NIHR Signal Whooping cough infection common in school aged children with stubborn coughs

Published on 26 June 2014

This NIHR-funded study found that almost a fifth of children aged five to 15 years who visited their GP with persistent cough showed signs of recent whooping cough infection, despite having a booster vaccination before school age. These data, from 22 GP practices in Thames Valley UK, describe the duration of vaccine-induced immunity and the burden of disease in adolescents. This may inform policy discussion about the potential need for a national adolescent whooping cough booster programme in the UK.

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Why was this study needed?

Whooping cough (pertussis) is one of the most common vaccine preventable diseases causing almost 300,000 childhood deaths a year worldwide. Primary vaccine coverage in the UK has been more than 90% since the vaccine was introduced in 1992. A pre-school booster vaccination, introduced in 2001, has achieved about 80% coverage. The effectiveness of vaccine fades over time and UK incidence of whooping cough in older children and adults has been increasing since 2011. A national outbreak was declared in the UK in April 2012.

In the last decade a number of other countries, including Australia, Canada, France, Germany and the US, have introduced an adolescent booster vaccination. In January 2012 the UK Joint Committee on Vaccination and Immunisation (JCVI) reviewed the need for an adolescent booster vaccination and concluded that further research was needed to estimate the burden of disease in the UK. The current study estimated the prevalence and clinical severity of whooping cough in school age children who went to their GP with a persistent cough.

What did this study do?

This prospective cohort study recruited 279 children aged 5 to 15 years between November 2010 and December 2012 who presented with persistent cough in 22 general practices in the Thames Valley, England. Of these, 261 had received whooping cough vaccinations, but there was variation in whether they had also received the preschool booster or other combinations of vaccine. Recent whooping cough infection was diagnosed using laboratory tests. The authors used a reliable approach as they recruited children to the study without healthcare providers knowing if they had confirmed whooping cough or not.

What did it find?

  • A fifth of all children with persistent coughing had evidence of recent whooping cough infection, whether they were fully vaccinated or not.
  • Whooping cough was more than three times as common in children who had received the pre-school booster seven or more years ago than in children who had received the booster vaccination less than seven years ago.

What does current guidance say on this issue?

Current 2015 Public Health England guidance states that the objective of the childhood immunisation programme is to provide a minimum of four doses of a pertussis-containing vaccine. The primary course of whooping cough vaccination consists of three doses of a pertussis-containing product. It is recommended for all infants from two months up to ten years of age. The fourth dose should be given as part of the pre-school booster, at three years and four months of age or soon after.

Currently, routine immunisation against whooping cough is not recommended for those aged ten years and over, except for pregnant women or as part of outbreak control.

What are the implications?

Whooping cough remains a significant cause of persistent cough among school children in the UK even after the implementation of the preschool booster vaccination and despite high levels of coverage. Burden of illness studies such as this informs cost-effectiveness calculations and will be important in discussions about an adolescent whooping cough booster vaccination policy in the UK.

Only children attending Thames Valley GP practices were studied. This relatively small sample may not be representative of the range of vaccine experiences of children across the UK as a whole.

If an adolescent booster vaccination were to be recommended in the UK it would likely be administered at 14 years of age, at the same time as routine meningitis C, tetanus, diphtheria, and inactivated polio adolescent booster vaccinations.

Citation

Wang K, Fry NK, Campbell H. Whooping cough in school age children presenting with persistent cough in UK primary care after introduction of the preschool pertussis booster vaccination: prospective cohort study. BMJ. 2014;348:g3668. This project was funded by the National Institute for Health Research School for Primary Care Research.

Bibliography

Caro JJ, Getsios D, El-Hadi W. Pertussis immunization of adolescents in the United States: an economic evaluation. Pediatr Infect Dis J. 2005;24(5 Suppl):S75-82

JCVI sub-committee on adolescent vaccinations meeting: January 2012. London: Joint Committee on Vaccination and Immunisation; 2012

Lavine JS, Bjørnstad ON, de Blasio BF, Storsaeter J. Short-lived immunity against pertussis, age-specific routes of transmission, and the utility of a teenage booster vaccine. Vaccine. 2012; 30(3):544-51.

