Whooping cough in children protocol. Causes, treatment and methods of preventing whooping cough in children

Currently, the problem of whooping cough is again relevant for practical health care in all countries of the world. Despite the vaccine prevention of this disease carried out for more than 50 years, the intensity of the epidemic process and morbidity rates have been steadily increasing since the late 90s of the 20th century.

At the same time, an increase in the number of manifest forms of whooping cough creates conditions for the involvement of children in the first months of life in the epidemic process, which is associated with an increase in the severity of the disease and mortality, and atypical, clinically unexpressed forms lead to a lack of alertness among clinicians to this infection from the first days of the disease, which are most favorable for laboratory diagnostics.

Etiology of whooping cough

Whooping cough is an acute airborne infection caused by microorganisms of the type Bordetella pertussis , characterized by damage to the mucous membrane mainly of the larynx, trachea, bronchi and the development of convulsive paroxysmal cough.

The bacteria that cause whooping cough were first isolated from a sick child in 1906 by two scientists - the Belgian Jules Bordet (the genus is named after him) and the Frenchman Octave Zhangou (in honor of both of them, the causative agent of whooping cough is also called the Bordet-Gengou bacillus). In addition to describing the microbe, they developed a nutrient medium for its cultivation, which is widely used to this day and is also called Bordet-Gengou medium in their honor.

In modern taxonomy, Bordetella belongs to the domain Bacteria, order Burcholderiales, family Alcoligenaceae, genus Bordetella. Within the genus, 9 species are described, 3 of which are predominantly pathogenic for humans:

• most often the disease is caused by B. pertussis, the causative agent of whooping cough, an obligate human pathogen;
• B. parapertussis is the causative agent of parapertussis (whooping cough-like disease, clinically similar to whooping cough), also isolated from some animals;
• B. trematum is a causative agent of wound and ear infections, described relatively recently.

There are 4 more species that are causative agents of animal diseases, but are also potentially pathogenic for humans (they cause infections in especially rare cases, usually in immunocompromised patients):

• B. bronchiseptica is the causative agent of bronchisepticosis (whooping cough-like disease of animals, in humans it occurs as an acute respiratory infection);
• B. ansorpii, B. avium, B. hinzii. B. holmesii is isolated only from humans, usually during invasive infections (meningitis, endocarditis, bacteremia, etc.), but the etiological role of this species in the development of infections has not been proven.
• B. petrii is the only representative of the genus isolated from the environment and capable of living in anaerobic conditions, but the possibility of its long-term persistence in humans has been described.

Previously, until the 30s of the last century, Bordetella was erroneously assigned to the genus Haemophilus only on the grounds that it was necessary to add human blood to the media for their cultivation.

Most media are still filled with defibrinated human blood. However, Breadford in later studies showed that blood is not a growth factor for Bordetella and an essential component during cultivation, but plays more of an adsorbent role for toxic metabolic products of bacteria.

In terms of genotype and phenotypic properties, Bordetella also differ significantly from Hemophilus, which was proven by Lopes in the 50s of the 20th century. This made it possible to distinguish them into an independent genus.

Epidemiology of whooping cough

It is necessary to note the epidemiological features of whooping cough. This is a strict anthroponosis, in which the main source of infection is a sick person; bacterial carriage, as yet considered, has no epidemiological significance and has not been registered in communities free from whooping cough, and among recovered children it accounts for no more than 1-2%, with a short duration it (up to 2 weeks).

Whooping cough is classified as a “childhood infection”: up to 95% of cases are detected in children and only 5% in adults. Although the real frequency of whooping cough in adults can hardly be reflected in official statistics due to incomplete registration of all cases, firstly, due to the prejudice of therapists about the age category susceptible to this infection - and therefore low alertness towards it, and secondly, because whooping cough in adults often occurs in atypical forms and is diagnosed as acute respiratory infections or acute respiratory viral infections.

Transmission mechanism The disease is aerogenic, and the path is airborne. The susceptibility of the population in the absence of pertussis immunity is very high - up to 90%.

But despite this, as well as the massive release of the pathogen into the external environment, transmission is only possible through close, long-term communication for the following reasons: the aerosol that is created when a patient with whooping cough coughs is coarse and quickly settles on environmental objects, spreading within a radius of no more than 2- 2.5 m, and its penetration into the respiratory tract is low, since large particles are retained in the upper respiratory tract.

In addition, Bordetella pertussis is not resistant to natural environmental factors - to insolation (both to UV rays and elevated temperatures), and at 50°C they die within 30 minutes when they dry out. However, wet sputum exposed to environmental objects can persist for several days.

Analyzing the incidence of whooping cough, let us remember that in the pre-vaccination period, before 1959, in our country it reached 480 cases per 100 thousand population with a very high mortality rate (0.25% in the structure of total mortality, or 6 per 100 thousand); by 1975, due to the success of mass vaccination with the DPT vaccine, the incidence rate dropped to 2.0 per 100 thousand, and this was a record low level, and the mortality rate decreased several hundred times and is now recorded in isolated cases - no more than 10 per year.

By the end of the 20th century and to the present day, there has been a steady annual increase in whooping cough incidence rates. Thus, in 2012, compared to 2011, it increased almost 1.5 times and amounted to 4.43 and 3.34 cases per 100 thousand population, respectively. Traditionally, the incidence is higher in megacities (St. Petersburg has occupied first place in the Russian Federation in recent years).

It should be noted that the actual incidence of whooping cough is apparently even higher than the statistical figures. This may be due to incomplete registration due to the presence of a large number of “atypical” forms of whooping cough, the lack of reliable laboratory diagnostic methods, the difficulty of differentiating from parawhooping cough, etc.

Features of whooping cough of the modern period are:

• “adulting” is an increase in the proportion of sick children in the age group of 5-10 years (the maximum occurs at 7-8 years), since the emerging post-vaccination immunity is not strong enough and long-lasting and by the age of 7 a significant number of children who are not immune to whooping cough accumulate (more 50%)); in connection with this, foci of infection appeared mainly in secondary schools with repeated cases of disease in organized groups;
• recent periodic rises occur against the backdrop of increased vaccination coverage among young children (for the above reason);
• the return of the highly toxic strain 1, 2, 3 (this serovariant circulated and predominated in the pre-vaccination period, in the first 10 years of vaccine prevention it was replaced by serovariant 1.0.3) and a large number of moderate and severe forms of whooping cough; now serovariant 1, 2, 3 occurs in 12.5% ​​of cases, isolated mainly from young, unvaccinated children with severe whooping cough;
• dominance of serovariant 1, 0, 3 (up to 70% among “deciphered cases”), which is isolated mainly from vaccinated people and patients with a mild form;
• an increase in the number of atypical forms of whooping cough.

Biological properties of the pathogen

The causative agents of whooping cough are gram-negative small rods, the length of which is close to the diameter, and therefore resemble oval cocci under microscopy, called coccobacteria; have a microcapsule, pili, are immobile and do not form spores.

They are aerobic, develop better in a humid atmosphere at a temperature of 35-36°C, and are “fastidious” or “capricious” bacteria with complex nutritional needs in terms of cultivation conditions. In addition to the nutritional base and growth factors, nutrient media must include adsorbents of toxic metabolic products of Bordetella, which are actively released during their life activity.

There are 2 types of adsorbents:

• defibrinated human blood, added in an amount of 20-30% to Bordet-Gengou medium (potato-glycerin agar) and which is not only an adsorbent, but also an additional source of native proteins and amino acids;
• activated carbon, used in semi-synthetic media such as casein charcoal agar (CCA), bordetellagar. The quality of semi-synthetic media can be improved by adding 10-15% defibrinated blood.

Colonies of the pertussis microbe are small (about 1-2 mm in diameter), very convex, spherical, with smooth edges, gray in color with a silvery tint, resembling droplets of mercury or pearls. They have a viscous consistency and grow in 48-72 hours, sometimes growth takes up to 5 days.

Colonies of the parapertussis microbe are similar to whooping cough, but larger (up to 2-4 mm), darkening of the medium may be detected around them, and a creamy or even yellow-brown tint may appear on the AMC; formation time is 24-48 hours.

When studying Bordetella colonies using a stereomicroscope with side lighting, the so-called comet tail is visible, which is a cone-shaped shadow of the colony on the surface of the medium, but this phenomenon is not always observed.

B. pertussis, unlike other representatives of the genus, is biochemically inert and does not decompose urea, tyrosine, carbohydrates, or utilize citrates.

Antigenic and toxic substances of Bordetella are quite diverse and are represented by the following groups: surface structures (microcapsule, fimbriae), structures localized in the outer membrane of the cell wall (filamentous hemagglutinin, pertactin) and toxins, the main of which involved in pathogenesis is pertussis toxin (PT ), consisting of component A (S1 subunit), which causes toxicity, and B (S2-, S3-, S4-, S5 subunits), responsible for attaching the toxin to ciliated epithelial cells.

Endotoxin, heat-labile toxin, tracheal ciliotoxin, and adenylate cyclase also play an important role. All of the above factors are present in freshly isolated strains of the pertussis microbe.

Of the Bordetella antigens, the most interesting are the surface ones, localized in the fimbriae, the so-called agglutinogens, otherwise called “factors”. These are non-toxic proteins with low molecular weight, which are important in the formation of protection against pertussis infection and are revealed in agglutination reactions, which was the reason for their name.

Anderson and Eldering, back in the 50s of the last century, described 14 Bordetella agglutinogens, designating them with Arabic numerals (currently 16 are already known). The generic common to all Bordetella is agglutinogen 7; specific for B. pertussis – 1 (obligatory), intraspecific (strain) – 2-6, 13, 15, 16 (optional); for B. parapertussis - 14 and 8-10, respectively, for B. bronchiseptica - 12 and 8-11. Their detection is used in the laboratory diagnosis of whooping cough to differentiate the corresponding species and to separate B. pertussis strains into serological variants.

The four existing serovars of B. pertussis are identified by combinations of factors 1, 2, 3; 1, 0, 0; 1, 2, 0; 1, 0, 3; 1, 2, 3.

Pathogenesis of pertussis infection

The entry point for infection is the mucous membrane of the respiratory tract. Whooping cough bacilli exhibit strict tropism for ciliated epithelial cells, attach to them and multiply on the surface of the mucous membrane without penetrating into the bloodstream.

Reproduction usually occurs over 2-3 weeks and is accompanied by the release of a number of strong exotoxins, the main ones being CT and adenylate cyclase. After 2-3 weeks, the causative agent of whooping cough is destroyed with the release of a large complex of intracellular pathogenicity factors.

At the site of colonization and invasion of the pathogen, inflammation develops, the activity of the ciliated epithelium is inhibited, mucus secretion increases, ulcerations of the respiratory tract epithelium (RT) and focal necrosis appear. The pathological process is most pronounced in the bronchi and bronchioles, less so in the trachea, larynx, and nasopharynx.

