Evidence of Bordetella pertussis infection in adults presenting with persistent cough in a french area with very high whole-cell vaccine coverage

Although France has had a vaccination program for 40 years, since 1990, an increase in whooping cough cases with parent-infant transmission has been observed. This study prospectively assessed the frequency of Bordetella pertussis infection in adults who consulted general practitioners for a persistent cough without an evident diagnosis. Among 217 patients, 70 (32%) confirmed whooping cough cases were identified. One case was culture positive, 36 were polymerase chain reaction positive, and 40 had increases or decreases of > or =2-fold in anti-pertussis toxin IgG titer between serum samples collected during the acute and convalescent phases. The median duration of cough in confirmed cases was 49 days (range, 13-123 days). Of the patients, 60% reported vaccination, and 33% reported whooping cough in infancy. Pertussis should be considered for diagnosis of acute and chronic cough in adults. Future studies should evaluate the public health interest of booster doses of pertussis vaccine in adults.     

Prevention of pertussis

Pertussis (whooping cough) is an acute respiratory disease caused by Bordetella pertussis. It occurs worldwide and is an important cause of morbidity and mortality in areas where immunization rates are low, particularly among children less than 1 year of age. The characteristic presentation of pertussis is paroxysmal coughing followed by a long inspiratory effort that produces the classic whoop. Lymphocytosis is frequently present. Complications include pneumonia and seizures secondary to hypoxia. The paroxysmal and convalescent stages of the illness can each last several weeks. Transmission occurs readily by respiratory droplets, and atypical or mild cases in older children and adults can be important in spread of the infection. Isolation, early erythromycin therapy, and erythromycin prophylaxis can reduce transmission, but vaccination is the primary means of control. An inactivated whole cell suspension of the bacterium has been an effective vaccine for protecting against pertussis since the 1950s, but whole cell vaccine may allow mild infections to occur and has been associated with local and systemic reactions that have eroded public acceptance. Component or acellular pertussis vaccines that are less reactogenic have been in use in Japan since 1981 and appear to be effective there. Development of an acellular preparation that is equally or more efficacious than whole cell vaccine may be possible, but clinical trials for measurement of protection against pertussis are difficult and trials with new pertussis vaccines will have to be carefully performed to avoid the controversies generated by earlier trials.     

Pertussis is a frequent cause of prolonged cough illness in adults and adolescents.

Although pertussis is increasingly recognized as a cause of prolonged cough illness in adolescents and adults, its prevalence is not well established. We evaluated pertussis infection in 442 adolescents and adults > or = 12 years old (mean age, 41.3 years) who had a cough-related illness of 7--56 days' duration. For 4 patients (0.9%), results of nasopharyngeal culture or PCR were positive for Bordetella pertussis; for 10 patients (2.3%), either results of culture or PCR were positive or pertussis antibody titers increased 4-fold. Eighty-eight patients (19.9%) had either laboratory-confirmed pertussis or laboratory evidence of pertussis. These patients had significantly longer duration of cough than did patients without laboratory evidence of pertussis (56 days vs. 46 days), and more of them had vomiting with cough (45.5% vs. 28.5%, respectively). Pertussis is a common cause of prolonged cough illness in adolescents and adults and is frequently associated with other symptoms of whooping cough.     

Outbreak of pertussis on a college campus

Background

Pertussis is increasing among adolescents and adults despite universal childhood vaccination. This investigation describes an outbreak of pertussis among undergraduate students and assesses the burden of cough illness on a college campus.

Methods

Students presenting with prolonged cough were evaluated with culture, polymerase chain reaction (PCR), and serology. An e-mail survey was performed to determine the burden of cough illness on campus.

Results

Thirty-seven undergraduates were evaluated. Their mean duration of cough was 28 days. No student had cultures positive for B. pertussis; one was PCR positive. Ten (27%) had serologic values consistent with acute pertussis infection. The e-mail survey was returned by 225/500 (45%) students. Of these, 66 (29%; 95% confidence interval [CI], 23%-36%) reported a cough of 2 weeks or longer duration during the fall semester. A conservative estimate showed that the campus-wide incidence of a cough illness meeting the Centers for Disease Control and Prevention case definition for pertussis was 13% (95% CI, 10%-16%) during the fall semester.

