Whooping Cough Increases Despite All the Vaccinations In the last 20 years, the number of cases of whooping cough increased overall in the US according to the US Centers for Disease Control and Prevention (CDC). Whooping cough, or pertussis, is caused by infection with the Bordetella pertussis bacterium. Symptoms of whooping cough include having a cough lasting 14 or more days accompanied by a gasping sound or "whoop" while coughing. Children may also vomit or have difficulty breathing during a coughing spell.
The number of pertussis cases has remained stable among children old enough to be vaccinated, but the increase in cases in children younger than 6 months indicates that "a true increase in pertussis circulation" has occurred.
From 1997 to 2000, over 7,000 pertussis cases among all age groups were reported each year in the US, compared with about 2,000 cases per year in the early 1980s. Pertussis remains an endemic disease. Adolescents and adults likely play an important role in transmitting pertussis to very young infants. Among the 29,000 persons with pertussis from 1997 to 2000 for whom ages were known, 29% were aged less than 1 year, 12% were aged 1 to 4 years, 10% were aged 5 to 9 years, 29% were aged 10 to 19 and 20% were 20 years or older.
Additional data collected by the National Health Interview Survey in 1998 suggest that 73% of children aged 7 to 18 months were vaccinated with three or more doses of acellular pertussis (DTaP), diphtheria and tetanus toxoids (DTP), or diphtheria tetanus toxoids (DT) vaccines. Vaccine effectiveness was estimated at 88% in children aged 7 to 18 months, with approximately two thirds of the vaccinations being DTaP and one third being DTP.
Morbidity and Mortality Weekly Report February 1, 2002;51:73-76
Midwest Whooping Cough Hits More Than 100
Fri Jul 9, 9:56 AM ET Add Health - AP to My Yahoo!
SPRINGFIELD, Ill. - An ongoing outbreak of whooping cough since March has sickened more than 100 people in the Chicago area and three dozen in North Dakota, officials said. Illinois health officials said 107 cases have been confirmed since March in four counties. No deaths have been reported. The outbreak has hit adolescents the hardest, with 80 percent of the cases involving 10 to 15 year olds.
In North Dakota, health officials are urging parents to vaccinate their children after cases increased sixfold to 36 in the past two weeks. The disease is highly contagious, and symptoms are similar to those of a cold, including runny nose, sneezing, low-grade fever and a cough that gradually worsens. Anyone displaying symptoms of the disease should seek medical attention to be treated with antibiotics, officials said. The Illinois Department of Public Health (news - web sites) plans to
send samples of the whooping cough strain to the Centers for Disease Control and Prevention (news - web sites) for scientific study, Ludicky said.
A five-dose vaccine is recommended for children beginning at 2 months of age. Children should then receive more doses as they grow older. But the vaccine's power wanes with time and can be completely gone 12 years after the final dose, which is usually given between the ages of 4 and 6.
Parents weigh decision to vaccinate
In low-rate Boulder, an illness reemerges
By Chryss Cada, Globe Correspondent, 9/9/2002
BOULDER, Colo. - Claudia McLaren Lainson has never regretted not getting her children vaccinated for pertussis, commonly known as whooping cough - even when all three of them got sick with the disease. 'We were expecting it, and when it arrived we met its challenge,'' she said of the summer when her children - then ages 3, 7, and 8 - became ill with whooping cough. ''My kids weathered that storm, and now they are stronger because of it.
''Too many people let fear drive their decisions,'' she said. ''I let education drive mine.'' After her firstborn had an adverse reaction to his first DTP (diphtheria, tetanus, and pertussis) vaccination, Lainson began researching the vaccinations that the medical community recommends for all children. ''I saw really investigating these vaccinations as a moral deed I needed to do for my children,'' she said. ''And after what I found out about possible reactions, I came to the clear and distinct conclusion that this vaccination wasn't right for my children.''