Forming mucopurulent plugs clog the bronchial lumen and lead to focal atelectasis. Constant mechanical irritation of DP receptors, as well as the effect on them of CT, dermonecrotisin and waste products of B. pertussis, cause the development of coughing attacks and lead to the formation of a focus of excitation of the dominant type in the respiratory center, as a result of which a characteristic spasmodic cough develops. At this point, the pathological process in the bronchi is self-sustaining in the absence of the pathogen.

And even after the complete disappearance of the pathogen from the body and inflammatory processes in the respiratory tract, the cough can persist for a very long time (from 1 to 6 months) due to the presence of a dominant focus in the respiratory center. Irradiation of excitation from the DP to other parts of the nervous system is possible, resulting in symptoms from the corresponding systems: contraction of the muscles of the face, torso, vomiting, increased blood pressure, etc.

Features of the infectious process in whooping cough are the absence of a bacteremia phase, primary infectious toxicosis with a pronounced temperature reaction and catarrhal phenomena, as well as the slow, gradual development of the disease. The absence of pronounced primary toxicosis is explained by the fact that B. pertussis produces a small amount of CT during its reproduction and death.

Despite this, CT has a pronounced effect on the entire body, and primarily on the respiratory, vascular and nervous systems, causing bronchospasm, increased permeability of the vascular wall and peripheral vascular tone. The resulting generalized vascular spasm can lead to the development of arterial hypertension and the formation of venous stagnation in the pulmonary circulation.

In addition, the causative agent of whooping cough can have an adverse effect on the gastrointestinal tract, increasing intestinal motility and promoting the development of diarrhea syndrome, leading to the disappearance of obligate representatives of the intestinal microflora and, as a consequence, to a decrease in colonization resistance, the proliferation of opportunistic enterobacteria, cocci and fungi and the development intestinal dysbiosis. These effects are due primarily to the action of CT and adenylate cyclase.

According to modern concepts, the apoptogenic effect of B. pertussis toxins on the cells of the body’s immune system is of no small importance in the pathogenesis of whooping cough. The resulting secondary immunodeficiency is a predisposing factor for the development of nonspecific complications of whooping cough, such as bronchitis and pneumonia, most often associated with the activation of the own bacterial flora of the respiratory tract or the “layering” of ARVI, chlamydial, mycoplasma infections, being an excellent “conductor” for them. Such complications significantly increase the risk of developing bronchial obstruction and respiratory failure.

Clinical picture of whooping cough

Whooping cough in its typical presentation (the “standard definition” of a case) is characterized by the following symptoms:

• dry cough with its gradual intensification and acquisition of a paroxysmal spasmodic character in the 2-3rd week of the disease, especially at night or after physical and emotional stress;
• phenomena of apnea, facial hyperemia, cyanosis, lacrimation, vomiting, leuko- and lymphocytosis in the peripheral blood, development of “whooping cough lung”, hard breathing, viscous sputum;
• mild catarrhal symptoms and a slight increase in temperature.

Whooping cough is a disease with a cyclical course. There are 4 consecutive periods:

• incubation, which lasts on average 3-14 days;
• catarrhal (preconvulsive) - 10-13 days;
• convulsive, or spasmodic, - 1-1.5 weeks in immunized children and up to 4-6 weeks in unvaccinated children;
• the period of reverse development (reconvalescence), in turn divided into early (developing 2-8 weeks from the onset of clinical manifestations) and late (after 2-6 months).

The main symptom of the catarrhal period is a dry cough, which gets worse day by day and is obsessive. In mild and moderate forms, the temperature remains normal or gradually rises to subfebrile levels. Catarrhal phenomena from the mucous membranes of the nose and oropharynx are practically absent or very scanty. General health does not suffer too much. The duration of this period correlates with the severity of the further course: the shorter it is, the worse the prognosis.

During the period of convulsive cough, the cough acquires a paroxysmal character with a series of rapidly successive expiratory impulses, followed by a wheezing inhalation - a reprise. It must be remembered that recurrences occur in only half of the patients. Coughing attacks may be accompanied by cyanosis of the face and the release of viscous transparent sputum or vomiting at the end; apnea is possible in young children.

With frequent attacks, puffiness of the face, eyelids, and hemorrhagic petechiae on the skin appear. Changes in the lungs, as a rule, are limited to symptoms of swelling of the lung tissue; single dry and wet rales can be heard, which disappear after a coughing attack and reappear after a short time.

With the development of spastic cough, the patient's infectiousness decreases, however, even in the 4th week, 5-15% of patients continue to be sources of the disease. During the period of resolution, the cough loses its typical character, becomes less frequent and easier.

In addition to typical forms, it is possible to develop atypical forms of whooping cough –

• erased, characterized by weak coughing, lack of consistent changes in periods of illness, with fluctuations in cough duration from 7 to 50 days;
• abortive - with a typical onset of the disease and the disappearance of cough after 1-2 weeks;
• subclinical forms of whooping cough are diagnosed, as a rule, in foci of infection during bacteriological and serological examination of contact children.

Based on severity, mild, moderate and severe forms are distinguished, which are determined by the duration of the catarrhal period, as well as the presence and severity of the following symptoms: frequency of coughing attacks, cyanosis of the face when coughing, apnea, respiratory failure, disorders of the cardiovascular system, encephalitic disorders.

Whooping cough is dangerous because of its frequency complications, which are divided into specific and nonspecific.

Specific ones are directly related to pertussis infection and are caused by the effect of B. pertussis toxins mainly on the cardiovascular, respiratory and nervous systems, to the cells of which they have tropism.

Nonspecific complications develop as a secondary infection with the most common localization in the respiratory tract. This is facilitated, on the one hand, by local inflammatory processes caused by bordetella, leading to the occurrence of ulcerations of the epithelium in the bronchi and bronchioles (less often in the trachea, larynx, nasopharynx), focal necrosis and the formation of mucopurulent plugs that clog the lumen of the bronchi; on the other hand, immunodeficiency states that develop against the background of pertussis infection.

The leading role among the causes of death associated with nonspecific complications of whooping cough is played by pneumonia (up to 92%), which increases the risk of developing broncho-obstruction and respiratory failure with specific complications - encephalopathies.

Methods for laboratory diagnosis of whooping cough

Laboratory diagnosis of whooping cough is of particular importance due to the difficulty of clinical recognition of whooping cough and is currently an important link in the system of anti-epidemic measures. In addition, only based on the isolation of the pathogen can it be possible to differentiate whooping cough and parapertussis.

Laboratory tests are carried out for diagnostic purposes (for children who have been coughing for 7 days or more or with suspected whooping cough based on clinical data, as well as adults with suspected whooping cough and whooping cough-like diseases working in maternity hospitals, children's hospitals, sanatoriums, children's educational institutions and schools) and for epidemic indications (persons who were in contact with the patient).

Laboratory diagnosis of pertussis infection is carried out in two directions:

1. direct detection of the pathogen or its antigens/genes in the test material from the patient;
2. detection using serological reactions in biological fluids (blood serum, saliva, nasopharyngeal secretions) of specific antibodies to pertussis bacillus or its antigens, the number of which usually increases in the dynamics of the disease (indirect methods).

The group of “direct” methods includes the bacteriological method and rapid diagnostics.

Bacteriological method is the gold standard, it allows you to isolate a pathogen culture on a nutrient medium and identify it to species. But it is successful only in the early stages of the disease - the first 2 weeks, despite the fact that its use is regulated until the 30th day of the disease.

The method has extremely low sensitivity: from the beginning of the 2nd week, the excretion of the pathogen rapidly decreases, on average, the confirmability of the diagnosis is 6-20%.

This is due to the “fastidiousness”, slow growth of B. pertussis on nutrient media, their insufficient quality, the use of antibiotics as a selective factor added to the media for primary sowing, to which not all strains of the pathogen are resistant, as well as the late period of examination, especially in background of taking antibacterial drugs, improper collection of material and its contamination.

Another significant drawback of the method is the long period of research - 5-7 days before the final answer is issued. Bacteriological isolation of the causative agent of whooping cough is carried out both for diagnostic purposes (if whooping cough is suspected, if there is a cough of unknown etiology for more than 7 days, but not more than 30 days), and for epidemiological indications (when monitoring contact people).

Express methods are aimed at detecting B. pertussis genes/antigens directly in the test material (mucus and laryngeal-pharyngeal washings from the posterior wall of the pharynx, saliva), respectively, using a molecular genetic method, in particular polymerase chain reaction (PCR), and immunological reactions (indirect reactions immunofluorescence, in enzyme immunoassay - ELISA, microlatexagglutination).

PCR is a highly sensitive, specific and fast method that allows you to give a response within 6 hours, which can be used at different stages of the disease, even while taking antibiotics, to identify atypical and erased forms of whooping cough, and also for retrospective diagnosis.

PCR for diagnosing whooping cough is widely used in foreign practice, but in the Russian Federation it remains only a recommended method and is not available to all laboratories, since it requires expensive equipment and consumables, highly qualified personnel, a set of additional premises and areas, and currently cannot be used. introduced into the practice of basic laboratories as a regulated method.

Direct methods used for rapid diagnosis can also be used to identify B. pertussis in pure cultures, including material from isolated colonies, during bacteriological examination.

Methods aimed at identifying pertussis antibodies include serodiagnosis, based on the determination of antibodies in blood serum, and methods that allow the detection of specific antibodies in other biological fluids (saliva, nasopharyngeal secretions).

Serodiagnosis can be used at a later date, starting from the 2nd week of the disease. In the presence of typical clinical manifestations of whooping cough, it can only confirm the diagnosis, while in the case of erased and atypical forms, the number of which has increased sharply at the present stage and when the results of the bacteriological method are usually negative, serodiagnosis can be decisive in identifying the disease.

The treatment with antibacterial drugs does not in any way affect the results of this method. A prerequisite is the study of “paired” patient sera taken at an interval of at least 2 weeks. Diagnostically significant is pronounced seroconversion, i.e. an increase or decrease of 4 times or more in the level of specific antibodies.

A single detection of B. pertussis-specific IgM, and/or IgA, and/or IgG in ELISA or antibodies in a titer of 1/80 or more in the agglutination reaction (RA) is allowed in unvaccinated children under 1 year of age who have not had whooping cough and in adults when specific IgM is detected in them by ELISA or when antibodies to B. parapertussis are detected by the RA method in a titer of at least 1/80.

The literature describes 3 types of reactions that can be used for this purpose: RA, passive hemagglutination reaction (RPHA), ELISA. However, it must be borne in mind that for the diagnosis of RPGA there are no standard industrially produced immunological test systems, and ELISA-based test systems that allow recording the amount of serum immunoglobulins of classes G, M and secretory A to individual B. pertussis antigens are not produced by the Russian industry, foreign-made test systems have a high cost.

RA, despite its relatively low sensitivity, is the only reaction available to any Russian laboratories that allows one to obtain standardized results, since for its production the Russian industry produces commercial pertussis (parapertussis) diagnostic kits.

In connection with the above, in modern conditions on the territory of the Russian Federation, the following methods for diagnosing whooping cough, regulated by regulatory documents, have been adopted for medical institutions providing diagnostic services to the population on a budgetary basis: the main ones are bacteriological and serodiagnosis and the recommended one is PCR.

