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Following concerns about the safety and reactogenicity profile of diphtheria, tetanus and whole cell pertussis vaccines (DTwP), new and less reactogenic alternatives were developed over the last two decades. The new diphtheria, tetanus and acellular pertussis vaccines (DTaP) no longer consist of the whole bacterial cell but of either extracts or of a few highly purified components. While it soon became clear that DTaP vaccines are significantly less reactogenic than DTwP vaccines, their efficacy was disputed and remained unproven. First studies and epidemiological data from Japan suggested vaccine efficacy rates (VE) of about 80%; however, the first blinded clinical trial from Sweden documented a much lower VE. Worldwide, seven large DTaP efficacy trials have recently been completed. Our own efforts included a large safety trial with 22505 vaccinees and, nested in this setting, a prospective household contact study. Typical WHO-defined pertussis developed in 7 of 112 DTaP vaccinated children following household exposure as compared to 96 cases in 173 children not vaccinated against pertussis. Thus, vaccine efficacy was calculated to be 88.7% (95% CI 76.6 to 94.6). The median duration of spasmodic cough in the few children vaccinated with DTaP who did start coughing was 17 days as compared to 35 days in unvaccinated children. No waning of protection was observed. None of the confounding variables analyzed influenced study results in favour of DTaP. Following administration of more than 67000 DTaP doses, 153 serious adverse events were reported. Eight events were considered possibly related and five were considered related to the study vaccine. According to additional study results from the other trials it can be concluded that DTaP vaccines, like DTwP vaccines, are safe and effective. The choice between DTwP and DTaP should be based on acceptance of the reactogenicity profile, coverage rates achieved, costs and other factors in each individual country.
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PMID:Safety and efficacy of acellular pertussis vaccines: the Mainz study and other recent studies. 928 26

A randomized, double-blind trial comparing a diphtheria-tetanus-acellular pertussis vaccine (DTaP) (pertussis toxoid and filamentous hemagglutinin) with a whole-cell vaccine (DTwP) was conducted. A case-contact study was nested in the trial to estimate absolute efficacy. From 1990 through 1994, 4181 children were randomized to receive one of the vaccines at 2, 4, and 6 months. Severe adverse events were monitored weekly during two visits after vaccination. Fewer serious adverse events were observed after DTaP. Surveillance for cough illnesses persisting more than 7 days, in children under 15 years of age, was made by weekly home visits. Examining physicians, blind to vaccination status, took samples for culture and serologic testing. Pertussis was defined as 21 or more days of cough confirmed by culture, serology, or contact with a culture-confirmed person. Beginning 28 days after the third vaccine dose, the overall ratio of pertussis incidence in the DTaP group relative to the DTwP group (RRac/wc) was 1.54 (95% CI, 1.23-1.93). In children younger than 18 months of age, RRac/wc was 1.16 (95% CI, 0.77-1.73) and 1.76 (95% CI, 1.33-2.33) in children older than 18 months, which suggests a shorter duration of protection with the acellular vaccine (P = 0.090). Absolute efficacy estimates derived from the case-contact study confirmed the lower protection afforded by the acellular vaccine compared with the whole-cell vaccine: 31% (95% CI, 7-49) versus 55% against the protocol case definition, and 85% (95% CI, 66-93) versus 96% for the more severe WHO case definition. Although vaccination with DTaP provided a lower degree of protection than the highly effective DTwP, this difference was less prominent before 18 months of age, the customary age for a fourth dose. The safer DTaP vaccine may prove a valuable substitute for whole-cell vaccines when used in a schedule that includes a booster-dose.
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PMID:A randomized double-blind trial comparing a two-component acellular to a whole-cell pertussis vaccine in Senegal. 936 90

A subanalysis of a recent cohort efficacy trial of a pertussis vaccine was performed to determine its efficacy against cough illnesses due to Bordetella parapertussis infections. Infants received four doses of either the Lederle/Takeda acellular pertussis component diphtheria and tetanus toxoids and pertussis (DTaP) vaccine or the Lederle whole-cell component diphtheria and tetanus toxoids and pertussis (DTP) vaccine at 3, 4.5, 6, and 15-18 months of age; controls received three doses of diphtheria and tetanus toxoids (DT) vaccine only. All subjects were prospectively followed for cough illnesses of > or = 7 days' duration; cases of B. parapertussis infection were confirmed by positive culture, household contact, or serology. Seventy-six cough illnesses due to B. parapertussis were identified; 24 occurred in 929 DTaP recipients, 37 in 937 DTP recipients, and 15 in 321 DT recipients, resulting in an efficacy of 50% for DTaP vaccine (95% CI [confidence interval], 5% to 74%) and 21% for DTP vaccine (95% CI, -45% to 56%). The data in the present analysis suggest that the Lederle/Takeda DTaP vaccine but not the Lederle whole-cell component DTP vaccine has efficacy against B. parapertussis infection.
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PMID:Evidence of efficacy of the Lederle/Takeda acellular pertussis component diphtheria and tetanus toxoids and pertussis vaccine but not the Lederle whole-cell component diphtheria and tetanus toxoids and pertussis vaccine against Bordetella parapertussis infection. 1019 85