Lainson is one of a small but growing number of parents nationwide who have chosen not to follow recommended guidelines for childhood vaccines. In this picturesque city at the base of the Rockies, a low vaccination rate is believed to be spurring a resurgence of whooping cough, which can be deadly for infants. 'Nationwide, parents who choose not to get any vaccinations for their children has held steady at less than one-half of 1 percent,'' said Barbara Fisher, president of the National Vaccine Information Center, which distributes information on possible side effects of vaccines. ''What is growing is the number of parents who pick and choose which vaccines are right for their children.''
If there is an epicenter of this trend, it is Boulder's Shining Mountain Waldorf School. About half of the 335 students enrolled at the school have received only some, if any, of the vaccinations recommended by the Centers for Disease Control and Prevention and the American Association of Pediatricians. Boulder, whose residents pride themselves on their reputation for questioning convention, historically has the lowest vaccination rate in the state. Residents of what Coloradans call ''the People's Republic of Boulder'' are also highly educated - in fact, according to the 2000 Census, Boulder has the most highly educated residents in the nation.
''They ask questions until they have enough facts to make a decision,'' said Shining Mountain Director Robert Schiappacasse of the parents at his school. ''They aren't going to blindly go along with the status quo.'' But by straying from the herd, Boulder parents may be putting the good of the larger community at risk. Boulder has one of the highest per-capita rates of whooping cough in the country. The problem started in 1993 when 52 people in Boulder were diagnosed with the disease. Since then, there have been about 80 cases a year.
''We now characterize it as endemic to our area,'' said Heath Harmon, communicable disease coordinator for Boulder County. ''But the past couple of years, we've had fewer cases than the counties surrounding us.'' People in those surrounding areas say they know from whom they caught the disease. ''Usually we don't have any cases, and this spring we had six kids so sick we had to keep them out of school for an extended period of time,'' said Valerie Lambiase, the district nurse for the St. Vrain Valley School District in nearby Longmont. ''We have a high vaccination rate in our district, but it [whooping cough] is coming from Boulder, where the vaccination rate is much lower.''
Even those who have been vaccinated can contract whooping cough, but in those cases symptoms will be milder. The vaccine is about 85 percent effective, with immunity waning at about age 10, according to the CDC. There is no approved vaccine for children older than 7. Pertussis begins with ''cold-like'' symptoms and a mild cough. The cough then progresses to fits of coughing, followed by a high-pitched whooping as the person tries to catch his breath. Many people will gag or vomit following a fit of coughing. The disease can last one to three months.
The number of cases is growing nationwide. There were 7,867 cases in 2000. At 1,411 cases, Massachusetts had the most cases of any one state in 2000. That year 17 people died from the disease, including two Colorado babies. According to information from the vaccine center, possible side effects of the pertussis vaccine include ''persistent crying for three or more hours, fever over 103 degrees, excessive sleepiness, and convulsions or collapse/shock that may lead to either death or permanent brain damage.''
'' It's clear that fear of adverse effects are, for the most part, unsubstantiated,'' said Dr. Robert Brayden, a Denver pediatrician. ''I have an open mind, and I believe a parent should get all the information they can,'' he said. ''But in the end, I think they'll find that vaccination is the best choice.''
This story ran on page A3 of the Boston Globe on 9/9/2002.
© Copyright 2002 Globe Newspaper Company.
Children catch whooping cough despite having vaccination jabs
TWO children contracted whooping cough last year despite being fully vaccinated, fuelling growing fears among parents about the state of Ireland's immunisation programme. 'The whooping cough vaccine is not one of the most effective vaccines and doesn't take in a percentage of children,' Dr de Souza said. 'The immunity doesn't last. Public confidence in Ireland's inoculation programme has been badly dented
The fact that fully vaccinated children contracted a potentially fatal disease is the latest in a number of disturbing revelations to undermine public confidence.These include news that thousands of children will have to be re-inoculated against TB as the vaccines they received were not potent enough, and that uptake of the controversial MMR vaccine has fallen to unsafe levels because parents are worried about a possible link with autism.In addition, a damning report first revealed in Ireland On Sunday, hints that vaccines may not always be kept properly refrigerated and are sometimes used after their expiry date.
