Pertussis (whooping cough) is often regarded as a vaccine-preventable disease of the past, yet the United States has experienced a marked resurgence of Bordetella pertussis infections between 2012 and 2024, including a sixfold increase in cases from 2023 to 2024. Diagnosis remains challenging: early symptoms frequently mimic those of a common cold, and vaccinated older children, adolescents, and adults often lack the classic "whooping" cough, delaying recognition and appropriate treatment.² Waning vaccine-induced immunity, low booster uptake, and childhood immunization coverage that remains below target in most states compound this risk, leaving both undervaccinated and previously vaccinated populations susceptible to infection and onward transmission.

To help pediatricians and other clinicians better recognize and manage pertussis in this evolving landscape, Contemporary Pediatrics spoke with Alesia McKeown, PhD, senior scientific manager of infectious disease in medical and scientific affairs at Roche Diagnostics. McKeown, a subject matter expert on Roche's high-throughput and point-of-care respiratory diagnostic solutions, discusses the clinical and immunological factors behind missed or delayed pertussis diagnoses, the public health consequences of diagnostic delay, and how molecular point-of-care polymerase chain reaction (PCR) testing may help clinicians differentiate Bordetella species and make more timely, targeted treatment decisions.

Q&A

Contemporary Pediatrics: Pertussis is often thought of as a vaccine-preventable disease of the past. What factors are contributing to missed or delayed diagnoses today, particularly in children and adolescents?

Alesia McKeown, PhD: While often considered a disease of the past, pertussis (whooping cough) is seeing a modern resurgence. It is frequently missed or diagnosed too late in older children, adolescents, and adults due to a combination of clinical, immunological, and diagnostic factors.¹²

Atypical symptoms and mimicking pathogens
In its early stages, pertussis can resemble a standard upper respiratory infection with symptoms such as nasal congestion, a runny nose, sneezing, and a mild cough, making it easy to overlook. Furthermore, vaccinated older children, adolescents, and adults rarely present with the classic "whooping" cough, exhibiting instead a mild, persistent cough that clinicians may not suspect. Diagnosis is further complicated by additional confounding pathogens, like Bordetella parapertussis and Bordetella holmesii, which can cause similar yet milder symptoms, but may not be differentiated using classic diagnostic tests.⁵˒²³

Waning immunity and vaccine gaps
Immunological factors also play a major role, as the protection from childhood vaccines naturally declines over time. This contributes to adolescents and adults being vulnerable to infection despite their earlier immunizations, and though regular boosters are recommended for specific adult populations, uptake remains low. Additionally, the natural 3- to 5-year cycle of pertussis surge has been influenced by rising vaccine hesitancy and disruptions to routine childhood immunization schedules during the COVID-19 pandemic.

Compounding these challenges, recent CDC data show that childhood immunization coverage for whooping cough remains below target levels in many states. Only four states—Connecticut, Delaware, Minnesota, and Wisconsin—reached or exceeded the 90% coverage goal established by the Healthy People 2030 initiative. Compared to the prior year's data for 2-year-olds, 16 states saw a decrease in DTaP coverage, 30 states saw an increase, and 5 states remained completely unchanged.⁶˒⁸

The diagnostics evolution
Historically, bacterial culture has been the gold standard reference method for diagnosing Bordetella pertussis. While it remains essential for specific applications such as surveillance and resistance tracking, its utility in routine diagnostic applications is limited.¹⁰

A bacterial culture is 100% specific, meaning a positive result is definitive confirmation of infection. It also isolates the live bacteria, which is essential for public health surveillance, tracking strain evolution, and monitoring antibiotic resistance.

However, B. pertussis is a fastidious, slow-growing organism. Results can take 7 to 10 days, limiting their utility for immediate, real-time clinical decision-making. Furthermore, its sensitivity is variable and drops drastically if the patient is late in their illness or has already started antibiotics.

Polymerase chain reaction (PCR) testing offers a major leap forward by detecting bacterial DNA, delivering results in hours rather than days, and boasting significantly higher sensitivity early in infection. With the emergence of molecular point-of-care PCR testing, clinicians can now bridge the gap between accuracy and speed, delivering central lab-quality results in minutes rather than hours.¹¹

Contemporary Pediatrics: What clinical features of pertussis can overlap with other respiratory illnesses, and how can pediatricians improve their ability to identify cases earlier in the course of disease?

