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PEDIATRICS Vol. 112 No. 5 November 2003, pp. 1069-1075

Clinical Presentation of Pertussis in Unvaccinated and Vaccinated Children in the First Six Years of Life

Alberto E. Tozzi, MD^*, Lucilla Ravà, DStat, Marta L. Ciofi degli Atti, MD^*, Stefania Salmaso, DBiol^* the Progetto Pertosse Working Group

^* Istituto Superiore di Sanità, Rome, Italy
Ospedale Pediatrico Bambino Gesù, Rome, Italy

Objectives. Identifying the determinants of the clinical presentation of pertussis is important for the purposes of diagnosis, therapy, and control and for predicting the disease’s clinical course and choosing an appropriate case definition for surveillance. Potential determinants include vaccination status, antibiotic treatment, age at diagnosis, and sex, although the available data are inconsistent. The objective of this study was to compare the clinical course of pertussis in unvaccinated and vaccinated children in a well-defined and strictly studied population and to identify determinants of the disease’s clinical presentation.

Methods. The clinical presentation of pertussis was studied in children who participated in a randomized, controlled clinical trial of efficacy of acellular pertussis vaccine. The children belonged to the same birth cohort and were followed from infancy to 6 years of age in 3 distinct periods (stages 1, 2, and 3). Children had received 1 of 2 three-component acellular pertussis vaccines produced by 2 manufacturers (diphtheria-tetanus-acellular pertussis from, Chiron Biocine [DTaP CB]; DTaP from SmithKline Beecham [DTaP SB]) or a diphtheria-tetanus vaccine only (DT; Chiron Biocine). Pertussis was confirmed through culture or serology. For each pertussis episode, information was collected on age at onset, sex, type of vaccine received, antibiotic treatment, culture results, duration of cough, spasmodic cough, and other symptoms. The simultaneous effect of potential determinants of clinical presentation of pertussis on the duration of cough and spasmodic cough was studied through analysis of variance models.

Results. The analysis was conducted on 788 laboratory-confirmed cases of pertussis. The median duration of cough in DT recipients varied from 52 to 61 days across the 3 stages, whereas the median duration of cough in DTaP recipients varied from 29 to 39 days. The median duration of spasmodic cough varied from 20 to 45 days in DT recipients and from 14 to 29 days in DTaP recipients. The results of the analysis of variance models showed that vaccination against pertussis reduced the length of cough from 3 to 10 days and the length of spasmodic cough from 4 to 8 days. Culture-positive patients had a cough 11 to 22 days longer and a spasmodic cough 12 to 22 days longer than culture-negative patients. Children who received an antibiotic had a duration of cough 6 to 11 days longer and spasmodic cough 4 to 13 days longer than untreated patients. Girls had a duration of spasmodic cough 7 days longer than boys only after 3 years of age. Age was directly related to duration of cough, whereas it was inversely related to duration of spasmodic cough after 3 years of age.

Conclusions. Duration of cough can be greatly influenced by vaccination status. A positive culture for Bordetella pertussis is more frequently found in patients with long duration of cough, and antibiotic therapy may be a marker of severe disease. Gender may affect the clinical presentation of pertussis only after infancy. Pertussis in older children may be characterized by short duration of spasmodic cough. These results should be taken into account in the clinical evaluation of patients with suspected pertussis. Clinical case definitions for the purpose of surveillance based on the presence of 2 weeks of spasmodic cough may not be appropriate where pertussis vaccination uptake is high.

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Key Words: pertussis • children • clinical presentation • cough • pertussis vaccine

Abbreviations: WHO, World Health Organization • DT, diphtheria-tetanus • DTaP, diphtheria-tetanus-acellular pertussis • CB, Chiron Biocine • SB, Smithkline Beecham • DTP, whole-cell diphtheria-tetanus-pertussis • PT, pertussis toxin • FHA, filamentous hemagglutinin • PRN, pertactin • PCR, polymerase chain reaction • IgG, immunoglobulin G • IgA, immunoglobulin A

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Received for publication Jul 1, 2002; Accepted Apr 25, 2003.

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