This latest revelation regarding the children with whooping cough will cause yet more heart-searching for parents. The disease causes coughing so violent that children have to 'whoop' to inhale and it can lead to fatal complications like pneumonia, brain swelling or brain haemorrhage. The children have not been named, but we can reveal that they live in the Southeast. Public health specialist Dr Neville de Souza of the South Eastern Health Board said the cases were unrelated to each other and that a small percentage of children contracting whooping cough after full immunisation is known to happen.
To most people, whooping cough is an illness from another era but it has never gone away. In a separate incident, two Irish children died from the disease last year.Statistics from the National Disease Surveillance Centre (NDSC) show that countrywide, recorded cases have been falling since the mid-1990s, but the story is very different in the Southeast, where cases have been rising in the past three years.In the year 2000, the South Eastern Health Board's figure was 11, but that has increased to 26 so far this year. And as only those who are taken to hospital are usually recorded, it is believed the true figures may be 10 times higher.
'The whooping cough vaccine is not one of the most effective vaccines and doesn't take in a percentage of children,' Dr de Souza said. 'The immunity doesn't last. While there will be a small percentage of children who do get the whooping cough after being fully immunised, it wouldn't be as severe as it is in unimmunised children and the children don't tend to carry the virus.'Dr Lorraine Hickey of the NDSC said: 'There is no such thing as a 100pc effective vaccine but the vaccines are generally very effective.'The wider issue of immunisation against TB and other major diseases continues to cause alarm, however.
Health Minister Micheál Martin last month set up an expert group to investigate vaccines after the Irish Medicines Board, which regulates drugs, withdrew a batch of BCG, which is given to babies to protect against TB. It was said the vaccines were not potent enough and that more than 2,500 children would have to be re-inoculated. Meanwhile, parents' fears have not been allayed by assurances that the MMR vaccine - given to protect against measles, mumps and rubella - is not linked to autism, and national uptake of the vaccine has dropped to just over 70pc. For the MMR programme to succeed, an uptake level of 95pc is required.It has also emerged that a large number of out-of-date polio vaccines were distributed in the late 1990s, forcing re-inoculation of thousands.
This picture of a shambolic vaccination programme is outlined in a confidential report conducted by the health boards and revealed by Ireland on Sunday earlier this year. A main recommendation in the report was the setting up of a new body to oversee the vaccination programme. Health Minister Martin has not, however, made any moves to establish the new body. Patients' Association spokesman Stephen McMahon said: 'Immunisation programmes are a crucial element for any society. The management, production, distribution and delivery must be well managed for everyone to have confidence in the programmes.'
Now doctors are calling whooping cough, Asthma! They can't have the vaccine not working so they change the name of the disease!
EPIDEMIC PREDICTED: Maxine Saunders and her children, Daniel and Louise, who have both had whooping cough this year. Mrs Saunders is worried that parents whose children have whooping cough symptoms are being told they have asthma.
DON SCOTT/The Press
Whooping cough spreads 11 September 2002
By MICHELLE BROOKER
A Canterbury mum fears children with whooping cough are being misdiagnosed with asthma as the contagious disease grips the region.
Maxine Saunders' son, Daniel, coughed for six weeks and was told three times by a GP that he had asthma before he was diagnosed with whooping cough. The eight-year-old, who was immunised against the disease, is one of the nine reported cases of whooping cough in Canterbury last week. His seven-year-old sister, Louise, is another. Health officials are predicting a whooping cough epidemic similar to the one that ravaged the country in 1999. Crown Public Health figures show there were 62 reported whooping cough cases during August in Canterbury, South Canterbury, and the West Coast, compared with 14 for the same time last year.
Acting Canterbury medical officer of health Daniel Williams said whopping cough had emerged in South Canterbury four months ago and had slowly spread. Whooping cough starts with cold-like symptoms, which progress within two weeks to severe coughing bursts often followed by a gasp with the characteristic whooping sound. Some people turned blue and/or vomited. It is particularly infectious in its early stages and is a danger to young children.
