Recognition and management of whooping cough 

Whooping cough, also known as pertussis, is a highly infectious bacterial respiratory infection caused by the Bordetella pertussis bacterium. Typically transmitted through respiratory secretions, it affects both the upper and lower respiratory tracts. 

Whooping cough presents with severe and prolonged bouts of coughing, followed by a characteristic “whoop”. It can also present with post-tussive vomiting. Pertussis primarily affects young children but can affect adults. Without treatment, people can remain infectious for 21 days from the onset of coughing, potentially spreading the disease to vulnerable individuals^​1​. Illness in infants under the age of six months can be particularly dangerous and is associated with high hospitalisation rates^​1​. This is likely because infants are too young to have completed routine immunisation for B. pertussis. While this disease can be prevented by vaccination, it persists as a significant public health concern in the UK.

Levels of pertussis have been rising rapidly in the past few years. Figure 1 highlights the highest prevalence of pertussis between April and June 2024, with over 7,500 cases across these months^​2​. It remains a notifiable disease under the Health Protection Legislation (England). Laboratory confirmed cases of pertussis rose from 856 in 2023 to almost 15,000 confirmed cases across 2024. Cases fell in 2025, to 502 cases in the first half of the year; however, it should be noted that pertussis is a cyclical disease and increases occur every three to five years^​2​.

Figure 1: Laboratory confirmed cases of pertussis each month in England (January 2023 – March 2025)

Pharmacists play a pivotal role in managing pertussis, with their involvement ranging from early detection, counselling and management, as well as referral to vaccine delivery and reinforcement of the broader public health response to the ongoing increase in cases. Given that pertussis outbreaks are cyclical in nature — with the highest rates in the spring months — it is crucial to coordinate this to vaccine enrolment and accessibility increasing this in the winter months to prepare^​2,3​. Pharmacists’ continued engagement with surveillance, vaccination uptake and public education is integral to reducing transmission and protecting vulnerable populations, particularly infants. 

Risk factors

Pertussis can affect individuals of all ages but can be particularly concerning in young infants. Other risk factors include:

• Pregnant women and neonates;
• Unvaccinated individuals, including those who have not completed the required immunisation programme for pertussis;
• Household members and carers of infected individuals^​4​.

Signs and symptoms

Pertussis symptoms typically present in individuals five to ten days after initial contact with the bacterium. Following the incubation period, pertussis progresses through three stages: the catarrhal phase, the paroxysmal phase and the convalescent phase^​5​.

Figure 2: Pertussis progresses through three stages: the catarrhal phase, the paroxysmal phase and the convalescent phase

During the convalescent phase, which can last up to three months, paroxysms reduce in both frequency and severity. Overall, the later stage symptoms can persist for one to six weeks but can last up to ten weeks^​6​. They can also present most severely at night.

Some individuals can present with red-flag symptoms, including the following, which would necessitate urgent referral:

• Apnoea or cyanosis in young infants;
• Difficulty feeding, dehydration or lethargy in young infants;
• Neurological symptoms (e.g. encephalopathy, seizures, apnoea etc);
• Cough-induced rib fractures, syncope or persistent vomiting;
• Progressive respiratory distress, particularly in young infants, immunocompromised patients and older adults^​7​.

Early detection of individuals with pertussis is crucial for effective treatment and management. It also reduces the potential for further spread of the infection, mitigating against further complications in vulnerable populations^​7​.

Differential diagnoses

Pharmacists must take a structured history, including cough duration, character (i.e. paroxysmal versus productive), presence of vomiting or apnoea and vaccination status to aid clinical diagnosis of pertussis and rule out differentials. In some cases, considering local epidemiology can also help to support clinical suspicion.

A persistent cough lasting at least two weeks — particularly if paroxysmal in nature and associated with a low-grade fever — normal chest auscultation between coughing episodes and, in some cases, post-tussive vomiting should raise suspicion of pertussis.

Diagnosis

Patients with pertussis typically present in primary care (i.e. GP practices), community pharmacies, walk-in urgent care centres or through NHS 111 online/telephone services. In some cases, individuals may present in emergency departments, particularly for severe or high-risk cases of pertussis.

Pharmacists play an important role in obtaining the initial structured assessment of the presenting patient. Particular consideration should be made for patients who are infants, pregnant women or immunocompromised. Immediate same-day referral should be made for patients displaying red-flag symptoms, such as apnoea, cyanosis and rapidly progressing respiratory distress. In the absence of these red-flag symptoms, pharmacists should refer to GP for clinical assessment and diagnostic testing. Pharmacists can offer self-care advice, where appropriate.

Diagnostic methods

Diagnosis of pertussis is typically made by a primary care clinician and involves a combination of clinical suspicion supported by laboratory confirmation.

