms may be no more distinctive than other upper respiratory tract infections.
Death and serious complications occur mainly in infants and can include apnea,
malnutrition, pneumonia, pulmonary hypertension, seizures, and encephalopathy. Older
individuals may suffer from sleep deprivation, sweating, syncope, rib fractures, hernia,
and urinary incontinence.
The differential diagnosis of pertussis includes other respiratory pathogens such as
adenoviruses, Bordetella parapertussis, Mycoplasma pneumoniae, Chlamydophila
(formerly Chlamydia) pneumoniae, and respiratory syncytial virus.
A brief note about B. parapertussis, a less common, non-reportable disease requiring no
public health action: Parapertussis has similar but milder symptoms than pertussis and
serious complications are rare. Parapertussis can be distinguished from pertussis by
culture or PCR. Unfortunately, infection with B. pertussis provides little cross-protection
against subsequent infection with the B. parapertussis and vice versa; pertussis vaccine
does not prevent parapertussis. However, antibiotic treatment and prevention messages
for parapertussis are the same as those for pertussis.
C. Pertussis in Washington State
DOH currently receives approximately 400 to 1000 reports of pertussis per year.
D. Reservoirs
Humans.
E. Modes of Transmission
B. pertussis is transmitted person to person through direct contact with respiratory
secretions or via droplets produced from talking or coughing. The precise duration and
intensity of exposure needed to cause infection is unclear; an hour or more in a confined
space with a contagious individual is generally felt to be a significant exposure.
Secondary attack rates are 25–60% among household contacts in the developed world

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and can reach 80% among fully susceptible persons (i.e., neither immunized nor
previously infected).
F. Incubation Period
Typical incubation period is 7–10 days (range 5–21 days).
G. Period of Communicability
Pertussis is highly contagious. Persons with pertussis are most infectious during the
catarrhal period and the first 2 weeks after cough onset. Communicability then decreases
but may continue for 3 or more weeks after the paroxysmal cough onset. Therefore,
cases are contagious from symptom onset to 21 or more days after the start of the
paroxysmal cough or until completion of 5 days of appropriate antibiotic therapy. Some
individuals, especially infants, may remain culture-positive for several weeks; there is no
chronic carrier state.
H. Treatment
Early treatment of pertussis cases (within first two weeks of paroxysmal cough) is much
more effective in preventing secondary spread than treatment started later. Initiating
treatment more than 3 weeks after onset of paroxysmal cough is unlikely to be beneficial
and should be limited to situations in which there is on-going contact with high-risk
individuals such as an infant under 1 year of age or a pregnant woman in the third
trimester.
Antibiotics used for treatment and prevention
The antibiotics and dosages used for treatment and post-exposure disease prevention
(often referred to as “chemoprophylaxis”) are the same (see Table 1 below). Antibiotics
given early in the catarrhal stage may attenuate the disease; when given during the
paroxysmal stage communicability is reduced but there is little effect on the course or
duration of illness. Azithromycin, clarithromycin and erythromycin eradicate B.
pertussis from the nasopharynx, rendering infectivity minimal 5 days after starting
treatment with any of these agents. In principle, chemoprophylaxis of asymptomatic
contacts helps to interrupt transmission by eliminating the organism during the incubation
period. Azithromycin and erythromycin are both pregnancy category B (minimal risk);
clarithromycin and trimethoprim-sulfamethoxazole are category C and should be used in
consultation with a prenatal care provider.
1. Azithromycin (Zithromax®)
Azithromycin is as effective as a 14-day course of erythromycin; greater convenience and
tolerability is accompanied by a high price (typically over $50 for an adult course). The
most frequently reported side effects are gastrointestinal; drug interactions are uncommon
but always inquire about other concurrent medications.
Note: Because of the very long half-life of azithromycin, recently released 1 and 3-day
courses (with the same total dose of 30mg/kg for kids or 1.5 grams for adults) may be as
effective as the 5-day course; however, they have not yet been studied for pertussis and
are not currently recommended for this disease.