McKeown: The most significant diagnostic challenge with whooping cough (pertussis) is that its early symptoms are virtually indistinguishable from other common respiratory infections, such as the common cold. Due to waning vaccine immunity and interruptions in routine immunizations, the disease is increasingly spreading among older children, adolescents, and adults.¹²

In these populations, symptoms can present much more atypically and are harder to readily recognize than the classic "whoop." This clinical overlap will often compel doctors to diagnose symptoms empirically while waiting hours or days for traditional lab results, a delay that allows the disease to worsen and spread. When clinicians treat empirically, the outcomes can vary wildly; in the best-case scenario, the patient and their close contacts happen to receive the correct antibiotic and the infection is cleared, but if the wrong antibiotic or antiviral is prescribed instead, symptoms will worsen, potentially causing complications, pushing the patient outside the optimal treatment window, and resulting in further community transmission.¹⁸

To improve their ability to identify cases earlier in the disease course, pediatricians and clinicians should consider strategies that look beyond common viral culprits, recognizing that respiratory symptoms may be caused by less frequently considered bacterial pathogens.

Utilize rapid point-of-care PCR testing
Instead of relying on centralized laboratory testing that can take days, pediatricians should consider molecular point-of-care PCR panels inclusive of bacterial targets that can be performed right in the office. This can eliminate diagnostic delays and empower clinicians to make definitive, same-visit treatment decisions before the infection progresses to a more severe stage or has a chance for further community transmission.¹¹,¹⁸

Differentiate between specific pathogens
Many routine diagnostic tests fail to accurately distinguish between the different pathogens that cause similar pertussis-like symptoms, increasing the risk of misdiagnosis. Clinicians may consider tests that can specifically differentiate between B. pertussis (classic whooping cough), B. parapertussis (which causes a milder illness), and B. holmesii (an emerging pathogen). This approach can help ensure that the patient and their close contacts receive the correct, targeted therapy at the earliest opportunity.²³

Monitor epidemiological surges
To assist with early identification, clinicians may find it helpful to remain aware of the natural 3- to 5-year cyclical prevalence of whooping cough. Understanding how factors such as vaccine hesitancy and pandemic-related vaccination gaps contribute to current surges can offer helpful context when evaluating patients, even when early symptoms resemble a routine cold.¹²

Contemporary Pediatrics: From a public health perspective, what are the consequences of delayed pertussis diagnosis for families, schools, health care settings, and broader community transmission?

McKeown: When a whooping cough (pertussis) diagnosis is delayed, the ripple effects across communities and healthcare systems can be severe.

For families, the most immediate consequence is that the disease has time to worsen before it's properly treated, putting highly vulnerable populations like infants and the elderly in extreme danger. This risk is amplified by the sheer infectivity of B. pertussis, which has a basic reproduction number (R0) of 12 to 17 in unvaccinated populations—meaning a single case can infect up to 17 naive individuals. This makes it far more contagious than common viruses like influenza (R0 around 1 to 2), SARS-CoV-2 (R0 around 2-4), or RSV (R0 around 1-5).¹⁴˒¹⁵˒¹⁶˒¹⁷

Pertussis infections are currently spreading across all age groups, including older children, adolescents, and adults, whose symptoms might be harder to recognize.¹² If these individuals aren't diagnosed quickly, they can easily and unknowingly pass this highly transmissible infection to a newborn or older relative who is at a much higher risk for hospitalization or life-threatening complications.¹²˒¹⁷

In health care settings, waiting hours or even days for traditional lab results means that doctors frequently have to diagnose empirically. Empirical diagnosis may lead to unnecessary antibiotic prescriptions, repeat doctor visits, and inappropriate isolation protocols, placing an unnecessary burden on both patients and the medical system.¹⁸

At the broader community level, including schools and daycares, delayed diagnoses mean that infected individuals remain out in the public, continuing to transmit the bacteria.

Without fast and accurate testing, it becomes incredibly difficult for public health officials to monitor disease prevalence, track outbreaks, and report accurate data. Ultimately, if we cannot quickly confirm B. pertussis cases and distinguish them from other similar respiratory infections, our ability to stop community-wide transmission is severely compromised.¹³

Contemporary Pediatrics: The conversation around respiratory infections often focuses on viruses such as RSV, influenza, and SARS-CoV-2. Why is it important for clinicians to also consider under-recognized bacterial pathogens like pertussis when evaluating patients with a persistent cough?

