Concurrent outbreaks of pertussis and Mycoplasma pneumoniae infection: clinical and epidemiological characteristics of illnesses manifested by cough

Curative Effects of Suhuang Zhike Capsule on Postinfectious Cough: A Meta-Analysis of Randomized Trials

Objective. In this paper, we intended to systematically evaluate the efficacy of Suhuang Zhike Capsule (SZC) on postinfectious cough (PIC) in adults (age > 18). Methods. MEDLINE (PubMed), Chinese National Knowledge Infrastructure (CNKI), Cqvip Database (VIP), and Wanfang Database were researched for the randomized controlled trials (RCTs) of SZC for PIC. The search was limited to human studies, using the search keywords or free-text terms “cough,” “post-infectious cough,” “postinfectious cough,” “post-cold cough,” “postviral cough,” “postcold cough,” “Suhuang Zhike capsule,” “Chinese Medicine,” and “randomized clinical trials”. Two reviewers individually extracted data from the included RCTs and then the extracted data were analyzed using Review Manager 5.3 software. Results. Seven RCTs involving 573 patients entered the inclusion criteria. Findings suggested that, compared with western conventional medicine (WCM) and other Chinese medicine, SZC could effectively improve the efficacy rate (OR 2.68, 95%  CI, 1.48–4.84, P = 0.001; OR 4.86, 95%  CI, 1.50–15.73, P = 0.008, separately). Moreover, SZC could also improve the efficacy rate of Chinese medicine symptom (MD −0.74, 95%  CI, −1.46~−0.02, P = 0.04). However, in terms of cough relief time, more evidence is needed to prove that SZC have an earlier antitussive effect (MD −1.31, 95%  CI, −3.06~0.45, P = 0.14). Conclusion. The current evidence shows that SZC is effective in the treatment of PIC in adults and can significantly improve the effective rate of Chinese medicine symptoms.

Association Between Vaccine Refusal and Vaccine-Preventable Diseases in the United States: A Review of Measles and Pertussis

IMPORTANCE

Parents hesitant to vaccinate their children may delay routine immunizations or seek exemptions from state vaccine mandates. Recent outbreaks of vaccine-preventable diseases in the United States have drawn attention to this phenomenon. Improved understanding of the association between vaccine refusal and the epidemiology of these diseases is needed.

OBJECTIVE

To review the published literature to evaluate the association between vaccine delay, refusal, or exemption and the epidemiology of measles and pertussis, 2 vaccine-preventable diseases with recent US outbreaks.

EVIDENCE REVIEW

Search of PubMed through November 30, 2015, for reports of US measles outbreaks that have occurred since measles was declared eliminated in the United States (after January 1, 2000), endemic and epidemic pertussis since the lowest point in US pertussis incidence (after January 1, 1977), and for studies that assessed disease risk in the context of vaccine delay or exemption.

FINDINGS

We identified 18 published measles studies (9 annual summaries and 9 outbreak reports), which described 1416 measles cases (individual age range, 2 weeks-84 years; 178 cases younger than 12 months) and more than half (56.8%) had no history of measles vaccination. Of the 970 measles cases with detailed vaccination data, 574 cases were unvaccinated despite being vaccine eligible and 405 (70.6%) of these had nonmedical exemptions (eg, exemptions for religious or philosophical reasons, as opposed to medical contraindications; 41.8% of total). Among 32 reports of pertussis outbreaks, which included 10,609 individuals for whom vaccination status was reported (age range, 10 days-87 years), the 5 largest statewide epidemics had substantial proportions (range, 24%-45%) of unvaccinated or undervaccinated individuals. However, several pertussis outbreaks also occurred in highly vaccinated populations, indicating waning immunity. Nine reports (describing 12 outbreaks) provided detailed vaccination data on unimmunized cases; among 8 of these outbreaks from 59% through 93% of unvaccinated individuals were intentionally unvaccinated.

CONCLUSIONS AND RELEVANCE

A substantial proportion of the US measles cases in the era after elimination were intentionally unvaccinated. The phenomenon of vaccine refusal was associated with an increased risk for measles among people who refuse vaccines and among fully vaccinated individuals. Although pertussis resurgence has been attributed to waning immunity and other factors, vaccine refusal was still associated with an increased risk for pertussis in some populations.