Conclusions

Adolescents and young adults are susceptible to pertussis infection. This study demonstrates that there was a substantial rate of pertussis infection during an outbreak on a college campus. Our findings support the routine use of the acellular pertussis vaccine in adolescents and adults.     

Evolución de los casos de tosferina tras la vacunación de la embarazada y la pandemia COVID-19

BackgroundWhooping cough has had an increased incidence and severity specially in infants and maternal immunization has been implemented as a prevention strategy. COVID-19 pandemic seems to decrease the incidence of other respiratory diseases.MethodsRetrospective study from 2012 to 2021 to assess the influence of pertussis maternal immunizations and the first year of COVID-19 pandemic in the cases of whooping cough.Results960 suspected cases from primary care and hospital, with 130 cases (104 children and 26 adults) being diagnosed of whooping cough. In the post-vaccination period, a reduction in the cases and severity in infants up to 6 months old was observed as well as in the pertussis diagnosis in adult women. There were no whooping cough cases during the COVID-19 period.ConclusionsBoth the pertussis vaccination in pregnancy and the first year of the COVID-19 pandemic have decreased the number of pertussis cases.     

A pertussis outbreak in a ward for severely retarded]

In June 2000, many cases with persistent cough were observed among inpatients and the staff of a ward for severely retarded. Some of them had symptoms suggestive of pertussis, such as whooping, post-tussive apnea. We performed a retrospective investigation to assess symptoms and serological findings suspicious of pertussis. There were a total of 14 cases of persistent cough over 3 weeks (4 to 9 weeks). 6 cases were inpatients and 8 were hospital staff. Of those, serological test for pertussis infection was performed in 10 cases and 6 cases were diagnosed as serologically confirmed pertussis. The other cases with persistent cough were also considered to be probable pertussis as they have had intensive contact with serologically confirmed cases. 12 cases were treated by antibiotics, but they all failed to respond. It was suggested that Bordetella pertussis must be considered as a causal organism of persistent cough even in adults. To prevent nosocomial transmission of pertussis, droplet precautions and macrolide treatment should be provided for patients with symptoms highly suggestive of pertussis.     

Conduite à tenir devant un ou plusieurs cas de coqueluche

The evolution of the epidemiology of pertussis, new licensed macrolides and vaccines, new recommendations for vaccination among adolescents and adults need an update of the French guidelines for prevention of the disease around one or grouped cases of the disease. A particular attention should be raised to the diagnosis of whooping cough in adults who are presently the main reservoir of Bordetella pertussis. Whooping cough in adults presents as an unexplained prolonged cough with nocturnal exacerbation witch accounts for most of the contaminations of young infants. A bacteriological confirmation of pertussis should be provided before implementation of preventive measures: culture and PCR are presently the gold standard for the diagnosis of pertussis in infants, children and even adults who have been coughing for less than 20 days. Later on, serology (Elisa, immuno-empreinte) is the only technique available, but cannot be interpreted if the patient has been vaccinated less than one year ago. Infants under three months should be admitted to hospital and every case submitted to respiratory isolation. Eviction from the community should be pronounced within the five first days following the onset of an effective antibiotic treatment. New macrolides should be favoured: clarithromycine for seven days or azithromycine for five days. Household contacts should be given the same prophylactic antibiotic treatment: children and adolescent not correctly immunized, parents of the index case as adults parents of not or not completely immunized infants. The vaccination program of the household should be updated. The same measures should be applied in case of grouped cases (at least two contemporary or consecutive cases in the same area). In that case, the Public Health System doctors should be involved in the investigation and the classification of the cases. The close contacts not or not completely immunized should be prescribed and antibiotic prophylaxis and an update of their vaccination program. Among the occasional contacts, high-risk people only should be treated. In the day care centres an antibioprophylaxis should be given to children who have received less than four vaccine shots against pertussis and to the personnel contact to the cases as well. In the schools, the antibiotic prophylaxis should be prescribed to all children of the classroom(s) not completely vaccinated and to the teacher(s) as well. In the boarding schools and institutions with handicapped children, antibiotic prophylaxis could be applied to every member if the pertussis vaccine coverage is at less than 50%. In hospitals, coughing personnel should wear masks and investigations towards pertussis should be performed in people with a more than seven day unexplained cough. Preventive measures should be applied in case of confirmation of pertussis.     

