EVIDENCE BASED MEDICINE – IF IT QUACKS LIKE A DUCK, IT’S PROBABLY A DUCK BUT RIGHT NOW IT DOESN’T EXIST BECAUSE THERE HAVE BEEN NO STUDIES.
(First, to all my English-savvy peeps, I am using “they” rather than he/she, with my doggone poetic license, which I have had much longer than my physician’s license, and, of course, for protection of the innocent).
This all started the week before Christmas. I had a patient who was having a coughing fit. Cough. Cough-cough-cough, wheeze. And I, attempting to be a Good Physician (GP), nonchalantly asked the patient if they were up to date with their pertussis (whooping cough) vaccine.
When the patient finally caught their breath, they gasped, “Oh, I had whooping cough last year. Turns out I didn’t build good immunity when I got my vaccine. My culture came back negative, but the immunity studies showed that I had it. Could I have it again?”
“Hmmm….” I said. “Good question.”
I rubbed my chin in good doctorly fashion, and felt my zebra-hunting hackles rising.
After a little data exploration, curbside consulting (that’s when I ask a fellow doc for some tete-a-tete advice), and harrumphing, looking at the length of time the cough was present and how the patient was coughing, and going over my 10-minute patient encounter allotment time, I went with the instinct.
It was a highly suspect case, especially with a history of immunity issues and immunosuppresants.
Unfortunately this clinic, like a lot of other clinics around the country, was not equipped to do the proper nasopharyngeal swab with a special applicator and technique to cultivate the bacteria or get sufficient secretions to do DNA PCR testing. The only thing we had was an MAID blood test for B. pertussis antibodies. According to the big commercial lab, this newer test had good sensitivity and specificity (big science words, meaning that we are pretty sure the results are mostly good—a hat off to Miracle Max).
So we treated the patient to the best of our ability, this probably being late to catch any viable bacteria anyway as the cough had been around for several weeks.
I got a pertussis booster. I was up-to-date with my TdaP, but it had been a couple of years. The documentation suggested that it is a good idea in a suspected case of pertussis to be treated with prophylaxis (meaning to take a pill to keep from getting sick–it is not only a reference to condoms). The drug of choice is the Z-pak (azithromycin).
Z for zebra. I like the Z-pak. Taking an antibiotic once a day was helpful in a helter-skelter world when I had little kids who needed treatment for their infectious issues. Yes, I know it works for bacteria not viruses. But you know, it is awfully hard to look at someone and know for sure if what you are seeing is a virus or not. Probably it is. Probably. Could there be a secondary bacterial infection? Could be. Probably not. Maybe. Yes, there is a world of bacterial resistance out there probably fueled by well-meaning or simply frustrated physicians who just throw the antibiotic book at everything because that’s all you can do in 5 or 10 minutes.
But I was skeptical. I figured this patient was probably not contagious, and I was just trying to be cautious, and I should be thinking horses.
They beat this into us in medical school and residency—hoofbeats = horses, not zebras. Unless, of course, as I like to point out, you are in parts of Africa.
We tried to report everything to the CDC which referred us to more local resources, like the state, and the medical assistants were not able to get anyone on the phone because it was the weekend. Then it was Christmas. Then it was the day after Christmas, and I got the results back, and they were positive!
Of course, all the government (federal, state, local) offices were closed for the extra day off, and of course there was another weekend in-between.
- INSERT RANT: Thanks, Obama (in this case, mind you, I can actually say that and mean it). We can thank both parties for budget north and southbound Zax stubbornness that caused mayhem with the CDC in recent years. Infectious disease doesn’t take a holiday, politicians. END RANT
I started a nasty cough. My sinuses were running. 6 days after I had seen the coughing patient. Naaahhhh….
And then that day I saw another patient—same exact presentation, more than 3 weeks of coughing getting worse. The patient was with their spouse. Couldn’t remember if they had ever had a TdaP. The spouse was a teacher–not sick. So I told the patient about the test, looked at the records, and they had never been treated with a Z-pak for this—but had been seen a week or so before and finished some amoxicillin (the usual evidence-based choice for sinus, ear, upper respiratory infections).
Just because I had seen it before, and we discussed the possibility of pertussis the patient consented to let me do an MAID test and treat her with a Z-pak.
I filled my Z-pak prescription. I also filled a prescription for my household. I had 4 people at home with asthma who were at high risk for respiratory problems.
None of the 4 ever got sick. They got prophylaxis.
My cough got worse. I had to use an inhaler. I coughed so hard when I was driving home that I had to change and do laundry. I was instructed to suck it up and go to work. If every doc who got sick stayed home, there would be no docs. It couldn’t possibly be pertussis, and even if it was, it’s not a problem in adults and everyone is vaccinated (including me, and multiple times). So I went to work, and I wore a mask and refused to see kids. Patients thanked me for wearing a mask, as they heard me cough.
