Pertussis (whooping cough)
Pertussis (whooping cough) is a highly contagious infection of the respiratory tract caused by the bacterium Bordetella pertussis. The National Advisory Committee on Immunization (NACI) recommends immunization against pertussis.
Agent of disease
Bordetella pertussis is a Gram-negative aerobic bacterium. Pertussis is primarily a toxin-mediated disease in which toxins produced by the bacteria are responsible for the majority of its clinical features.
Spectrum of Clinical Illness
The clinical course of pertussis is divided into three stages. The initial catarrhal stage is characterized by runny nose, sneezing, low-grade fever, and a mild cough, similar to a cold. After 1 to 2 weeks of gradually worsening cough, the paroxysmal stage begins.
The paroxysmal stage is characterized by bursts of rapid coughing, ending with an inspiratory whoop and sometimes post-tussive vomiting. This stage can last from 2 to 8 weeks. In the convalescent stage, recovery is gradual and may take weeks to months.
The clinical course varies with age. In young infants, who are at the highest risk, clinical symptoms are frequently atypical. Whoop and post-tussive vomiting may be absent. The presentation may be characterized solely by episodes of apnea. Serious complications occur mainly in infants and may include pneumonia, atelectasis, seizures, encephalopathy, hernias and death.
Pertussis may be milder in adolescents and adults but symptoms can range from asymptomatic infection to a very prolonged, debilitating cough. Pertussis is a common and often unrecognized cause of cough persisting for over 2 weeks in adolescents and adults.
Complications in adolescents and adults include sleep disturbance, rib fractures, subconjuctival haemorrhages, rectal prolapse, and urinary incontinence, all from intense and persistent coughing. Adolescents and adults with a cough, and less so in those who are asymptomatic, are a source of infection for those most at risk, namely infants.
Pertussis is highly communicable with studies showing 80% secondary attack rates among susceptible household contacts. Pertussis is usually transmitted by the respiratory route through inhalation of respiratory droplets; indirect spread through contaminated objects occurs rarely, if at all. The incubation period is 9 to 10 days (range, 6 to 20 days) and may rarely be as long as 42 days.
Infectiousness is greatest during the catarrhal stage and during the first 2 weeks after cough onset. In general, an individual should be considered infectious from the beginning of infection to 3 weeks after onset of coughing, if not treated with antibiotics. Patients are no longer contagious after 5 days of appropriate antibiotic treatment.
Disease Distribution (Global)
Pertussis is endemic worldwide and occurs year round, even in regions with high vaccination coverage. The World Health Organization (WHO) has estimated that, there are between 20-40 million cases of pertussis worldwide, 95% of which were in developing countries.
Incidence rates are highest among young children in countries where vaccination coverage is low. With approximately 400,000 deaths per year, pertussis remains one of the leading causes of death among non-immunized children, mainly in developing countries.
As a result of widespread immunization programs, proper nutrition and good medical care pertussis incidence has decreased in high income countries.
Highest pertussis rates are typically reported in unimmunized infants and adolescents, while mortality is rare in industrialized countries and is estimated to occur in 1 out of every 1000 unprotected children, the most vulnerable cohort. Pneumonia is the most common cause of death, principally occurring in infants less than 6 months of age.
Information about immunization requirements and recommendations related to travel can be found in the Canadian Immunization Guide.
Pertussis can affect individuals of any age; however, severity is greatest among infants who are too young to be protected by a complete vaccine series. Young infants are also at highest risk of pertussis-associated complications.
Immunity to pertussis from childhood vaccination and natural disease wanes with time; therefore, adolescents and adults who have not received a booster vaccination are at risk of infection and its consequent transmission of the bacteria to others.
Prevention & control
Pertussis can be prevented by immunization. Primary immunization for all children is recommended at 2, 4 and 6 months of age. Booster doses are recommended at 12 to 23 months (generally given at 18 months of age), 4 to 6 years, and 14 to 16 years of age.
One dose of acellular pertussis-containing vaccine (Tdap) vaccine should be administered to adults if they have not previously received pertussis vaccine in adulthood (18 years of age and older).
Immunization for pregnant women is ideally recommended at 27-32 weeks of gestation, irrespective of previous Tdap immunization history. Immunization between 13 and 26 weeks of gestation or later on in pregnancy may also be considered if the 27-32 week window was missed, please refer to the most recent version of the Canadian Immunization Guide for these considerations.
For further information about the immunization recommendations, please refer to the most recent version of the Canadian Immunization Guide.
Cases of pertussis should be reported to the local health authority. Confirmed and suspected cases should be isolated from young children and infants until the patients have received at least 5 days of antibiotics.
Suspected cases who do not receive antibiotics should be isolated for 3 weeks after onset of paroxysmal cough or until the end of cough, whichever comes first.
