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Do not forget about protecting adolescents from pertussis
Although the incidence of pertussis has been dramatically reduced, reported cases have been increasing since the 1980s.
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Despite the inclusion of vaccination against pertussis in the recommended pediatric immunization schedule, this serious respiratory infectious disease is increasing.
Although pertussis vaccine products for use in infants and children have been available for more than 50 years, it is only recently, since 2005, that vaccine products for use in adolescents and adults have become available.
Pertussis, or whooping cough, remains a problematic infectious illness in the United States.
Although the incidence of pertussis has been dramatically reduced since the widespread use of pertussis vaccine products in the 1950s, reported cases have been increasing since the 1980s.
In 2005, 25,616 cases of pertussis were reported in the United States, representing a 40-year high. Approximately 30% of these cases occurred in adolescents. In 2005, nearly 8,000 cases of pertussis were reported in adults, and it has been estimated that 600,000 cases of pertussis occur annually in adults between age 19 and 64 years. Despite the high use of pertussis vaccine products in infants and children, immunity to pertussis wanes after five to 10 years.
Pertussis is highly communicable and adolescents and adults have been identified as common sources of infection. Pertussis is spread primarily by respiratory droplets produced from coughing or sneezing. Infants aged younger than 12 months are at most risk for serious morbidity, including death, from pertussis.
During the period of 2000-2004, 100 deaths due to pertussis were reported, and of these, 90 deaths occurred in infants aged younger than 4 months and 92 deaths occurred in infants aged younger than 12 months. An average of 2,488 cases of pertussis among infants aged younger than 12 months were reported annually during the period of 2000-2004. Most infants with pertussis during this period, greater than 60%, required hospitalization because of serious illness.
Adolescents and adults remain a significant reservoir for pertussis transmissibility to infants.
Adolescents with pertussis may present with only mild cough, or they may present with symptoms more consistent with classic pertussis. Infected adolescents may also be asymptomatic. Results of studies have revealed that up to 20% of adolescents and young adults seeking medical care have pertussis when they present with nonspecific cough for more than one week. Most adolescents with pertussis do not seek medical care and thus remain contagious for several weeks or more.
Health care personnel can also be a significant source of pertussis infection to infants. Nosocomial spread of pertussis has been shown to occur in a variety of health care settings, including in-patient facilities, out-patient clinics and long-term care institutions. Health care personnel are at risk for exposure to pertussis and may act as a source of infectivity to infants. Several publications have documented the exposure of numerous health care personnel, including nurses, physicians, radiology technicians and respiratory therapists to pertussis from infected patients. Result of one interesting study in Canada estimated the risk for contracting pertussis among health care personnel as compared with the general population and indicated that pertussis among health care personnel was 1.7 times higher than the general population.
Adolescent and adult pertussis vaccines
In 2005, two pertussis vaccine products labeled for use in adolescents and adults became available, Boostrix (GlaxoSmithKline) and Adacel (Sanofi Pasteur) [tetanus toxoid, reduced diphtheria toxoid and acellular pertussis]. Boostrix is labeled for use for ages 10 to 18 years and Adacel is labeled for use in ages 11 to 64 years, and both vaccines are labeled as a single booster dose in individuals who have received the full DTaP/DTP series. These TDaP vaccines contain similar pertussis antigens as DTaP, with some antigens in reduced quantity. The main benefit realized by the use of Boostrix and Adacel is protection of adolescents and adults from pertussis while continuing to provide protection against tetanus and diphtheria. An additional important potential benefit is a reduction in the reservoir of Bordetella pertussis and in the incidence of pertussis in infants.
The Advisory Committee on Immunization Practices of the CDC has recommended that adolescents aged 11 to 18 years receive a single dose of TDaP if they have completed the childhood DTaP/DTP series.
The preferred age for receipt of TDaP is 11 to 12 years of age.
Adolescents aged 11 to 18 years who received Td (tetanus and diphtheria toxoid vaccine) should receive a single dose of TDaP, provided that they received the DTaP/DTP series. A period of five years should exist between receipt of Td and TDaP to minimize local and systemic reactions. However, TDaP may be given in situations when Td was given within a period of less than five years previously. These situations may include those of increased risk for pertussis, such as pertussis outbreaks, increased pertussis activity in the community or close contact with a case of pertussis.
Other situations to consider use of TDaP when Td had been given within the past five years includes administration to adolescents with significant underlying medical conditions or to adolescents who have close contact with an infant aged younger than 12 months. Results of several studies have documented the safety of TDaP administration within periods as short as two years of Td use. Intervals of less than two years between Td and TDaP use may be considered in specific situations if the benefit of TDaP administration is assessed to outweigh the risk of increased local or systemic adverse effects. Adolescents with a history of pertussis should continue to receive TDaP. The American Academy of Pediatrics Committee on Infectious Diseases has published similar recommendations for use of TDaP in 2006.
TDaP is contraindicated in individuals with a history of a serious allergic reaction to any of the vaccine components. The ACIP recommends that individuals with a history of allergic reaction to components included in all TDaP and Td vaccines be referred to an allergist, due to the importance of tetanus vaccination. TDaP is also contraindicated in adolescents with a history of encephalopathy within seven days of administration of a vaccine containing pertussis components.
Health care personnel
Adacel is labeled for use in adults aged 11 to 64 years. A special emphasis should be made to educate health care personnel who have direct patient contact on the importance of receiving Adacel. In pediatrics, this also applies to adults who have direct contact with young infants, such as parents and health care personnel in pediatric offices and institutions.
Additional information on the use of TDaP, such as administration to adolescents with a history of no or incomplete pediatric DTaP/DTP/DT or Td vaccination can be found in published recommendations documents from the ACIP or Committee on Infectious Disease of the AAP (see references).
For more information:
- Edward A. Bell, PharmD, is a Professor of Pharmacy Practice at Drake University College of Pharmacy, Blank Children’s Hospital in Des Moines, Iowa.
- Advisory Committee on Immunization Practices. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. MMWR. 2006;55(RR-3):1-43.
- Advisory Committee on Immunization Practices. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR. 2006;55(RR-17):1-37.
- Committee on Infectious Disease, American Academy of Pediatrics. Prevention of pertussis among adolescents: recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Pediatrics. 2006;112:965-978.