The bacteriological diagnostic scheme for whooping cough includes 4 stages

Stage I (1st day):

1. Material sampling (twice, daily or every other day):

• the main material is mucus from the back wall of the pharynx, which can be selected in two ways - “posterior pharyngeal” swabs (sequentially dry, then moistened with saline according to E.A. Kuznetsov’s prescription) and/or “nasopharyngeal” swab (the tampon method is used as in diagnostic studies and studies for epidemiological indications), as well as the “cough patch” method (only for diagnostic studies);
• additional material - laryngeal-pharyngeal swabs from the back wall of the pharynx, bronchial lavage water (if bronchoscopy is performed), sputum.

1. Sowing on Bordet-Gengou plates with 20-30% blood or AMC, bordetellagar with the addition of the selective factor cephalexin (40 mg per 1 liter of medium); thermostatting at 35-36°C, 2-5 days with daily viewing.

Stage II (2-3 days):

1. Selection of characteristic colonies and screening into sectors of the KUA or Bordetellagar plate for the accumulation of pure culture, thermostating.
2. Study of morphological and tinctorial properties in a Gram smear.
3. In the presence of many typical colonies, study the antigenic properties in slide agglutination with polyvalent pertussis and parapertussis sera and issue a preliminary answer.

I I I stage(4-5thday):

1. Checking the purity of the accumulated culture in Gram smears.
2. Study of antigenic properties in slide aggutination with polyvalent pertussis, parapertussis and adsorbed factor sera 1 (2, 3) and 14, issuing a preliminary answer.
3. Study of biochemical properties (urease and tyrosinase activity, ability to utilize sodium citrate).
4. Study of motility and the ability to grow on simple media.

Stage IV (days 5-6):

• accounting for differential tests; issuing a final answer based on a set of phenotypic and antigenic properties.

Depending on the availability of laboratory confirmation and other criteria, there is the following gradation of whooping cough cases:

• An epidemiologically linked case is a case of acute illness in which there are clinical signs that meet the standard case definition of pertussis and an epidemiological link to other suspected or confirmed cases of pertussis;
• the probable case meets the clinical case definition, is not laboratory confirmed, and has no epidemiological link to the laboratory confirmed case;
• confirmed – meets the clinical case definition, is laboratory confirmed and/or has an epidemiological link to a laboratory confirmed case.

Laboratory confirmation is considered to be a positive result in at least one of the following methods: bacteriological isolation of a pathogen culture (B. pertussis or B. parapertussis), detection of specific fragments of the genomes of these microorganisms using the PCR method, detection of specific antibodies during serodiagnosis.

Accordingly, the diagnosis is confirmed: whooping cough caused by B. pertussis or parapertussis caused by B. parapertussis. A laboratory-confirmed case does not necessarily have to meet the standard clinical case definition (atypical, indolent forms).

Principles of whooping cough treatment

The main principle of treatment for whooping cough is pathogenetic, aimed primarily at eliminating respiratory failure and subsequent hypoxia (prolonged stay in the fresh air, especially near water bodies, in severe cases - oxygen therapy, hormone therapy with glucocorticoids) and improving bronchial conductivity (use of bronchodilators, mucolytics), as well as symptomatic treatment of specific complications of whooping cough.

It is possible to carry out specific immunotherapy for severe forms using antipertussis immunoglobulin.

Etiotropic antibacterial therapy is carried out when there is a risk of developing or developed nonspecific complications associated with secondary bacterial flora (bronchitis, pneumonia, etc.), while the choice of antibacterial drugs should be made taking into account the sensitivity of the causative agents of the “layered” infection to them.

Specific prevention of pertussis infection

Whooping cough is a “preventable infection” against which routine vaccination of the population is carried out in accordance with the national vaccination calendar.

The first pertussis vaccine appeared in the USA in 1941. Currently, all countries of the world carry out vaccination against whooping cough, and DTP vaccines are included in the mandatory set of vaccines recommended by the World Health Organization. There are two fundamentally different types of vaccines used to prevent whooping cough:

1. Adsorbed pertussis-diphtheria-tetanus vaccine (DTP, international abbreviation - DTP), containing a corpuscular pertussis component (109 killed microbial cells per dose) and diphtheria (15 Lf/dose), tetanus (5 EU/dose) toxoids, currently used in the Russian Federation and some other countries, and until the end of the 70s - throughout the world.

1. Acellular DTP vaccines contain an acellular pertussis component (based on pertussis toxoid with various combinations of a number of protective antigens), devoid of lipopolysaccharides of the bacterial membrane and other cell components that can cause undesirable reactions in vaccinated individuals; used in the USA, Japan, and most European countries.

It was believed that the DTP vaccine is the most reactogenic due to the corpuscular pertussis component. In some cases, it causes the following adverse reactions and complications in children: local (hyperemia, swelling and pain at the injection site) and general - a high-pitched scream, convulsions and, most seriously, post-vaccination encephalitis, the development of which is associated with the presence of undetoxified pertussis toxin in the DTP vaccine . However, currently such cases are interpreted as having a different etiology.

In this regard, in the 80s of the 20th century, a number of countries refused DTP vaccination. The first version of an acellular vaccine based on pertussis toxoid was developed in Japan following the official refusal of the Ministry of Health of this country to use whole-cell vaccines and the subsequent epidemic of whooping cough - a pattern that also befell other countries that refused, at least temporarily, vaccination.

Later, numerous, more effective versions of acellular vaccines were created, including various combinations of 2 to 5 components of B. pertussis, significant in the formation of effective immunity - modified pertussis toxin (anatoxin), filamentous hemagglutinin (FHA), pertactin and 2 fimbriae agglutininogen. Now they form the basis of vaccination schedules against whooping cough in all developed countries of the world, despite their relatively high cost.

The low reactogenicity of acellular pertussis vaccines allows them to be administered as a second booster dose at the age of 4-6 years, which allows prolongation of immunity. There is currently no such Russian-made vaccine.

In the Russian Federation, the use of the following DTP vaccines containing pertussis toxoid, PHA and pertactin is officially authorized: “Infanrix” and “Infanrix-Hexa” (SmithKline-Beecham-Biomed LLC, Russia); "Tetraxim" and "Pentaxim" (Sanofi Pasteur, France). In addition to diphtheria, tetanus and pertussis components, they include inactivated poliovirus and/or Hib component and/or hepatitis B vaccine.

The DTP vaccination schedule includes three doses at age 3; 4.5 and 6 months with revaccination at 18 months. According to the Russian preventive vaccination calendar, the 2nd and 3rd revaccination against diphtheria and tetanus with ADS-M is carried out at 6-7 and 14 years of age, respectively, and then revaccination of adults every 10 years. If desired, in commercial structures at the age of 4-6 years, revaccination against whooping cough can be carried out with the DTaP vaccine.

To achieve a satisfactory level of herd immunity, timely start (at 3 months) should be in at least 75% of children, complete vaccination coverage (three vaccinations with DPT vaccine) and revaccination should be in 95% of children aged 12 and 24 months of life, respectively, and by three years - no less than 97-98%.

An important way to assess the effectiveness of vaccination of the population is serological monitoring of the level of collective anti-pertussis immunity in children aged 3-4 years old who have not had whooping cough, with a documented vaccine history and no more than 3 months since the last vaccination.

Persons in whose blood serum agglutinins are determined at a titer of 1:160 or higher are considered protected from whooping cough, and the criterion of epidemiological well-being is the identification of no more than 10% of persons in the examined group of children with an antibody level of less than 1:160.

Tyukavkina S.Yu., Kharseeva G.G.

is an acute infectious disease of the respiratory tract caused by a gram-negative pathogen Bordetella pertussis. Another representative of the genus Bordetella is Bordetella parapertussis causes parawhooping cough, a disease that has similar clinical symptoms, but is much milder.

According to the recommendations of the WHO and the Centers for Disease Control and Prevention (CDC), whooping cough is defined as an acute illness with a cough that lasts more than 14 days, in the presence of one of the following conditions - paroxysmal cough, vomiting that occurs after coughing, recurrent episodes.

Etiology

Bordetella pertussis is a small, aerobic, gram-negative bacterium that does not form spores and colonizes exclusively the ciliated epithelium of the respiratory tract. The bacterium has no invasive properties and does not cause bacteremia. The pathogen is not stable in the external environment; carriage of B. Pertussis is short-term and does not have important epidemiological significance.

Epidemiology

Whooping cough is a highly contagious disease that occurs when exposed to B. pertussis 99-100% of susceptible individuals get sick. The pathogen is transmitted by airborne droplets; the spread of the pathogen with small drops of saliva and mucus during coughing is of great importance.

As a rule, infection occurs as a result of relatively long-term contact with a sick person (unlike measles, when there is a high risk of infection in case of short-term contact), and therefore almost all non-immune members of the family who come into contact with the sick person at home are infected, and approximately 50% non-immune students - classmates of the patient.

The source of infection is a sick person, regardless of the severity of the infectious process (including the asymptomatic form). The infection is transmitted through close contact with a sick person. The pathogen is released from the patient no more than 2-2.5 meters; it is unstable in the external environment.

The most dangerous patients are in the catarrhal period and in the 1st week of spasmodic cough - in 90 - 100% of them it is secreted B. pertussis. In the second week, the infectivity of patients decreases; the pathogen can be isolated in only 60-70% of patients. After 4 weeks from the onset of the disease, patients are not dangerous to others.
Newborns and children in the first months of life are susceptible to the pathogen.

According to modern data, past illness and preventive vaccination do not provide lifelong immunity.

Pathogenesis

B. pertussis produces several toxins, the main of which is pertussis toxin (PT), the most virulent viral protein. This toxin increases tissue sensitivity to histamine, leads to lymphocyte dysfunction, and stimulates insulin secretion.

After commit B. pertussis on the ciliated epithelium of the respiratory tract (thanks to adenylate cyclase and RT), damage to epithelial cells occurs. The drainage function of the epithelium of the respiratory tract is disrupted, which prevents the rapid elimination of bacteria from the body.

Tracheal cytotoxin and dermanenecrotic factor increase mucus production and promote the absorption of RT.
The pathogen also produces: fibrous hemagglutinin FHA, agglutinogen (especially type II-III fimbriae) and pertactin Pn.

Most clinical symptoms of whooping cough are associated with damage to the epithelial cells of the respiratory tract. First of all, the drainage function of the mucous membranes suffers, which leads to the accumulation of viscous mucus. Thick, viscous mucus reduces the permeability of small bronchi and bronchioles. This leads to the development of atelectasis, nonspecific bronchopneumonia, and emphysema. The mechanism for eliminating mucus is coughing, which becomes frequent, obsessive, and paroxysmal. The accumulation of viscous secretion in the throat provokes vomiting.

As a result of frequent coughing attacks, a dominant type of excitation is formed in the respiratory center, which can spread to other parts of the nervous system - vasomotor, emetic, etc. In this regard, during an attack, vasospasm, vomiting, etc. may occur. The formation of a dominant focus is also facilitated by the action of pertussis toxin.
In the future, attacks of spasmodic cough may occur when receptive fields are irritated, not associated with the cough reflex (for example, with strong sound stimuli, examination of the pharynx, injections).

