UKK Infeksi & Penyakit Tropis IDAI

A – Z Pertusis

Anggraini Alam
Outline

• Pertusis:
• Epidemiologi
• Etiologi & patofisiologi
• Klinis
• Laboratorium
• Faktor risiko
• DD/
• terapi
Definisi
Orang dengan batuk terus menerus (batuk paroksismus) yang berlangsung minimal selama 2
minggu dengan ditemukan minimal 1 tanda berikut:
a. Batuk rejan pada saat inspirasi atau napas dalam (inspiratory whoop)
b. Muntah setelah batuk (post-tussive vomiting)
c. Muntah tanpa ada penyebab yang jelas
Atau
Kasus apneu (berhenti nafas) dengan atau tanpa sianosis pada anak usia <1 tahun dengan
batuk tanpa ada batasan durasi.
Atau
Jika dokter menduga pertusis pada pasien dengan batuk tanpa ada batasan durasi
The World Health Organization diagnostic criteria had a low sensitivity (15%), but high specificity (92%)
Kemenkes RI. Petunjuk surveilans pertussis. 2021
Gopal Krishnan S, et al. PLoS One. 2019 Jul 10;14(7):e0219534
 Epidemiology

• Pertussis is a disease of
worldwide distribution
• Epidemic cycles every three or
five years.
• 16 million annual cases and
about 200 thousand deaths is
estimate
• The fifth place among causes of
death by vaccine-prevented
diseases in <5 years old
Whooping Cough. IHME, Global Burden of Disease, 2020
Jiang W et al. Journal of Microbiology, Immunology and Infec/on, hUps://
doi.org/10.1016/j.jmii.2020.03.006
Esposito S, et al. Frontiers in immunology. 2019;10: 1344.
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1.714.471 anak tidak mendapat Imunisasi Dasar Lengkap (IDL) pada 2019-2021. Mayoritas di Jawa Barat, Aceh, Sumatera Utara, Riau, dan Sumatera Barat.
 First described in the Paris
epidemic of 1578.
Causative organism was
discovered in 1906

Gram negative coccus

Aerob 35-370C
incubation period lasts from 5
to 10 (6-20) days and
transmission 5–7 days after
contact, persisting
for 3 weeks when not treated

does not invade tissues and

bloodstream.
Highly contagious pertussis
has a secondary attack rate
of up to 90%

Octave Gengou
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Soft clinical manifestations are common in partially immunized children:
• only prolonged dry cough, > 21 days
• leading to diagnostic confusion with bronchitis, sinusitis, atypical
pneumonia and allergies
Slide Anggi Pertussis. Centers for Disease Control
and Prevention (CDC). 2016.
Risk factors for acquiring pertussis & impact clinical presentation

Epidemic exposure

Lack of immunization, time elapsed from vaccination

Close contact with an infected individual

Age, pregnancy

immunological status
 • Culture is most
sensitive if
sample collection
is conducted
within 2 weeks of
onset.
• The PCR assay is
more sensitive
and allows
specimen
collection up to 4
weeks after
onset.

Sunarno S, et al. PLoS

One. 2022 Apr
20;17(4):e0266033.

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Tata laksana

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 Antibiotik:
Makrolid

• Eritromisin > clarithromisin > azithromisin, akan

mencegah atau meringankan gejala klinis pertusis
bila diberikan pada masa inkubasi atau stadium Penisilin
kataral
• Antibiotika pada stadium paroksimal tidak • Ampisilin dengan dosis 100 mg/kgbb/hari, dibagi dalam 4 dosis.

mengubah perjalanan klinis, namun dapat • Jika tidak memungkinkan penggunaan per-oral, maka dapat diberikan secara

menghilangkan bakteri dari nasofaring ~ mengurangi IV jika gejala berat.

penularan.
• Eritromisin dengan dosis 40-50 mg/kgbb/hari
dibagi dalam 4 dosis selama 7 hari
• Eliminasi B.pertussis di nasofaring 2-7 hari (rata rata
3-4 hari) à memperpendek transmisi
• Bayi <1 month: azithromycin.

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Antibiotik profilaksis untuk kontak erat
(postexposure antimicrobial prophylaxis)

• Kontak serumah

• Orang berisiko tinggi dalam 21 hari sejak terpapar kasus:

• Bayi dan wanita hamil trimester 3
• Imunokompromais

• Asma sedang-berat (walaupun dalam pengobatan)

• Kontak erat dari individu di atas Kemenkes RI. Petunjuk surveilans pertussis. 2021
Complications: seen in the paroxysmal phase
• Cyanosis and apnea, edema, facial Kazantzi et al. described characteristics of 31
congestion and petechia arising from
cough patients with pertussis admitted to six ICUs
• Otitis media caused by B. pertussis or over an 11-year period,
secondary infection
• Dehydration, vomiting, or low ingestion • highlighting hyponatremia (serum sodium
• Among respiratory complications:
• atelectasis between 125-133 mmol/dL) secondary to
• B. pertussis pneumonia and viral or
bacterial superinfection. inappropriate secretion of antidiuretic
• Neurological complications are less hormone as a risk factor for death
frequent and include
• seizures, blindness, and deafness.

Machado MB, et al. Rev Paul Pediatr. 2019 Jun 19;37(3):351-362.