Parapertussis and pertussis: differences and similarities in incidence, clinical course, and antibody responses.

OBJECTIVES: To compare the incidence, clinical course, and serologic response to Bordetella antigens in patients with parapertussis and pertussis. DESIGN: Two studies were performed in Sweden during the 1990s, when pertussis vaccines were used only in clinical trials. Study I was a retrospective study of patients with positive Bordetella cultures obtained in clinical routine, and study II involved an active search for patients with Bordetella infections during a placebo-controlled trial of a pertussis toxoid vaccine. RESULTS: Study I includes 58, and study II 23 patients with parapertussis. In study I, the incidence of parapertussis was 0.016 cases per 100 person years in children 0 to 6 years old and 0 in older children and adults. In study II, the incidence rates of parapertussis and pertussis were 0.2 and 16.2 per 100 person years, respectively, in children followed from 3 months to 3 years of age. The median number of days with cough was 21 in parapertussis and 59 in pertussis. The proportions of children with whooping and vomiting were lower in parapertussis than in pertussis. Geometric mean serum filamentous hemagglutinin IgG increased from 6 to 63, and pertactin IgG from 4 to 12 units/mL in parapertussis patients, which was similar to increases in children with pertussis. CONCLUSIONS: Disease caused by Bordetella parapertussis is diagnosed less commonly and is milder and of shorter duration than disease caused by Bordetella pertussis. Parapertussis induced serum IgG against filamentous hemagglutinin and pertactin of similar magnitude as does pertussis, and did not induce serum IgG against pertussis toxin.     

Pertussis – eine impfpräventable Erkrankung

Pertussis (whooping cough) is caused by Bordetella pertussis and B. parapertussis. It is a purely respiratory infection, which can be highly contagious. In countries with vaccination programs, the main targets are young infants, older non-vaccinated children, adolescents and adults. The disease remains endemic and cyclical worldwide, even in countries with a sustained high vaccination coverage. Pertussis is a notifiable disease in Germany but epidemiological data might not reflect the true burden of the disease. The main symptom is coughing for prolonged periods, which can be paroxysmal. The disease can take a severe course in infants with a possible fatal outcome but adults can also have a high rate of complications. Pertussis can be diagnosed by detecting Bordetella DNA by PCR or by detection of IgG antibodies to pertussis toxin. Antibiotics, such as macrolides can stop transmission but might not relieve the symptoms. Infant vaccination, which in Germany is carried out with four doses of combination vaccines with acellular pertussis components, can prevent the majority of cases. As immunity after infection and vaccination is not permanent, additional strategies comprising school entry boosters and the vaccination of adolescents and adults, as well as vaccinating special risk groups, such as pregnant women are recommended.     

Antibody Response from Whole-Cell Pertussis Vaccine Immunized Brazilian Children against Different Strains of Bordetella pertussis

Bordetella pertussis is a gram-negative bacillus that causes the highly contagious disease known as pertussis or whooping cough. Antibody response in children may vary depending on the vaccination schedule and the product used. In this study, we have analyzed the antibody response of cellular pertussis vaccinated children against B. pertussis strains and their virulence factors, such as pertussis toxin, pertactin, and filamentous hemagglutinin. After the completion of the immunization process, according to the Brazilian vaccination program, children serum samples were collected at different periods of time, and tested for the presence of specific antibodies and antigenic cross-reactivity. Results obtained show that children immunized with three doses of the Brazilian whole-cell pertussis vaccine present high levels of serum antibodies capable of recognizing the majority of the components present in vaccinal and non-vaccinal B. pertussis strains and their virulence factors for at least 2 years after the completion of the immunization procedure.     