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2. Clarithromycin (Biaxin®)
A 7-day course of clarithromycin is as effective as a 14-day course of erythromycin;
again greater convenience and tolerability come at a higher price. Although uncommon,
the most frequently reported side effects are gastrointestinal; drug interactions occur so
inquire about concurrent medications.
3. Erythromycin (many brands and generic)
Erythromycin, especially the estolate preparation, has long been the recommended drug
for pertussis treatment and prophylaxis. Patient compliance with the cumbersome 4-
times-daily, 14-day course is poor and gastrointestinal side effects are common.
Although the CDC still recommends a 14-day course of erythromycin (see Table 1), one
study has shown that a 7-day course may be equally effective (Halperin SA, et al. Seven
days of erythromycin estolate is as effective as fourteen days for treatment of Bordetella
pertussis infections. Pediatrics. 1997;100(1):65–71).
Use of erythromycin in infants can be complicated by infantile hypertrophic pyloric
stenosis; when prescribing erythromycin to infants under 3 months of age providers
should inform parents about the possible risks for infantile hypertrophic pyloric stenosis
(IHPS) and counsel them about signs of developing IHPS. Overall, serious side-effects
are rare with erythromycin UNLESS the patient is taking other medications; be sure to
ask and consult with a pharmacist if there is any concern about interactions.
4. Trimethoprim-Sulfamethoxazole, TMP-SMX (Bactrim®, Septra®, generic)
TMP-SMX also appears to be effective in eradicating B. pertussis from the nasopharynx;
it is recommended as an alternative antibiotic for patients who cannot tolerate any of the
above macrolides. This drug can cause nausea, vomiting, and rash. TMP-SMX is
contraindicated for infants aged < 2 months (risk for kernicterus).

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Table 1: Recommended antimicrobial treatment and postexposure prophylaxis for pertussis, by age group
Primary agents Alternate agent*
Age group Azithromycin Erythromycin Clarithromycin TMP-SMZ
Under 1 month Recommended agent. Not preferred. Not recommended Contraindicated for
10 mg/kg per day in a Erythromycin is associated (safety data infants aged < 2 months
single dose for 5 days with infantile hypertrophic unavailable) (risk for kernicterus)
(only limited safety data pyloric stenosis. Use if
available.) azithromycin is unavailable;
40–50 mg/kg per day in 4
divided doses for 14 days
1–5 months 10 mg/kg per day in a 40–50 mg/kg per day in 4 15 mg/kg per day in 2 Contraindicated at age <2
single dose for 5 days divided doses for 14 days divided doses for 7 days months. For infants aged
>2 months, TMP 8 mg/kg
per day, SMZ 40 mg/kg
per day in 2 divided
doses for 14 days
Infants (6 months 10 mg/kg in a single dose 40–50 mg/kg per day 15 mg/kg per day in 2 TMP 8 mg/kg per day,
and older) and on day 1 (maximum: 500 (maximum: 2 g per day) in divided doses SMZ 40 mg/kg per day in
children mg/day) then 5 mg/kg 4 divided doses for 14 days (maximum: 1 g per day) 2 divided doses for 14
per day on days 2–5 for 7 days days (maximum: adult
(maximum: 250 mg/day) dose)
Adults 500 mg in a single dose 2 g per day in 4 divided 1 g per day in 2 divided TMP 320 mg per day,
on day 1 then 250 mg per doses for 14 days doses for 7 days SMZ 1,600 mg per day in
day on days 2–5 2 divided doses for 14
Pregnancy category C
days
Pregnancy category C
* Trimethoprim sulfamethoxazole (TMP-SMZ) can be used as an alternative agents to macrolides in patients aged > 2 months who are
allergic to macrolides, who cannot tolerate macrolides, or who are infected with a rare macrolide-resistant strain of B. pertussis.
Source: MMWR 2005;54:RR–14

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I. Immunity
The duration of immunity after natural infection with B. pertussis is postulated to be
lifelong but laboratory confirmed second infections have been reported. Efficacy of the
“whole-cell” vaccine was 70–90%, but after 5–10 years protection waned. The acellular
vaccine series (recommended in the United States for the entire series since 1996) has an
efficacy of approximately 80% in young children but immunity also appears to wane
after 5–10 years. Those over age 10 years are considered fully susceptible, unless they
have received a dose of Tdap (Tetanus toxoid, reduced diphtheria toxoid, acellular
pertussis vaccine), although duration of immunity after receiving this relatively new
vaccine is unknown.
3. CASE AND CONTACT DEFINITIONS
A. Clinical Criteria for Diagnosis of Cases
A cough illness lasting ≥ 2 weeks with one of the following: paroxysms of coughing,
inspiratory “whoop,” or post-tussive vomiting, without other apparent cause (as reported
by a health professional).
B. Laboratory Criteria for Diagnosis of Cases
1. Isolation of Bordetella pertussis from clinical specimen or
2. Positive polymerase chain reaction (PCR) assay for B. pertussis.
C. Case Definition (1997)
1. Probable: a case that meets the clinical case definition, is not laboratory confirmed, and is
not epidemiologically linked to a laboratory-confirmed case.
2. Confirmed:
a. a case with an acute cough illness of any duration that is culture confirmed, or
b. a case that meets the clinical case definition and is confirmed by PCR, or
c. a case that meets the clinical case definition and is epidemiologically linked directly
to a culture or PCR-confirmed case.
Comments:
• The clinical case definition is appropriate for endemic or sporadic cases. In outbreak
settings, including households, a case may be defined as a cough illness lasting ≥2
weeks.
• Because some studies have documented that direct fluorescent antibody testing of
nasopharyngeal secretions has low sensitivity and variable specificity, it should not be
relied on as a criterion for laboratory confirmation.
• Serologic testing for pertussis is available in some areas but is not standardized and,
therefore, should not be relied on as a criterion for laboratory confirmation for
national reporting purposes.
• At this time, a case with a positive PCR result must meet the clinical case definition
in order to be counted as a confirmed case. It is important to let the person know that