The duration of cough in patients with H1N1 influenza

BACKGROUND

Cough is one of common symptoms of influenza, the cough duration and prevalence of postinfectious cough (PIC) after viral upper respiratory tract infection has not been well described.

OBJECTIVES

We aim to investigate the duration of cough and prevalence of PIC and its relation with acute symptoms, airway inflammation and cough sensitivity in patients with H1N1 influenza.

METHODS

Patients with acute symptoms of H1N1 influenza were enrolled and followed up until cough relived. Spirometry, induced sputum test, capsaicin challenge test were conducted in patients with PIC. Cough sensitivity was presented as logarithm of provocative concentration inducing five or more coughs (logC5).

RESULTS

A total of 141 cases with H1N1 influenza were enrolled. In patients with H1N1 influenza, 97.2% of them complained cough. The duration of cough was as following: <1 week (73.0%); 1-2 weeks (7.8%); 2-3 weeks (7.8%); ≥3 weeks (8.5%). Twelve (8.5%) patients had cough lasting more than 3 weeks (PIC), 4 (2.8%) patients developed chronic cough (>8 weeks). Acute symptoms, spirometry, bronchial responsiveness and sputum differential cell count were similar between patients with PIC and those without PIC, however, there was a higher prevalence of previous PIC (58.3% vs 14.7%, P < 0.05) and elevated cough sensitivity (lgC5: 1.18 ± 0.58 vs 2.73 ± 0.33, P < 0.01) in patients with PIC as compared with the patients without PIC.

CONCLUSIONS

Acute cough is common in patients with H1N1 PIC, only a few of patients develop chronic cough. Acute symptoms cannot predict PIC which is related with previous PIC and increased cough sensitivity.

The efficacy of QingfengGanke granule in treating postinfectious cough in pathogenic wind invading lungs syndrome: a multicenter, randomized, double-blind, placebo-controlled trial

BACKGROUND

Postinfectious cough (PIC) significantly affects cough-related quality of life but still lacks effective treatments. This study aims to investigate the efficacy of QingfengGanke granule (QFGKG) in treating PIC induced by pathogenic wind invading lungs syndrome.

METHODS

A multicenter, randomized, double-blind, placebo-controlled clinical trial was conducted. A total of 180 eligible participants were randomly (1:1:1) assigned to group A (QFGKG 6 g plus QFGKG-matched placebo 6 g), group B (QFGKG 12 g), and group C (QFGKG-matched placebo 12 g). All herbal medications were orally administered twice daily for 10 consecutive days. The primary outcome was time to cough resolution, and secondary outcomes included time to cough alleviation, mean changes in cough symptom score (CSS), visual analogue scale (VAS) score, cough-specific quality of life questionnaire (CQLQ) score, and traditional Chinese medicine (TCM) syndrome score from baseline to Day 10, as well as adverse events.

RESULTS

A total of 173 participants were included in the efficacy and safety analyses (group A, n = 57; group B, n = 57; group C, n = 59). The median time to cough resolution in groups A, B, and C was more than 10 days, 8 days, and more than 10 days, respectively (P < 0.0001), and the median time to cough alleviation was 4, 4, and 6 days, respectively (P < 0.0001). Compared with the placebo condition, groups A and B showed significantly greater improvements in CSS (P = 0.0005, P < 0.0001, respectively), VAS (P = 0.0002, P < 0.0001, respectively), CQLQ (P = 0.0258, P = 0.0003, respectively), and TCM syndrome (P = 0.0031, P < 0.0001, respectively). The time to cough resolution was faster in group B compared with group A (P = 0.0091). The adverse event profiles were comparable among the three groups.

CONCLUSION

QingfengGanke granule is efficacious in the treatment of PIC induced by pathogenic wind invading lungs syndrome.

Chinese herbal medicine for postinfectious cough: a systematic review of randomized controlled trials

Chinese herbal medicine has been commonly used in the treatment of postinfectious cough. The aim of this review is to systematically evaluate the efficacy and safety of Chinese herbal medicine for postinfectious cough. An extensive search for RCTs was performed using multiple electronic databases, supplemented with a manual search. All studies included were confirmed with specific inclusion criteria. Methodological quality of each study was examined according to the Cochrane risk of bias assessment. Quality of evidence was evaluated using rating approach developed by GRADE working group. The literature search yielded 352 results, of which 12 RCTs satisfied the inclusion criteria, offering moderate-to-high levels of evidence. Methodological quality was considered high in three trials, while in the other nine studies the unclear risk of bias was in the majority. Findings suggested that, compared with western conventional medicine or placebo, Chinese herbal medicine could effectively improve core symptoms of postinfectious cough, act better and have earlier antitussive effect, and enhance patients' quality of life. No serious adverse event was reported.