"Whooping cough occurs in epidemics," he said. "South Canterbury was the start of the epidemic in 1999." Mrs Saunders is worried that parents whose children have whooping cough symptoms are being told they have asthma. She said Daniel was given asthma inhalers by his GP which did not work. "I was very concerned," she said. "I asked him (the GP) for blood tests and antibiotics but he refused." Mrs Saunders took Daniel to another GP and tests confirmed he had whooping cough. She knows a dozen children who have the disease. Several have been told they have asthma. Mrs Saunders said parents should demand blood tests if they thought their child had whooping cough. Christchurch Hospital clinical director of Paediatrics Professor George Abbott said whooping cough was not an easy disease to diagnose.
"We have had a bad winter and spring with two influenza viruses which leave people coughing for weeks." Professor Abbott said the disease was highly contagious and if it went undiagnosed it could spread rapidly through day care centres, and schools. Several children have been admitted to hospital with whooping cough in the last few months. "We know it is in the community," he said. "It is a bad disease for children. Once a baby gets whooping cough they are often in hospital for several days or weeks.
"They need careful nursing, and support with their breathing when they have terrible coughing spasms." Professor Abbott said babies or young children with the disease could stop breathing, have fits, go blue, and get nose bleeds and collapsed lungs.
The disease was sometimes fatal in children. Whooping cough often worsened in spring and summer. "It is likely we are going to be seeing a lot more cases," he said. Dr Williams said Crown Public Health had told doctors whooping cough was prevalent in the community. Dr Williams said adults suffering from whooping cough might just get a hacking cough. "Immunising children on time is the biggest thing people can do to protect their children," he said. "Immunisation is 75 to 80 per cent effective at preventing the disease."
HOW SAFE WAS MY BABY'S JAB?
BY ANDREW MOSLEY
12:00 - 14 September 2002
A devon mother has spoken of her fear that a combined jab may have caused her six-month-old baby to suffer epileptic seizures. Just four days after baby Trinity Bowen received her vaccination against diphtheria, whooping cough and tetanus, she suffered a massive convulsion.
Now her parents Mellissa and Simon are hoping their daughter will not be permanently epileptic or suffer from brain damage. Mrs Bowen, 31, of Park Street, Crediton, said: "I was so scared. She developed meningitis-type symptoms with high fever and a tiny rash on her chest. She was in her cot and she was convulsing in a major way.
"I literally thought: 'She's dying'. My husband was away, so I was on my own. I was going to ring a doctor but I went straight for an ambulance instead. "She was treated, but she had five more seizures that day and four more after that. She could have died. It was extremely frightening. "The nurse asked if Trinity had received any jabs, but I didn't think much about it at the time." She has since learnt that 120 families are planning legal action against the vaccine's manufacturer Glaxo Wellcome.
Mrs Bowen said: "Trinity's OK at the moment but she is taking epilepsy medicine and will have a brain scan in a couple of months' time." She said neither her family nor her husband's had any history of epilepsy. Mrs Bowen, who said Trinity had received her first two monthly doses of DPT without problems, said: "She is our first child and we love her to death. We will do anything we can for her.
"I want an investigation to be opened into this."
Mrs Bowen praised staff at the RD &E for their treatment of Trinity, but added: "We shouldn't have been there in the first place." Glaxo Wellcome, now part of GlaxoSmithKline, is already being sued by 2,000 families over the controversial triple MMR (measles, mumps, rubella) vaccine. A spokesman for the drugs company said no group action had been taken against the company so far relating to its DPT jab although he added: "We have been told the Legal Services Commission is considering more than 100 cases.
"There was a test case in 1988 which found no evidence, so I don't know why that doesn't still stand." Cases lodged with the Legal Services Commission are seeking Legal Aid funding so that people can pursue legal action. The Department of Health, which recommends the triple vaccine, says no evidence has been produced to link it to epileptic seizures or brain damage. However, the diseases which the vaccine combats are threats to children's health.