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you will be checking back to learn the duration of cough if the initial interview is
done early in the course of the illness. If you are unable to document a cough
duration of at least two weeks in a person with a positive PCR, the report cannot be
classified as a “confirmed” or “probable” case. Instead, these cases should be
classified as “suspect” and marked as outbreak-related if appropriate. For case and
contact management purposes, these individuals should be considered likely to have
pertussis. Only confirmed and probable cases are reported to CDC.
D. Close Contact (of a pertussis case)
Pertussis spreads by direct contact with infectious respiratory secretions by droplet
transmission. Such droplets generally travel 3 feet or less when an infected person talks,
coughs, or sneezes. The risk for transmission of pertussis is a function of multiple factors
including clinical features of the source case as they relate to communicability (e.g., stage
of illness, character of cough), proximity and duration of contact, ventilation, and use of
appropriate infection control measures (mask, eye protection). Consult with a CDES
epidemiologist as needed on a case-by-case basis regarding determinations of close-
contacts.
Examples of close contact include:
1. Direct face-to-face contact with a symptomatic case-patient during the contagious period.
This includes household and immediate family members, boyfriends/girlfriends, and
child care contacts (those who spend many hours together or sleep under the same roof).
2. An obvious exposure that involves direct contact with respiratory, oral, or nasal
secretions from a case-patient during the contagious period (e.g., a cough or sneeze in the
face, sharing eating utensils, sharing water bottles, kissing, mouth-to-mouth resuscitation,
or performing intubation or nasotracheal suctioning without a mask).
3. Close proximity for a prolonged period of time with a case-patient during the contagious
period. Risk of droplet exposure increases with longer duration and closer proximity of
contact.
Examples of persons who may be at increased risk include:
ƒ non-household close friends or other social contacts
ƒ some passengers during shared transportation
ƒ some contacts at community activities or at the place of employment
ƒ some healthcare workers caring for a case without wearing a mask
ƒ children attending an after-school care group or play group on the same days
Note: Close contact does not include activities such as walking by a person or briefly
sitting across a waiting room or office.
E. High-risk Cases and Contacts
High-risk persons include persons at increased risk for severe pertussis and persons who
may transmit pertussis to persons at high risk for severe pertussis. High-risk groups are:
1. Children under one year of age: Increased risk for severe disease.

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2. Pregnant women, particularly those in the last three weeks of pregnancy: Potential for
transmission to the newborn, other pregnant women (e.g., in obstetrical offices or
prenatal classes) and to health care workers.
3. Healthcare worker with face-to-face patient contact: Potential for transmission to persons
(patients) at increased risk for severe disease
4. Close contacts of a pertussis case who have an increased likelihood of transmitting
pertussis to individuals at high risk for severe disease (e.g., persons working with infants
or pregnant women, members of household with infants and pregnant women).
4. DIAGNOSIS AND LABORATORY SERVICES
A. Diagnosis
Isolation of B. pertussis by culture and detection of B. pertussis by polymerase chain
reaction (PCR) are the only ways to confirm the diagnosis of pertussis.
1. Nasopharyngeal Culture: Culture is the most specific test for pertussis. Culture from the
posterior nasopharynx is most sensitive in the first 2 weeks of illness and is more
sensitive in young children than in adolescents and adults. However, positive
nasopharyngeal cultures have occasionally been obtained from untreated adults up to 6
weeks after the onset of any symptoms. Because B. pertussis is fastidious and its
isolation in culture is easily obscured by the growth of other nasopharyngeal organisms,
proper specimen collection and subsequent handling of the specimen will improve the
rate of recovery. Specimens collected after the initiation of any type of antibiotic therapy
are less likely to yield B. pertussis isolation. Since so many factors can affect the
sensitivity of culture for B. pertussis, a negative culture result should not be considered
evidence that pertussis has been ‘ruled out’. (Throat and anterior nares swabs have
unacceptably low rates of recovery of B. pertussis and should not be used.)
2. Polymerase Chain Reaction (PCR): PCR testing for B. pertussis should be used in
addition to culture. It is at least as sensitive as culture and results are available more
quickly. Published data suggests that PCR may detect B. pertussis when culture is
negative. It is necessary to use Dacron® or rayon swabs on a metal handle. Calcium
alginate swabs or wood handles can render the specimen unsatisfactory for PCR testing.
A negative PCR result on an exposed symptomatic high-risk person such as a health care
worker should not be considered evidence that pertussis has been ‘ruled out’.
3. Direct Fluorescent Antibody (DFA) Testing: A DFA test was used for screening in the
past but lacks sensitivity and specificity for B. pertussis. Use of this test is discouraged.
No public health action is warranted by reports of positive DFA tests for pertussis.
4. Serologies: Although serology may have a role in the future, the lack of standardization
of these antibody tests and their unknown correlation with pertussis illness limits their
current usefulness. No public health action is warranted by sporadic reports of positive
serologic tests for pertussis because cases are unlikely to be contagious by the time the
tests are reported. Use discretion about the need for further investigation if a convincing
serologic test is found among a well defined group with suspected on-going transmission.
The best approach in such a situation may be to find an untreated person with a recent
onset of illness and collect specimens for culture and PCR.

