Elsevier

The Lancet

Volume 367, Issue 9526, 10–16 June 2006, Pages 1926-1936
The Lancet

Seminar
Recent developments in pertussis

https://doi.org/10.1016/S0140-6736(06)68848-XGet rights and content

Summary

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.

Section snippets

Clinical features of pertussis

Pertussis (whooping cough) is an infectious respiratory disease caused by the bacterium Bordetella pertussis, an exclusively human pathogen recorded worldwide. The differential diagnosis includes a wide range of respiratory pathogens, such as Bordetella parapertussis and respiratory syncytial virus infection.3

Pertussis is very infectious with high secondary attack rates in households.4 Published incubation periods range between 5 and 21 days, with 7 days being most common, and rarely lasting

Microbiology

B pertussis is a small gram-negative coccobacillus, strictly aerobic, and fastidious, needing special media (such as charcoal blood agar with cefalexin) for its isolation. The bacterium produces a range of adhesins, fimbriae, and toxins. Some are associated with adhesion and colonisation, including filamentous haemagglutinin, pertactin, and components of pertussis toxin, and some are implicated in the pathogenesis of clinical pertussis, including other components of pertussis toxin, an

Treatment

Supportive treatment is most important for infants. For optimum clinical effectiveness, antibiotic treatment should be given rapidly: it also shortens the infectious period.33 There is probably no effect on outcome if started more than 1 week after onset of illness. Erythromycin is the traditional treatment, but the newer macrolides azithromycin and clarithromycin have similar effectiveness with fewer side-effects.58, 59 7 days of treatment with erythromycin have been shown to be as effective

Whole-cell and acellular pertussis vaccines

Whole-cell pertussis vaccines were developed in the 1940s and have been used worldwide for many years, having been part of the WHO Expanded Program of Immunization since its launch in 1974. Whole-cell pertussis vaccine is a suspension of killed B pertussis organisms. Safety of whole-cell vaccines has been reviewed in detail, and of a range of adverse events considered, evidence suggests a causal relation only for anaphylaxis, prolonged or inconsolable crying, and febrile seizures.65 For other

Routine surveillance

Surveillance of pertussis is a challenge because the clinical range is wide, all ages can be affected, and laboratory confirmation is not straightforward. Data from different countries are difficult to compare because surveillance systems vary greatly: case definitions, diagnostic methods, clinical and reporting practice, and public-health law all differ.97 Surveillance of pertussis in most countries relies on statutory clinical notifications and laboratory reports.98 Both are recognised to

Conclusions

Pertussis is a substantial health burden worldwide, and for many developing countries the challenge is simple—to achieve high vaccination coverage of timely immunisation for infants. Public-health authorities could do much to improve the quality of routine information used to assess changes to vaccination programmes, such as adolescent and adult boosters. All countries should apply standardised case definitions for surveillance and outbreak investigation, and make better use of laboratory

Search strategy and selection criteria

In 2005, a literature review was undertaken using MEDLINE complemented by a collection provided by WHO Geneva originally compiled by Artur Galazka and then extended to include articles held in WHO regional databases. MEDLINE searches of articles used the MeSH terms “pertussis complications”, “epidemiology”, “mortality”, “prevention and control”, and “transmission” to identify articles published since 1966. Papers were prioritised to meet the space constraints of the Seminar.

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