Then I started a fever along with my nasty cough and got a couple of days off, long enough to finish my Z-pak.
Z-pak can treat bacterial sinusitis, bacterial ear infections, bacterial throat infections, and some bacterial lung infections, and is the treatment of choice for most cases of community-acquired (walking) pneumonia. It is also the treatment of choice for B. pertussis.
One of the local health department guys called to follow up on our reported case. Wondered if maybe something like an Amber alert should go out. I told him I was concerned, but wanted a few more positive tests before I would know for sure to feel comfortable about pressing the panic button. I told him what I was seeing and promised to get back with him.
There was a particular presentation that I started to see with my patients. They all had severe nasal congestion, ear pressure, a scratchy or sore throat with post-nasal drip, red (injected) conjunctiva evident in the lower eyelids, some had dry cough, some had more productive cough, some had a lot of forceful cough with vomiting or urination, some a little, most had a hoarse voice. Lungs were clear. A few people reported diarrhea. Most had some episodes of low-grade temperature elevations or frank fevers that would come and go if it had been more than a couple of days. Patients with asthma or COPD had to use their rescue inhalers—some for the first time in years, and those folks did wheeze. Most did not know about the pertussis vaccine, were adults, and if they did have one, it was more than 4 or 5 years ago. They were teachers, restaurant workers, grandparents, recently on a cruise, saw someone coughing at the grocery store, moms with coughing kids who were getting over “a cold.”
I did the most reading I have ever done on B. pertussis. It is one of the major causes of mortality in the world. Half of the children under the age of 1 who get it in the US end up in the hospital, reasoned due to incomplete DtaP vaccination series and swelling of the nasopharynx that in the very young with soft tender throats lead to an inspiratory whoop (stridor), with difficulty breathing in, and in older kids and adults may sound more like a hoarse voice or laryngitis (which is also similar to the presentation of croup and parainfluenza).
- Sound of Infant whooping
- Sounds of different severities of pertussis in kids, one without whooping
- Adults may not make a whooping noise
The vaccine used in the US, the aP in TdaP and DtaP, stands for acellular pertussis and replaced the old vaccine which was a “whole cell” vaccine (the old TDP and DTP). To confirm pertussis for epidemiology (the health department), a patient should be coughing for a couple of weeks (the only way to truly differentiate from the similar early presentation in various colds and influenza types) and have a postitive culture. The culture is rarely ever done, because although the B. pertussis organism is virulent (easy to spread to others) it is very very difficult to collect on a swab without killing it and to grow in a petri dish and thus PROVE that it is there (or was there—Kilroy was here!—usually by the time the bad cough starts, the bacteria is gone). Newer tests find the DNA of the pertussis organism. And even newer tests, like the MAID, check for the presence of elevated antibodies that when raised beyond a certain lab-determined level indicate a PROBABLE exposure to B. pertussis. In addition there are variants of B. pertussis like parapertussis out there (good luck getting that one diagnosed). The vaccine IS ALSO NOT A GUARANTEE THAT YOU WON’T GET PERTUSSIS. B. pertussis goes in 14 day phases where a nasty cough settles in after 2 weeks. It is known as the “100 day cough.” As I sit down to write this, I have been coughing for 4 weeks.
AND the aP vaccine is only good for about 4 years… at 5 years the protection goes down to the 30% range. BUT there are no recommendations to do boosters every 5 years. Because (drum roll here) the CDC stated it was not cost-effective.
Not cost effective. Major cause of mortality in the world. Or is it really? How do we know, because IT IS VERY HARD TO CULTURE AND NOBODY DOES IT!
And, it seems to have a fairly benign progress in adults—like a cold with an annoying cough.
So back to the duck analogy…. If it quacks like a duck, you would think….
I have seen a lot of quacking and I started doing a lot of blood tests—I chose patients carefully on both presentation of the signs and symptoms I mentioned AND a link to kids under the age of one, to the public, or to others in the family who might have an immune-compromised state. All of these patients received a Z-pak prescription from me. And I wrote them for the families. For others without the child link, I had a low threshold to prescribe a Z-pak.
Some patients were resistant and threw the Mayo Clinc book at me for evidence and cultures. I had to sum up the new evidence, and patients agreed. In fact, I encouraged them to follow up with their regular doctors and get that culture—‘cause I couldn’t.
And here’s the shocker: Ninety percent of the patients that I tested came back with PROBABLE exposure to pertussis. I had MORE positive results on pertussis than I had on influenza.
After I started getting a handful of positive cases, I tried to recontact the health department person but had no luck in getting the message through.
I wrote to the CDC—“Hey, is there an outbreak of Pertussis in Houston? I have these tests and I can’t get a hold of the Texas Department of Health.” They wrote back—“Contact your local health department, we can’t help you, it’s not our job.” I wrote back, “What if this was Ebola? This is a contagious reportable disease! I can’t get a hold of the Texas Health Department, and I need your help! Little babies are at risk!” They relented and wrote back that they passed the word along.