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5. Susceptibility Testing: Routine susceptibility testing of B. pertussis isolates is not

recommended since resistance to macrolide antibiotics is rare. Consult with CDES if a
patient has a positive B. pertussis culture after completion of an appropriate course of
antimicrobial therapy and patient compliance with therapy has been verified.
B. Tests Available at the Washington State Department of Health Public Health
Laboratories (PHL)
PHL can perform microbiologic cultures and PCR for pertussis on posterior
nasopharyngeal specimens. PHL can also confirm that pure isolates submitted from other
laboratories are B. pertussis.
The policy with regards to testing for pertussis at PHL follows:
Only samples approved by the local health jurisdiction (LHJ) will be accepted at
PHL. When submitting to PHL, appropriate samples for both standard microbiology
cultures and PCR must be submitted simultaneously. LHJs should notify the
Communicable Disease Epidemiology Section (CDES) when they have given approval
for pertussis testing at PHL. CDES will then notify PHL that the submitter is sending
specimens to the state lab.
An LHJ can approve specimens for pertussis testing at DOH PHL based on the public
health significance of the situation. The LHJ, in consultation with the DOH
Communicable Disease Epidemiology Section, will approve samples based on the
following criteria:
1. The ill person is a health care worker
2. The ill person was in a health care environment while contagious (e.g., a new
mother who was coughing at the time of delivery)
3. The ill person has been in a situation while contagious where there are public
health concerns due to potential exposure of high risk persons* (e.g., the ill
person works in the infant room in a daycare, or the ill person teaches prenatal
classes to expectant couples)
* See Section 3E for definition of high-risk groups.

When a pertussis outbreak in the community is suspected, the LHJ may approve testing
of specimens from a few persons who do not meet the above criteria in order to confirm
pertussis as the cause of the outbreak. However, once a pertussis outbreak is confirmed,
testing of additional persons associated with the outbreak should be done through a
commercial laboratory, unless they meet the criteria for testing at DOH PHL.
Standard microbiological culturing for pertussis at private laboratories should be
encouraged for all symptomatic persons living in areas with known outbreaks. When no
other laboratory testing option is available, samples can be submitted to the PHL for
culture (only) with LHJ approval.
Note that PHL requires all clinical specimens have two patient identifiers, a name and a
second identifier (e.g., date of birth) both on the specimen label and on the submission
form. Due to laboratory accreditation standards, specimens will be rejected for testing if
not properly identified. Also include specimen source and collection date.

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C. Specimen Collection
Obtain a posterior nasopharyngeal specimen as early as possible in the illness (during the
first three weeks is optimum) and prior to administration of antibiotics. Instructions for
proper specimen collection are included in Appendix A; they can accompany health
department communicable disease staff on case investigations or be sent to health care
providers upon request. Collection and transport procedures must be followed as closely
as possible for the best results.
An information sheet containing information about criteria for testing through PHL and
the requirement that health care providers contact the local health jurisdiction for
approval to test at PHL will now be included in the pertussis test kits supplied by PHL. If
testing is to be done at PHL, be sure to include a completed PHL Microbiology Form
with the submission (http://www.doh.wa.gov/EHSPHL/PHL/Forms/Microbiology.pdf).
5. ROUTINE CASE INVESTIGATION
Interview the case and others who might be able to provide pertinent information.
A. Evaluate the Diagnosis
Review the clinical presentation and laboratory test results. Conduct a public health
investigation for the following:
1. All confirmed and probable cases (see Section 3C).
2. Persons with a cough illness lasting at least 2 weeks in an outbreak setting.
3. Persons with a positive PCR for B. pertussis and a compatible illness whose duration of
cough has been less than 14 days at the time of reporting.
4. Persons with an epidemiologic link to a confirmed case and a compatible illness whose
duration of cough has been less than 14 days at the time of reporting.
5. Other high-risk persons with symptoms highly suspicious for pertussis who do not meet
the probable or confirmed case definitions.
Note: For persons described in 2 and 3, follow-up on or after the 14th day after cough
onset to establish duration of cough and criteria for clinical case definition.
B. Identify Potential Sources of Infection
During the initial interview, ask about contacts who had a respiratory illnesses
compatible with pertussis during the 1 to 3 week interval prior to onset. Because mild or
atypical illnesses are common, it is not always possible to identify the actual source of
infection. If a potential source patient is identified, investigate this person as a possible
case.
C. Identify Potentially Exposed Persons
1. Identify close contacts
Identification of close contacts of cases is important for three reasons:
• High-risk asymptomatic contacts and asymptomatic household contacts need
prophylaxis.