Natural immune boosting in pertussis dynamics and the potential for long-term vaccine failure

Incidence of whooping cough, unlike many other childhood diseases for which there is an efficacious vaccine, has been increasing over the past twenty years despite high levels of vaccine coverage. Its reemergence has been particularly noticeable among teenagers and adults. Many hypotheses have been put forward to explain these two patterns, but parsimonious reconciliation of clinical data on the limited duration of immunity with both pre- and postvaccine era age-specific incidence remains a challenge. We consider the immunologically relevant, yet epidemiologically largely neglected, possibility that a primed immune system can respond to a lower dose of antigen than a naive one. We hypothesize that during the prevaccine era teenagers' and adults' primed immunity was frequently boosted by reexposure, so maintaining herd immunity in the face of potentially eroding individual immunity. In contrast, low pathogen circulation in the current era, except during epidemic outbreaks, allows immunity to be lost before reexposure occurs. We develop and analyze an age-structured model that encapsulates this hypothesis. We find that immune boosting must be more easily triggered than primary infection to account for age-incidence data. We make age-specific and dynamical predictions through bifurcation analysis and simulation. The boosting model proposed here parsimoniously captures four key features of pertussis data from highly vaccinated countries: (i) the shift in age-specific incidence, (ii) reemergence with high vaccine coverage, (iii) the possibility for cyclic dynamics in the pre- and postvaccine eras, and (iv) the apparent shift from susceptible-infectious-recovered (SIR)-like to susceptible-infectious-recovered-susceptible (SIRS)-like phenomenology of infection and immunity to Bordetella pertussis.     

Whooping cough in adults: an update on a reemerging infection

Pertussis, or whooping cough, which is commonly thought of as a pediatric illness, is an underappreciated adult pathogen. Recent outbreaks highlight the significance of pertussis in adults and the risk of transmission to at-risk infants who are most susceptible to complications, including death. This article describes the recent epidemiologic shifts and reviews the clinical presentation, diagnosis, and treatment of pertussis. New vaccination recommendations by the Advisory Committee on Immunization Practices in response to recent outbreaks and infant deaths are highlighted.     

Progress in the diagnosis,prevention, and treatment of pertussis

Pertussis (“whooping cough”), caused by the gramnegative pleomorphic bacillus Bordetella pertussis, is a highly contagious, potentially life-threatening respiratory tract illness that has re-emerged worldwide as a cause of substantial morbidity and mortality in infants, children, and adolescents, even in countries with high vaccination rates. Waning immunity after immunization during childhood has been associated with a growing pool of susceptible adolescents and adults who are capable of transmitting pertussis to vulnerable unvaccinated or incompletely vaccinated infants. The use of acellular pertussis vaccine boosters in adolescents has been proposed and is likely to be recommended. Active immunization and improved methods for early diagnosis are key in the management of pertussis, and represent the most rapidly evolving aspects of this disease.     

A search for Bordetella pertussis infection in university students.

University students with persistent cough of greater than or equal to 6 days' duration were evaluated for evidence of infection with Bordetella pertussis. Of 130 students studied during a 30-month period, 34 (26%) were found to have evidence of recent infections with B. pertussis. Infection was identified by direct fluorescent antibody assay of a nasopharyngeal specimen in one student and serologically in 33 additional subjects. B. pertussis was not recovered on culture of nasopharyngeal specimens from any subjects. Students with B. pertussis infection were identified in seven of the eight 3-month periods in which students were enrolled during the 30-month investigation, suggesting an endemic rather than epidemic pattern of infection in this university population. Illnesses of students with pertussis were similar to the illnesses of students without pertussis. The findings in this study suggest that adult populations in which endemic illness occurs at a relatively constant rate may be the reservoirs for pertussis outbreaks in susceptible children. Immunization programs in the future will need to employ booster doses for adults if complete control of B. pertussis infection is our goal.     

Infection control in paediatrics

Infection control has a particularly important role in paediatric hospitals and must take into account the specificity of the needs and environment of the paediatric patient. Children are susceptible to infections that are prevented in older patients by vaccination or previous natural exposure. Consequently, the nosocomial pathogens and most common health-care-associated infection sites in children differ from those observed among adults. The immunological naivety of young children, especially neonates, translates into an enhanced susceptibility to many infections with important health consequences as well as higher rates and longer duration of microorganism shedding. In particular, respiratory virus infections, rotavirus, varicella zoster virus, and pertussis represent persistent challenges in children's hospitals. Specific factors such as the use of breastmilk, toys, or therapy animals are associated with an increased risk for health-care-associated infections. We review the emergence of antimicrobial-resistant organisms and strategies to prevent health-care-associated infections in the paediatric setting.     