McKeown: While viruses like RSV, influenza, and SARS-CoV-2 rightfully dominate respiratory discussions, overlooking bacterial pathogens like Bordetella pertussis (whooping cough) can lead to missed diagnoses, inappropriate treatments, and serious public health consequences.¹²

For patients presenting with a persistent cough, clinicians should consider the following:

Atypical presentations
Early symptoms may mimic those of a common cold. Older children and adults often lack the classic "whooping" cough, making the bacterial infection easy to misdiagnose.²²

Increased prevalence in the United States
The U.S. has experienced a resurgence of Bordetella pertussis between 2012 and 2024, highlighted by a sixfold increase in cases from 2023 to 2024.³˒¹²˒²⁰

Species-specific treatment
Bordetella infections require specific antibiotic therapy. Testing can differentiate between three distinct species (B. pertussis, B. parapertussis, and B. holmesii) and help guide proper treatment when necessary.²³

Severe risks to infants
Infants and children are especially vulnerable to whooping cough complications, with unvaccinated or partially vaccinated infants facing the highest risks.¹⁷

One in 3 babies under one year of age who are diagnosed with whooping cough requires hospitalization with complications¹⁷ that could include:

• Apnea (68%)
• Pneumoniae (22%)
• Convulsions (2%)
• Encephalopathy (0.6%)
• Death (1%)

A leading source of infection in infants is transmission by adolescent or adult family members.¹³

mPOC Diagnostics Can Contribute to Healthier Communities
Bordetella pertussis ranks among the most contagious respiratory pathogens in the United States, with an infection rate 4 to 6 times higher than that of SARS-CoV-2, influenza, or RSV. A single infected individual can pass the bacteria to 12–17 susceptible (non-immunized) people. Because the window for spreading the disease is so wide, rapid and accurate diagnostic testing is the first line of defense in breaking the chain of transmission.¹⁴˒¹⁵˒¹⁶

Early diagnosis transforms community health outcomes in three critical ways:

• Fast-Tracking Treatment: Prompt antibiotic use quickly lowers the patient's bacterial load, drastically shortening the window during which they are contagious.²¹
• Immediate Isolation: Clear, definitive results support guidance for patients to self-isolate immediately, keeping the virus out of schools and workplaces²¹.
• Proactive contact tracing: Swift confirmation enables families and health officials to identify exposed contacts and help limit further transmission.¹³

Contemporary Pediatrics: As respiratory pathogen surveillance and diagnostic testing continue to evolve, what strategies can help clinicians maintain awareness of emerging trends and ensure they are not overlooking less commonly suspected causes of respiratory illness?

McKeown:

Utilize advanced, differentiating point-of-care diagnostics
Because early symptoms of many respiratory infections are virtually indistinguishable, relying on clinical presentation alone is no longer sufficient. Clinicians can now consider molecular point-of-care tests that can test for a range of conditions—such as SARS-CoV-2, Influenza A/B, RSV, Group A Streptococcus, and Bordetella—during a single patient consultation.¹¹ Utilizing panels that differentiate between related species is vital, and new point-of-care PCR tests enable clinicians to specifically identify B. pertussis (classic whooping cough), B. parapertussis, and the emerging pathogen B. holmesii.²³

Understand the limitations of routine testing
To avoid overlooking emerging causes of illness, clinicians must recognize the blind spots in standard diagnostic methods. For instance, many routine diagnostic tests cannot accurately distinguish B. pertussis from the emerging pathogen B. holmesii, increasing the risk of misdiagnosis and compromising outbreak surveillance. Shifting toward highly sensitive, lab-quality point-of-care PCR tests will help close this technological gap and ensure accurate identification.²³

Shift away from empirical diagnosis
Traditionally, doctors have had to rely on empirical diagnosis while waiting hours or days for lab results, a delay that can allow diseases to worsen and spread. By incorporating point-of-care PCR testing into their workflow, clinicians can supplement clinical judgment with definitive, same-visit molecular results, ensuring patients receive targeted therapies immediately.¹¹

Tracking resurgence and atypical presentations
Maintaining awareness requires tracking the cyclical prevalence of certain diseases, such as whooping cough. Clinicians must also consider how broader public health factors—such as pandemic-related interruptions in routine childhood vaccinations, vaccine hesitancy, and waning immunity—are driving surges. These factors may be contributing to a shift in infections toward older children and adults—populations in which symptoms often present more atypically and can be harder to recognize.¹²

As we navigate this modern resurgence of pertussis, the imperative for diagnostic precision becomes increasingly clear. While vaccination remains the cornerstone of prevention, our ability to identify, differentiate, and treat respiratory infections in real time is critical to curbing transmission and protecting vulnerable populations. By moving away from empirical diagnosis and embracing the benefits of advanced, rapid point-of-care molecular diagnostics, clinicians can complement their clinical acumen with diagnostic precision and minimize the gaps caused by diagnostic uncertainty.¹⁹˒²³

Accurate, timely identification of Bordetella species not only ensures appropriate patient management but also enables public health systems to track trends and outbreaks more effectively. Ultimately, integrating these precision tools into the standard clinical workflow is essential for transforming the patient journey, improving outcomes, and setting a higher, more responsive standard of care.

References

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