Human parainfluenza virus type 3 (HPIV 3) community-acquired pneumonia (CAP) mimicking pertussis in an adult: the diagnostic importance of hoarseness and monocytosis

BACKGROUND

There are relatively few causes of acute community-acquired pneumonias (CAPs) in adults associated with prolonged cough. In adults the most common acute CAPs with a prominent and persistent nonproductive cough are due to Mycoplasma pneumoniae, Chlamydophilia (Chlamydia) pneumoniae, or Bordetella pertussis (pertussis). Pertussis is an underrecognized and underappreciated cause of CAP in adults. Different from classic pertussis in children, pertussis in adults presents with prolonged dry cough, that is, the "100-day cough." In pertussis, the characteristic nonspecific laboratory findings are leukocytosis and relative lymphocytosis. Dry cough accompanied by hoarseness with CAP in an adult should suggest C. pneumoniae or a respiratory virus (eg, influenza, parainfluenza, respiratory syncytial virus).

METHODS

We present the case of a young woman who presented with a prominent and persistent pertussis-like cough with hoarseness. She had no leukocytosis or relative lymphopenia, which argued against the diagnosis of pertussis. Notably, she had persistent monocytosis. Her protracted pertussis-like cough that persisted during her hospitalization was so impressive that the diagnostic impression was pertussis. Direct fluorescent antibody (FA) and throat cultures were negative for pertussis. Furthermore, her hoarseness suggested the possibility of C. pneumoniae, but her C. pneumoniae immunoglobulin-M titer was negative.

RESULTS

Because C. pneumoniae was ruled out, her hoarseness suggested a respiratory viral cause. A respiratory FA viral panel and viral throat cultures were obtained. The respiratory FA viral panel was negative for influenza A/B, respiratory syncytial virus, metapneumovirus, adenovirus, cytomegalovirus, and parainfluenza viruses. However, her viral throat cultures grew parainfluenza virus type 3 (HPIV 3), confirming the diagnosis.

CONCLUSION

To the best of our knowledge, this is the first case of HPIV 3 CAP presenting with a prominent and persistent pertussoid cough in an adult mimicking pertussis with hoarseness and monocytosis.

High prevalence of gastroesophageal reflux symptoms in patients with both acute and nonacute cough

Although there have been many studies that showed a close association between gastroesophageal reflux disease (GERD) symptoms and chronic cough, it has been unknown whether acute cough is also associated with GERD. The aim of this study was to evaluate the relationship between GERD and respiratory symptoms in general practice. 1725 consecutive patients who first attended our hospital were enrolled in the present study. They were asked to respond the F-scale questionnaire regardless of their chief complaints. Over all, 656 (38%) patients were diagnosed as GERD and 226 (13%) had respiratory symptoms. Patients with respiratory symptoms had GERD symptoms more frequently than patients without respiratory symptoms (p < 0.05). Forty-three (37%) of 115 patients with acute cough and 48 (43%) of 111 with nonacute cough had GERD symptoms, suggesting that development of GERD is not associated with the period of respiratory symptoms. Patients with respiratory symptoms are at a significantly increased risk of developing GERD. Whether or not treatment for GERD or respiratory diseases is useful for the prevention of respiratory symptoms and GERD, respectively, should not be driving management decisions in primary care.