The dominant focus will persist for a long time - therefore, spasmodic cough can be observed even after the elimination of whooping cough infection.
When stronger centers of excitation arise, the dominant focus is inhibited. This explains the cessation of seizures during an exciting game.

Clinical picture

Whooping cough is a long-term disease during which several stages can be identified - catarrhal, spasmodic cough stage and resolution stage. The incubation period of the disease is 5-20 days (usually 10-12 days). The catarrhal stage lasts
1-2 weeks and is characterized by low-grade fever, sneezing, difficulty breathing through the nose, serous nasal discharge, lacrimation, conjunctival hyperemia.

Against the background of subsidence or even complete disappearance of catarrhal symptoms, a cough appears, which characterizes the beginning of the stage of spasmodic cough. This stage lasts
2-6 weeks. During the first few days, the cough is dry and periodic, then it becomes more frequent and becomes paroxysmal in nature. The cough occurs mainly at night and ends with vomiting.

The transition to the upcoming spasmodic period occurs gradually. Typical attacks of spasmodic cough appear. The cough occurs suddenly or after a brief aura: a feeling of sore throat, tightness in the chest, anxiety. An attack consists of a series of short coughing impulses that come directly one after the other without resting for inspiration. Then a convulsive deep breath occurs, which, due to spasmodic narrowing of the glottis, is accompanied by a whistling sound (reprise). During a coughing attack there may be several repetitions.

The more severe the form of whooping cough, the longer the coughing attacks and the greater the number of recurrences. A coughing attack ends with coughing up viscous transparent sputum, sometimes with vomiting. In severe coughing attacks, the sputum may contain blood. Vomiting after coughing is not an absolute permanent symptom. In mild cases of whooping cough, vomiting occurs rarely or may not occur.

During an attack, the patient’s appearance is very characteristic: the face turns red or blue, the eyes become bloodshot, the neck veins swell, lacrimation appears, the tongue protrudes. During a severe attack, there may be random passage of feces and urine. With significant tension, hemorrhages into the conjunctiva are possible. At the height of a coughing attack, breathing may stop.

The occurrence of attacks is facilitated by various external stimuli (feeding, examination of the pharynx, loud noise, dressing and undressing, etc.). The occurrence of coughing attacks at night is typical. During the day, especially during walks in the fresh air, the child coughs much less often or stops coughing altogether.

Due to frequent coughing attacks, the patient's face becomes puffy, the eyelids swell, and hemorrhages are often detected on the skin and conjunctiva.
Sometimes the equivalent of a cough can be spasmodic sneezing, which can result in a nosebleed.

When examining the oral cavity, there is sometimes a wound on the frenulum of the tongue. This wound occurs due to friction of the frenulum against the edges of the lower incisors. As the number of attacks decreases, the wound gradually disappears.

The general condition of uncomplicated whooping cough is not impaired (even with frequent attacks).
In the intervals between attacks, patients are active, play, and their appetite is preserved.
Body temperature is slightly increased during the catarrhal period, and by the time coughing attacks develop, it drops to normal levels, only occasionally being low-grade. Severe fever during the spasmodic period indicates the presence of complications. Only in some patients with uncomplicated whooping cough does the elevated body temperature persist for a long time.

When examining the lungs:

• With percussion, a box or tympanic sound is determined;
• Auscultation - dry, silent moist rales;
• X-ray – increased pulmonary pattern, low diaphragm, increased transparency of the pulmonary fields, the presence of linear cords.

From the cardiovascular system:

• During an attack, tachycardia and increased blood pressure are noted;
• Capillary resistance decreases, which may result in hemorrhages in the mucous membranes and skin;
• Sometimes an accent of the second tone appears over the pulmonary artery;
• In severe whooping cough, slight expansion of the heart to the right (due to the right ventricle).

Damage to the nervous system can manifest itself as convulsive twitching of facial muscles, adynamia, lethargy, and impaired consciousness.

The period of spasmodic cough lasts from 2 to 8 weeks. Then it gradually moves into the third period (permission). The cough becomes less frequent and its paroxysmal nature disappears. The third period lasts 2-4 weeks, and ends with the disappearance of all symptoms of the disease.
Thus, whooping cough lasts on average from 5 to 12 weeks, sometimes longer.
At the end of the cough and even after complete elimination of all symptoms, typical coughing attacks sometimes return. These attacks occur in connection with the addition of any other infection (tonsillitis, ARVI) according to the mechanism of a sequential reaction. In this case, there are no blood changes characteristic of whooping cough, and there is no pertussis bacillus in the body.

There are three main forms of whooping cough:

• Light form.
  The patient's health is not affected, the attacks are short, vomiting is rare. The number of attacks is up to 15 times a day, the number of repetitions is up to 5;
• Moderate form.
  The patient's well-being is slightly impaired. The number of attacks is up to 25 times a day, repetitions are up to 10. Attacks often end in vomiting.
• Severe form.
  The patient's health is impaired. Lethargy, fever, sleep and appetite disturbances are noted. The attacks are prolonged and can last up to 15 minutes. The number of reprises is more than 10. Reprises almost always end in vomiting.

Also found erased form whooping cough With this form, there are no typical coughing attacks and relapses, and the course of the disease can be shortened.
In these cases, a diagnosis of tracheobronchitis or tracheitis may be erroneously made. This form of the disease is observed in vaccinated children.

They also diagnose asymptomatic form disease in which
there are no clinical symptoms, but hematological and cyclic immunological disorders occur in the body.

During the illness, secondary immunodeficiency occurs with a decrease in both cellular and humoral immunity. RT and adenyl cyclase toxin inhibit the phagocytic function of lymphocytes, suppressing a number of other cells of the immune system and inducing apoptosis of macrophages. The so-called pertussis anergy occurs, which is mainly caused by a decrease in the production of γ-interferon.

Clinical examination data in uncomplicated disease are usually not very informative. Sometimes pinpoint hemorrhages appear in the conjunctiva, petenchial rashes, and ulcers on the frenulum of the tongue. Changes in the lower respiratory tract are detected only in pneumonia.
In vaccinated children, whooping cough is characterized by a shortening of all stages of the disease.

Typical complications include bronchitis, encephalopathy, cerebral hemorrhages, rectal prolapse, hernias, hemorrhages in the conjunctiva, and brain.
These complications of whooping cough can be caused by the action of the pathogen itself, prolonged bouts of coughing, hypoxia, or occur due to the addition of a secondary viral or bacterial infection.

Whooping cough in children in the first months of life is very severe; in 3-10% of patients the disease is fatal. The course of the disease may resemble pneumonia or bronchiolitis. Considering the incubation period of the disease, the first symptoms of the disease may appear as early as 7-10 days of life. The initial signs of the disease are manifested by deterioration of sucking, tachypnea, coughing is so insignificant that it does not cause alarm among parents or medical personnel.

Sometimes it is possible to establish the catarrhal stage of the disease, which has typical signs of an acute respiratory infection of the upper respiratory tract (nasal discharge, sneezing, coughing) and lasts several hours, less often several days.

Significant diagnostic difficulties arise from diagnosing the disease without a cough or spasmodic cough and without recurrences. In these cases, attacks of apnea, bradycardia, and cyanosis come to the fore. Episodes of apnea occur due to exhaustion during paroxysmal coughing attacks, excessive vagal irritation, or the direct effect of a bacterial toxin on the central nervous system.

In prematurely born infants, episodes of apnea are often misdiagnosed as apnea of ​​prematurity. In some patients, repeated, multiple exhalations without inhalation are observed, which also quickly cause hypoxia and hypoxemia.
Against the background of hypoxia caused by respiratory failure, convulsions occur.
Neonatal whooping cough is characterized by a long and complicated course.

Superinfection caused by viruses (adenovirus, PC virus, cytomegalovirus), bacteria (streptococcus, staphylococcus, gram-negative pathogens) causes secondary lung damage. Clinically, the development of pneumonia is manifested by an increase in body temperature, changes in the blood, and changes in the radiograph.

In modern conditions, whooping cough in children under three years of age often (up to 60% of cases) occurs in combination with acute respiratory viral diseases, which change the course of the disease, complicating its diagnosis. In children in the first month of life, cases of a combination of pertussis infection with respiratory syncytial infection have been described.

Neurological complications of whooping cough in children under three years of age may include convulsions (mainly caused by hypoxia), encephalopathy, subarachnoid hemorrhages, and cortical atrophy.

Acute pulmonary hypertension is a common cause of death in infants, the causes of which are not yet clear. Pulmonary hypertension quickly leads to heart failure (myocardial weakness), the signs of which are refractory tachycardia (160-250 per minute), arterial hypotension, which is not corrected by the administration of inotropic drugs or the prescription of a sufficient volume of infusion fluid.

Mortality in infants remains high despite the introduction of extracorporeal membrane oxygenation, mechanical ventilation with nitrous oxide, the use of pulmonary vasodilators, or exchange transfusions to correct hyperleukocytosis.

Newborns with acute whooping cough may develop severe hypoglycemia, which is apparently caused by hyperinsulinism through the effect of RT on the pancreas.

Features of whooping cough in children of the first year of life.

• The incubation period is shortened (up to 3-5 days);
• The catarrhal period is shortened (up to 2-6 days), sometimes it may be absent, and a spasmodic cough appears from the first days of the illness;
• Repetitions and vomiting occur less often than in older children;
• Often coughing attacks end in apnea;
• Gas exchange disorders are more pronounced;
• Impaired consciousness and convulsions occur more often;
• Due to the absence of teeth, there is no wound on the frenulum of the tongue;
• Complications from the respiratory system (pneumonia, bronchitis) occur more often. Pneumonia is characterized by early development and has a confluent nature.

Diagnostics

Leukocytosis or hyperleukocytosis (15.0 – 100.0 x 10 9 /l) can be detected already in the catarrhal stage of the disease. The blood smear is dominated by lymphocytes. ESR often does not change. In children under three years of age, less pronounced lymphocytosis is noted. An increase in the number of neutrophils during the disease indicates bacterial complications.

On radiography, in most patients, minor changes can be detected, which indicate the presence of infiltrates, edema, and minor atelectasis. Compaction of the lung parenchyma characterizes the development of pneumonia. Less commonly, pneumothorax, pneumomediastium, bronchiectasis, and air in the soft tissues of the neck or chest can be diagnosed.

The diagnostic standard today is culture isolation. B.pertussis c ciliated epithelium of the respiratory tract. Mucus is collected using cough strips, nasopharyngeal aspiration, or using a swab from the back of the throat.

The material can be taken through the nasal passages or through the mouth; it is important not to touch other parts of the oral mucosa, teeth and try to hold the tampon on the wall of the throat for about 10 seconds. Since cotton wool contains fatty acids that are toxic to the pathogen, the procedure should not be carried out using standard cotton swabs. For this purpose, use loops made from calcium aglinate, or sticks with tampons made from elastic nylon (for example, Rayon, Dracon).