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• Low-risk asymptomatic contacts outside of the household need to be educated about

seeking medical care and using respiratory etiquette if symptoms develop. These
contacts can also be referred to their healthcare providers to discuss post-exposure
prophylaxis.
• Symptomatic contacts may need testing, treatment or both.
Close contacts are identified through routine communicable disease interview of case or
proxy. The top priority is finding exposed high-risk contacts (e.g., children under 1 year
of age, pregnant women, healthcare workers), in order to provide prophylaxis promptly.
If groups such as a class or a sports team are identified as close contacts, it may be
helpful to obtain the name and phone number of teachers, principals, or coaches.

2. Identify settings where the case spent time while communicable and where
transmission to high-risk contacts may have occurred
These settings include schools, child care settings, workplaces, healthcare facilities and
other organizations. See Managing Special Situations below.
3. Prioritize follow-up of contacts with respiratory symptoms
Symptomatic contacts of confirmed pertussis cases may meet the confirmed case
definition at the time of initial interview and are thus reportable; like other confirmed
cases, they should be interviewed. Other symptomatic contacts of confirmed cases may
not meet the confirmed case definition at the time of interview; determine in consultation
with local health authority or CDES whether to act on these as if they were cases. For
example, investigation of a smoker with a chronic cough that is unchanged since pertussis
exposure is less urgent than inquiring after a daycare employee with a cough of 7 days
duration.
D. Environmental Evaluation: None
6. CONTROLLING FURTHER SPREAD
A. Case Management
Treat cases: Make sure that the case is being appropriately treated with antibiotics (see
Section 2H above). If a case has not had a medical evaluation, then ideally they should
be referred to a clinician for assessment, laboratory testing, and consideration of
treatment. The clinician should be made aware of the reasons for referral. If these clients
can not afford laboratory testing, the clinician may consider taking advantage of the free
pertussis culture services at PHL.
B. Infection Control Recommendations
1. Hospitalized patients should be cared for using droplet precautions; health care workers
in out-patient settings should wear surgical masks and eye protection when evaluating
proven or suspected pertussis patients. Droplet precautions should be maintained until 5
days after the patient is placed on effective therapy.
2. Work, School and Child-Care Restrictions: All cases and symptomatic contacts should be
excluded from child-care, school, and health care settings until 5 days of therapy with an
appropriate antibiotic has been completed (i.e., until day 6 after starting treatment).

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Treated persons can be considered no longer contagious after five days of antibiotics
even if they continue to cough and/or if the course of antibiotic treatment is not yet
completed. Cases who do not take appropriate antimicrobial treatment should be
excluded from childcare, school, and health care setting for 21 days from onset of
paroxysmal cough.
3. All cases and symptomatic contacts should also be taught “respiratory etiquette” and
encouraged to avoid contact with other persons at social activities, especially those
settings which might include high-risk persons.
C. Contact Management
1. Symptomatic Contacts
If a symptomatic close contact has not had a medical evaluation, then ideally they should
be referred to a clinician for assessment, laboratory testing, and consideration of
treatment. The clinician should be made aware of the reasons for referral. If pertussis is
suspected, the symptomatic contact should be excluded according to the same guidelines
used for cases. If these clients cannot afford laboratory testing, the clinician may
consider taking advantage of the free pertussis culture services at PHL.
2. Chemoprophylaxis (Asymptomatic Contacts)
Most pertussis in adults and adolescents is neither diagnosed nor reported and antibiotic
prophylaxis does not control the transmission of pertussis when it is widespread in the
community. The effort to provide antibiotic prophylaxis for pertussis must focus on
household contacts and high-risk close contacts of pertussis cases (see Section 3). All
household members and high-risk asymptomatic close contacts of pertussis cases should
receive antibiotic prophylaxis either from their healthcare provider or from the LHJ
regardless of immunization status. Other asymptomatic close contacts can discuss the
need for prophylaxis with their healthcare provider. Contacts with underlying
immunodeficiency or lung disease should contact their healthcare provider promptly.
Initiating prophylaxis more than 3 weeks after exposure has limited benefit and is not
recommended, with the exception of high-risk contacts for whom prophylaxis may be
considered for up to 6 weeks after exposure (see Section 3 for contacts considered to be
at high risk).
3. Active Immunization
Exposed children who received their third dose of DTaP 6 months or more before
exposure to pertussis should be given a fourth dose at this time. Children who have had 4
doses of pertussis vaccine should receive a booster DTaP unless a dose has been given
within the last 3 years or they are 7 years of age or older. Adolescents over age 11 who
have not received Tdap should get it at this time. Those over age 11 who received a Td
booster should receive Tdap if a 5 year interval has elapsed since the last dose. Tdap may
be given at an interval of less that 5 years if the benefits of protection outweigh the risk of
an adverse reaction.
Note: Post-exposure vaccination is not recommended as post-exposure prophylaxis, or in
place of chemoprophylaxis if indicated, but rather but to prevent future infections.