NHS Choices. Teens could be given whooping cough booster. London: NHS Choices; 2014

PHE. Pertussis: the green book, chapter 24. In: Immunisation against infectious disease. Public Health England. 2013. Last updated: 28 April 2015

PHE. Pertussis: guidance, data and analysis. Public Health England. 2014. Available from: https://www.gov.uk/government/collections/pertussis-guidance-data-and-analysis

Rozenbaum MH, De Cao E, Postma MJ. Cost-effectiveness of pertussis booster vaccination in the Netherlands. Vaccine. 2012; 30(50):7327-31.

Why was this study needed?

Whooping cough (pertussis) is one of the most common vaccine preventable diseases causing almost 300,000 childhood deaths a year worldwide. Primary vaccine coverage in the UK has been more than 90% since the vaccine was introduced in 1992. A pre-school booster vaccination, introduced in 2001, has achieved about 80% coverage. The effectiveness of vaccine fades over time and UK incidence of whooping cough in older children and adults has been increasing since 2011. A national outbreak was declared in the UK in April 2012.

In the last decade a number of other countries, including Australia, Canada, France, Germany and the US, have introduced an adolescent booster vaccination. In January 2012 the UK Joint Committee on Vaccination and Immunisation (JCVI) reviewed the need for an adolescent booster vaccination and concluded that further research was needed to estimate the burden of disease in the UK. The current study estimated the prevalence and clinical severity of whooping cough in school age children who went to their GP with a persistent cough.

What did this study do?

This prospective cohort study recruited 279 children aged 5 to 15 years between November 2010 and December 2012 who presented with persistent cough in 22 general practices in the Thames Valley, England. Of these, 261 had received whooping cough vaccinations, but there was variation in whether they had also received the preschool booster or other combinations of vaccine. Recent whooping cough infection was diagnosed using laboratory tests. The authors used a reliable approach as they recruited children to the study without healthcare providers knowing if they had confirmed whooping cough or not.

What did it find?

  • A fifth of all children with persistent coughing had evidence of recent whooping cough infection, whether they were fully vaccinated or not.
  • Whooping cough was more than three times as common in children who had received the pre-school booster seven or more years ago than in children who had received the booster vaccination less than seven years ago.

What does current guidance say on this issue?

Current 2015 Public Health England guidance states that the objective of the childhood immunisation programme is to provide a minimum of four doses of a pertussis-containing vaccine. The primary course of whooping cough vaccination consists of three doses of a pertussis-containing product. It is recommended for all infants from two months up to ten years of age. The fourth dose should be given as part of the pre-school booster, at three years and four months of age or soon after.

Currently, routine immunisation against whooping cough is not recommended for those aged ten years and over, except for pregnant women or as part of outbreak control.

What are the implications?

Whooping cough remains a significant cause of persistent cough among school children in the UK even after the implementation of the preschool booster vaccination and despite high levels of coverage. Burden of illness studies such as this informs cost-effectiveness calculations and will be important in discussions about an adolescent whooping cough booster vaccination policy in the UK.

Only children attending Thames Valley GP practices were studied. This relatively small sample may not be representative of the range of vaccine experiences of children across the UK as a whole.

If an adolescent booster vaccination were to be recommended in the UK it would likely be administered at 14 years of age, at the same time as routine meningitis C, tetanus, diphtheria, and inactivated polio adolescent booster vaccinations.

Citation

Wang K, Fry NK, Campbell H. Whooping cough in school age children presenting with persistent cough in UK primary care after introduction of the preschool pertussis booster vaccination: prospective cohort study. BMJ. 2014;348:g3668. This project was funded by the National Institute for Health Research School for Primary Care Research.

Bibliography

Caro JJ, Getsios D, El-Hadi W. Pertussis immunization of adolescents in the United States: an economic evaluation. Pediatr Infect Dis J. 2005;24(5 Suppl):S75-82

JCVI sub-committee on adolescent vaccinations meeting: January 2012. London: Joint Committee on Vaccination and Immunisation; 2012

Lavine JS, Bjørnstad ON, de Blasio BF, Storsaeter J. Short-lived immunity against pertussis, age-specific routes of transmission, and the utility of a teenage booster vaccine. Vaccine. 2012; 30(3):544-51.