Diphtheria is an acute infection of the nose and throat which may prove fatal if not treated early, whooping cough (pertussis) is a highly infectious bacterial disease that settles in the lungs and throat, and tetanus enters via wounds and can prove fatal. The DPT vaccine is given in three monthly stages. Known potential side effects include pain at the injection site, headache, spasms and vomiting.
As a triple jab, DPT has been around for more than 40 years, although its components have been altered in that time. Devon consultant in communicable diseases Dr Mark Kealy said there had been controversy over many years regarding the pertussis component of the jab: "There have been views expressed that it has caused brain damage in a very small number of children, although this has never been substantiated.
"If it does cause such problems it is at a very low level of incidence.
"Children do have fits when their temperature rises and it is easier for parents to remember that they have just had a jab and link it to that rather than anything else," he said. Dr Kealy said he regarded the vaccine as safe.
Exeter-based British Medical Association spokesman Dr Adrian Midgley also said he believed the vaccination was safe. He said: "Seizures in babies are enormously frightening when they are happening and a parent should immediately call 999. By the time an ambulance arrives they will probably have finished convulsing.
"Babies have fits at random times and this can obviously be after they have been immunised. We are alert to this possibility. "If DPT was causing fits we would expect to see that the proportion of children having fits after having DPT was greater than the proportion otherwise. That is not the case," he said.
Father joins legal battle to highlight vaccine risks
Sep 14 2002
Madeleine Brindley Madeleine.Brindley@Wme.Co.Uk, The Western Mail
EVERY night Philip Yendle lies awake watching his 12-year-old daughter intensely, fearful she will die as her body writhes under the strain of an epileptic seizure. Every afternoon he monitors the television programmes she watches with more than just a parent's protective eye, afraid the sequence of flickering scenes will trigger an hour-long grand mal episode.
And every day he regrets ever allowing Sara to receive the second dose of the DTP vaccine that has changed her life forever. "She was a perfectly normal baby, everything a child should be before she had the vaccine," the father-oftwo said. "She'll be a teenager next year but she'll never have a boyfriend, she'll next get married, she'll never grow up. "It's extremely hard knowing that I will have a toddler with temper tantrums for a daughter for the rest of my life all because of a vaccine."
The Yendles, who live in Tonteg, are one of 120 families attempting to sue the manufacturers of the combined diphtheria, pertusiss (whooping cough) and tetanus vaccine, Glaxo-SmithKline. The Government has already acknowledged the DTP vaccine seriously damaged Sara when it paid out almost £90,000 compensation for her brain injuries.
But the family wants recognition from the pharmaceutical company of the dangers they claim the jab presents, despite GSK's repeated denials of any health risks. Sara suffered a massive hour-long fit just 12 hours after she received the second dose of DTP when she was six months old. Twelve years later and the little girl, who weighs barely three stone and stands just four feet tall, has suffered thousands of similar seizures, trance-like states and mini fits. She has the mental capacity of a child just a third of her age.
Sara has been diagnosed with severe epilepsy and brain damage, as a result of a bad reaction to the whooping cough element of the DTP vaccine. She must take handfuls of different drugs every day in a bid to minimise the intensity and number of seizures but health experts have said there is little hope her condition will ever improve.
Instead her frail body is slowly being poisoned by the large amounts of medication as it is racked by the daily fits. The seizures are most dangerous when Sara is asleep, when she could choke on her tongue and suffocate.
"When she had the first jab she was gasping for breath and her eyes were going funny. We thought there was some sort of problem and we were scared to go ahead with the second dose," Mr Yendle said. "We took advice from a consultant paediatrician who said it was a perfectly normal reaction and we should go ahead with the second dose. But after she had it she had a fit for 45 minutes and she's been fitting ever since. We believe she had a mini fit after the first dose and she never should have had the second."
Mr Yendle no longer works as he is Sara's sole carer. His marriage buckled under the strain of looking after the 12-year-old, who cannot read or write and is sensitive to the light, 24-hours a day.
