Philippine Society for Microbiology and Infectious Diseases
GUIDANCE ON THE PREVENTION AND
POST-EXPOSURE MANAGEMENT OF PERTUSSIS
AMONG HEALTHCARE WORKERS
16 April 2024
I. Introduction
A. What is Pertussis?
Pertussis is a respiratory infection that is highly contagious. The disease is also called
whooping cough, and is caused by a bacterium named Bordetella pertussis. Pertussis occurs
worldwide, where it is endemic, but with epidemics that come every 2–5 years.
B. pertussis is a gram-negative bacteria that is fastidious, needing special media to grow on
culture. The bacteria attaches to the respiratory epithelial cells, called cilia. The toxins produced
by the bacteria paralyze the cilia, cause respiratory tract inflammation, and interfere with the
clearing of respiratory secretions. B. pertussis produces many antigens and other products such
as:
• Pertussis toxin
• Filamentous hemagglutinin (FHA)
• Agglutinogens
• Adenylate cyclase
• Pertactin
• Tracheal cytotoxin
The actions of all the above lead to the clinical features of this toxin-mediated disease. And
after the infection, the resultant immune response results in immunity.
Pertussis is a disease of humans only. It is most dangerous in infants, causing significant
morbidity and mortality in this age group. Initial symptoms usually appear 7 to 10 days after being
infected, which include mild fever, rhinorrhea and cough, typically developing into a hacking cough
followed by a whoop. The cough of classic pertussis may last for many weeks. Pneumonia is a
common complication, while seizures and brain disease are rare events.
The incubation period of pertussis is commonly between 5 to 10 days, to as long as 3 weeks
after being exposed. The disease has 3 stages: catarrhal, paroxysmal, and convalescent.
• Stage 1 is the catarrhal stage (first 1-2 weeks of infection), and the symptoms are runny
nose, low-grade fever, and mild coughing. Patients are highly contagious in this stage.
• Stage 2 is the paroxysmal stage (occurring 1-6 weeks after, and may last up to 10 weeks)
characterized by episodic rapid coughing, which can be followed by the typical “whoop”
sound, and possibly post-tussive vomiting.
• Stage 3 is the convalescent stage (2-3 weeks), when gradual recovery occurs (improvement
of cough and less coughing fits).
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B. Case Definition
Case Classification Case Definition
Suspected Case Any person with cough lasting at least 2 weeks with at least one
of the following:
• Paroxysms (i.e. fits) of coughing
• Inspiratory “whooping”
• Post-tussive vomiting (i.e. vomiting immediately after
coughing) without other apparent cause
• Apnea, with or without cyanosis (for infants < 1 year old)
Confirmed Case • A suspect case that is laboratory confirmed or
epidemiologically linked to a laboratory-confirmed case
• Laboratory criteria for diagnosis: Isolation of Bordetella
pertussis from clinical specimen
Source: Philippine Integrated Surveillance and Response (PIDSR) Case Investigation Form for
Pertussis Version 2019
C. Mode of transmission
Pertussis spreads from person to person very easily through droplets produced during
coughing or sneezing. Silent transmission has been known to occur in humans.
D. Period of communicability
Patients are contagious from the onset of the first symptoms until at least 2 weeks after the
coughing begins, even up to 3 weeks after. Many children who get infected may have coughing
spells up to 4 to 8 weeks.
Because of its infectivity, up to 90% of household contacts, and around 50% to 80% of
classroom contacts become infected after they have been exposed.
People of all ages are susceptible. Before the vaccination era, almost all children were
infected. The disease is particularly dangerous in young infants, who are at high risk for
hospitalization and death, but the disease is particularly bothersome at any age. Important to
highlight is the fact that the clinical presentation in adults and adolescents may be less severe and
so the diagnosis may be missed.
Taking an antibacterial (e.g., macrolide) early in the disease course may shorten the
duration of the disease’s communicability, and sometimes lessen severity.
Patients who receive effective antibacterial treatment for pertussis are considered no
longer contagious after 5 days of the medication.
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E. Definition of significant exposure to a pertussis patient
Quantifying the risk of getting pertussis in health workers is difficult because exposure is
not well-defined. The B. pertussis bacteria are present in respiratory, oral, or nasal secretions from
infected source patients, and their deposition onto the mucous membranes of a susceptible health
worker may lead to infection.
An unprotected health worker (e.g., no facemask), who was in close proximity and had face-
to-face contact with an infectious pertussis patient, or had contact with their secretions may be
considered “significantly exposed.” The performance of physical examination on, feeding, or
bathing a patient; doing bronchoscopy; performing intubation; or the administration of
bronchodilators are all considered close contact, among others.
