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How Effective is Pertussis Vaccine?


vaccine effectiveness

After a century of pertussis vaccination programs, vaccinologists are still unsure how pertussis infections - or many other infections - stimulate long lasting cell mediated and humoral immunity in the body. 1 This lack of basic scientific knowledge relates directly to the inability of vaccine makers to develop and manufacture vaccines that provide long lasting artificial immunity and to the lack of correlates for immunity to accurately measure the kind of immunity vaccines do or do not provide. 2 3

Most public health officials maintain that when pertussis vaccine is used on a widespread basis in a population, it appears to lessen the overall incidence of the disease and that vaccinated children have less severe cases of pertussis whooping cough.

However, studies published in the 1980’s reported that the highly reactive whole cell DPT vaccine licensed in 1949 did not prevent infection or transmission,4 and provided only two to five years of temporary immunity at best.5 6 The efficacy of whole cell pertussis vaccine in the DPT shot was measured to be between 30 and 85 percent, depending upon the type of DPT and vaccine manufacturer.7 8 9 10 11

The less toxic acellular DTaP vaccine, licensed in the U.S. in 1991, and currently in use in the United States and other developed countries, has also failed to prevent infection or transmission of pertussis.12 13 14 Studies have also demonstrated that DTaP vaccine provides only between two and five years of temporary immunity from pertussis.15 16 17 Acellular pertussis vaccine efficacy in clinical trials has been measured to be between 40 and 89 percent, depending upon the DTaP vaccine manufacturer.18 19 20

According to a 2005 study in the journal Pediatrics, pertussis containing DTP and DTaP vaccines were estimated to be from 83.6 percent to as much as 97.7 percent effective, depending on the number of doses administered, the combinations of vaccine used in the shot containing pertussis vaccine, and age of the child at which it was administered.21 However, a 2010 analysis of a California whooping cough outbreak published in the medical literature revealed that more than 80% of those affected were fully vaccinated and the pertussis vaccine was found to be between 24 and 41 percent effective in children two to 18 years of age three years post-vaccination.22 In 2010, the Tdap vaccine, recommended in 2006 for adolescents as a booster dose of acellular pertussis vaccine, 23 was found to be only about 66 percent effective.24

By 2012, the CDC acknowledged that pertussis vaccine immunity had waned in older children, that DTaP/Tdap immunity begins to wane within five years of vaccination, and that unvaccinated individuals and children with vaccine exemptions were not to blame for the ongoing whooping cough outbreaks.25

In fact, child pertussis vaccination rates in the U.S. have remained very high since 196126 and consistently more than 94 percent of kindergarten children have had four to five pertussis-containing vaccines.27 As well, nearly 94 percent of all children have received at least three doses of DTaP vaccine,28 and 88 percent of teenagers attending high school have received a sixth pertussis booster shot.29

However, reported numbers of pertussis cases differ substantially from the total number of actual cases of pertussis in the United States, as most pertussis cases are not being diagnosed or reported by doctors to the government.30 Public health officials do not have reliable lab tests to measure pertussis immunity and are unable to agree about how to diagnose pertussis when infected people, especially vaccinated people, are seen in doctor’s offices with mild symptoms.31 32 33Further, there is evidence that millions of vaccinated children and adults living in the U.S. become infected with pertussis whooping cough but are never identified as doctors are not diagnosing or reporting them.34 35 36 37 In fact, a person, vaccinated or unvaccinated, can develop a silent asymptomatic pertussis infection and transmit it to another person without even knowing it.38 39 40 Both natural and vaccine acquired immunity is temporary41 and while vaccination may prevent clinical symptoms, it does not block infection, carriage or transmission.42 43

In fact, a review of the medical literature has revealed that the experts are unhappy with their lack of knowledge of the B. pertussis microbe44 and are disagreeing with each other about if, when, how and why pertussis vaccines have consistently failed to achieve herd immunity and prevent B. pertussis whooping cough from circulating in highly vaccinated populations around the world.45 46 47

In 1976, after only approximately 1,000 cases of pertussis were reported in the U.S.48, pertussis rates began to climb. In the 1980’s and 1990’s, researchers became aware that the whole cell pertussis vaccine found in DPT was not capable of preventing infection and transmission of the disease.49 50 51 52 53 Just like before the introduction of widespread DPT vaccination programs, pertussis increases continued to be reported in cycles of three to five years, 54 55 56 57 58 59 including in the U.S. where over 94 percent of children had gotten three to five DPT shots. 60 61