Prevalence, pathogenesis, and causes of chronic cough

Cough is a reflex action of the respiratory tract that is used to clear the upper airways. Chronic cough lasting for more than 8 weeks is common in the community. The causes include cigarette smoking, exposure to cigarette smoke, and exposure to environmental pollution, especially particulates. Diseases causing chronic cough include asthma, eosinophilic bronchitis, gastro-oesophageal reflux disease, postnasal drip syndrome or rhinosinusitis, chronic obstructive pulmonary disease, pulmonary fibrosis, and bronchiectasis. Doctors should always work towards a clear diagnosis, considering common and rare illnesses. In some patients, no cause is identified, leading to the diagnosis of idiopathic cough. Chronic cough is often associated with an increased response to tussive agents such as capsaicin. Plastic changes in intrinsic and synaptic excitability in the brainstem, spine, or airway nerves can enhance the cough reflex, and can persist in the absence of the initiating cough event. Structural and inflammatory airway mucosal changes in non-asthmatic chronic cough could represent the cause or the traumatic response to repetitive coughing. Effective control of cough requires not only controlling the disease causing the cough but also desensitisation of cough pathways.

Postinfectious cough: ACCP evidence-based clinical practice guidelines

BACKGROUND

Patients who complain of a persistent cough lasting >3 weeks after experiencing the acute symptoms of an upper respiratory tract infection may have a postinfectious cough. Such patients are considered to have a subacute cough because the condition lasts for no >8 weeks. The chest radiograph findings are normal, thus ruling out pneumonia, and the cough eventually resolves, usually on its own. The purpose of this review is to present the evidence for the diagnosis and treatment of postinfectious cough, including the most virulent form caused by Bordetella pertussis infection, and make recommendations that will be useful for clinical practice.

METHODS

Recommendations for this section of the guideline were obtained from data using a National Library of Medicine (PubMed) search dating back to 1950, which was performed in August 2004, of the literature published in the English language. The search was limited to human studies, using the search terms "cough," "postinfectious cough," "postviral cough," "Bordetella pertussis," "pertussis infection," and "whooping cough."

RESULTS

The pathogenesis of the postinfectious cough is not known, but it is thought to be due to the extensive inflammation and disruption of upper and/or lower airway epithelial integrity. When postinfectious cough emanates from the lower airway, this is often associated with the accumulation of an excessive amount of mucus hypersecretion and/or transient airway and cough receptor hyperresponsiveness; all may contribute to the subacute cough. In these patients, the optimal treatment is not known. Except for bacterial sinusitis or early on in a B pertussis infection, therapy with antibiotics has no role, as the cause is not bacterial infection. The use of inhaled ipratropium may be helpful. Other causes of postinfectious cough are persistent inflammation of the nose and paranasal sinuses, which leads to an upper airway cough syndrome (previously referred to as postnasal drip syndrome), and gastroesophageal reflux disease, which may be a complication of the vigorous coughing. One type of postinfectious cough that is particularly virulent is that caused by B pertussis infection. When the cough is accompanied by paroxysms of coughing, posttussive vomiting, and/or an inspiratory whooping sound, the diagnosis of a B pertussis infection should be made unless another diagnosis is proven. This infection is highly contagious but responds to antibiotic coverage with an oral macrolide when administered early in the course of the disease. A safe and effective vaccine to prevent B pertussis is now available for adults as well as children. It is recommended according to CDC guidelines.

CONCLUSIONS

In patients who have a cough lasting from 3 to 8 weeks with normal chest radiograph findings, consider the diagnosis of postinfectious cough. In most patients, a specific etiologic agent will not be identified, and empiric therapy may be helpful. A high degree of suspicion for cough due to B pertussis infection will lead to earlier diagnosis, patient isolation, and antibiotic treatment.

Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines

BACKGROUND

The purpose of this review is to present the evidence for the diagnosis and treatment of cough due to acute bronchitis and make recommendations that will be useful for clinical practice. Acute bronchitis is one of the most common diagnoses made by primary care clinicians and emergency department physicians. It is an acute respiratory infection with a normal chest radiograph that is manifested by cough with or without phlegm production that lasts for up to 3 weeks. Respiratory viruses appear to be the most common cause of acute bronchitis; however, the organism responsible is rarely identified in clinical practice because viral cultures and serologic assays are not routinely performed. Fewer than 10% of patients will have a bacterial infection diagnosed as the cause of bronchitis. The diagnosis of acute bronchitis should be made only when there is no clinical or radiographic evidence of pneumonia, and the common cold, acute asthma, or an exacerbation of COPD have been ruled out as the cause of cough. Acute bronchitis is a self-limited respiratory disorder, and when the cough persists for >3 weeks, other diagnoses must be considered.