Determining close contact becomes even more important in those exposed persons who
have increased risk for severe pertussis. They are as follows:
• Household contacts of a pertussis patient (even if they were immunized).
• Infants (particularly those under 12 months of age, and most especially in the under 4
months of age)
• Women in the third trimester of pregnancy
• Those with pre-existing health conditions that may be exacerbated by contracting
pertussis (e.g., immunocompromised patients, those with moderate to severe asthma)
II. Infection Control Procedures
A. Transmission-based Precautions
Standard and droplet precautions are implemented for patients known or suspected to be
infected with agents transmitted by close respiratory or mucous membrane contact with
respiratory droplets, as pertussis, that are generated by a patient when coughing, sneezing or
talking. Isolation precautions shall be implemented until 5 days after initiation of effective
antibiotic therapy or, if not treated, until 21 days after the onset of cough.
Certain risk-prone procedures for droplet transmission in hospitals can occur and include:
• Coughing up or inducing sputum production for laboratory tests; collecting of throat
swabs
• Endotracheal suctioning (open and closed) of ventilated patients
• Chest physiotherapy
• Taking chest X-rays from patients who are coughing, especially with poor cough
etiquette
• Bronchoscopy
• Re-use of ventilator circuits and respiratory equipment
• Washing and cleaning respiratory ventilation equipment in clinical areas without
adequate protection
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B. Guidelines for droplet precautions
Patient placement
• Place patient in single room with bathroom. Preferably keep the door closed.
• When single-patient rooms are in short supply, the following principles apply in decision-making
on patient placement:
a. prioritize patients who have excessive cough and sputum production for single-patient
room placement
b. consider patients ability to perform hand hygiene and follow appropriate cough
etiquette
c. place together in the same room (cohort) patients who are infected with the same
pathogen and are suitable roommates
• If it becomes necessary to place patients who require droplet precautions in a room with a
patient who does not have the same infection:
a. avoid placing patients on droplet precautions in the same room with patients who have
conditions that may increase the risk of adverse outcomes from infection or that may
facilitate transmission (e.g. those who are immunocompromised, have anticipated
prolonged lengths of stay, have cardiac conditions or muscular dystrophy)
b. ensure that patients are physically separated (> one meter apart) from each other and
draw the privacy curtain between beds to minimize opportunities for close contact.
• Place clean, unused PPE outside patient room
• Clinical notes should stay outside patient area
Hand Hygiene (HH)
• Perform HH according to the WHO 5 Moments of HH
• HH has to be performed before donning and after removal of PPE
Respiratory or cough etiquette
• Cover your mouth and nose with a tissue when you cough or sneeze. Put your used tissue in the
garbage
• Cough or sneeze into your upper sleeve or elbow (not your hands) if you don’t have a tissue.
Personal protective equipment (PPE)
• Surgical mask is to be worn before entering the patient room, with hand hygiene practiced
before putting on the mask and after taking off the mask.
• Surgical masks are single-use items and must be discarded after removal, just before leaving the
isolation area.
• Replace damp, soiled or contaminated masks immediately
• An N95 respirator must be used if patient will undergo an aerosol generating procedure for the
duration of the procedure. The procedure should be undertaken in a treatment room, away
from other patients (if the patient is cohorted with others).
• Additional PPE like gloves and apron might be indicated, depending on the nature of the patient
interaction.
Maintenance of a clean environment
B. pertussis may survive for 3–5 days on inanimate dry surfaces; 5 days on clothes, 2 days on paper, and
6 days on glass, so appropriate cleaning is critical.
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B. pertussis has been shown to be sensitive to glutaraldehyde; most vegetative bacteria are susceptible
to low concentrations of chlorine, 70% ethanol, or phenolics.
A. Concurrent cleaning
• Wear appropriate PPE
• Use dedicated cleaning equipment
• Clean all surfaces daily with detergent and water and then disinfect using 70% alcohol or
hypochlorite solution 1000 ppm
B. Terminal cleaning
• Remove bed linen and privacy/ inter-bed curtains and place in yellow bag and send to the
laundry
• Upon discharge clean and disinfect all equipment in the room before taking it to the storage
area.
• Clean all surfaces, including walls to hand height with soap and water and then disinfect using
70% alcohol or hypochlorite solution 1000 ppm
• Remove PPE and perform HH after completion of the task
Patient care equipment
• Dedicated equipment is preferred. Using equipment between patients poses a risk of
transmission.