In 1988, researchers began warning that the B. pertussis microbe had begun to evolve in order to evade the whole cell pertussis vaccine.62 63 64 65 The evolving of the B. pertussis microbe had begun following the mass introduction of the DPT vaccine in 1950’s.66 67 68

In a fight to survive, the B. pertussis microbe has created new strains of pertussis that produce more toxin to suppress the human immune system and cause more serious disease. Today, the pertussis strains included in the vaccine no longer match the pertussis strains causing whooping cough disease.69 70 71 72 73 There is compelling scientific evidence that B. pertussis bacteria have evolved to survive vaccine pressure and as a result, there are more virulent pertussis strains that are more efficiently transmitted by vaccinated children and adults with waning immunity. In 2014, public health officials at the CDC and around the world admitted that “most mutations in genes encoding acellular vaccine components arose in the period in which the whole cell vaccine was used.” 74

Another Bordetella pertussis whooping cough disease, B. parapertussis is also circulating in the United States and elsewhere.75 B. parapertussis whooping cough can look identical to B. pertussis whooping cough,76 however symptoms are usually milder. B. parapertussis is increasing in the U.S. and other countries, which have had high pertussis vaccination rates for few decades. There are estimates that perhaps up to 30 percent of whooping cough disease in highly vaccinated populations may be caused by B. parapertussis organisms.77 Pertussis vaccines widely used around the world do not protect against parapertussis and there is no vaccine for parapertussis.78

It is possible to have both B. pertussis and B. parapertussis infections at the same time. B. parapertussis is often milder than B. pertussis but can also involve serious complications, which lead to pneumonia and death.79

IMPORTANT NOTE: NVIC encourages you to become fully informed about Pertussis and the Pertussis vaccine by reading all sections in the Table of Contents , which contain many links and resources such as the manufacturer product information inserts, and to speak with one or more trusted health care professionals before making a vaccination decision for yourself or your child. This information is for educational purposes only and is not intended as medical advice.

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References

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2 Thakur A, Pedersen LE, Jungersen G. Immune markers and correlates of protection for vaccine induced immune responses. Vaccine 2012; 30(33): 4907-4920.

3 Flaxman A, Ewer KJ. Methods for Measuring T-Cell Memory to Vaccination: From Mouse to Man. Vaccines 2018; 6(43).

4  Fine PEM, Clarkson JA. The Recurrence of Whooping Cough: Possible Implications for Assessment of Vaccine Efficacy. Lancet 1982; 1(8273): 666-669.

5 Trollfors B. Bordetella Pertussis Whole Cell Vaccines: Efficacy and Toxicity. Acta Pediatrica Scandinavica. 1984 73: 917-923.

6Transcript (partial) of May 12, 1986 ACIP Meeting discussion of DPT risks and failures. Pgs. 34-37. NVIC.org.

7 Preston NW, Stanbridge TN. Efficacy of Pertussis Vaccines: A Brighter Horizon. Brit Med J 1972; 3:448-451.

8 Broome CV, Preblud SR, Bruner B et al. Epidemiology of pertussis, Atlanta, 1977J Pediatr 1981; 98(3): 362-267.

9 Fine PE, Clarkson JA. Reflections on the efficacy of pertussis vaccines. Rev Infect Dis 1987; 9(5): 866-883.

10 Greco D, Salmaso S, Mastrantonio P et al. A Controlled Trial of Two Acellular Vaccines and One Whole-Cell Vaccine Against Pertussis. N Engl J Med 1996; 334(6): 341-348.

11 Schmitt HJ, Schuind A, Knuf M et al. Acellullar Pertussis Vaccines: The Rationale for an Efficacy Trial in Germany. J Infect Dis 1996; 174(Suppl 3): S287-S290.

12 Lavine J, Bjornstad O, et al. Short-lived immunity against pertussis, age-specific routes of transmission, and the utility of a teenage booster vaccine. Vaccine 2012; 30(3): 544-551.

13 Cherry JD. Why Do Pertussis Vaccines Fail? Pediatrics 2012; 129(5).

14  Warfel JM, Zimmerman LI, Merkel TJ. Acellular pertussis vaccines protect against disease but fail to prevent infection and transmission in a nonhuman primate model. Proc Natl Acad Sci USA. 2014; 111(2): 787–792

15 Misegades LK, Winter K, Harriman K et al. Association of Childhood Pertussis With Receipt of 5 Doses of Pertussis Vaccine by Time Since Last Vaccine Dose, California, 2010 JAMA 2012; 308(20): 2126-2132.