Transmission of pertussis among adults is being increasingly recognized. About 1 or 2 in 1,000 adolescents and adults develop pertussis each year, > or = 12% of persons with acute cough illnesses of at least 1-2 weeks' duration have evidence of pertussis infection, and adults have been the source of pertussis for younger children. The advent of acellular pertussis vaccines, if safe and effective in adults, offers the opportunity to prevent transmission of pertussis in older populations. Several issues should be clarified before routine immunization is recommended, including the health burden of pertussis in adults and adolescents to be prevented by vaccination and how much morbidity resulting from pertussis in infants and children would be indirectly prevented. Preliminary studies suggest that pertussis vaccines are safe and immunogenic in adults. Potential recommendations for future vaccination might include all adolescents and adults at 10-year intervals along with the adult tetanus-diphtheria toxoids booster. Cost-benefit or cost-effectiveness analyses would be useful in developing vaccination policies for adults.
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PMID:Pertussis in adults: epidemiology, signs, symptoms, and implications for vaccination. 1044 34

Pertussis is increasingly being recognized as an important cause of cough illness in adolescents and adults. To evaluate the safety and immunogenicity of an adult formulation of a five-component (pertussis toxoid, filamentous hemagglutinin, pertactin, fimbriae 2 and 3) acellular pertussis vaccine combined with diphtheria and tetanus toxoids, we randomly allocated 749 healthy adolescents and adults from 12-54 years of age recruited from five Canadian communities to receive either tetanus-diphtheria vaccine (Td), acellular pertussis vaccine (aP) or combined diphtheria-tetanus-acellular pertussis vaccine (TdaP). Subjects and personnel were unaware of the vaccine allocation. Antibody levels were measured before and one month postimmunization; adverse events were collected at 24 and 72 h and 8 to 10 days. Adverse events were reported in similar frequency amongst the three vaccine groups. Moderate pain at the injection site was reported less frequently in the aP group than the TdaP group (10.7% compared to 19.4%; relative risk 0.6, 95% confidence interval 0.3-0.9). Chills were reported less frequently after Td (5.3%) than after TdaP (12.5%; relative risk 0.4, 95% confidence interval 0.2-0.9). There were no statistically significant differences between recipients of Td and TdaP in tetanus and diphtheria antitoxin levels achieved. Antibody response against Bordetella pertussis antigens was vigorous in all groups although recipients of aP alone had higher levels of antibody levels against pertussis toxoid, fimbriae, and agglutinins and lower antibody levels against pertactin than did TdaP recipients. We conclude that this adult formulation 5-component acellular pertussis vaccine is safe and immunogenic in adolescents and adults and is a candidate vaccine for adolescent and adult immunization programs.
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PMID:An adult formulation of a five-component acellular pertussis vaccine combined with diphtheria and tetanus toxoids is safe and immunogenic in adolescents and adults. 1061 27

Seventy nine traditional birth attendants (TBAs) of Raipur Rani community development block, Haryana were interviewed to assess the effectiveness of continuing training in changing their knowledge and practices regarding maternal and newborn care. Seventy three percent of them reported participation in continuing training sessions. However, analysis of attendance register showed that only 35.4% had attended more than 50% sessions in year 1993. Most (83.5%) of the TBAs gave advice to pregnant women for increased food intake, 47% advised tetanus toxoid, 16.5% for more rest, and 31.6% for iron tablets. Many of them were aware of maternal complications i.e. anaemia (64.6%), oedema (26.6%), bleeding per veginum (39.2%), abnormal presentation (77.2%) and high fever (48.1%). Risks to newborn like low birth weight, fever, cough/rapid breathing and hypothermia were known to 20.2%, 31.6%, 17.7% and 1.3% of the TBAs respectively. Knowledge regarding causes of low birth weight baby like 'weak' mother, less diet in pregnancy, short birth interval and preterm delivery were reported by 69.6%, 63.3%, 12.6% and 3.8% respectively. About two fifth of TBAs advised referral to hospital in case of prolonged labour and 88.6% for very low birth weight babies. Disposable Dai Kit and weighing machine were available with 32% and 73% TBAs. Significantly higher proportion of TBAs participating in continuing training advised tetanus toxoid vaccination, appropriate feeding practices of the newborn, hospital referral in case of prolonged labour and were less inclined to advise injection to speed up labour. Therefore, efforts should be made to increase the attendance of TBAs in continuing training sessions so as to sustain modern maternal and newborn care practices acquired after initial training.
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PMID:Effect of continuing training on knowledge and practices of traditional birth attendants about maternal and newborn care. 1143 75