• Clean shared equipment (if any) after patient use.
Correct management of used linen
• Treat all linen as contaminated and infectious
• Place in yellow plastic bag inside room, seal and place in linen bag dedicated for
contaminated/infected linen
• Ensure prompt removal
• Double bag, if leakage hazard exists and ensure safe transportation
• Attach list of contents to outside of bag
Patient transport
• Limit movement outside of room
• Patient should wear surgical mask when leaving the room for another department or for
procedures
• Inform receiving department in advance of the infectious status of the patient and maintain
precautions
• Inform the theatre if the patient is scheduled for surgery
• The patients must be last on the theatre list to ensure for adequate cleaning/disinfection and
ventilation of the environment
• Theatre staff has to wear N95 respirators if patient has concomitant infections such as influenza,
SARS or TB.
Visitors
Visitors should:
• Always announce themselves to the person in charge of the unit
• Be informed of the reason for isolation
• Be restricted. Preferably no children, immunocompromised visitors or those not previously
exposed as a close contact of the patient
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• Adhere to the prescribed PPE
• Wear a surgical mask before entering
• Perform HH before and after leaving the room
Discontinue isolation precautions
• According to diagnosis and infectious period for the condition, immunocompetence and clinical
improvement of patient
• Decision made in collaboration with the IPC practitioner/team and clinical team
C. Immunization as Routine Prevention Activity
Vaccination is the best way to help protect against pertussis. A vaccine combination of tetanus-
diphtheria-acellular pertussis (Tdap) specifically developed for adults is widely available. It protects
against tetanus, diphtheria and pertussis and it is underutilized.
Recommendations:
1. All eligible healthcare worker/s (HCW/HCWs) should receive one dose of Tdap vaccine. This may be
given anytime.
For pregnant HCWs, a single dose of Tdap should be given during each pregnancy, preferably at 27
to 36 weeks AOG, for the protection of both the mother and the baby. This timing was
recommended because of rapid waning of anti-pertussis antibodies and optimal timing of placental
antibody transfer. Please see Figure 1.
Figure 1. Pertussis Vaccination
2. Vaccination should be given to eligible HCWs but prioritization according to the following grouping
should be considered if there are limited stocks of the vaccine:
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• Priority group 1: HCWs with regular and close clinical contact with severely ill young
infants* and women in the last month of pregnancy. This includes:
o clinical staff working with women in the last month of pregnancy (for example
midwifery, obstetrics and maternity settings)
o neonatal and pediatric intensive care staff who are likely to have close and or
prolonged clinical contact with severely ill young infants
o HCWs assigned to the emergency room
*Young infants are considered those under 3 months of age
• Priority group 2: HCWs with regular clinical contact with young unimmunized infants in
hospital or community settings. This includes:
o general pediatric staff
o pediatric cardiology staff
o pediatric surgery staff
o health visitor staff
• Priority group 3: HCWs with intermittent clinical contact with young unimmunized infants
in the community. This includes HCWs in general practice.
III. Post-exposure management
A. Post exposure prophylaxis (PEP)
The use of PEP is highly recommended for HCWs fulfilling the criteria for high-risk exposure
or close contact:
1. All asymptomatic HCWs with household exposure to a pertussis patient within 21 days
of the onset of cough of the index patient
2. High risk HCWs who belong to the following groups and are exposed within 21 days to
a pertussis case:
• Women in their 3rd trimester of pregnancy
• HCWs with pre-existing health conditions (eg., immunocompromised,
moderate to severe asthma etc.) that may be exacerbated by pertussis
infection
• HCWs who have a high probability of having close contact with high risk
individuals
• HCWs in high risk settings who will have close contact with infants under 12
months of age or women in the 3rd trimester of pregnancy (eg, neonatal
intensive care units, child care setting, maternity wards)
The antibiotics recommended for post-exposure prophylaxis include:
• azithromycin 500mg on day 1, followed by 250mg on days 2-5 or
• clarithromycin 500mg 2x a day for 7 days or
• erythromycin 500mg 4x a day for 14 days
• alternative: TMP-SMX 160/800mg 2x a day for 14 days
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In HCWs who are pregnant, azithromycin is the preferred agent. TMP-SMX can be used as
an alternative agent to macrolides for HCWs who are allergic to macrolides, who cannot tolerate
macrolides, or who are exposed to a rare macrolide-resistant strain of Bordetella pertussis.
Because Tdap coverage may be suboptimal among HCWs, and the duration of protection
afforded by Tdap is unknown or may wane over time, vaccination status does not change the need
for postexposure prophylaxis in exposed HCWs.