16 Matthias J, Pritchard S, Martin SW et al. Sustained Transmission of Pertussis in Vaccinated, 1–5-Year-Old Children in a Preschool, Florida, USA. Emerg Infect Dis Jan. 15, 2016.

17 Klein NP, Bartless S, Fireman B, Baxter R. Waning Tdap Effectiveness in Adolescents. Pediatrics Feb. 3, 2016.

18 Gustafsson L, Hallander HO, Olin P et al. A Controlled Trial of a Two-Component Acellular, A Five-Component Acellular, and a Whole Cell Pertussis VaccineNew Engl J Med 1996; 334(6): 349-355.

19 Greco D, Salmaso S, Mastrantonio P et al. A Controlled Trial of Two Acellular Vaccines and One Whole-Cell Vaccine Against Pertussis. N Engl J Med 1996; 334(6): 341-348.

20 Zhang L, Prietsch SOM et al. Acellular vaccines for preventing whooping cough in children (Review)The Cochrane Library 2014, Issue 9.

21 Bisgard KM, Rhodes P et al. Pertussis vaccine effectiveness among children 6 to 59 months of age in the United States, 1998-2001. Pediatrics. 2005 Aug;116(2):e285-94.

22 Witt MA, Katz PH, Witt DJ Unexpectedly limited durability of immunity following acellular pertussis vaccination in preadolescents in a North American outbreak. Clin Infect Dis. 2012 Jun;54(12):1730-5

23 CDC. Prevention and Control of Influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR July 28, 2006; 55(RR10): 1-42.

24 Wei SC, Tetti K, Cushing K et al. Effectiveness of Adolescent and Adult Tetanus Reduced-Dose Diphtheria and Acellular Pertussis Vaccine against Pertussis. Clin Infect Dis 2010; 51(3): 315-321.

25 CDC Pertussis Epidemic in Washington State- 2012 Telebriefing. Jul. 19, 2012

26 Hinman A, Orenstein WA, Schuchat A. Vaccine Preventable Diseases, Immunization and MMWR 1961-2011.MMWR Oct. 7, 2011; 60(04): 49-57.

27 CDC. Vaccination Coverage for Selected Vaccines, Exemption Rates, and Provisional Enrollment Among Children in Kindergarten — United States, 2016–17 School Year. MMWR. Oct. 13, 2017 -  66(40);1073–1080

28 CDC. Vaccination Coverage Among Children Aged 19–35 Months — United States, 2016. MMWR Nov. 3, 2017 / 66(43);1171–1177

29 CDC. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2016. MMWR. Aug. 25, 2017 66(33);874–882

30 Bamberger ES, Srugo I. What is new in pertussis? Eur J Pediatr 2008; 167: 133-139.

31 Cherry JD. Why Do Pertussis Vaccines Fail? Pediatrics 2012; 129(5).

32 Zouari A, Smaoui H, Kechrid A. The diagnosis of pertussis: which method to choose? Crit Rev Microbiol 2012; 38(2): 111-121.

33 Van der Zee A, Schellekens JF, Mooi FR. Laboratory Diagnosis of PertussisClin Microbiol Rev 2015; 28(4): 1005-1026.

34 Sutter RW, Cochi SL. Pertussis Hospitalizations and Mortality in the United States, 1985-1988: Evaluation of the Completeness of National ReportingJAMA 1992; 267(3): 386-391.

35 Deville JG, Cherry JD, Christenson PD et al. Frequency of Unrecognized Bordetella pertussis Infections in Adults. Clin Infect Dis 1995; 12: 639-642

36 Cherry JD. The Epidemiology of Pertussis: A Comparison of the Epidemiology of the Disease Pertussis With the Epidemiology of Bordetella pertussis Infection. Pediatrics 2005; 115(5).

37 Ward JI, Cherry JD, Chang S et al. Efficacy of an Acellular Pertussis Vaccine among Adolescents and Adults. N Eng J Med 2005; 353(15): 1555-1563.

38 Long SS, Lischner HW et al. Serologic evidence of subclinical pertussis in immunized children. Pediatr Infect Dis 1990; 9(10): 700-705.

39 He Q, Viljanen MK, Nikkari S et al. Outcomes of Bordetella pertussis Infection in Different Age Groups in an Immunized Population. J Infect Dis 1994; 170: 873-877.