Kazantzi MS, et al. J Paediatr Child Health. 2017;53:257-62.
Severe Pertussis In Childhood
In the 2000s, the concept of malignant pertussis was
established, being characterized by severe and high lethality,
defined by the presence of acute respiratory failure, pulmonary
hypertension and hyperleukocytosis above 50,000/mm3.
Patient’s profile with severe pertussis
Pathogenesis
• The median age of patients was 2 months • Hyperleukocytosis causes blood hyper-
(IQR 1-4 months) viscosity and increases pulmonary vascular
• 90.3% of the patients aged < 6 months
resistance, leading to:
• 56.9% of the patients aged < 3 months.
• pulmonary hypertension
• Mortality 34.2% à <6 weeks (76.9%)
• hemodynamic collapse

• Death due to hypoxemia and refractory

shock

Shi T, et al. BMC Infect Dis. 2021 Oct 12;21(1):1057.

Machado MB, et al. Rev Paul Pediatr. 2019 Jun 19;37(3):351-362.
 Risk factors associated with death and/or neurological sequele

• Less than 6 month of age (esp. < 2 mo)

• Change in mental state

• Seizure

• Apnoea (OR 23.722, 95%CI 2.796-201.26, P = 0.004)

• Bradycardia during episodes of cough the greatest associations with death in

infants with severe pertussis admitted
• hyperleukocytosis (OR 63.708, 95%CI 3.574-1135.674, P
to the PICU.
= 0.005)

• Pulmonary hypertension (OR 26.109, 95%CI 1.800- Seizures and pulmonary hypertension as
isolated predictive factors
378.809, P = 0.017) for death
• Associated with pneumonia & comorbidities

• Shock

Liu C, et al. BMC Infect Dis. 2020 Nov 16;20(1):852.

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Machado MB, et al. Rev Paul Pediatr. 2019 Jun 19;37(3):351-362
 Pertussis outbreaks have occurred in countries using DTwP or DTaP for primary vaccination

Countries using DTwP Countries using DTaP

Brazil Netherlands
10.000 10.000
Reported pertussis cases per year

Reported pertussis cases per year

0 0
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

Colombia United Kingdom

10.000 10.000

0 0
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015
Figures independently drawn based on data from WHO, 2018
DTaP, diphtheria, tetanus and acellular pertussis vaccine; DTwP, diphtheria, tetanus and whole cell pertussis vaccine
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World Health Organization (WHO), 2018. Reported cases of selected vaccine-preventable diseases. http://www.who.int/entity/immunization/monitoring_surveillance/data/incidence_series.xls?ua=1
(accessed September 2018)
 Pertussis outbreaks: why are they happening?

Suboptimal vaccine Cyclical incidence of

pertussis (epidemic
coverage (mainly in peaks occurring every
older age groups)1,3 2–5 years)4

Waning immunity High communicability

following vaccination of B. pertussis1 & &
or natural infection1,2 genetic modification

Need for booster

vaccinations5,6

1. Poland GA. Vaccine 2012;30:6957–6959; 2. Plotkin SA. Clin Infect Dis 2014;58:830–833; 3. Gabutti G et al. Hum Vaccin Immunother 2015;11:108–117; 4. Edwards KM, Decker MD. Chapter 23: Pertussis vaccines. In: Vaccines, Plotkin SA et al. (Eds). 6th edn.
Philadelphia: Saunders Elsevier; 2013. pp. 447–492; 5. Australian Government Department of Health, 2018. Australian Immunisation Handbook – Pertussis. https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/pertussis-whooping-cough
(accessed September 2018); 6. Public Health England (PHE), 2018. Guidelines for the public health management of pertussis in England.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/731241/Guidelines_for_the_public_health_management_of_pertussis_in_England.pdf (accessed September 2018)
Kejadian luar biasa (KLB)
Definisi operasional

• Suatu wilayah kab/kota dinyatakan KLB pertusis jika ditemukan satu suspek pertusis dengan konfirmasi
laboratorium PCR/kultur positif

atau

• Jika ditemukan Suspek Pertusis yang mempunyai hubungan epidemiologi dengan kasus PCR/kultur positif

• Ditetapkan oleh Kadinkes Koka atau Kadinkes Povisnsi atau Kemenkes sesuai dengan Permenkes 1501/2010

Pencabutan status KLB pertusis dapat ditetapkan Jika di suatu wilayah tidak ditemukan lagi kasus pertusis
selama 2 kali masa inkubasi terpanjang dihitung sejak dari kasus terakhir (28 hari)
 The diagnosis of pertussis in neonates is often very challenging,
resulting in treatment delays

Cough is often faint and

less likely to be
associated with the
characteristic whoop

Can appear very benign Common to progress to

with only mild rhinorrhea severe symptomatology
or coryza that is difficult to in a short period of time
distinguish from the with very subtle changes
common cold in the clinical exam

Swamy GK and Wheeler SM. Neonatal pertussis, cocooning and maternal immunization. Expert Rev. Vaccines 13(9), 1107–1114 (2014
 Immunization strategies are needed
to prevent early infant morbidity & mortality

Infant
immunization

“Cocooning”
strategy
Maternal
immunization
World Health Organization. Pertussis Position Paper August 2015. Weekly Epidemiological Record. 28 Aug 2015. No. 35, 2015, 90, 433–460
Take home messages
• Pertusis adalah penyakit infeksi akibat B. pertussis yang
menyebabkan morbiditas dan mortalitas tinggi
• Penularan tinggi melalui droplet
• Terapi umumnya terlambat karena diberi saat stage paroksismal
• Perlu surveilans/PE apabila ditemukan index case – berikan antibiotis
profilaksis dan lengkapi imunisasi difteri
• Pencegahan lebih baik daripada mengobati – dengan imunisasi difteri
Teurimong gaseh