The bacteriological method is highly specific, low sensitivity
(antibiotic therapy also affects the culture result) and today it is not recommended to be used as a single method to confirm the diagnosis.
PLR is characterized by high sensitivity and specificity, both during the catarrhal phase of the disease and the phase of spasmodic cough; the examination result is little affected by the patient's treatment with antibiotics.
According to the latest CDC recommendations, if pertussis is suspected, the patient should undergo a bacteriological examination and PLR.

According to the WHO and CDC recommendations, whooping cough is considered confirmed if it has a typical clinical picture and positive PLR ​​results or established contact with a patient with whooping cough (who has a laboratory-confirmed case of the disease). The diagnosis of whooping cough is established in the presence of a cough of any duration and a positive bacteriological culture B.pertussis.
Serological methods can detect antibodies of the IgA, IgM, IgG classes to B. pertussis in the blood.

• An increase in immunoglobulin A indicates the acute phase of the disease;
• Immunoglobulin M increases first in the acute phase of infection and is detected within 3 months;
• Immunoglobulin G - indicates an acute infection and appears 2-3 weeks after infection and persists for life.

Treatment and prevention of whooping cough will be discussed in.

Mikhail Lyubko

Literature:

• Infectious diseases in children. S.A. Kramarev O.B. Nadragi. Kyiv. 2010
• Clinic, diagnosis, treatment and prevention of infectious diseases in children.
  S.A. Kramarev Kyiv 2010

Whooping cough in children, despite the modern level of medicine, is the most dangerous childhood infectious disease, which is caused by the bacterium Bordatella pertussis and manifests itself as a persistent paroxysmal cough.

Dr. Komarovsky, who formerly worked as an infectious disease doctor, believes that whooping cough is a manageable disease that is controlled by vaccination. But the DTP vaccination is difficult for children to tolerate, so many parents, having received it once, refuse further vaccination.

They just don’t understand that after a one-time immunization, only half of the vaccinated children develop immunity against whooping cough. Therefore, recently, despite the high level of medicine, the incidence of whooping cough has increased significantly.

For 100% immunization, a child must be vaccinated against whooping cough 4 times.

The disease is caused by Bordatella pertussis or, as it is called, whooping cough bacillus. The pathogen was first identified in 1906 by Zhang and Borde.

A type of whooping cough bacterium was also isolated - the parawhooping cough bacillus (Bordеtella parapertussis), which causes parawhooping cough - a disease similar in clinical course to whooping cough, occurring in a mild form.

Bordetella pertussis looks like a small oval rod that cannot move. The whooping cough bacillus is not Gram stained.

Bordetella pertussis produces heat-stable toxins, hyaluronidase, lecithinase and plasmacoagulase. Bacteria have a core O antigen and capsular antigens.

The whooping cough bacillus is unstable in the external environment, as it is inactivated by ultraviolet rays within 60 minutes. Also detrimental to the causative agent of whooping cough is high temperature (when heated to 56°C, the sticks die after 15 minutes, and when boiled, instantly) and disinfectant solutions (phenol, Lysol, ethyl alcohol).

There is no innate immunity to whooping cough, so symptoms of whooping cough can be observed even in newborns.

The only source of the disease is a person sick with any form of whooping cough.

A sick child is considered contagious from the first day of the catarrhal period until the 30th day from the onset of the disease. The most dangerous for others are patients in the catarrhal period and with asymptomatic course, Komarovsky emphasizes, because such persons are not isolated, and they manage to infect other children or adults with whooping cough.

Vaccination against whooping cough is not a 100% preventive measure for the disease, but in immunized children the disease is mild and without serious complications.

Susceptibility to the whooping cough bacillus in unvaccinated children is higher than in vaccinated children and is 80-100%. A child who has had whooping cough develops lasting, lifelong immunity. Re-infection with whooping cough is rare.

Whooping cough most often affects young children. In adults, the disease cannot always be recognized, since its course is mostly asymptomatic.

The mechanism of spread of the whooping cough bacillus is aerogenic, which is carried out by airborne droplets. But, since the pathogen is unstable in the external environment and cannot move, infection occurs only through direct contact with the patient.

The peak incidence of whooping cough occurs in the autumn-winter period. Also, whooping cough is characterized by cyclicality with an increase in incidence every 4 years.

Invasion of Bordetella pertussis into the body occurs through the epithelium of the upper respiratory tract. The pathogen does not penetrate the cells of the cylindrical ciliated epithelium of the respiratory tract, but attaches to them. Enzymes secreted by the whooping cough bacillus directly affect the epithelial layer of the larynx, trachea and bronchi.

Bordetella pertussis toxins penetrate the nerve endings of the vagus nerve and irritate them, thereby forming a focus of excitation in the part of the medulla oblongata that regulates respiratory function.

Therefore, a sick child develops a strong cough in response to various irritants (pain, sound, light, etc.). Dr. Komarovsky calls whooping cough a unique disease and considers it more of a disease of the nervous system than of the upper respiratory tract.

In the medulla oblongata there is a vomiting center, a vasoregulatory center and a center responsible for skeletal muscles, which can also be irritated by Bordetella toxins, as a result of which the child experiences vomiting, arterial hypertension, and convulsions.

Bordetella pertussis toxins have an immunosuppressive effect, due to which secondary bacterial and viral flora are often associated with whooping cough.

Classification of whooping cough

Whooping cough can occur typically and atypically.

Typical forms of the disease are characterized by a cyclical course, in which successive periods can be distinguished:

• incubation;
• catarrhal;
• spasmodic or convulsive;
• permissions;
• recovery or convalescence.

Interesting! Based on the severity of symptoms, whooping cough can be divided into mild, moderate and severe.

Among the atypical forms of whooping cough, erased, abortive and asymptomatic forms are observed.

The incubation period begins from the moment of invasion of the pathogen into the epithelium of the upper respiratory tract and continues until the time when the first signs of the catarrhal period of whooping cough appear. The average incubation period for Bordetella in the body is 5-7 days.

In the catarrhal period of whooping cough, symptoms of intoxication are observed in the form of low-grade fever (37–37.9°C), rarely body temperature rises to febrile levels (38–38.9°C), general weakness, irritability, moodiness, and poor appetite.

The child is also worried about catarrhal symptoms from the upper respiratory tract (nasal congestion, rhinorrhea, cough). The cough is dry, worsens at night, and is not relieved by antitussives, which should lead one to think about whooping cough.

The period of catarrhal phenomena lasts on average 2 weeks, but in severe cases of the disease it can be reduced.

Period of spasmodic cough. During this period, the cough becomes paroxysmal and hacking, and at the end of the attack, a long wheezing inhalation occurs, which is called a reprise.

After an attack of whooping cough, the child feels well and can play, sleep, and eat.

Before an attack, a child may experience warning signs such as a sore throat, anxiety, fear, etc.

What does a whooping cough attack look like and how long does it last? During an attack, the child’s face turns red, the eyes are wide open, the neck veins swell, the tongue sticks out like a tube, and there may be cyanosis of the nasolabial triangle.

After an attack, a reprise is heard, thick sputum may be released or vomiting may occur, and involuntary urination or defecation, loss of consciousness, and convulsions may also occur. Prolonged coughing attacks lead to the child’s face becoming puffy, with pinpoint hemorrhages in the conjunctiva of the eyes. A coughing attack can last up to 4 minutes.

Important! Factors that provoke coughing attacks include bright light, a sudden sound signal, excitement, fear and strong emotions of the baby. In patients with whooping cough, it is forbidden to examine the throat with a spatula or spoon, as this may cause a coughing attack.

The severity of the patient's condition is determined by the number of coughing attacks:

1. Light degree– up to 10 attacks per day without vomiting. The general condition of the patient is not disturbed.
2. Moderate degree– 11-15 attacks per day, which end in vomiting. The patient's condition during the interictal period is normal.
3. Severe degree– 20 attacks or more. Children present with hypoxia, anxiety, pale skin, acrocyanosis, tears and ulcers of the frenulum of the tongue, loss of consciousness, convulsions, and dyspnea.

The spasmodic period lasts up to 2 months, after which the number of attacks decreases and a period of resolution begins.

The period of resolution of the disease lasts up to 30 days. Symptoms of whooping cough gradually subside. The child's condition is improving.

The recovery period can take up to 6 months. The child is still weakened and susceptible to other infections.

Important! The erased form of whooping cough is characterized by a prolonged cough (1-3 months), which is not relieved by antitussives, without attacks of hacking cough and recurrences.

Abortive form of whooping cough. This form of the disease is characterized by a paroxysmal hacking cough for 2-3 days, which goes away on its own.

With asymptomatic whooping cough, there are no symptoms, and the disease can be recognized only after a bacteriological analysis or serological examination has been carried out.

Whooping cough in children under one year of age

Whooping cough is most dangerous for newborns and infants, since there is no innate immunity.

The following features of the course of whooping cough in infants can be distinguished:

• the period of spasmodic cough in infants lasts for 2-3 months;
• the course of the disease is undulating;
• body temperature is not elevated;
• at the height of the attack, respiratory arrest often occurs;
• an attack of whooping cough can be manifested by sneezing, which ends with nosebleeds;
• there is a risk of cerebrovascular accident and hypoxic encephalopathy;
• complications of whooping cough often develop, especially pneumonia, which can lead to the death of the baby.

Treatment of whooping cough in children under one year of age should be carried out exclusively in an infectious diseases hospital. Antibiotics are required to prevent bacterial consequences.

Parapertussis occurs more often in preschool children and even in persons vaccinated against whooping cough. Children are less susceptible to parapertussis than whooping cough.

Parapertussis has a development mechanism similar to whooping cough.

Signs of parawhooping cough:

• mild catarrhal symptoms from the upper respiratory tract;
• the child’s condition is not impaired;
• body temperature is within normal limits;
• dry paroxysmal paroxysmal cough with repeated episodes;
• rare attacks of whooping cough;
• dry wheezing in the lungs;
• An x-ray of the chest organs reveals signs of expansion of the roots of the lungs, an increase in the vascular component and, rarely, peribronchial inflammation of the lung tissue;
• blood test is within normal limits. There may be a moderate increase in the number of white blood cells and an increase in lymphocytes;
• very rarely the consequences of the disease in the form of pneumonia are observed.

Complications of whooping cough in children

Whooping cough in children can be complicated by inflammation of the bronchi and/or lungs, otitis, mediastenitis, pleurisy, pulmonary atelectasis, hypoxic encephalopathy, hemorrhoids, umbilical hernia

Pneumonia, pleurisy and mediastenitis occur due to the layering of other pathogenic flora on top of the pertussis infection.

Interesting! The symptoms of these complications cannot always be determined during the spasmodic period of whooping cough, since paroxysmal cough comes to the fore.

Pertussis hypoxic encephalopathy occurs after 2-3 weeks of illness. The child experiences symptoms such as loss of consciousness, convulsions, fainting, decreased hearing and vision. If you do not seek medical help in time, encephalopathy can cause the baby's death.

0.04% of patients die from whooping cough.

Diagnosis of whooping cough in children

Typical signs of whooping cough - paroxysmal cough and repeated episodes will allow you to accurately make a diagnosis.

