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Prenatal pertussis vaccination recommended to reduce infant pertussis deaths

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Joint effort required to improve prenatal pertussis immunization

The resurgence of pertussis in the United States and many other countries in the world has become a major problem, with no immediate solution in sight. Sadly, the rising disease rate is accompanied by an increase in deaths from pertussis, almost exclusively in young infants. We have learned that the immunity induced by acellular pertussis vaccines, the only type of vaccine used in the United States since the late 1990s, is not durable and wanes rapidly over just a few years. No sooner is one cohort of children protected from pertussis through immunization than another, older, cohort becomes susceptible again. We merely are treading water in our efforts to control pertussis with currently available vaccines.

As well-outlined in the Global Pertussis Initiative review, we must circle the wagons around young infants. It is clear that we must focus on bridging the protection of infants from birth until they themselves can be effectively immunized. We are falling woefully short. All of us can do better.

Obstetricians and family physicians must immediately increase their efforts to immunize during pregnancy because it is the standard of care and will continue to be for the foreseeable future. The anticipated birth of a child is a good opportunity to ensure that everyone who will have contact with the infant has received recommended pertussis vaccines.

We desperately need a new pertussis vaccine. Every indication is that large-scale pertussis outbreaks will continue until a new approach is developed. In the meantime, the best primary strategy to prevent infant deaths is to immunize every pregnant woman during every pregnancy and to present the immunization schedule as the standard of care rather than as an option.

Mark H. Sawyer, M.D., is a professor of clinical pediatrics and a pediatric infectious disease specialist at the University of California San Diego School of Medicine and Rady Children’s Hospital in San Diego, Calif. Sarah S. Long, M.D., is a professor of pediatrics and infectious diseases at Drexel University College of Medicine in Philadelphia, and chief of the Section of Infectious Diseases at St. Christopher’s Hospital for Children in Philadelphia. Dr. Sawyer is a member and Dr. Long is an ex-officio member of the American Academy of Pediatrics Committee on Infectious Diseases, and both are members of the Vaccines and Related Biological Products Advisory Committee to the U.S. Food and Drug Administration. Dr. Long is also an associate editor of Red Book: 2015 Report on the Committee on Infectious Diseases and a liaison to the Pertussis Workgroup of the Advisory Committee on Immunization Practices. They made their remarks in an accompanying editorial.


 

FROM PEDIATRICS

References

Prenatal vaccination, followed by cocooning, is the most effective strategy for reducing pertussis complications and death in young infants, according to recommendations from the Global Pertussis Initiative (GPI).

GPI is an expert scientific forum that aims to reduce the worldwide burden of pertussis, particularly in infants under 6 weeks old who are too young to be vaccinated.

Infants under 6 months of age are at the highest risk for death and complications from pertussis, but the first pertussis vaccine dose is not recommended in most countries until 6-8 weeks of age.

“There is strong evidence that the pregnancy booster directly protects young infants through the transfer of maternal pertussis antibodies, in addition to being effective, safe, and well tolerated,” Dr. Kevin Forsyth of Flinders University in Adelaide, Australia, and his associates reported online. “A key benefit of this approach is that it provides protection to the very young from birth until infant-generated immunity is achieved from the primary series of pertussis immunization,” they wrote (Pediatrics 2015 May 11 [doi:10.1542/peds.2014-3925]).

The U.S. Advisory Committee on Immunization Practices recommends the Tdap booster during the third trimester of pregnancy, and similar recommendations exist in Argentina, Belgium, Israel, New Zealand, and the United Kingdom. Multiple studies have found higher levels of maternal pertussis antibodies and lower disease burden among infants born to mothers who received a pregnancy booster, compared with those who did not. Based on this evidence, the GPI recommends maternal prenatal vaccination as the primary strategy for protecting infants from pertussis. If prenatal immunization is not possible or families want extra protection, the GPI recommends that all individuals with close contact with infants under 6 months old be vaccinated with Tdap during pregnancy or immediately post partum.

“A high priority should be given to achieving a complete cocoon, defined as full immunization of the family, since the robustness of protection against pertussis is a function of the number of infant contacts vaccinated,” the authors wrote. If not everyone can be vaccinated, the parents should be vaccinated, or at least the mother, though little real-world data exist regarding the effectiveness of the cocooning strategy.

Support for this writing and the Global Pertussis Initiative are funded by Sanofi Pasteur. Drs. Forsyth, Plotkin, Tan, and Wirsing von König have received honoraria, consulting fees and/or grants from Sanofi Pasteur, Merck, GlaxoSmithKline and/or Novartis. Dr. Tan has received personal fees from GlaxoSmithKline Biologicals and Sanofi Pasteur.

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