METHODS

Recommendations for this review were obtained from data using a National Library of Medicine (PubMed) search dating back to 1950, which was performed in August 2004. The search was limited to literature published in the English language and human studies, using search terms such as "cough," "acute bronchitis," and "acute viral respiratory infection."

RESULTS

Unfortunately, most previous controlled trials guiding the treatment of acute bronchitis have not vigorously differentiated acute bronchitis and the common cold, and also have not distinguished between an acute exacerbation of chronic bronchitis and acute asthma as a cause of acute cough. For patients with the putative diagnosis of acute bronchitis, routine treatment with antibiotics is not justified and should not be offered. Antitussive agents are occasionally useful and can be offered as therapy for short-term symptomatic relief of coughing, but there is no role for inhaled bronchodilator or expectorant therapy. Children and adult patients with confirmed and probable whooping cough should receive a macrolide antibiotic and should be isolated for 5 days from the start of treatment; early treatment within the first few weeks will diminish the coughing paroxysms and prevent spread of the disease; the patient is unlikely to respond to treatment beyond this period.

CONCLUSION

Acute bronchitis is an acute respiratory infection that is manifested by cough and, at times, sputum production that lasts for no more than 3 weeks. This syndrome should be distinguished from the common cold, an acute exacerbation of chronic bronchitis, and acute asthma as the cause of acute cough. The widespread use of antibiotics for the treatment of acute bronchitis is not justified, and vigorous efforts to curtail their use should be encouraged.

Molecular pathogenesis, epidemiology, and clinical manifestations of respiratory infections due to Bordetella pertussis and other Bordetella subspecies

Bordetella respiratory infections are common in people (B. pertussis) and in animals (B. bronchiseptica). During the last two decades, much has been learned about the virulence determinants, pathogenesis, and immunity of Bordetella. Clinically, the full spectrum of disease due to B. pertussis infection is now understood, and infections in adolescents and adults are recognized as the reservoir for cyclic outbreaks of disease. DTaP vaccines, which are less reactogenic than DTP vaccines, are now in general use in many developed countries, and it is expected that the expansion of their use to adolescents and adults will have a significant impact on reducing pertussis and perhaps decrease the circulation of B. pertussis. Future studies should seek to determine the cause of the unique cough which is associated with Bordetella respiratory infections. It is also hoped that data gathered from molecular Bordetella research will lead to a new generation of DTaP vaccines which provide greater efficacy than is provided by today's vaccines.

Abordagem diagnóstica da tosse crônica em pacientes não-tabagistas: diagnostic approach

A tosse, como mecanismo fisiológico, tem fundamental importância na remoção das secreções respiratórias, constituindo, assim, um dos mecanismos de defesa pulmonar. No entanto, os quadros de tosse crônica constituem uma das principais causas de procura por assistência médica no mundo, o que ressalta o significado da correta identificação e tratamento dos fatores desencadeantes e/ou perpetuadores. Dentre os vários fatores relacionados aos quadros de tosse crônica, alguns assumem papel de relevada importância, tais como o refluxo gastroesofágico, a rinorréia posterior ou a asma, já que, isolada ou conjuntamente, constituem cerca de 95% das causas. O passo fundamental para o sucesso terapêutico nos quadros de tosse crônica é uma abordagem diagnóstica racional, que investigue a tosse crônica de maneira progressiva, permitindo, assim, a instituição do tratamento de forma mais custo-efetiva. Para isso, a proposta de um algoritmo a ser seguido serve como base para essa investigação inicial.

Role of Mycoplasma pneumoniae and Chlamydia pneumoniae in children with community-acquired lower respiratory tract infections

In order to evaluate the role of Mycoplasma pneumoniae and Chlamydia pneumoniae, we studied 613 children aged 2-14 years who were hospitalized for community-acquired lower respiratory tract infections (LRTIs). The patients were enrolled in the study by 21 centers in different regions of Italy from May 1998 through April 1999. Paired serum samples were obtained on admission and after 4-6 weeks to assay the titers of M. pneumoniae and C. pneumoniae antibodies. Nasopharyngeal aspirates for the detection of M. pneumoniae and C. pneumoniae were obtained on admission. Acute M. pneumoniae infections in 210 patients (34.3%) and acute C. pneumoniae infections in 87 (14.1%) were diagnosed. Fifteen of the 18 children with M. pneumoniae and/or C. pneumoniae infections whose treatments were considered clinical failures 4-6 weeks after enrollment had not been treated with macrolides. Our study confirms that M. pneumoniae and/or C. pneumoniae plays a significant role in community-acquired LRTIs in children of all ages and that such infections have a more complicated course when not treated with adequate antimicrobial agents.