Pertussis in adults. What physicians need to know

Although there is increased awareness among physicians regarding their role in protecting adults against vaccine-preventable diseases, many physicians are unaware that adults develop pertussis. Studies of adults with prolonged cough have found that 20% to 25% have serologic evidence of recent pertussis infection. Investigations of outbreaks have documented that adults develop infection with Bordetella pertussis and transmit the organism to susceptible children. Adults are the major reservoir of infection for children who may develop severe illness. Pediatric health care workers and patients infected with the human immunodeficiency virus might be at higher risk than the general population. Because most adults are susceptible to pertussis, physicians must consider pertussis in the differential diagnosis of patients with prolonged cough. Physicians who care for adults should be active in the diagnosis and treatment of pertussis, supportive of studies of the epidemiology of pertussis in adults, and interested in the development and testing of new diagnostic and preventive measures.     

Recent developments in pertussis

Pertussis causes nearly 300,000 deaths in children every year. Most deaths take place in developing countries, but the infection remains a priority everywhere. Pertussis vaccination protects infants and children against death and admission to hospital, but breakthrough disease in vaccinated people can happen. In high-mortality countries, the challenge is to improve timeliness and coverage of childhood vaccination and surveillance. In regions with low mortality and highest coverage, pertussis is frequently the least well-controlled disease in childhood vaccination programmes. Some countries have reported a rise in pertussis in adolescents, adults, and pre-vaccination infants, but how much these changes are real or a result of improved recognition and surveillance remains uncertain. In response, several countries have introduced adolescent and adult acellular pertussis vaccine boosters. The effect so far is unknown; assessment is impeded by poor data. Uncertainties still persist about key variables needed to model and design vaccination programmes, such as risk of transmission from adults and adolescents to infants. New vaccination strategies under investigation include vaccination of neonates, family members, and pregnant women.     

Bordetella pertussis and chronic cough in adults.

To evaluate Bordetella pertussis as a cause of persistent cough in adults, we examined 201 patients who had a cough for 2-12 weeks and no pulmonary disease. We obtained the following at presentation: medical history, chest radiograph, respiratory function measurement, nasopharyngeal aspirate for polymerase chain reaction (PCR), nasopharyngeal swab specimen for culture, and a blood sample (acute serum). Four weeks later a second blood sample (convalescent serum) was obtained. Control sera were obtained from 164 age-matched healthy blood donors with no history of cough during the previous 12 weeks. Four patients were B. pertussis culture-positive; 11 (including the culture-positive patients) were B. pertussis PCR-positive; and 33, including 10 of the 11 PCR-positive patients, had serological evidence of recent B. pertussis infection. Pertussis-positive and -negative patients could not be discriminated by a history of cough. We conclude that B. pertussis infection is a common cause of persistent cough in adults. This is of concern, because these patients may be B. pertussis reservoirs from which transmission may occur to infants, in whom the disease can be devastating.     

Frequency of pertussis in children with prolongued cough

To determine the frequency of pertussis in children < or = 16 y who had prolonged cough (> or = 14 d), a prospective study was conducted at an outpatient clinic of a paediatric hospital. Nasopharyngeal swabs were taken for culture and nucleic acid testing by polymerase chain reaction (PCR) for Bordetella pertussis. Immunoglobulin A and immunoglobulin G antibodies against pertussis toxin (PT) were tested by ELISA in paired serum samples. A total of 148 patients were recruited during 1 y. Pertussis was detected in 25 (16.9%) patients with at least 1 of the tests. PCR was positive in 12 patients, and 9 cases was diagnosed serologically. Both PCR and serology were positive in 4 children. Duration of cough was longer in the patients with pertussis (median 33 vs 20, p = 0.03). Seropositivity of pertussis toxin was higher in pertussis negative patients during enrollment (24% vs 65%, p = 0.005). From the results of this study, B. pertussis seems to be common in our population despite high immunization rates with whole cell vaccine. Although the duration of cough is defined as longer than 21 d in some studies for pertussis case definition criteria, it was shorter than this in 3 of our cases.     

Pertussis surveillance in Switzerland, 1992 to 1997 - a large epidemic in 1994. What next?

Cases of whooping cough have been recorded by the Swiss Sentinel Surveillance Network Sentinella (SSSN) since June 1991 to monitor pertussis trends in Switzerland and to assess the current vaccination strategy. The Sentinella network consists of a sampl