Contacts, especially children, must have their immunization status verified. If immunization status is incomplete and no contraindications are identified, recommended doses of vaccine should be given.
Vaccinating pregnant women increases maternal antibody transfer providing immediate protection to the vulnerable newborn who is not yet immunized. Vaccinating pregnant women also prevents them from acquiring infection that they may pass onto their newborn baby.
Specific disease management and control guidelines may be available at the provincial, territorial, or local level.
Epidemiology of Pertussis in Canada
Pertussis is a cyclical disease, which peaks at two to five year intervals. With the introduction of whole cell pertussis vaccine in 1943, the incidence of pertussis decreased significantly, from an average of 156 cases per 100,000 population in the five years prior to vaccine introduction, to a low of 5 cases per 100,000 (2005 to 2011). Refer to Figure 1.
A resurgence of pertussis was observed beginning in 1990, likely due to a combination of factors including:
- low effectiveness of the combined diphtheria-tetanus-whole cell pertussis vaccine used in children between 1980 and 1997;
- waning immunity among adolescents and adults;
- increased physician awareness; and
- improved diagnosis and reporting of pertussis infection.
The whole cell pertussis vaccines were replaced with acellular pertussis vaccines in 1997/1998, which was followed by a steady decline incidence to 2.0 cases per 100,000 in 2011.
A seven-fold increase in national incidence to 13.9 per 100,000 was observed in 2012, due to outbreaks in multiple jurisdictions across the country.
The incidence of pertussis is highest in infants and children, and decreases significantly in those older than 14 years (refer to Figure 2).
The highest mean incidence rates from 2005 to 2011 were:
- 72.2 cases per 100,000 population among infants less than 1 year of age (mean: 261 cases per year),
- 25.6 cases per 100,000 population among 1 to 4 year olds (mean: 362 cases per year), and
- 16.0 cases per 100,000 population among 10 to 14 year olds (mean: 328 cases per year).
Following the introduction of a single adolescent dose of acellular pertussis vaccine in 2004, between 2005 and 2011, the incidence of pertussis decreased in all age groups, most notably among those aged 10 to14 years (84% decrease) and those aged 15 to 19 years of age (81% decrease).
During the 2012 outbreak, increases in incidence were observed across all age groups nationally, with the highest incidence rates in those less than one year (120.8 per 100,000; n=460) and those 10-14 years of age (64.1 per 100,000; n=1203).
Hospitalization and death are more common among infants, particularly those 3 months of age or less.
One to four deaths related to pertussis occur each year in Canada, typically in infants who are too young to be immunized, or children who are unimmunized or only partially immunized.
More detailed information on the epidemiology of pertussis in Canada can be found in the Canadian Communicable Diseases Report.
*Case data from 1924 to 2011 were obtained from the Canadian Notifiable Diseases Surveillance System. Case data for 2012 were obtained directly from provinces and territories by CIRID and are preliminary. PEI did not report 1924-1928; Newfoundland did not report until 1949; Yukon did not report 1924-1955; Northwest Territories did not report 1924-1958; Nunavut data for 1999 are only partial, for 2007 & 2009 are missing, and for 2008, 2010-2011 are preliminary
Text Equivalent - Figure 1
Figure 1. Reported cases and incidence rate (per 100,000 population) of pertussis in Canada by year, 1924 to 2012*
*Case data from 1924 to 2011 were obtained from the Canadian Notifiable Diseases Surveillance System. Case data for 2012 were obtained directly from provinces and territories by CIRID and are preliminary. PEI did not report 1924-1928; Newfoundland did not report until 1949; Yukon did not report 1924-1955; Northwest Territories did not report 1924-1958; Nunavut data for 1999 are only partial, for 2007 & 2009 are missing, and for 2008, 2010-2011 are preliminary. Population data (July 1st annual estimates) were obtained from Statistics Canada.
This is a combined bar and line graph showing the number of pertussis cases, in bars, and the incidence rate of pertussis per 100,000 population, using a line, in Canada over time. The primary y axis is the number of cases and ranges from 0 to 25,000. The secondary y axis is the incidence rate per 100,000 population and ranges from 0 to 250 cases per 100,000. The x axis is year and ranges from 1924 to 2012. The years in which immunization programs were introduced are also depicted as follows:
1943 = whole cell vaccine
1981 to 1985 = adsorbed whole cell vaccine
1997 to 1998 = acellular vaccine
1999 to 2004 = adolescent acellular vaccine
The overall trend of the graph can be broken down into six sections:
- An increase between 1924 and 1934, with cases increasing from 6,377 to 19,484 and incidence rate increasing from 68 to 181 cases per 100,000.
- Stable between 1935 and 1943, with the number of cases ranging between 16,003 and 19,878 and the incidence rate ranging between 144 and 175 cases per 100,000.