Analysis with a combination of macrorestriction endonucleases reveals a high degree of polymorphism among Bordetella pertussis isolates in eastern France

From 1990 to 1996, routine screening for whooping cough identified 399 patients with a calmodulin-dependent adenylate cyclase-positive test result and yielded 69 Bordetella pertussis isolates. None of the patients were fully vaccinated, and most were less than 6 months old. Analysis of total DNA by pulsed-field gel electrophoresis (PFGE) after XbaI, SpeI, or DraI macrorestriction yielded 19, 15, and 5 different patterns, respectively, whereas ribotyping failed to demonstrate any strain polymorphism. Discrimination among the isolates was improved by combining the PFGE profiles. Some patterns were more frequent, but the corresponding patients were not clearly epidemiologically related. The patterns for two strains obtained during a 3-month period from patients who were neighbors differed by the length of a single DNA fragment. These data strongly suggest that one type of isolate is widely spread throughout the world and is carried by individuals other than patients who develop a true illness.

Seroepidemiology of Mycoplasma pneumoniae infections in Iceland 1987-96

Mycoplasma pneumoniae is a common cause of respiratory tract infections in humans. The aim of the present study was to analyse the seroepidemiology of M. pneumoniae infections in Iceland during a 10-y period. A retrospective analysis of all serological diagnosis of M. pneumoniae infections at the Department of Medical Virology, National University Hospital in Reykjavík was performed. A total of 13,201 test results from 1987 to 1996 were reviewed and altogether 762 patients were found to have raised M. pneumoniae antibody titres, using a conventional complement fixation assay. Infections were most common amongst young people (< or=16 y) but a second peak in incidence was observed around the age of 35 y. Significant annual (p < 0.0001) and seasonal variations (p=0.0003) were observed; M. pneumoniae infections were most common during the winter period. Three major outbreaks with intervals of three to five years were observed during the observation period. Patients diagnosed during these outbreaks had higher M. pneumoniae titres than those found when infections were less frequent (p=0.0017). Furthermore, the middle aged and elderly patients (> 50 y) had significantly lower M. pneumoniae titres than younger patients (p=0.0014). The findings of this study show that M. pneumoniae infections have definite annual and seasonal variations and also confirm previous studies showing community outbreaks of M. pneumoniae infections every 3-5 y.

A serologic study of organisms possibly associated with pertussis-like coughing

OBJECTIVE

To assess the frequency of serologic evidence for an infection with microorganisms other than Bordetella pertussis in children with pertussis-like coughs.

METHODS

The study was performed within a protective efficacy trial of an acellular pertussis vaccine. Children who coughed for >7 days and had no laboratory evidence of recent infection with B. pertussis were eligible for the present study. Antibodies to Mycoplasma, Chlamydia, respiratory syncytial virus and influenza viruses A and B were measured by complement fixation, and antibodies to adenovirus and parainfluenza viruses 1, 2 and 3 were measured by enzyme-linked immunosorbent assay (ELISA) in acute and convalescent serum samples. Significant titer rises (4-fold titer rise in complement fixation, 100% increase of units in ELISA) and concentrations of antibodies beyond age-specific reference values were regarded as indicative of recent infection. In some children IgM antibodies to Epstein-Barr virus and to cytomegalovirus were also measured by ELISA.

RESULTS

A total of 149 of 1179 (12.6%) children had no laboratory evidence of B. pertussis infection. Serologic evidence for other infections were found in 56% (83 of 149). Adenovirus (33), parainfluenza viruses 1, 2 and 3 (18), Mycoplasma pneumoniae (15) and respiratory syncytial virus (14) were most common. Of this group 48% had been vaccinated against pertussis.

CONCLUSION

We present data that a proportion of pertussis-like coughs in children may be caused by adenovirus, parainfluenza viruses, respiratory syncytial virus and Mycoplasma. The differential diagnosis of pertussis-like coughs by laboratory methods should include these infections, especially in vaccinated children.