The diagnosis is confirmed for typical and atypical courses using laboratory diagnostic methods:

• complete blood count: leukocytosis, lymphocytosis, increased ESR;
• bacteriological analysis of mucus from the back wall of the pharynx, which is carried out in the first 14 days of the disease and allows you to get the result in 5-7 days;
• serological methods, such as agglutination reactions, complement fixation, passive hemagglutination. An analysis in which the titer of antibodies to Bordetella pertussis in vaccinated children has increased 4 times, and in unvaccinated children is 1:80, is considered positive.

Treatment of whooping cough in children with a mild course is carried out at home under the supervision of a local pediatrician and an infectious disease specialist.

Moderate and severe forms of whooping cough require hospital treatment.

The child must be provided with peace, factors that may cause coughing must be eliminated, and a well-ventilated separate room must be allocated.

Provide sufficient air humidity - a humidifier, a bowl of water, wet towels. You can walk outside, only away from other children, if the patient’s body temperature is within normal limits.

To relieve cough, Dr. Komarovsky recommends walking early in the morning near the lake in the summer, and also for several hours before bedtime.

If you live in a city where there are no reservoirs, then it is better to go to relatives in the village or to the country.

Nutrition for whooping cough

You need to feed your baby 5-6 times in small portions. In infants, the number of feedings should be increased by 2 per day.

Increase your baby's drinking regime with compotes, tea, fruit drinks, juice, still mineral water, Regidron, Humana Electrolyte.

The menu of a patient with whooping cough should consist of pureed soups, liquid porridges, broths, vegetable and fruit purees, and fermented milk products.

Etiotropic treatment

For whooping cough, broad-spectrum antibiotics are prescribed for 5-7 days, such as protected semi-synthetic penicillins, aminoglycosides and macrolides in doses appropriate to the patient’s age.

Important! Antibiotics are used to kill Bordetella pertussis and prevent the bacterial consequences of whooping cough. But it is impossible to cure whooping cough with antibacterial therapy, since the source of cough has already been formed and is located in the brain.

Also, in patients with whooping cough, a specific anti-pertussis gammaglobulin is used.

Pathogenetic therapy

Pathogenetic agents are used to weaken the cough reflex, improve oxygenation of brain tissue and eliminate hemodynamic disturbances. Patients are prescribed the following pathogenetic agents:

• neuroleptics and sedatives (Aminazine (only in hospital settings), Seduxen, Sibazon);
• antihistamines (Tavegil, Suprastin, Cetrin, Pipolfen);
• infusion rehydration (solutions of Sodium Chloride, Ringer Locke, Trisol, Disol);
• oxygen therapy;
• vitamin therapy (vitamins B, C, A, E).

Antitussives are ineffective for whooping cough. It is strictly forbidden to use mustard plasters, jars and other distracting means.

It is advisable to prescribe sputum thinners, such as Ambroxol, Acetylcysteine, herbal syrups, since blockage of the bronchi with thick sputum is the main factor in the development of pneumonia in whooping cough.

When the body temperature is above 38.5°C, antipyretics are used - Nurofen, Efferalgan, etc.

Also, to relieve cough in children, you can try folk remedies, such as boiled milk with crushed garlic cloves, fig decoction, a mixture of butter and honey, plantain leaf tea, onion decoction with honey, licorice root decoction, etc.

Prevention of whooping cough

Vaccination against whooping cough is carried out with the DTP vaccine according to the national vaccination calendar at 3, 4-5, 6 and 18 months.

Unvaccinated children under one year of age in contact with a patient with whooping cough are administered human immunoglobulin 3 ml for 48 hours.

Vaccinated contact children of preschool age are quarantined for 14 days from the moment of contact with a sick child.

Whooping cough is one of the common causes of cough in children and adults. A typical manifestation of whooping cough is a paroxysmal cough with a characteristic sound when inhaling. In babies in the first months of life, whooping cough can occur with respiratory arrest, which is very dangerous.

How can a child become infected with whooping cough?

Whooping cough is caused by the bacterium Bordetella pertussis. A child can only become infected with whooping cough from a sick person: the infection is transmitted by airborne droplets during sneezing, coughing, or laughing. Since whooping cough in older children and adults often occurs mildly, with only a slight cough, they, unsuspectingly, can transmit the infection to the child. If a family member has whooping cough, a child who is not vaccinated against whooping cough has an 80% chance of getting sick.

The first symptoms of whooping cough appear on average 7-10 days, sometimes 21 days after infection. A sick person is contagious from the moment a runny nose appears until the fifth day of taking an antibiotic.

Can a child who is vaccinated against whooping cough become infected with whooping cough?

The anti-whooping cough component is included in many vaccines, for example, DPT, Infanrix, Pentaxim. According to the calendar, vaccination against whooping cough is carried out at 3, 4½, 6 months and then revaccination at 1½ years. Vaccination quite reliably protects a child from whooping cough for several years, but after 3-5 years the level of protection drops. Therefore, whooping cough often affects children under 6 months of age who have not yet completed the full course of vaccination, and children over 6-7 years of age who received their last whooping cough vaccine at the age of 1½ years. A child who is vaccinated against whooping cough usually gets sicker from this infection than a child who does not receive the vaccine.

How does whooping cough occur?

Typically, the picture of whooping cough develops within 1-3 weeks.

First, the child’s body temperature rises slightly (low-grade fever occurs), a slight runny nose and cough appear. After 1-2 weeks, the cough intensifies, the child begins to suffer from coughing attacks that can last more than one minute, coughing attacks can be accompanied by facial redness, shortness of breath, respiratory arrest, vomiting, and between coughing shocks noisy breaths occur, which are called reprises. Between coughing attacks, the child usually feels well. Against the background of whooping cough, a child may develop pneumonia, which will manifest itself as a new rise in body temperature and deterioration in well-being. In children under one year of age, whooping cough is complicated by pneumonia in one out of five cases.

A child begins to recover from whooping cough after 3-4 weeks, when the coughing attacks with repeated episodes stop, but the cough can sometimes persist for another 1-3 months.

Children in the first months of life may suffer from whooping cough in a different way. They sometimes do not have typical coughing attacks. Instead of coughing or against its background, they may experience attacks of respiratory arrest (apnea).

You should not delay consulting a doctor if your child has coughing attacks, coughing to the point of vomiting, repeated coughing, shortness of breath or apnea, or if the child is very lethargic.

How can you tell if your baby has whooping cough?

Take your child to see a doctor. If you suspect whooping cough, the doctor will take blood tests for antibodies to the causative agent of whooping cough and/or a nasopharyngeal swab for PCR for whooping cough. A chest x-ray may be required.

What treatment is required for whooping cough?

If a diagnosis of whooping cough is made during the first month of illness, the doctor will prescribe an antibiotic to the child. Be sure to follow the antibiotic regimen recommended by your doctor. An antibiotic slightly shortens the duration of the disease and reduces the contagiousness (infectiousness) of the disease. Unfortunately, despite a timely prescribed antibiotic, the infection can persist for quite a long time.

To relieve coughing attacks, your doctor may prescribe inhalations and cough drops.

In order not to provoke vomiting, parents are advised to feed and water the child often and in small portions.

Tobacco smoke is a serious provocateur of coughing attacks, so try to ensure that your child is not exposed to second-hand smoke.

To this day, whooping cough and its pathogen remain a serious problem not only for Russia, but for the whole world. According to WHO, about 60 million people worldwide fall ill with whooping cough every year, and about 1 million children die, mostly under the age of one year.

Back in 1928, A. Stevonen wrote about whooping cough: “There is a disease, especially common in childhood, characterized by attacks of coughing so severe that it seems as if the child is suffocating; after coughing, viscous mucus is released. This disease drives mothers into despair, because it causes a lot of suffering to the child due to the duration of its course.” The first description of whooping cough was made in 1578 by Guillaume de Bayu, who observed an epidemic of this disease in Paris, which was highly fatal.

Whooping cough is an acute infectious disease caused by the pertussis bacillus with airborne transmission of infection, characterized by the occurrence of paroxysmal cough and the development of complications from the bronchopulmonary and central nervous system.

In 1906, Jules Bordet and Octave Gengou first isolated the causative agent of whooping cough - Bordetella pertussis. Since 1920, the incidence of whooping cough begins to be recorded in the world (150 per 100 thousand population, mortality - 6 per 100 thousand). In 1926, the first whole-cell vaccine against whooping cough was registered, 1927 - diphtheria toxoid, 1933 - tetanus toxoid. 1948 - the beginning of mass use of the first combined pertussis-diphtheria-tetanus vaccines adsorbed on aluminum (DPT). The introduction of compulsory vaccination against whooping cough in 1959 made it possible to sharply reduce the incidence of this infection; in 1969, the incidence rate in Russia was 3 per 100 thousand population. In Novosibirsk, until the mid-80s, a 3-year epidemic cycle was formed with an increase in incidence for 2 years and a yearly decline; the maximum increase was observed in 1978, 1979, 1981 and 1982. (19.6, 14.0, 19.2 and 34.4, respectively), the minimum in 1974, 1977 and 1980. (1.0, 3.6 and 10.6 respectively). In 1984, the city showed a tendency towards an intensive increase in the incidence rate with its maximum increase to 160.2, minimum - 25.5 (rise in 1984, 1990, 1991, 1993; decline in 1986, 1992). A similar situation was observed in all regions of Russia. Society is invulnerable against any infection only if 95% of the population has strong immunity. Since 1978, both in Russia as a whole and in Novosibirsk, there has been a tendency towards a decrease in the immune layer among the child population due to an increase in the number of children with medical exemptions from vaccination, which led to an increase in the incidence of whooping cough and an increase in the proportion (up to 50-70% ) sick among unvaccinated) children. In 1979, medical exemptions from the pertussis component were given to 12.2% of children, in 1990 - already 40.5%, and in 1994, 60.2% of children in the first year of life were vaccinated with the ADSM vaccine (without the pertussis component) . If in 1968 the proportion of unvaccinated children among those sick with whooping cough was 50%, then at the end of the 70s it increased to 70%, and in 1993 it was 80%, which confirms the involvement of unvaccinated children in the epidemic process.

The low level of vaccination is associated with an increase in the number of medical withdrawals due to unfavorable premorbid background (damage to the central nervous system, congenital pathology, allergic diseases), as well as parental refusal to vaccinate. Other reasons for the increase in the incidence of whooping cough are the untimely implementation of anti-epidemic measures due to late diagnosis of the disease, as well as tactical and therapeutic errors by doctors. This is facilitated not only by the difficulties in diagnosing mild and erased forms of whooping cough, especially in the presence of a concomitant viral infection, but also by a decrease in the alertness of pediatricians regarding whooping cough.