Pertussis (i.e., whooping cough) is associated typically with an inspiratory "whoop," prolonged paroxysmal cough, and posttussive vomiting; however, persons infected with Bordetella pertussis sometimes experience atypical symptoms, making prompt recognition difficult and probably increasing infection transmission. All infants aged <6 months and any infants who have not yet received 3 doses of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine are especially vulnerable to B. pertussis infection. This report summarizes the investigations of two pertussis deaths that occurred in 2000. Clinicians should consider pertussis as a cause of illness, especially among vulnerable infants who present with cough illness, respiratory distress, or apnea. Timely diagnosis of pertussis in caregivers and other contacts of infants could prevent infant pertussis fatalities.
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PMID:Pertussis deaths--United States, 2000. 1223 2

Child survival in Cameroon is measured in the 1991 Demographic and Health Survey and found to be substantially improved. The survey includes a sample of 3871 women aged 15-49 years and a sample of 814 husbands. Community services data is also collected. Child mortality is reported as declining from 198 to 126 deaths per 1000 births during 1976-91. Infant mortality is shown to decline to 65/1000. Mortality of children aged 1-4 years is 66/1000. 79% receive prenatal care from some source, and 70% receive a dose of tetanus toxoid vaccine during pregnancy. A health professional is present at delivery for 64% of pregnant women. 52% of children aged 12-23 months have a health card, and 41% have tuberculosis, polio, diphtheria, pertussis, tetanus, and measles immunization. One in five still does not have any immunization. 62% of children with mothers who have at least a secondary school education are immunized. Diarrhea morbidity in the two weeks preceding the survey is 18% for children aged under 5 years. 9% have a cough and rapid breathing, and 23% have a fever. Child mortality among children aged 1-5 years is due to diarrhea (27%), malaria (23%), measles (27%), and respiratory infections (16%). Only 3% of children aged under 5 years has acute malnutrition. One in four are stunted, which reflects prolonged or chronic undernutrition. The total fertility rate is 5.8 children per woman, which is a 10% decrease from 1978. The lowest fertility is among women in the main cities of Yaounde and Douala (4.4 children) and among women with a secondary or higher education (4.5). Over 50% of women have sexual intercourse before the age of 16 years, and 50% are married before the age of 17 years. 50% of married women have their first child at the age of 19 years. Contraceptive usage is 16% among women in any union, of which 25% is use of a modern method. Only 1 in 25 women use an effective method, but this rate is double the rate in 1978. Total fertility would be 10% if unwanted fertility were avoided. Most men and women want large families.
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PMID:Improved child survival in Cameroon. 1228 22

In the prevaccine era pertussis epidemics followed a cyclic pattern, with peaks every 2 to 5 years. With the marked reduction of pertussis by vaccination, the same cyclic pattern still occurs. Studies relating to reported pertussis and Bordetella pertussis infection have been reviewed and analyzed. The increase in reported pertussis over the last 2 decades is mainly due to a greater awareness of pertussis and perhaps to the use of several less efficacious vaccines. Studies of prolonged cough illnesses in adolescents and adults reveal that 13% to 20% are a result of B pertussis infection. Serologic studies suggest that the rate of B pertussis infection in adolescents and adults is approximately 2.0% per year. The rate of cough illnesses (pertussis) caused by B pertussis infection in adolescents and adults is between 370 and 1500 per 100,000 population. These data suggest that there are between approximately 800,000 and 3.3 million cases per year in the United States. The coming availability of adolescent- and adult-formulated diphtheria and tetanus toxoids and acellular pertussis vaccines for adolescents and adults and their widespread use should reduce the reservoir of B pertussis disease. It is suggested that a universal program of adolescent and adult boosters would decrease the circulation of B pertussis in these age groups and possibly could lead to the elimination of the organism from the population.
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PMID:The epidemiology of pertussis: a comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. 1619 28

Pertussis is a highly contagious, vaccine-preventable bacterial illness characterized by paroxysmal cough, posttussive vomiting, and inspiratory whoop. Pertussis also can occur as a mild or moderate cough illness in persons who are partially immune. In the United States, most hospitalizations and nearly all deaths from pertussis are reported in infants aged <6 months, but substantial morbidity does occur in other age groups. Infant/childhood vaccination has contributed to a reduction of more than 90% in pertussis-related morbidity and mortality since the early 1940s in the United States. Estimates of childhood vaccination coverage with > or =3 doses of pertussis-containing vaccine have exceeded 90% since 1994; however, reported pertussis cases increased from a historic low of 1,010 in 1976 to 11,647 cases in 2003. A substantial increase in reported cases has occurred among adolescents, who become susceptible to pertussis approximately 6-10 years after childhood vaccination. Recently, booster vaccines for adolescents and adults combining pertussis antigens with tetanus and diphtheria toxoids (Tdap) were approved by the Food and Drug Administration (FDA). On June 30, 2005, the Advisory Committee on Immunization Practices (ACIP) recommended Tdap for all persons aged 11-18 years. This report summarizes national surveillance data on pertussis reported to CDC during 2001-2003 and focuses on pertussis reported among persons aged 10-19 years before implementation of national recommendations for adolescent pertussis vaccination.
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PMID:Pertussis--United States, 2001-2003. 1637 44


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