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4. Education
Advise close contacts of pertussis cases of the risk of infection; counsel them to watch for
signs or symptoms of pertussis occurring within 21 days after the last exposure. The
method for communicating with contacts will depend on the situation; schools, childcare
settings and organized groups can often be efficiently contacted by letter or handout in
collaboration with the respective administrators or leaders. If symptoms are present or
develop in these contacts, they need to understand that respiratory etiquette (see Section
8B) should be followed and medical care should be sought promptly. Remember,
providers must be made aware of the pertussis exposure in order to appropriately evaluate
and treat the contact, and in order to limit risk to others in the office. During outbreaks
and periods of increased community pertussis activity, local health care providers should
be updated on the current situation and reminded about the signs and symptoms of
pertussis, diagnostic testing options, prophylaxis/treatment recommendations and
infection control for the office by local health authorities.
D. Environmental Measures: None
7. MANAGING SPECIAL SITUATIONS
A. Case Works at or Attends School or Day Care (Probable or Confirmed Case)
1. Notification and Case Finding
a. Notify parents of children in the same classroom(s) as soon as possible but within 72
hours. Quicker notification is appropriate in settings with children under age 1 year.
In addition to providing background information on pertussis and details regarding
the exposure circumstances (e.g., date, time, setting), the notice should advise the
parents to:
i) verify their child’s pertussis immunizations and get remaining doses in the series
if necessary;
ii) report any respiratory illness that occurs within 3 weeks of last contact with the
case and seek medical care for diagnosis and appropriate treatment.
iii) obtain chemoprophylaxis for their child, if indicated.
b. Ask about pertussis-like illnesses (possible cases) among attendees or employees
within the previous 4 weeks. In settings involving children under age 1 year, all
potential cases should be investigated and necessary measures taken to stop further
transmission.
2. Preventing Further Spread
a. Assess the immunization status of all students and refer for immunization as needed.
b. Recommend prophylaxis as indicated.
c. Refer symptomatic students, teachers, volunteers, and other staff to their health care
providers for treatment and nasopharyngeal specimen collection.
d. Day care operators should notify their LHJ of any additional respiratory illness
occurring during the period of surveillance. The advisability of new admissions to
the facility should be evaluated according to level of risk for pertussis complications.

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3. Exclusion from Day Care or School (Probable or Confirmed Case)

a. All confirmed and probable cases should be excluded from childcare or school until
the 6th day after starting appropriate antimicrobial treatment (that is until 5 days are
completed).
b. Confirmed and probable cases (along with PCR-positive persons and persons with
pertussis-like symptoms who may not yet meet case definition) who do not take
appropriate antimicrobial treatment should be excluded from childcare or school for
21 days from onset of cough. If cough ceases in less than 21 days without treatment,
readmission can be discussed with local health authorities.
c. In settings where children under age 1 year have been exposed, the local health
authority may also consider excluding asymptomatic contacts who elect not to take
antibiotics or persons who are not up-to-date with pertussis immunization (especially
children who have not had the initial 3-dose series of a pertussis-containing vaccine)
for 21 days after their last date of exposure.
B. Case is a Health Care Worker
The infection control practitioner (ICP) of the affected facility should identify and refer
all symptomatic close contacts (patients and coworkers) for medical evaluation and
presumptive treatment immediately. In addition, prophylaxis should be given to all
asymptomatic health care workers with close contact because of the risk they would pose
to other patients should they develop pertussis. Asymptomatic health care workers who
have appropriately followed standard and droplet precautions (including wearing a
surgical mask) during close contact with an infected patient do not require prophylaxis.
Contacts may remain in the workplace if they comply with prophylaxis and lack
respiratory symptoms; they should be under surveillance for 21 days after their last
known exposure. Health care workers should contact the facility ICP if respiratory
symptoms develop and stay away from the workplace until 5 days of antibiotic therapy
have been completed, unless pertussis can be excluded as a cause of their symptoms (see
section 4. A. 1 and 2). If the facility has no ICP, the LHJ can consult with CDES for
guidance. Health care workers with direct patient contact should receive (or have already
received) a dose of Tdap unless contraindicated.
C. Outbreak Situations
Pertussis outbreaks are defined as two or more cases clustered in time (e.g., cases that
occur within 42 days of each other) and space (e.g., in a particular child care center or
classroom). In outbreak settings, including households, a case may be defined as a cough
illness lasting 2 weeks or longer. Outbreaks are more likely in certain settings, e.g.,
schools with a large proportion of unimmunized children or day care centers with many
infants who have not completed a primary DTaP series. Outbreaks also occur in older
students whose immunity to pertussis has waned after immunization.
If there are multiple cases of pertussis in a childcare or school setting, work with the
administration to facilitate distribution of an appropriate letter to inform
parents/guardians and staff about pertussis; local health care providers should also be
alerted. Letters can be distributed to classes, grades, extracurricular groups, or to the
entire childcare center or school depending on the situation. School-wide or community-