40 Zhang Q, Yin Z, Shao LH et al. Prevalence of asymptomatic Bordetella pertussis and Bordetella parapertussis infections among school children in China as determined by pooled real-time PCR: a cross-sectional study. Scand J Infect Dis 2014; 46(4): 280-287.

41 Wendelboe AM, Van Rie A et al.Duration of immunity against pertussis after natural infection or vaccination. Pediatr Infect Dis J 2005; 24(Suppl 5): S58-S61.

42 Tavernise S. Whooping Cough Study May Offer Clue on Surge. The New York Times. Nov. 25, 2013

43 Warfel JM, Zimmerman LI, Merkel TJ. Acellular pertussis vaccines protect against disease but fail to prevent infection and transmission in a nonhuman primate model. Proc Natl Acad Sci U S A. 2014 Jan 14;111(2):787-92.

44 Hewlett EK, Burns DL Cotter PA et al. Pertussis Pathogenesis – What We Know and What We Don’t Know. J Infect Dis 2014; 209: 982-985.

45 Robbins JB, Schneerson R, Kubler-Kielb J et al. Toward a new vaccine for pertussis. PNAS 2014; 111(9): 3213-3216.

46 Riolo MA, Rohani.Combating pertussis resurgence: One booster vaccination schedule does not fit all. Proc Nat Acad Sci 2015; 112(5): E472-477.

47 De Celles MD, Magpantay FMG et al.The pertussis enigma: reconciling epidemiology, immunology and evolution. Proc R Soc B 2016; 283.

48 CDC. Pertussis (Whooping Cough) Cases by Year (1922-2014). Sept. 8, 2015.

49 Fine PEM, Clarkson JA. The Recurrence of Whooping Cough: Possible Implications for Assessment of Vaccine Efficacy. Lancet 1982; 1(8273): 666-669.

50 Marchant CD, Loughlin AM, Lett SM et al. Pertussis in Massachusetts, 1981-1991: incidence, serologic diagnosis, and vaccine effectiveness. J Infect Dis 1994; 169(6): 1297-1305.

51 Tanaka M, Vitek CR, Pascual B et al.Trends in Pertussis Among Infants in the United States, 1980-1999.JAMA 2003 Dec 10;290(22):2968-75..

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53 Yih WK, Lett SM, desVignes FN et al. The increasing incidence of pertussis in Massachusetts adolescents and adults 1989-1998. J Infect Dis 2000; 182(5): 1409-1416.

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62 Mooi FR, van Oirschot H, Heuvelman K et al. Polymorphism in the Bordetella pertussis Virulance Factors P. 69/Pertactin and Pertussis Toxin in The Netherlands: Temporal Trends and Evidence for Vaccine-Driven Evolution Infect Immun 1998; 66(2): 670-675.

63 Simondon F., Guiso N. Genetic evolution under vaccine pressure: the Bordetella pertussis model. Bull Soc Pathol Exot 2000; 93(3): 202-205.

64 De Melker HE, Schellekens JFP, Neppelenbroek SE et al. Reemergence of Pertussis in the Highly Vaccinated Population of the Netherlands: Observations on Surveillance Data. Emerg Infect Dis 2000; 6(4): 348-357.

65 Mooi FR, vanLoo IHM, King AJ . Adaptation of Bordetella pertussis to vaccination: A Cause for Its Reemergence? Emerg Infect Dis 2001; 7(3): 526-528.

66 Weber C, Boursaux-Eude C, Coralie G et al. Polymorphism of Bordetella pertussis Isolates Circulating for the Last 10 Years in France, Where a Single Effective Whole-Cell Vaccine Has Been Used for More than 30 Years. J Clin Microbiol 2001; 39(12): 4296-4403.

67 Bart MJ, van Gent M, van der Heide HGJ et al. Comparative genomics of prevaccination and modern Bordetella pertussis strains. BMC Genomics 2010; 11: 627.

68 Xu Y, Liu B et al. Whole-genome sequencing reveals the effect of vaccination on the evolution of Bordetella pertussis. Sci Rep 2015; 5: 12888.

69 Mooi FR, van Loo IHM, van Gent M et al. Bordetella pertussis Strains with Increased Toxin Production Associated with Pertussis Resurgence. Emerg Infect Dis 2009; 15(8): 1206-1213.

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79 He Q, Viljanen MK et al. Whooping cough caused by Bordetella pertussis and Bordetella parapertussis in an immunized population. JAMA. 1998 Aug 19;280(7):635-7.


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