I got a call from the Pertussis expert in Houston the next morning who spoke with me and approved of what I was doing. He begged for cultures, but couldn’t say for sure if there was an outbreak because they needed the cultures to make it definitive enough to report.
The other doctors I was working with were giving out a lot of amoxicillin and Tamiflu, neither of which would or did do anything for this syndrome, although with time, I knew this would get better on its own. Lots of time. Weeks. Maybe months.
I saw patient after patient with the same presentation. Some were in for physicals and were “getting over a cold.” Yeah, everyone in the family has been really sick, ran a fever for a while, but I’m getting better now. Hack. Hack. Cough. Clear lungs. Congestion. Red eyes. Retracted ear drums. Teachers reported that they have been seeing kids who never miss school who are out for several days sick.
Did I say 90%?
So the other day, a colleague came up to me and asked me why I was doing all these tests. The doc didn’t really trust or understand the significance of the labs. This doc did not believe it was possible that so many people could have pertussis because this doc had been practicing for 20 years and never came across it. “Really? Congestion and a sore throat? Come on…. WE WOULD HAVE SEEN IT BROADCAST FROM THE HEALTH DEPARTMENT.”
The doc was absolutely right…. you would think it would be broadcast by now.
(English majors, am I allowed to call this irony? I am not sure what that word means any more, thank you, Alanis Morissette.)
I took it to heart, and that zebra throw started to look a little worn. “It must be me. What am I thinking? Okay, I won’t test.” I was so conflicted.
Did I say 90%?
I was off the next day, and I called the local health department. Am I nuts? What am I seeing? I have many probable cases—so many that I now have an exact idea of who has this and who does not based on the clinical presentation alone.
I spoke to the Pertussis expert again, and he was still in agreement of what I was doing. He said that the elevations from the labs are indeed considered probable exposure, and that they have been working with the same lab as well. The hard part is getting a proper culture–usually the outbreaks are in a specific area or school, rather than widespread, but that the criteria of waiting for the long term cough is still part of the profile, so it takes some time to get all the data. It’s not uncommon to have pertussis outbreaks. (The last data I saw was about 2410 cases in the entire state of Texas, and I have seen a lot in the past month!). The PDF letter dated 2013 from the Texas Department of health (below) listed 1935 cases reported to the CDC as the highest number in 50 years. We are now quite a bit above that.
NOBODY tests for this thing. And should we? And who pays for it?
But…. We are in the middle of an outbreak and there is a way to head it off at the pass, BEFORE it spreads more.
It is this pre-diagnostic tender time that the Z-pak makes a difference, before it has a full-on presentation with more evidence for diagnosis.
I, rookie that I am, can spot this presentation within a couple of days of symptoms, even before the fever, especially as I know this is the bug-du-jour that is palling around with influenza (everybody knows about influenza).
He said, if we can identify a particular school or area and get a culture, that would be ideal, although from a public health perspective, what I am doing with the blood tests and presumptive treatment is in the best interest of the patients and their families, including giving out Z-pak prescriptions to other family members.
Most of the docs will still be doing amoxicillin and tamiflu. They are following the evidence.
Nowhere on the public websites is there note that in this city of millions of people there is a PROBABLE spread of a disease that is potentially fatal to kids under the age of one.
These are the things that I wonder:
- How do we ever communicate with other health workers on potential outbreaks? There’s no comment forum or thread on the CDC or on state or local health department websites for docs to post a, “Hey, guys, I found these cases of PROBABLE pertussis with this presentation, you might want to be on the lookout! Schools and hospitals might want to know.”
- We aren’t even sure who we are supposed to report to other than to be as local as possible so that the chain of health departments can push the data along to the right places. There are city health departments, county health departments, state, CDC, and if you don’t pick the right one and that agency doesn’t work with the right agency, your report might just end up lost in the bureacracy—unless somebody dies or starts a lawsuit, of course. And then the fingerpointing starts. Plus neither medical assistants nor doctors have the (literal) 2-hour hold time to wait to speak with someone.
- How do we notify the safety chain to get the word out quickly. Heads up?
- Is the vaccine even effective? You can get the vaccine and still get ill. Perhaps the acellular version just isn’t that good. I saw three young children, all with updated vaccines, all coughing with history of fever and earache and mom that had elevated pertussis antibodies and no recent vaccine. She had PROBABLE pertussis, and that means her kids did, too, despite their vaccines.
- Is it really that bad of an illness, and if it isn’t, why does the CDC and the state and local health departments fuss about it when nobody is doing anything to be proactive other than a dubious vaccine?
- It’s treatable—why are we not treating it?
- How about parapertussis? Is something else going around?
- Who is doing the cultures, how do we get one, and who is gonna pay for it?
- Will someone please beat the dust out of my zebra rug? NOW. PLEASE.
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