B. Work restriction for exposed and symptomatic HCWs
Advise the exposed HCW, especially those with incomplete vaccination history, to monitor
for signs and symptoms of pertussis until 21 days after the last exposure. Laboratory testing is not
required for exposed and asymptomatic HCWs. No work restriction is needed for asymptomatic
HCWs. HCWs should observe infection control procedures as discussed in Section II of this
document.
If a HCW develops symptoms after a known or suspected pertussis exposure, he should be
excluded from work from the beginning of catarrhal stage until the third week after onset of
symptoms (if untreated) or until 5 days after effective antimicrobial therapy.
C. Vaccination
Vaccination can be given to eligible HCW but prioritization should be considered if there are
limited stocks of the vaccine as recommended above (see Section II.C.2).
Tdap booster vaccination is appropriate even for HCWs who have had a recent clinical
episode of pertussis. Tdap may be administered regardless of the interval since the last dose of Td.
If it is not possible to determine whether a HCW has had a Tdap booster, it is prudent to administer
a dose and ensure that it is properly documented.
REFERENCES:
1. Centers for Disease Control and Prevention. Pertussis (Whooping Cough). Last Reviewed: August 4,
2022. US Department of Health & Human Services. https://www.cdc.gov/pertussis/index.html
2. Centers for Disease Control and Prevention. Pertussis (Infection Control in Healthcare Personnel:
Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and
Patients). Last Reviewed: November 2, 2022. US Department of Health & Human Services.
https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/selected-
infections/pertussis.html#:~:text=Unprotected%20(e.g.%2C%20not%20wearing%20a,considered%20
an%20exposure%20to%20pertussis.
3. Decker MD, Edwards KM. Pertussis (Whooping Cough). The Journal of Infectious Diseases, Volume
224, Issue Supplement_4, 1 October 2021, Pages S310–S320, https://doi.org/10.1093/infdis/jiaa469
4. World Health Organization. Pertussis. 2024. https://www.who.int/health-topics/pertussis#tab=tab_1
5. Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) - National
Health and Medical Research Council (NHMRC)
6. Barbeau, B. Pertussis (Whooping cough): Utah public health disease investigation plan. 2019.
7. CDC Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare
settings, 2007. Appendix A.
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007_appendixA.pdf later version:
http://www.cdc.gov/hicpac/2007IP/2007ip_appendA.html
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8. DOH-DM-2023-0284-Interim-Guidelines-on-the-PDITR-Strategy-and-Outbreak-Response-for-
Pertussis-and-Diphtheria.pdf.
9. Kline, J., et. al. Pertussis: Common Questions and Answers. Am Fam Physician. 2021; 104(2):186-192.
10. PSMID CPG-ADULT-IMMUNIZATION-2018
11. Immunization of Healthcare Personnel: Recommendations of the Advisory Committee on
Immunization Practices. MMWR November 25, 2011 / 60(RR07);1-45
12. Tiwari T, Murphy TV, Moran J, National Immunization Program, CDC. Recommended antimicrobial
agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines. MMWR
Recomm Rep. 2005;54(RR-14):1.
13. Uptodate: Pertussis infection in adolescents and adults: Treatment and prevention.
https://www.uptodate.com/contents/pertussis-infection-in-adolescents-and-adults-treatment-and-
prevention?search=pertussis%20post%20exposure%20prophylaxis&topicRef=3889&source=see_link
#H3296861715. Accessed 06April 2024
14. https://www.gov.uk/government/publications/pertussis-occupational-vaccination-of-healthcare-
workers/pertussis-occupational-vaccination-of-healthcare-workers#fnref:1 Accessed 06April2024
15. https://www.cdc.gov/vaccines/vpd/dtap-tdap-
td/hcp/recommendations.html#:~:text=CDC%20only%20recommends%20Tdap%20in,%2C%20or%20
a%20previous%20pregnancy).
16. Guidelines for the Public Health Management of Pertussis in England. Pertussis Guidelines Group.
May 2018 V2.0.
17. https://assets.publishing.service.gov.uk/media/5a747c33ed915d0e8bf18ab0/Guidelines_for_the_Pu
blic_Health_Management_of_Pertussis_in_Healthcare_Settings_2016.pdf
Prepared by:
Dr. Jemelyn Garcia (PSMID Standards of Care Committee)
Dr. Joseph Adrian Buensalido (PSMID Standards of Care Committee)
Dr. Pamela Rose Matti (PSMID Infection Prevention and Control Committee)
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