CME Article
Pertussis: review of epidemiology, diagnosis, management and prevention

https://doi.org/10.1016/j.prrv.2008.05.010Get rights and content

Summary

Bordetella pertussis the cause of pertussis or whooping cough – is an exclusively human pathogen. Disease elimination by vaccination should, therefore, be possible, but has proved elusive. Many industrialised countries with long established immunisation programs are currently seeing a resurgence of pertussis, despite universal vaccination with high uptake, with the highest burden in the least immunised age groups (infants under 6 months of age and persons over 10 years old). However, low recognition and reporting and insensitive diagnostic tests mean that the true burden of pertussis is still underestimated. Recently, efforts to improve diagnostic yield include the expanded use of polymerase chain reaction and serological tests but both have significant limitations. The range of antibiotics available for treatment and prophylaxis has expanded to include the newer macrolides, azithromycin and clarithromycin, and a range of universal and targeted vaccination strategies have been implemented or proposed. This paper reviews the current epidemiology of pertussis in developed countries, including modes of clinical presentation, diagnosis, management and potential vaccination strategies.

Section snippets

Epidemiology of pertussis

Surveillance of pertussis in most countries is based on clinical notifications and laboratory reports. In developed countries with long-established vaccine programs, the general trend has been for increasing incidence with a shift to infection in older persons, although the highest incidence continues to be in infants too young to be eligible for vaccination. Comparison of pertussis incidence between countries is problematic due to differences in case definitions, access to diagnostic tests,

Possible explanations for current epidemiology

The possible reasons for the change in epidemiology leading to increasing rates in those under 5 months old and those over 10 years in developed countries with well-established immunisation programs are numerous and include the following:

  • duration of protection and waning immunity following infection and vaccination

  • incomplete protection from vaccination

  • infection source for infants

  • infection source for adolescents

  • strain polymorphism

  • increased diagnosis and reporting.

Diagnosis

The identification and clinical management of pertussis requires a combination of clinical suspicion, appropriate laboratory tests and consideration of antibacterial therapy (see algorithm in Table 2).

Acute pertussis infection

Infection in infants under 6 months old may require hospitalisation for supportive care of complications, for example apnoea, hypoxia or feeding difficulties. Treatment with antibiotics does not significantly shorten the clinical course in infected patients but aims to reduce transmission to other persons. In the past, erythromycin was the first-line antibiotic for pertussis treatment but it was associated with significant adverse effects including hypertrophic pyloric stenosis in infants and

Current vaccine strategies for prevention

Vaccines using inactivated whole B. pertussis organisms (Pw) of three serotypes were first developed in the 1930s and subsequently combined with diphtheria and tetanus toxoids for widespread use in immunisation programs.75 In many industrialised countries currently acellular pertussis vaccines (Pa) that include up to five antigens, (PT, FHA, PRN and two different fimbrial proteins) are used. All manufacturers include PT and PRN as sub-studies from Pa efficacy trials have implicated PT and PRN,

International collaborations

International collaborative efforts to address the rising incidence of pertussis have commenced. The GPI was created in 2001, following an educational grant from Sanofi Pasteur, and includes over 30 scientific experts from 17 countries who were divided into three regional subgroups – Europe, North America and International. The focus of this group is to raise global awareness of pertussis as an important preventable disease and to develop and communicate evidence-based recommendations for

Conclusion

Globally, pertussis remains a challenge in both developing and developed countries. In both settings, infants under 5 months of age have the highest rates of pertussis disease, morbidity and death. In developed countries widespread universal vaccination of infants has dramatically decreased the incidence of pertussis, especially hospitalisation and death, among those aged 1–10 years, but the burden of disease has shifted to older ages with adolescents and adults now most likely to transmit

Key points

  • In countries with well-developed immunisation programs, symptomatic pertussis infections are now predominantly in the least well-immunised groups (over the age of 10 years and under 5 months).

  • In adults and older children, diagnosis of pertussis is often delayed because classic symptoms are frequently absent, resulting in the potential to transmit infection for several weeks.

  • The sensitivity of laboratory tests for pertussis is reduced by the use of antibiotics early in the course of infection,

Educational Aims

  • To understand the current epidemiology of pertussis and recent changes in the burden of disease.

  • To appreciate the different clinical presentations of pertussis in infants and adolescents.

  • To understand the sensitivity, specificity and limitations of available laboratory investigations to diagnose pertussis infection.

  • To understand antibiotic use in the treatment of pertussis and groups for whom prophylactic treatment is recommended.

  • To understand the rationale underlying the different vaccination

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