- A decrease from 1943 to 1975 and stable until 1989, at which point cases ranged between 1301 and 3387 and incidence rates between 5 and 13 cases per 100,000.
- A re-emergence in the 1990s with major peaks in activity occurring in 1990 (cases= 8,330; incidence rate= 30 cases per 100,000), 1994 (cases=10,117; incidence rate= 35 cases per 100,000) and 1998 (cases=8,896 incidence rate= 30 cases per 100,000).
- A decrease from 1998 to 2011, with cases and incidence rate declining steadily to 697 cases and an incidence rate of 2 cases per 100,000.
- A sharp increase in 2012 to 4,845 cases and an incidence rate of 13.9 per 100,000.
Within each overarching trend described above, peaks in activity are observed every 2 to 5 years.
*Case data from 1980 to 2011 were obtained from the Canadian Notifiable Diseases Surveillance System. Case data for 2012 were obtained directly from provinces and territories by CIRID and are preliminary. Nunavut data for 1999 are only partial, for 2007 & 2009 are missing, and for 2008, 2010-2011 are preliminary; Population data (July 1st annual estimates) was obtained from Statistics Canada.
Text Equivalent - Figure 2
Figure 2. Incidence rate (per 100,000 population) of pertussis reports in Canada by age group (in years) and year, 1980 to 2012*
*Case data from 1980 to 2011 were obtained from the Canadian Notifiable Diseases Surveillance System. Case data for 2012 were obtained directly from provinces and territories by CIRID and are preliminary. Nunavut data for 1999 are only partial, for 2007 & 2009 are missing, and for 2008, 2010-2011 are preliminary. Population data (July 1st annual estimates) were obtained from Statistics Canada.
This is a line graph that shows the incidence rate of pertussis per 100,000 population by age group in years in Canada over time. The y axis is the incidence rate per 100,000 population and ranges from 0 to 300. The x axis is year and ranges from 1980 to 2012. In the graph there is a line for each of 11 age groups (<1, 1 to 4, 5 to 9, 10 to 14, 15 to 19, 20 to 24, 25 to 29, 30 to 39, 40 to 59, >60, and unknown); however, the incidence rates of cases over 15 years of age and of those with unknown age are so low compared to the younger age groups the values are not discernible.
The less than one year age group has the highest incidence each year. The second highest incidence rate is the 1 to 4 year age group from 1980 to 1996, the 5 to 9 age group from 1997 to 1999, the 10 to 14 age group from 2000 to 2005, the 1 to 4 age group from 2006 to 2011 and the 10 to 14 age group in 2012. The less than one group had its lowest incidence in 1984 with 25 cases per 100,000 and highest incidence in 1994 with 270 cases per 100,000. In 2012, the less than one group had 121 cases per 100,000.
Pertussis Surveillance in Canada
Health professionals in Canada play a critical role in identifying and reporting cases of pertussis. See the Surveillance section for more information on pertussis surveillance in Canada.
- Vaccination and pregnancy (fact sheet)
- Pertussis Surveillance in Canada: Trends to 2012 (2014)
- Preliminary results from the 2017 childhood National Immunization Coverage Survey (cNICS)
Pertussis Guidelines and Recommendations
- Update on Immunization in Pregnancy with Tetanus Toxoid, Reduced Diphtheria Toxoid and Reduced Acellular Pertussis (Tdap) Vaccine (2018)
- Literature review on immunization in pregnancy with tetanus toxoid, reduced diphtheria toxoid and reduced acellular pertussis (Tdap) vaccine: safety, immunogenicity and effectiveness (2018)
- Statement on the booster for 4-6 year-olds for protection against pertussis, February 2014
- Statement on the recommended use of pentavalent and hexavalent vaccines, February 2007 (archived)
- Interval Between Administration of Vaccines Against Diphtheria, Tetanus, and Pertussis, October 2005 (archived)
- Interchangeability of Diphtheria, Tetanus, Acellular Pertussis, Polio, haemophilus Influenzae Type B Combination Vaccines Presently Approved for Use in Canada for Children <17 Years of Age, February 2005 (archived)
- Clarification: Prevention of pertussis in adolescents and adults, March 2004 (archived)
- Prevention of Pertussis in Adolescents and Adults, September 2003 (archived)
- Statement on Adult/Adolescent Formulation of Combined Acellular Pertussis, Tetanus, and Diphtheria Vaccine, May 2000 (archived)
Other Resources on Pertussis
- National case definition: Pertussis
- Canadian Immunization Guide
- Provincial/Territorial Immunization Programs
- Canada Communicable Disease Report (CCDR)
- National Advisory Committee on Immunization (NACI)
- Travel Vaccines
- Vaccine Safety
- Additional Information for professionals on Immunization & Vaccines
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