Reported cases of pertussis have reached a 40-year high, according to the Centers for Disease Control and Prevention (CDC) in Atlanta. Pertussis cases have increased from a low of 1,020 in 1976 to more than 19,000 cases in 2004.

Preteens and teens are thought to be most at risk, because protective immunity from early childhood pertussis vaccination wanes 5 to 10 years after the patient's last dose. To address these concerns, the CDC's Advisory Committee on Immunization Practices (ACIP) in June recommended that 11- and 12-year-olds be given newly licensed tetanus, diphtheria, and pertussis (Tdap) boosters to help reduce the number of pertussis cases among adolescents. Previously, a booster containing only tetanus and diphtheria (Td) was recommended for adolescents.

New Vaccines Meet Immunization Needs
The US Food and Drug Administration (FDA) licensed GlaxoSmithKline's Boostrix Tdap vaccine for adolescents in May, and in June it licensed Sanofi Pasteur's Adacel Tdap vaccine. Boostrix is licensed for patients ages 10 through 18, and Adacel is licensed for patients ages 11 through 64. The ACIP also recommended that two additional groups receive the Tdap vaccine: adolescents ages 13 to 18 who missed their age 11 to 12 dose of Td and adolescents ages 11 to 18 who have already been vaccinated with Td.

In a press release from the CDC, Steve Cochi, MD, acting director of the CDC's National Immunization Program, said treatment of pertussis is effective only if given early—often before symptoms are recognized as pertussis. "Therefore, vaccination is the best way to prevent suffering from pertussis," he said. "This recommendation is an important step in reducing this potentially serious disease." Given that pertussis can be a life-threatening disease in infants, Cochi advised parents to vaccinate their children on time: at 2, 4, 6, and 15 to 18 months and between ages 4 and 6.

The ACIP did not make a recommendation for the use of Tdap in adults. The group will consider adult Tdap immunization at a later date to allow members more time to review adult pertussis immunization data.

A Sports Medicine Issue?
A. J. Grove, MD, a pediatrician and sports medicine physician at Columbia Park Medical Group in Andover, Minnesota, says he has noted a number of pertussis outbreaks in his community, including one that involved a girl's hockey team. He says most cases are clustered in the middle school age-group, though some patients have been high school students. "Even this summer we saw sporadic cases, but the disease activity seemed primarily in the winter," he says.

Grove says team members are at risk when a player has pertussis. "Pertussis is highly contagious, with an airborne spread and from contact with nasal secretions," he says. "Teams are in close contact, and sick players often hack and cough on the bench, as well as share water bottles."

When a player is diagnosed as having pertussis, the team should be informed and the teammates tested. Prophylactic treatment may be appropriate for the teammates and household contacts, he says, noting that the larger concern is when a young, active patient who has pertussis puts younger siblings at home at risk.

Observing community pertussis patterns and having a high index of suspicion when a patient has paroxysmal coughing are the keys to diagnosis, Grove says. "If in doubt, I test," he says. Grove says he anticipates that his clinic will adopt the ACIP pertussis booster recommendations quickly as it did for the meningitis vaccine.

When an athlete is diagnosed as having pertussis, Grove usually recommends that he or she stay home during the first 5 days of treatment. Fatigue from the coughing is a concern for many athletes, he says. The usual pharmacologic treatment is 14 days of erythromycin or a 5-day course of azithromycin. "If a patient has more severe disease, I usually go with the erythromycin because it's still the established treatment of choice," Grove says.