ROYAL FREE LONDON NHS FOUNDATION TRUSTCHILDREN SERVICES GUIDELINES

Management of Whooping Cough (Bordetella Pertussis Infection)

(Cross site RFH & BH guideline)

Author(s): Dr Karnika Raja (ST8 Paediatrics)

Contact author: Dr Karnika Raja (ST8 Paediatrics)

Other contributors: Dr Rahul Chodhari, Dr Stephanie Paget, Chloe Benn

Previous authors: Dr Robin Basu-Roy (SpR Paediatrics)

Related guidelines or documents:

Approved by/date: The Women Services Guidelines Group on behalf of the

Women, Children and Imaging Services Division

Issue no (Version): Month Year (version no.)

File name: Management of Whooping Cough (Bordetella Pertussis

Infection)

Key words: (up to 10) Whooping cough, pertussis, pernasal swab

Supercedes: Clinical guideline for the management of confirmed/ suspected Bordetella Pertussis infection 2013

Significant change in practice:

New Public Health England guidelines 2016- change in antibiotic

policy, immunisation programme for pregnant women

Stakeholders consulted Paediatric Consultants, Microbiology Consultants,

Pharmacist

Target clinical audience Paediatrics, Staff on Galaxy and 6 North, ED cross site

Implementation and launch plan:

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Audit/monitoring plan SEE APPENDIX ONE

Service Line Lead Paediatrics: Rahul ChodhariClinical Director Tim WickhamDirector of Midwifery Mai Buckley

Date for review: Month Year or in response to practice developments

ContentsINTRODUCTION..........................................................................................................2WHEN TO SUSPECT PERTUSSIS..............................................................................2WHAT TO DO IF SUSPECTING PERTUSSIS...........................................................2NOTIFICATION............................................................................................................4MANAGEMENT OF SUSPECTED OR CONFIRMED PERTUSSIS AND OF CONTACTS...................................................................................................................4WHEN TO CONSIDER ADMISSION.........................................................................5PREVENTION...............................................................................................................6MONITORING COMPLIANCE...................................................................................6REFERENCES...............................................................................................................6EQUALITY STATEMENT...........................................................................................7APPENDIX 1: MONITORING TOOL..........................................................................8APPENDIX 2: EQUALITY ANALYSIS checklist.....................................................10

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INTRODUCTION

Pertussis (whooping cough) is an acute bacterial infection caused by Bordetella pertussis, an exclusively human pathogen. Transmission occurs as a result of close direct contact with an infected person. It is highly contagious, with up to 90% of household contacts developing the disease. The incubation period of pertussis is on average between 7-10 days (range 5-21 days). The disease is cyclical with peaks occurring every 3-4 years (latest in 2008 and 2012).

WHEN TO SUSPECT PERTUSSIS

Young unimmunised infants are the most vulnerable group with the highest rates of complications and death.

There are 3 identified stages:1. Catarrhal stage (1-2 weeks) - Mild symptoms with fever, cough and coryza.2. Paroxysmal stage (2-6 weeks) - Paroxysms of cough which usually increase in

frequency and severity as the illness progresses. These paroxysms may end in vomiting, cyanosis and/or a characteristic inspiratory whoop, although whoop may be absent in babies.

3. Convalescent phase (2-6 weeks but can persist longer) - Improving of symptoms.

Patients are most infectious in the initial catarrhal stage and during the first 3 weeks after the onset of cough.

Atypical presentations may occur in young infants and in vaccinated individuals Catarrhal stage very short or absent Paroxysms of cough are common, resulting in

- Gagging- Apneoa- Cyanosis- Bradycardia

Infants may appear well in between episodes.

Complications include weight loss, subconjunctival haemorrhages, epistaxis, otitis media, and in more severe cases, pneumonia, seizures, encephalitis and death in 1% of all infected infant and unvaccinated children.

WHAT TO DO IF SUSPECTING PERTUSSIS- INVESTIGATIONS

Bloods: There may be leucocytosis on FBC

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Microbiology: Upto 3 weeks of onset of cough > 2 weeks post onset

Any age Pernasal swab for PCR (reference lab)Pernasal swab for culture (Barnet/RF lab)*

Serum for serology (not recommended if vaccinated <1 year ago, or in infants <12 months). Consider alternative diagnoses and if clinical concerns, discuss with Microbiology

*Samples are sent to Colindale and should reach lab as early as possible.