NHS Choices. Teens could be given whooping cough booster. London: NHS Choices; 2014

PHE. Pertussis: the green book, chapter 24. In: Immunisation against infectious disease. Public Health England. 2013. Last updated: 28 April 2015

PHE. Pertussis: guidance, data and analysis. Public Health England. 2014. Available from: https://www.gov.uk/government/collections/pertussis-guidance-data-and-analysis

Rozenbaum MH, De Cao E, Postma MJ. Cost-effectiveness of pertussis booster vaccination in the Netherlands. Vaccine. 2012; 30(50):7327-31.

Whooping cough in school age children presenting with persistent cough in UK primary care after introduction of the preschool pertussis booster vaccination: prospective cohort study

Published on 26 June 2014

Wang, K.,Fry, N. K.,Campbell, H.,Amirthalingam, G.,Harrison, T. G.,Mant, D.,Harnden, A.

Bmj Volume 348 , 2014

OBJECTIVE: To estimate the prevalence and clinical severity of whooping cough (pertussis) in school age children presenting with persistent cough in primary care since the introduction and implementation of the preschool pertussis booster vaccination. DESIGN: Prospective cohort study (November 2010 to December 2012). SETTING: General practices in Thames Valley, UK. PARTICIPANTS: 279 children aged 5 to 15 years who presented in primary care with a persistent cough of two to eight weeks' duration. Exclusion criteria were cough likely to be caused by a serious underlying medical condition, known immunodeficiency or immunocompromise, participation in another clinical research study, and preschool pertussis booster vaccination received less than one year previously. MAIN OUTCOME MEASURES: Evidence of recent pertussis infection based on an oral fluid anti-pertussis toxin IgG titre of at least 70 arbitrary units. Cough frequency was measured in six children with laboratory confirmed pertussis. RESULTS: 56 (20%, 95% confidence interval 16% to 25%) children had evidence of recent pertussis infection, including 39 (18%, 13% to 24%) of 215 children who had been fully vaccinated. The risk of pertussis was more than three times higher (21/53; 40%, 26% to 54%) in children who had received the preschool pertussis booster vaccination seven years or more previously than in those who had received it less than seven years previously (20/171; 12%, 7% to 17%). The risk of pertussis was similar between children who received five and three component preschool pertussis booster vaccines (risk ratio for five component vaccine 1.14, 0.64 to 2.03). Four of six children in whom cough frequency was measured coughed more than 400 times in 24 hours. CONCLUSIONS: Pertussis can still be found in a fifth of school age children who present in primary care with persistent cough and can cause clinically significant cough in fully vaccinated children. These findings will help to inform consideration of the need for an adolescent pertussis booster vaccination in the United Kingdom. STUDY REGISTRATION: UK Clinical Research Network portfolio ID 8361.

Whooping cough booster vaccinations during adolescence were provided in Australia, Canada, France, Germany, and the United States as a result of increased incidence of whooping cough in adolescents. Any booster programme would aim through herd immunity to not only reduce the incidence of whooping cough in adolescence, but by reducing the rates of illness in family members also protect pre-vaccinated infants. The US booster vaccination (Tdap) has only been partially effective is preventing the admission of infants to hospital due to whooping cough, although since introduction there has been a decrease in the ratio of the incidence of whooping cough in adolescents compared with other age groups.

Commentary

The most serious cases of pertussis (whooping cough) are in very young infants, before they are old enough to be immunised. Because protection given by the vaccine weakens with time, adults and older siblings who have been vaccinated can still catch the disease themselves and could pass it on to vulnerable young infants. The UK has recently become the first country to introduce pertussis vaccination in pregnancy to provide protection to the newborn, through antibodies which cross the placenta, and thereby to have a major impact on the disease in these most vulnerable infants. The study by Wang and colleagues shows the ongoing transmission of pertussis amongst school age children which provides new knowledge to guide the development of pertussis vaccine policy and makes the case for intervention to further reduce the burden of pertussis amongst children and thus to improve child health.

Professor Andrew J Pollard, Professor of Paediatric Infection and Immunity & Director of the Oxford Vaccine Group, University of Oxford