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wide notification through a media alert is best done by consensus with school officials
and local health department staff.
In the setting of an outbreak, lab testing of each symptomatic contact may not be
necessary or feasible. Consider limiting testing of symptomatic persons in this situation
to high-risk contacts (see Section 3 for persons considered to be at high risk). Classroom-
wide prophylaxis is generally not recommended except in high-risk settings such as child
care settings where infants under 1 year of age are cared for. In rare situations, the DOH
Immunization Program in conjunction with CDES may recommend an accelerated DTaP
schedule for infants in an attempt to provide earlier immunity for this high-risk group.
For more information on outbreak management, see
(http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm).
8. ROUTINE PREVENTION
A. Immunization Recommendations
Immunization with acellular pertussis vaccines in combination with diphtheria and
tetanus toxoids as DTaP is recommended for all children younger than 7 years of age
according to the following schedule:
Routine DTaP Vaccination Schedule
Dose Age Minimal Interval
Primary 1 2 months N/A
Primary 2 4 months 4 weeks
Primary 3 6 months 4 weeks
Primary 4 15–18 months 6 months
Booster* 4–6 years
* The booster dose is not needed if the fourth dose is given on or after the fourth birthday
For additional information regarding use of the DTaP vaccine during childhood, adverse
reactions and contraindications see the most recent Red Book.
During spring 2005, two tetanus toxoid, reduced diphtheria toxoid and acellular pertussis
vaccine (Tdap) products were licensed in the United State for use in adolescents.
BOOSTRIX® was licensed for use in persons aged 10–18 years and ADACEL™ was
licensed for use in persons aged 11–64 years. The Advisory Committee on Immunization
Practices (ACIP) currently recommends that:
1. Adolescents aged 11–18 years should receive a single dose of Tdap instead of tetanus and
diphtheria toxoids vaccine (Td) for booster immunization against tetanus, diphtheria, and
pertussis if they have completed the recommended childhood diphtheria and tetanus
toxoids and whole cell pertussis vaccine (DTP) / diphtheria and tetanus toxoids and
acellular pertussis vaccine (DTaP) vaccination series (five doses of pediatric DTP/DTaP
before the seventh birthday; if the fourth dose was administered on or after the fourth
birthday, the fifth dose is not needed) and have not received Td or Tdap. The preferred
age for Tdap vaccination is 11–12 years.

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2. Adolescents aged 11–18 years who received Td, but not Tdap, are encouraged to receive
a single dose of Tdap to provide protection against pertussis if they have completed the
recommended childhood DTP/DTaP vaccination series. An interval of at least 5 years
between Td and Tdap is encouraged to reduce the risk for local and systemic reactions
after Tdap vaccination. However, an interval less than 5 years between Td and Tdap can
be used.
3. Vaccine providers should administer Tdap and tetravalent meningococcal conjugate
vaccine (Menactra®, sanofi pasteur, Swiftwater, Pennsylvania) to adolescents aged 11–18
years during the same visit if both vaccines are indicated and available.
4. Adults <65 years who have not previously received a dose of Tdap should receive a
single dose of Tdap in place of a single dose of Td for booster immunization if the most
recent tetanus toxoid-containing vaccine was received at least 10 years earlier. Adults in
close contact with an infant aged <1 year who have not previously received Tdap should
receive a dose of Tdap; an interval as short as 2 years since the most recent Td is
suggested.
5. Healthcare personnel in hospitals and ambulatory care settings with direct patient contact
who have not previously received Tdap should receive a dose of Tdap; an interval as
short as 2 years since the most recent Td is recommended.
For additional information regarding the use of Tdap, see:
Recommendations of the Advisory Committee on Immunization Practices (ACIP).
Preventing Tetanus, Diphtheria, and Pertussis Among Adolescents: Use of Tetanus
Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccines. MMWR
2006;55(RR03):1–34.
B. Prevention Recommendations
In addition to immunization, persons should practice “respiratory etiquette” or good
health manners to stop the spread of respiratory pathogens.
Persons can keep respiratory pathogens to themselves by:
• Covering the nose and mouth with a tissue when sneezing, coughing or blowing the nose.
• Throwing out used tissues in the trash as soon as possible.
• Always washing hands after sneezing, blowing the nose, or coughing, or after touching
used tissues or handkerchiefs.
• Washing hands often when sick.
• Using warm water and soap or alcohol-based hand sanitizers to wash hands.
• Staying home if coughing and febrile.
• Seeing a doctor as soon as possible if coughing and febrile, and following their
instructions, including taking medicine as prescribed and getting lots of rest.
• If requested, using face masks provided in doctors’ offices or clinic waiting rooms.
Persons can keep pathogens away by:
• Washing hands before eating, or touching eyes, nose or mouth.