B. pertussis is a delicate organism and therefore processing delays may affect likelihood of a positive culture. Sensitivity is also highly dependent on specimen quality and is affected by increasing patient age, vaccination status and length of illness. THEREFORE A NEGATIVE CULTURE DOES NOT EXCLUDE PERTUSSIS.

How to take swab

1. Get correct swab (Blue lid with wire stalk in Amies medium) 2. Ensure child held still3. Lift the tip of the nose4. Without touching the nostrils insert the swab along the floor of the nose until

you reach the palate5. Rotate swab to improve sampling

How to send off

Request on Powerchart/Cernero If sending PCR/cultures–request ‘pernasal swab–pertussis’ o If sending serology–request ‘Bordetella antibodies’

Fill in the HPA form attached here

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NOTIFICATION

Suspected cases should be notified to the local health protection team (HPT) by telephone as soon as is practicable and in writing within 3 days.

For confirmed cases, written notification from all diagnostic laboratories to their local HPT is required within 7 days of the agent being identified, or if the case is considered to be urgent, the HPT should be notified by phone promptly.

If contacted by microbiology with a positive result, Paediatric Matron on site will notify public health and speak to family about review by their GP. Common numbers include North London HPU – 0203 8377084, some of the BCF patients will fall into the South Herts catchment – 03003038537.

MANAGEMENT OF SUSPECTED OR CONFIRMED PERTUSSIS AND OF CONTACTS

General See next section for when to admit. Supportive care is the mainstay of treatment. Avoidance of known triggers for coughing paroxysms

o Exerciseo Cold temperatureso Nasopharyngeal suctioning

Management of contacts See table below for those at risk For contacts of inpatient, the clinical team is responsible (in liaison with

Infection Control and Microbiology) For contacts of patients in community discussion with the local Health

Protection Unit (HPU) is required

Antibiotics/Chemoprophylaxis Should ideally be administered as soon as possible after onset of symptoms

to eradicate organism and limit ongoing transmission In neonates the preferred agent for use is oral Clarithromycin

7.5mg/kg twice daily for 7 days

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For those over 1 month antibiotic of choice is oral Azithromycin 10mg/kg (max 500mg) once daily for 3 days

For those requiring hospital admission and not tolerating oral antibiotics, use Clarithromycin IV 7.5 mg/kg (max. 500 mg) every 12 hours 7.5 mg/kg (max. 500 mg) every 12 hours for 7 days.

If macrolides are contra-indicated or not tolerated, co-trimoxazole may be used although this is not licensed in infants below 6 weeks of age.

Oral co-trimoxazole dose: 6 weeks to 5 months: 120mg twice a day for 7 days6 months to 5 years: 240mg twice a day for 7 days6 to 11 years: 480mg twice a day for 7 days12 to 17 years: 960mg twice a day for 7 days

Chemoprophylaxis of close contacts in a priority group (see table below) is the same choice of antibiotic and dose as of treatment.

Contacts should be advised to see their GP for prescription of prophylaxis, as they are best placed to assess appropriate choice of treatment based on the medical history.Adult prophylaxis doses Oral Azithromycin 500mg once a day for 3 daysOral co-trimoxazole 960mg twice a day for 7 daysPregnant women: Preferred antibiotic Erythromycin (-not known to be harmful). Oral Erythromycin 500 mg every 6 hours for 7 days

Exclusion from nursery/school (see Flowchart below)

Vaccination (see Flowchart below)Vaccination in pregnant women is recommended from 16 weeks to 32 weeks of pregnancy, but can be given upto 38 weeks. If not given in pregnancy, it can be given to mother in the first two months following birth.

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WHEN TO CONSIDER ADMISSION

Hospitalization is indicated if there is:

Respiratory distress Evidence of pneumonia Inability to feed Cyanosis or apnoea Seizures <3 months of age

In infants 3 months – 1 year have a low threshold for admission & discuss with senior before discharge

In infants and children that require hospitalisation, supportive care is the mainstay of treatment. This includes

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Respiratory support- this can range from low flow nasal cannula oxygen to high flow oxygen therapy (e.g Vapotherm/Optiflow) to CPAP.

In the event of persistent or prolonged apnoeas, or increasing FiO2 requirement (to >50%) please seek urgent senior/consultant and anaesthetic review.