Since 1995, with the introduction into health care of recommendations for vaccination against whooping cough with a revision of the list of medical exemptions, the number of ADSM vaccinations (i.e. without the whooping cough component) has sharply decreased, which undoubtedly has affected the incidence. In 2010, the incidence in Novosibirsk was 25.1, and the average in the Russian Federation was 15.8 per 100 thousand population. If in the pre-vaccination period it was mainly preschoolers who were ill, then at present the main proportion of those ill with whooping cough are school-age children, as well as children in the first months of life (as a rule, these are the younger brothers or sisters of schoolchildren who have whooping cough and who have not yet had time to complete the course vaccinations). In school-age children, post-vaccination immunity weakens over time, so they get whooping cough, but the disease most often occurs in a mild and atypical form with prolonged cough syndrome. Children of the first year of life, on the contrary, become seriously ill, having no protection against this pathogen. Fatal outcomes from modern whooping cough are rare and occur only in children in the first six months of life in the presence of an aggravated condition, a layer of secondary infection or serious errors in treatment. In addition to active immunization, the decrease in the spread and severity of whooping cough is due to the fact that over the past decades there has been a change from the more virulent and toxic strain of the pertussis microbe 1.2.3 to the less virulent and toxic strain 1.0.3. The two main reasons for the continued incidence today are the insufficient percentage of those vaccinated against whooping cough, especially among children in the first year of life, and the weakening of post-vaccination immunity in school-age children. The mask of whooping cough in adults is a prolonged cough. As studies by foreign authors over the past 10 years have shown, in 26% of adults with a similar clinic, after laboratory examination of sputum, the diagnosis of whooping cough is confirmed.

The basic pathogenetic mechanism for whooping cough is still the adhesion of the pathogen to the mucous membrane of the trachea and bronchi. In addition to pertussis toxin, Bordetella also produces a number of other virulence factors, including fibrous hemagglutinin, pertactin, fimbriae, which promote the survival of bacteria in the respiratory tract by attaching to ciliated epithelial cells, macrophages and neutrophils. Recent studies have shown that pertussis not only attaches to epithelial cells and multiplies extracellularly, it also moves and survives within macrophages, providing indirect evidence for the important role of cell-mediated immunity in protection. The bronchogenic spread of bordetella goes all the way to the bronchioles and alveoli (there is no bacteremia).

The thermostable toxin is the main inducer of the paroxysmal phase of the disease, which determines the clinical specificity; it is called pertussis toxin (syn. “lymphocytosis-stimulating factor”, “pertussigen”, “pancreatic islet function activation factor”, “histamine-sensitizing factor”). Under the influence of pertussis toxin, bronchospasm occurs and the tone of the peripheral vessels of the skin increases, as well as generalized vascular spasm with an increase in blood pressure (BP). The waste products of the pertussis bacillus cause long-term irritation of the receptors of the afferent fibers of the vagus nerve (impulses enter the respiratory center of the central nervous system). The response is a cough (like an unconditioned reflex), which initially has the character of a normal tracheobronchial cough. The pathognomonic symptom of whooping cough is a paroxysmal convulsive cough due to a tonic spasm of the respiratory muscles.

Bordetella has a unique bronchotropic effect in the evolution of paroxysmal cough: it is absent in the catarrhal phase at the peak of maximum colonization of the bronchi by Bordetella, but persists in the period when bacteria become few or not detected at all. Inflammatory changes remain in the mucous membrane of the bronchial tree, which increase reactivity to irritants that are harmless to the normal respiratory tract. In mild forms of whooping cough, the upper parts of the respiratory tract are affected; in more severe forms, the entire bronchial tract up to the bronchioles is affected.

Constant impulses from the receptors of the respiratory tract epithelium enter the medulla oblongata, where a stagnant focus of excitation is formed with signs of dominance according to A. A. Ukhtomsky in the preconvulsive period, but its signs are most clearly expressed in the convulsive period, especially at 2-3 weeks.

Due to damage to the cilia and the associated violation of the cleansing of the mucous membrane from exudate, a large amount of thick and viscous sputum accumulates in the lumen of the bronchi, and respiratory function is impaired, especially exhalation. The result of this is emphysema and stagnation of lymph and blood circulation. Pulmonary circulatory disorders are one of the manifestations of peripheral circulatory disorders characteristic of whooping cough. They are expressed in spasm of both small and larger vessels, impaired blood flow speed, increased vascular permeability, changes in venous and blood pressure. Respiratory and circulatory disorders cause hypoxia, which is one of the most severe manifestations of whooping cough. Hypoxia is particularly important in the etiology of CNS disorders, enhancing changes caused by direct exposure to pertussis toxin. Possible changes in the hypothalamus, damage to the adrenal system and thymus.

Whooping cough is especially severe in newborns, who have a number of features that make it possible to classify this disease as one of the most severe in this age group.

The course of infection in newborns largely depends on their initial condition, in particular on damage to the central nervous system. In its absence, whooping cough often has a fairly typical course.

Children with central nervous system damage have a number of features:

1. The catarrhal period is sharply reduced.
2. The disease often occurs in the presence of a weak cough impulse, almost without recurrences; respiratory arrest and general cyanosis of the skin are often observed.
3. In some patients, for a long time, the only manifestation of the disease is sudden “blueness.”
4. Prolonged attacks often end in convulsions.
5. An important indicator of the severity of whooping cough in such children is apnea, attacks of which at the height of the disease are recorded in up to 80% of cases (without CNS pathology - in 20-45% of children).
6. In newborns, the pronounced effect of hypoxia contributes to damage to certain areas of the brain, manifested by a variety of symptoms, among which the most severe is swallowing disorder. Usually on the 20-25th day of illness, against the background of severe respiratory failure, frequent coughing attacks and apnea, choking appears during feeding, food gets into the nasal cavity, food can remain in the mouth for a long time (chewing gum symptom).
7. If the hypoxic factor leads to disruption of connections between the hemispheres and the caudal group of nerves, signs of pseudobulbar palsy may occur.
8. In newborns with intracranial birth injury, whooping cough is often complicated by pneumonia. In the genesis of pneumonia, the factor of food aspiration cannot be excluded.
9. Short-term intestinal dysfunction is possible. This symptom is due to the spread of the stimulating effect of the central nervous system on intestinal motility and is an indicator of the severity of whooping cough in this age group.

The relevance of timely clinical diagnosis is determined by three provisions. Firstly, the disease develops gradually and gives the classic manifestation of the clinical picture only at 1-2 weeks, which is why bacteriological diagnosis of whooping cough is usually delayed, as a result of which its results are often negative; secondly, whooping cough in young children often occurs atypically - in the absence of attacks of spasmodic coughing and recurrences. Thirdly, there is a similarity of specific clinical manifestations (spasmodic cough) of whooping cough with those of chlamydia, mycoplasmosis, non-infectious pathology of the bronchopulmonary system in children, etc. The above aspects pose the problem of accurate verification of the pathogen in order to determine etiologically based approaches to treatment.

Until now, the main criteria for diagnosis in the catarrhal period are clinical and laboratory signs of whooping cough:

1) epidemiological history (contact with people who cough for a long time);
2) gradual onset of the disease against the background of normal or subfebrile temperature with a satisfactory condition of the patient;
3) absence of pronounced catarrhal phenomena;
4) prolonged coughing for 1-2 weeks, increasing over time;
5) lack of effect from the ongoing symptomatic therapy;
6) paucity of auscultatory data;
7) the presence of hematological changes - leukocytosis, lymphocytosis with normal ESR or isolated lymphocytosis in older and vaccinated children;
8) presence of bacterial seeding Bordetella pertussis.

Period of convulsive cough

• Lasts from 2-3 to 6-8 weeks.
• A coughing attack is coughing impulses following each other on exhalation, interrupted by a whistling convulsive sigh - a reprise that occurs when air passes through a narrowed glottis (due to laryngospasm). At the end of the attack, thick viscous glassy mucus and sputum are discharged. Vomit.
• Possible paroxysms - coughing attacks for a short period of time

During the period of spasmodic cough, the clinical diagnosis of whooping cough can be complicated by the presence of whooping cough-like syndrome in a number of infectious diseases, including those caused by RS viruses, Mycoplasma рneumonia, Haemophilus influenzae, as well as somatic diseases and conditions (pulmonary cystic fibrosis, leukemia, lymphogranulomatosis, tuberculosis of the intrathoracic lymph nodes, etc.).

The most common complication of whooping cough is pneumonia. Let us dwell on the factors contributing to the development of pneumonia. The very condition of the respiratory tract during whooping cough predisposes to the development of pneumonia:

• These are, first of all, inflammatory changes in the mucous membrane of the respiratory tract and alveolar epithelium.
• Violation of the drainage function of the bronchi and bronchioles, their spasm, mucus retention with the formation of muco-epithelial plugs and areas of atelectasis, from where the inflammatory process most often begins, accompanied by the development of pulmonary emphysema.
• Changes in the function of the respiratory muscles.
• Congestion in the pulmonary circulation and the development of hypoxemia and hypoxia.

The development of pneumonia is promoted by the following premorbid conditions: prematurity, malnutrition, dysbacteriosis, diathesis, anemia, as well as immune dysfunction that develops with whooping cough (to a greater extent, the insufficiency of humoral defense mechanisms in children of all age groups).

The classic method for laboratory confirmation of whooping cough is still the isolation of a pure culture of the pathogen. The material for research is nasopharyngeal mucus. The best result of bacteriological isolation of the pathogen, obtained under ideal conditions, is 80%; in clinical practice it is much lower. Thus, according to domestic researchers, the percentage of bacteriological confirmation in patients with whooping cough generally does not exceed 10% and in rare cases reaches 30%. Failures in isolating the pathogen are associated with the peculiarity of the microorganism and its slow growth, low quality of culture media, late examination of patients, contamination of the test material with other microorganisms, incorrect collection of the test material, and the use of antibacterial drugs before the start of the bacteriological examination.

Bacteriological diagnosis of whooping cough

“Gold standard” for diagnosing whooping cough (WHO):

• Material: nasopharyngeal aspirate/smear from both nasal passages (from the posterior nasopharynx, not from the larynx!).
• Collection method: swab with Dacron/calcium alginate (not cotton wool!).
• Direct inoculation onto the medium and cultivation or transfer to a transport medium (REGAN-LOWE, storage at 37 °C for no more than a day).
• Transportation to the laboratory at ambient temperature is only possible in a special transport medium.
• Inoculation on REGAN-LOWE or BORDET-GENGOU agar with cephalexin (40 mg/ml).

The low percentage of bacteriological confirmation for whooping cough prompted researchers to develop more sensitive tests for indicating the pathogen, and in the early 60s a new method for determining the pertussis microbe using fluorescent antibodies appeared. The material for the study is nasopharyngeal mucus; smears are processed according to the generally accepted method for fluorescent microscopy. Successful use of this test is possible up to 4-5 weeks of illness during antibiotic treatment, but with the use of high-quality reagents and highly qualified personnel, otherwise the percentage of false positive results is very high. Considering the above, the method is recommended as an additional one and is rarely used in practical medicine.

Enzyme-linked immunosorbent assay (ELISA) uses purified protein antigens B. pertussis for measuring serum immunoglobulins of classes G, M, A after illness or vaccination. ELISA is a sensitive, specific, relatively inexpensive test and requires a small amount of serum. However, the accuracy of the test depends on the purity of the antigens used. Currently, the determination of antibodies to CT by ELISA is widely used in the laboratory diagnosis of whooping cough in most countries with a developed healthcare system.