Typically, PCR testing of nasopharyngeal or throat swabs are used, as they are more sensitive than culturing. For older children and adults, serological tests may sometimes be used, where PCR results have been less reliable^​7​.

Clinical suspicion involves considering the symptomology and epidemiological context. This is highly relevant in the case of outbreaks; however, clinical suspicion should never be used for diagnosis in isolation^​7​.

Management

If diagnosis occurs within the first 2 weeks of the onset of symptoms, antibiotics should be given to best improve the clinical course of the illness. The use of antibiotics beyond 14 days has little population level effect. After 2 weeks, antibiotics are usually only given to reduce the transmission of pertussis to close contacts who are at particular risk of the condition (e.g. infants and immunocompromised individuals)^​8​.

Note, previously it was recommended to give antibiotics within the first 21 days of the onset of the cough; however, this has now changed and antibiotics must be given within 14 days of onset^​8​.

NICE recommend that macrolides are prescribed as first line, typically for 7 days:

• Clarithromycin is preferred for infants aged under one month^​1​;
• Azithromycin or clarithromycin is preferred for children aged over one month and non-pregnant adults;
• Erythromycin should be prescribed for pregnant women^​1​.

Co-trimoxazole should be prescribed if macrolides are not tolerated or are contraindicated; however, co-trimoxazole should not be prescribed to pregnant women or infants aged less than six weeks old^​1​.

Antibiotic therapy is typically administered via the oral route, but alternative routes of administration may be considered by specialists in certain circumstances, such as hospitalisation or severe deterioration.

Pharmacists must be familiar with the UK Health Security Agency (UKHSA) pertussis public health management guidance for antibiotic choices, durations and indications^​9​.

See Table for antibiotic treatment and chemoprophylaxis recommendations based on the age of the patient^​8​.

Table: Antibiotic treatment and chemoprophylaxis recommendations

Side effects and contraindications:^​10​

• Macrolides can cause gastrointestinal upset and QT prolongation, which can also interact with drugs such as statins;
• Erythromycin has a greater risk of gastrointestinal intolerance, while clarithromycin and azithromycin are generally better tolerated;
• Pharmacists must take an adequate cardiac and drug history to rule out any potential contraindications or drug interactions with certainty prior to making any recommendations or dispensing. 

Hospital admission should be considered for infants aged under six months and in cases where there are significant breathing difficulties or complications (e.g. pneumonia); however, most individuals can be managed at home with antibiotics, if appropriate, and self-care measures. Advice for self care can be seen in Box 1.

Prevention

As pharmacists play a vital role in administering vaccines, it is crucial to understand the current vaccines available and their associated schedules. Pharmacists can also help identify individuals who have not been vaccinated yet. Understanding why this might be the case and explaining the importance of the vaccination may help to promote it and, therefore, increase uptake. 

The pertussis vaccination is currently offered as a component of routine childhood immunisations for children aged under 10 years. This is administered as part of the six-in-one vaccine (i.e. diphtheria, tetanus, pertussis, poliovirus, Hib and hepatitis B), which is offered at the ages of 8, 12 and 16 weeks^​13,14​.

A four-in-one preschool booster vaccine (i.e. diphtheria, tetanus, pertussis, and polio) is then offered for children aged around 3 years and 4 months.

UK maternal pertussis vaccination programme

Pregnant mothers are typically vaccinated against pertussis during weeks 16–32 of the pregnancy to generate high levels of maternal antibodies that cross the placenta and protect the newborn until their primary immunisations can commence^​15​.

In July 2024, the pertussis vaccine given during pregnancy was changed from Boosterix-IPV to Adacel. This vaccine contains pertussis, along with tetanus and diphtheria. The vaccine is inactivated, which can then be safely given as one dose during pregnancy^​15​.

Studies have shown high effectiveness of the vaccine in pregnancy with no risk of harm to mother or to baby upon administration^​15​.

Pharmacists should be aware of the different formulations in each of the vaccines offered. This is important for ensuring that vaccinations are appropriately matched to the patient, thereby upholding patient safety. Vaccinations can only be given as prescription and require appropriate patient group directions (PGD). 

Pharmacists should promote vaccination at appropriate opportunities, this includes:

• Active signposting of pregnant women to vaccination services;
• Administering pertussis vaccines via commissioned enhanced services or PGDs, where possible;
• Promoting public health messaging on vaccine safety and significance, particularly to vulnerable groups;
• Collaborating with primary care teams to close any vaccination gaps in communities.

The role of pharmacists in bridging any vaccination gaps will reduce pressure on primary care teams and reduce spread of this highly infectious disease in the community.