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Pertussis is increasing in unimmunised infants: is a change of policy needed?
  1. CRAIG SMITH, Senior Registrar, Queen’s Medical Centre,
  1. University Hospital, Nottingham NG7 2H, UK
    1. HARISH VYAS, Consultant in Intensive Care, Queen’s Medical Centre
    1. University Hospital, Nottingham NG7 2H, UK

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      Editor,—Our experience of pertussis infection in unimmunised infants is similar to that of Ranganathanet al.1 Awareness of the illness has fallen and it may go undetected or unreported, even in the event of death.2 The presenting features are atypical and may include apnoea or seizures.

      We have managed nine cases of severe infantile pertussis recently, all but one presenting in the past two years. The patients presented between 2 and 6 weeks of age with a history of poor feeding and cough, bronchiolitis being the provisional diagnosis. Five were ventilated for recurrent apnoea, two for seizures, and two for respiratory failure. Six of them died. Ventilation was difficult as thick secretions produced areas of collapse, consolidation, and hyperinflation. Complications included pneumothorax, hypotension, pulmonary hypertension, seizures, and coinfection. One survivor required prolonged extracorporeal membranous oxygenation and high frequency ventilation in addition to 700 hours of conventional ventilation. In three cases the deterioration to death was rapid, with diagnosis being made postmortem.

      We agree that the organism continues to circulate, often silently, among family members.3 In six of our cases the mother was symptomatic and thought to be the source of infection. Immunisation produces temporary immunity making adults susceptible to infection. We were unable to confirm immunisation in all of the mothers. There is now a cohort of adults whose parents declined vaccination during the 1970s who are susceptible to primary infection and of reproductive age. This fatal resurgence in infantile pertussis should lead to a debate on reviewing the accelerated immunisation schedule.4 If the safety of the newer acellular vaccines are accepted, then their use in later childhood or adolescence may be necessary to halt this trend. In the short term a new generation of general practitioners and paediatricians need to be aware of these aspects of pertussis and have a higher index of suspicion, only then will the prevention of secondary transmission be possible, particularly in the presence of a new baby.

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