Since 1999, a complete DNA detection method has been developed and tested in Novosibirsk B. pertussis using polymerase chain reaction (PCR) using commercial test systems from DNA Technology (Moscow) (specialized laboratory of DNA diagnostics of the Novosibirsk Research Institute of Tuberculosis). Advantages of the PCR method compared to the bacteriological method:

1. The PCR method achieves the highest possible sensitivity - up to one pathogen in a sample, which allows you to obtain a positive result within 6 weeks from the moment of illness against the background of antibiotic therapy.
2. The specificity of the method ranges from 85% to 100%, and therefore contamination of the test material with foreign microflora does not affect the result.
3. Quick receipt of analysis results - within one day. Currently, sputum PCR can be considered an alternative to the bacteriological method of pathogen isolation.

Thus, the problem of laboratory diagnosis of whooping cough in children is still far from being finally resolved. The experience of previous studies suggests that for a reliable laboratory diagnosis of whooping cough, several complementary tests should be used. The most effective is considered to be a combination of pathogen indication methods (bacteriological and sputum PCR).

Treatment of whooping cough

Treatment of patients with whooping cough includes two main stages:

1) relief of acute manifestations of pertussis infection;
2) prevention of the development of complications and adverse consequences.

Of the complications, stage I should prevent: the development of delays and cessations of breathing, convulsive and hemorrhagic syndromes, specific changes in the bronchopulmonary system.

At stage II, the nature of therapy is determined by the risk of developing bacterial complications in patients with whooping cough.

At the first stage, the most important is the impact on the causative agent of whooping cough - early administration of antibacterial therapy in combination with the correct organization of regimen, care and nutrition. Nutrition should be complete, physiological depending on age. Infants are shown expressed breast milk and adapted formulas.

It is recommended to increase the number of feedings by 1-2 times a day with a decrease in the one-time volume. After vomiting, the child needs to be fed additionally within 10-15 minutes. The volume of fluid consumed should be physiological. Control of the weight curve is necessary.

Particularly important is the operating mode of the whooping cough department, which excludes the possibility of secondary infection: immediate filling of the wards, isolation of patients with nonspecific complications, hospitalization of children of the first year of life in a separate ward.

Psycho-emotional peace is important: elimination of external stimuli, longer sleep, walks in the fresh air (at a temperature not lower than -12 ° C), hospitalization with the mother. It is necessary to teach the mother methods of breathing exercises, learn to distract the child from coughing, not to be afraid of its approach, and first aid for apnea.

Clinical indications for hospitalization:

1) moderate and severe severity;
2) complicated course;
3) severe concomitant diseases, regardless of the severity of whooping cough;
4) age (children under one year old, unvaccinated against whooping cough).

Epidemiological: from closed medical institutions, orphanages, hostels, etc., socially disadvantaged families.

Treatment of patients with whooping cough is determined by the severity of the disease.

Treatment algorithm for patients depending on the severity of the disease:

With a mild form (in vaccinated people, older children)

Antibacterial therapy is indicated for young children, as well as those with chronic foci of infection. The drugs of choice are macrolides: erythromycin in an age-specific dosage, usually per os for 5-7 days; azithromycin 10 mg/kg/day one hour before meals or two hours after meals No. 3-5.

Sedatives are indicated as pathogenetic and symptomatic therapy: valerian infusion 5-10.0 ml 3-4 times a day. Depending on age; tincture of valerian, motherwort, peony - a drop for a year of life 3-4 times a day, 7-10 days.

Good effect from the use of antispasmodics: mixture with belladonna extract - 0.015, calcium gluconate 5% - 100.0, 5-15.0 ml 3 times a day, 7-10 days.

Vitamins A, C, P in age-specific dosages.

Desensitizing therapy is indicated in the presence of allergies.

In moderate form

The determining factor when choosing antibacterial therapy is the presence or absence of bacterial complications. In uncomplicated cases, macrolides remain the drugs of choice; when pneumonia develops, third-generation cephalosporins and combinations of antibacterial drugs are prescribed, depending on the need.

The purpose of symptomatic and pathogenetic therapy should ensure the fulfillment of the following tasks: improving mucociliary clearance, influencing cough, reducing swelling of the mucous membrane and hypersecretion of sputum, counteracting bronchoconstriction, improving sputum discharge.

An important place is occupied by bronchomucolytic drugs administered via a nebulizer, which promotes deeper penetration into the bronchopulmonary system: Berodual at the rate of 1 drop per kg of body weight, Lazolvan 0.5-2.0 ml, depending on age, 2-4 times a day. Bromhexine, Bronchicum, Stoptussin, Sinekod, Eufillin 2-4 mg/kg/dose, etc. are also shown in age-specific dosages.

In the presence of a very severe paroxysmal cough, in order to reduce the number of attacks and their duration, you can use neuroplegics: Pipolfen 2.5%, 0.5-1.0 mg/kg/day for 5-7 days, Seduxen 0.5% - 0.5-1.0 mg/kg/day, usually before night and daytime sleep. The dose is selected individually: it is sufficient if after administration of the drug the child falls asleep within 10-15 minutes and daytime sleep lasts 2.5-3 hours, and nighttime sleep lasts 6-8 hours.

Antitussive drugs are not effective for whooping cough, but are sometimes used for painful dry cough: glaucine hydrochloride 1 mg/year per dose 3 times/day, 7-10 days; Levopront, Stoptussin in age-specific dosages; Codeine preparations are contraindicated. From the 2nd week of the spasmodic period, massage and breathing exercises are indicated; we observed a positive effect from the use of acupuncture according to the Chinese method No. 7-10.

An assessment of the clinical and immunological effectiveness and safety of various immunomodulatory therapy (IMT) regimens and their appropriateness for the prevention of complications in whooping cough was carried out in a comparative non-randomized open study (MBUZ Children's City Clinical Hospital No. 3, 1995-2005). When deciding on the timing of inclusion of BMI in the complex therapy of whooping cough, we were guided by the following provisions: given that immune dysfunction develops already at the beginning of spasmodic cough, immunomodulators should be prescribed from the very beginning of treatment. According to V.I. Kirillov, for bacterial infections, IMT should be prescribed simultaneously with antibiotics. In this case, the pathogen is dealt a “double” blow: the antibiotic reduces the functional activity of the microbe, and the immunomodulator increases the activity of phagocytic cells, thereby achieving more effective elimination of the pathogen from the body and at the same time preventing bacterial complications.

The most effective combination of drugs was: sodium nucleinate in an age-specific dosage 3 times a day after meals for 2 weeks and IRS-19, 1 inhalation into each nostril 2-3 times a day for a month.

Severe forms are observed mainly in newborns, young children and older children who have not been vaccinated against whooping cough with an unfavorable premorbid background.

Combinations of macrolides, III-IV generation cephalosporins, etc. are often used as etiotropic therapy.

Along with aerotherapy, oxygen therapy carried out in an incubator or oxygen tent is vital (the optimal concentration of oxygen in the inhaled mixture is up to 40%, at a temperature of 28-30 ° C, relative humidity - 80-90%) for 30-40 minutes several times per day.

In addition to the therapy used in patients with moderate forms, the use of hormones is justified. Their purpose is justified by the membrane-protective effect, which helps to reduce vascular permeability and reduce brain swelling, reduce metabolic disorders associated with hypoxia, as well as with a replacement function in protecting the body from functional exhaustion of the adrenal glands: prednisolone at the rate of 2-5 mg/kg/day, hydrocortisone - 5-10 mg/kg/day, 3 times, IM, 3-5-7 days. If necessary, dehydration therapy is prescribed: Lasix (furosemide) 1-3 mg/kg/day in a short course. Children with central nervous system pathology are prescribed drugs that improve cerebral circulation (Trental, Cavinton).

Other principles of therapy correspond to the treatment of moderately severe patients, but are carried out more vigorously.

Prevention of whooping cough

Since immunity to whooping cough is not transmitted transplacentally, specific DPT prophylaxis is indicated for all children aged three months to three years. The vaccination course consists of three intramuscular injections of the drug (0.5 ml each) with an interval of 1.5 months. Revaccination with DPT vaccine is carried out once 1-1.5 years after the completed 3-fold vaccination. Children over three years of age are not vaccinated with the DTP vaccine. The controversy that has unfolded in recent years about the dangers of vaccination with the DPT vaccine has significantly affected vaccination work. Currently, there are only three contraindications for vaccination with this vaccine:

1) a severe reaction to the first vaccination in the form of a fever above 40.5 °C, a shrill cry and uncontrollable prolonged crying for three or more hours, an anaphylactic reaction or Quincke's edema;
2) progressive oncological diseases or progressive lesions of the central nervous system;
3) active tuberculosis.

In case of adverse reactions or as an alternative, acellular vaccines Infanrix (Glaxo Smith Klein, Belgium) or Pentaxim (Sanofi Pasteur, France) can be used. The timing of vaccination and revaccination is the same; it can be used in children over three years of age.

The vaccines comply with WHO requirements for the production of substances of biological origin and vaccines against diphtheria, tetanus and whooping cough, and Pentaxim, in addition to those listed, against polio and Haemophilus influenzae.

Literature

1. Babachenko I. V., Kurova N. N., Tseneva G. Ya. Pertussis infection in conditions of antigenic drift of Bordetella pertussis // Issues of modern pediatrics. 2006. No. 6. P. 24-27.
2. Petrova M. S. and others. Whooping cough and cytomegalovirus infection in children // Epidemiology and infectious diseases. 2008. No. 5. P. 57-61.
3. Namazova L. S., Gevorkyan A. K., Galeeva E. A. Is pertussias a problem for the Russian pediatrics? Can we overcome it? // Pediatric pharmacology. 2006. No. 4. P. 6-9.
4. Crespo I. Epidemiology of pertussis in a country with high vaccination coverage // Vaccine. 2011. Vol. 29, No. 25. P. 4244-4248.
5. Zouari A. The new health legacy: When pertussis becomes a heritage transmitted from mothers to infants // J. Med. Microbiol. 2011. Vol. 29, No. 3. P. 613-619.
6. Kirillov V. I. Clinical practice and prospects for immunocorrective therapy: review material // Practitioner. 1998. No. 12. P. 9-12.
7. Khaitov R. M., Pinegin B. V., Andronova T. M. Domestic immunotropic drugs of the latest generation and the strategy for their use // Treating Doctor. 1998. No. 4. P. 46-51.
8. Manko V. M., Petrov R. V., Khaitov R. M. Immunomodulation: history, development trends, current state and prospects // Immunology. 2002. T. 23. No. 3. P. 132-138.
9. Vaccines for the prevention of whooping cough (WHO position) // Pediatric pharmacology. 2008. No. 1. P. 91-94.

L. M. Panasenko,
E. I. Krasnova,Doctor of Medical Sciences, Professor
A. V. Vasyunina, Doctor of Medical Sciences, Professor

NSMU, Novosibirsk