Pertussis Infection in Fully Vaccinated Children in Day-Care Centers, Israel
Emerging Infections Diseases
Vol. 6, No. 5, September-October 2000
Pertussis, an acute disease of the upper respiratory tract caused by the gram-negative bacillus Bordetella pertussis, lasts 6 to 8 weeks and has three clinical stages. The initial (catarrhal) stage resembles a common cold with a mild cough. The second (paroxysmal) stage is characterized by episodes of repetitive coughing during a single expiration, followed by a sudden inspiration that generates the typical “whoop.” The final (convalescent) stage, which lasts 1 to 2 weeks, marks a decrease in the severity and frequency of the cough.
Since the introduction of routine childhood vaccine, pertussis has been considered preventable, and pertussis-associated illness and deaths are uncommon. However, vaccine-induced immunity wanes after 5 to 10 years, making the vaccinated host vulnerable to infection. This susceptibility has been described in outbreaks of pertussis infection in highly vaccinated populations.
A recent study by Yaari et al. showed that infection in a vaccinated person causes milder, nonspecific disease, without the three classical clinical stages. Whooping cough is seen in only 6% of such cases; instead, the illness is characterized by a nonspecific, prolonged cough, lasting several weeks to months. Because of these atypical symptoms, pertussis infection is underdiagnosed in adults and adolescents, who may be reservoirs for infection of unvaccinated infants. In a study in France, up to 80% of infections in unvaccinated children were acquired from siblings and parents, suggesting that adults and even young siblings play a fundamental role in the transmission of pertussis.
We demonstrated B. pertussis infection in fully vaccinated children ages 2-3 years and 5-6 years who had contact with an infected child. We investigated whether younger or recently vaccinated children may be protected from classical clinical illness but remain susceptible to infection and become asymptomatic carriers.
The effects of whole-cell pertussis vaccine wane after 5 to 10 years, and infection in a vaccinated person causes nonspecific symptoms. Vaccinated adolescents and adults may serve as reservoirs for silent infection and become potential transmitters to unprotected infants. The whole-cell vaccine for pertussis is protective only against clinical disease, not against infection. Therefore, even young, recently vaccinated children may serve as reservoirs and potential transmitters of infection.
We used PCR, EIA, and culture to confirm B. pertussis infection in two highly vaccinated groups of children in two day-care centers. Three (10%) of 30 2- to 3-year-old children were seropositive for recent infection; one had nasopharyngeal colonization and a clinical illness that met the modified WHO case definition. In the day-care center for the 5- to 6-year-old group, 9 (55%) of 16 children were IgM positive, 4 (25%) of whom had nasopharyngeal colonization. Of these four children, three had nonspecific cough, and only one met the modified WHO definition for pertussis. None of the children in our study, including those who met the WHO definition, had been examined by a physician before our investigation.
Children who were seropositive and remained both asymptomatic and PCR negative probably had sufficient immunity from vaccines or natural boosters to protect them against persistent colonization and clinical disease. Their seropositivity could not be due to vaccine because the children were tested more than a year after having been vaccinated. Yet not all the children were protected from infection and from colonization with the bacteria. Whether a child who is serologically or PCR positive for pertussis and is clinically asymptomatic is a potential transmitter of infection has not been established. What is certain, however, is that vaccine-induced immunity against infection does not persist throughout adulthood. In France, booster vaccinations have been recommended for adolescents and teenagers. We found that immunity does not even persist into early childhood in some cases. We also observed that DPT vaccine does not fully protect children against the level of clinical disease defined by WHO. Our results indicate that children ages 5-6 years and possibly younger, ages 2-3 years, play a role as silent reservoirs in the transmission of pertussis in the community. More studies are needed to find the immunologic basis of protection against infection and colonization and thus an effective way to eradicate pertussis.