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• Washing hands after touching anyone else who is sneezing, coughing, blowing their nose,
or whose nose is running.
• Not sharing things like cigarettes, towels, lipstick, toys, or anything else that might be
contaminated with respiratory germs.
• Not sharing food, utensils or beverage containers with others.

ACKNOWLEDGEMENTS
This document is a revision of the Washington State Guidelines for Notifiable Condition Reporting and Surveillance
published in 2002 which were originally based on the Control of Communicable Diseases Manual (CCDM), 17th
Edition; James Chin, Ed. APHA 2000. We would like to acknowledge the Oregon Department of Human Services
for developing the format and select content of this document.

UPDATES
December 2007:
Section 3D: Revisions were made to the examples of close contact.
Section 6C(2): “Regardless of immunization status” was added to the following statement, “All household
members and high-risk asymptomatic close contacts of pertussis cases should receive antibiotic prophylaxis
either from their healthcare provider or from the LHJ regardless of immunization status.”
December 2008:
Section 3C: Persons with a positive PCR test and a paroxysmal cough of less than 2 weeks duration should be
classified as a “suspect” case.
Section 4C: The link to the PHL Microbiology form was updated.
March 2009:
Section 4B: The policy for testing for pertussis at PHL was revised.
October 2009:
Section 4B: The policy for testing for pertussis at PHL was clarified.
January 2011:
The Legal Reporting Requirements section has been revised to reflect the 2011 Notifiable Conditions Rule revision.

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APPENDIX A: SPECIMEN COLLECTION PROCEDURES

1. If needed, request a Bordetella pertussis Collection Kit from PHL by calling 206-418-5579.
The kit includes appropriate forms, two Dacron® polyester swabs, charcoal media (for
pertussis culture), a sterile transport tube (for pertussis PCR), shipping materials and detailed
instructions regarding collection and shipping of specimens.
2. Collect posterior nasopharyngeal specimens as soon as possible after symptoms develop.
Specimens may be collected up to four weeks after onset as long as antibiotics have not been
started.
Note: Throat specimens, nares swabs, and sputum samples are unacceptable specimens and
will not be processed.
3. Use a Dacron® or rayon swab on a flexible wire shaft to collect a nasopharyngeal specimen.
Do not use wooden shafted swabs or Calcium
alginate swabs (contraindicated for PCR testing).
Healthcare providers may consider piggybacking
two swabs if a specimen is need for both culture and
PCR.
a. Bend wire(s) so that it mimics the curve of the
nasal airway.
b. Gently pass swab(s) through the nostril to the
posterior nasopharynx. DO NOT force the
swab(s). A slight resistance will be felt when the
posterior nasopharynx is reached.
c. Rotate the swab(s) and ideally leave in place for
10 seconds or until the patient coughs.
4. Aseptically streak one nasopharyngeal swab onto the charcoal transport media for culture.
Leave the swab on top of the media. Do not stab the swab into the charcoal slant. Cut the
top of the wire with scissors so the cap of the media tub can be screwed on. Bending the
wire into the tube can introduce contamination (skin flora) into the media. If indicated, place
another swab into a sterile screw top transport tube for PCR. If able to collect only one swab,
use the charcoal transport media and submit a specimen for culture only. Swabs for PCR
will not be accepted without a swab for culture.
5. Label the tubes with the client’s name and complete all sections of the Public Health
Laboratories’ Nose and Throat form available at:
http://www.doh.wa.gov/EHSPHL/PHL/Forms/Microbiology.pdf.
6. Ship specimens at ambient temperature. They should reach the Public Health
Laboratories within 24 hours of collection. Since January 1, 2007 the required shipping
label is “Biological Substance, Category B, UN 3373”.
Please contact the Special Respiratory Unit of the Communicable Disease Microbiology
Laboratory at PHL (general: 206-418-5400, direct 206-418-5492) for handling and transport
issues not specifically addressed in these guidelines.

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