Feeding support- Where oral feeding is not tolerated, consider NG feeds in infants whenever possible. Those that have marked respiratory distress may require IV fluids.

Severity of illness is unpredictable. Clinical decline may occur rapidly without warning.

PREVENTION

Vaccination provides the most effective strategy for preventing pertussis transmission and the current vaccination schedule is as follows:

- Primary schedule- 3 primary doses at 2,3 and 4 months of age- Booster at pre-school age (3 years 4 months to 3 years 6 months)- Temporary immunisation programme for pregnant women at around 20

weeks’ gestation (introduced by DOH in 2015 in response to marked increase in infant deaths).

MONITORING COMPLIANCE

This guideline will be subject to annual audit and multidisciplinary review as described in the monitoring table in Appendix 1.

REFERENCES

1. Public Health England: Guidelines for the Public Health Management of Pertussis in England. July 2016. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/541694/Guidelines_for_the_Public_Health_Management_of_Pertussis_in_England.pdf

2. Green Book for Notifiable Diseases: Chapter 24 Pertussis. April 2016. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/514363/Pertussis_Green_Book_Chapter_24_Ap2016.pdf

3. NICE Clinical Knowledge Summaries: Whooping Cough. Last Revised July 2015. https://cks.nice.org.uk/whooping-cough#!topicsummary

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4. Tiwari T, Murphy T V, Moran J. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines. MMWR Recomm Rep 2005;54(RR-14):1–16. https://www. cdc .gov/mmwr/PDF/rr/rr5414.pdf

EQUALITY STATEMENT

The equality analysis for this guideline is in Appendix 2.

The Royal Free London NHS Foundation Trust is committed to creating a positive

culture of respect for all individuals, including job applicants, employees, patients,

their families and carers as well as community partners. The intention is, as required

by the Equality Act 2010, to identify, remove or minimise discriminatory practice in

the nine named protected characteristics of age, disability (including HIV status),

gender reassignment, marriage and civil partnership, pregnancy and maternity, race,

religion or belief, sex or sexual orientation. It is also intended to use the Human

Rights Act 1998 to treat fairly and value equality of opportunity regardless of socio-

economic status, domestic circumstances, employment status, political affiliation or

trade union membership, and to promote positive practice and value the diversity of

all individuals and communities.

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APPENDIX 1: MONITORING TOOL

Element to be monitored

Lead Tool Frequency Reporting arrangements

Acting on recommendations and Lead(s)

Change in practice and lessons to be shared

Number of per nasal swabs sent/Positive rates

Micro Consultants

Once every six months

@ CD meeting

Or

Data sent to Service Line Lead

Identify and promote correct specimen collection – Lead by Micro team

Micro advise and review once every year.

Support GP’s for poor vaccination program by identifying cluster of cases.

PICU transfer of whooping case

Attending consultant

SI review

Ad hoc Risk meeting Nursing assessment/training – Mike Cliff

Medical management – Attending consultant

Share learning in risk newsletter.

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APPENDIX 2: EQUALITY ANALYSIS CHECKLIST

Go through each protected characteristic below and consider whether the policy, practice, function, business case, project or service change could have any impact on groups from the identified protected characteristic, involve service users where possible and get their opinion, use demographic / census data (available from public health and other sources), surveys (past or maybe carry one out), talk to staff in PALS and Complaints and Patient Experience. Please ensure any remedial actions are Specific, Measureable, Achievable, Realistic, and Timely( SMART).

Equality Group Identify negative impacts

What evidence, engagement or audit has been used?

How will you address the issues identified?

Identifies who will lead the work for the changes required and when?

Please list positive impacts and existing support structures

Age This guideline clarifies support to pregnant mothers when an index case (child) presents to hospital. All eligible mothers will be supported by medical team for vaccination. This is particularly relevant as half of our mothers are born outside UK and represents a vulnerable group.

Disability

Gender Reassignment

Marriage and Civil Partnership

Pregnancy and maternity None.Literature review and following state of the art guidance from Public Health England

Review of the notes. Attending consultant

medical team.

Equality Group Identify negative impacts

What evidence, engagement or audit has been used?

How will you address the issues identified?

Identifies who will lead the work for the changes required and when?

Please list positive impacts and existing support structures

Race

Religion or Belief

Sex

Sexual Orientation

Carers

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