He spends the few hours Sara is at a special school every day washing the sheets she has wet during the night and her clothes which have become soaked with her own saliva - a side effect of the anti-seizure drugs. At night he lies awake listening to every breath Sara takes as she sleeps in the same room as him, waiting for the half-dozen nightly seizures to start in the early hours of the morning.
"She knows now that there is something wrong - She tells me `Daddy I'm not feeling well,' or `I'm feeling funny,' and asks for her baby medicine, a form of valium we have to give her in an emergency. "We've got no quality of life. We're locked into a cycle of fits
Father said whooping cough victims had their shots
By REBECCA LOPEZ / WFAA-TV
Monday night, News 8 reported on two children in Lewisville that were diagnosed with whooping cough. Health officials issued an alert and encouraged all parents to get their children immunized. But in both cases, the sick children had all their shots. One of the victims was a 10-year-old boy. His parents told News 8 that his doctors encouraged him to continue to play on his football team, because they didn't realize the child had whooping cough. They said since the beginning of August, doctors thought he had asthma.
"My frustration was that we specifically kept asking about whooping cough, and it was discounted," said the boy's father, who did not want to be identified. The father also says the child was fully immunized, but still got sick. "There are cases where children who recieve the full compliment are not protected. The vaccine is not 100 percent effective for all children," said Suzy Hancock of the Denton County Health Department.
But how effective are the vaccinations? According to some medical experts, the primary vaccine for pertussis - or whooping cough - is about 80 percent effective. "I would like parents to be calm but to realize that even if your child is immunized there's a chance they could get sick," the boy's father said.
"The immunity will wane and sometimes by the time five years has passed since the last immunization that vaccine has lost its effectiveness," Hancock said. Still, health experts said that not vaccinating your children would be worse, because for smaller children, the disease can be deadly. "We have more children who don't get the illness, so it's really still a good idea to get your children all the vaccines," Hancock said.
So while the vaccine isn't 100 percent effective, it still prevents thousands of children from getting ill.
Friday, 29 November, 2002, 00:05 GMT
Call for whooping cough jab for adults
Researchers say young mums could be vaccinated
Adults working or living with young children should be immunised against whooping cough to stop them passing on the disease, researchers have suggested. The disease can be fatal for children, and the researchers suggest parents and healthcare staff could be vaccinated as a precautionary measure. The incidence of whooping cough, or pertussis, increases in adults as the protection from childhood vaccination diminishes. But many people do not realise adolescents and adults can have whooping cough, and the researchers want to highlight the risks. Pre-school booster The main symptom of the disease is prolonged coughing.
A suitable vaccine is available.
Children in the UK are given the DTP vaccine, which immunises them against whooping cough as well as diphtheria and tetanus, at two, three and four months of age. From last year, they are also given a pre-school booster around the age of four. So far this year, there have been 332 laboratory reports of whooping cough received by the Public Health Laboratory Service (PHLS), which covers England and Wales. Just over 100 of those were in babies under three-months-old. Protecting children An international team of researchers, led by Dr Carl Heinz Wirsing von König of the Institut für Hygiene und Laboratoriumsmedizin, in Krefeld, Germany, carried out the study.
He said selectively immunising adults could be the answer to preventing adults passing on the disease to vulnerable children. Dr Wirsing von König told BBC News Online: "One of the things that could be done is to think about vaccinating young mothers in order to protect the infants. "The second thing, which is now being implemented in Germany, is to immunise people in healthcare and childcare." Vaccination of adolescents is recommended n France, Germany, and parts of Canada. Dr Natasha Crowcroft, a consultant epidemiologist at the PHLS, said: "We know that adults in the UK get whooping cough. "We know that adults in the UK sometimes infect babies and we are concerned about it." But she said experts wanted to have time to evaluate the impact of the pre-school booster on the number of whooping cough cases before they considered extending vaccination to teenagers or adults. "There seems to be quite a lot of infections going on in primary school age children. "We haven't really had long enough [of the pre-school booster] to see if that's going to be affected." But she said public health experts would consider changing the vaccination regime if the evidence supported that. Hospitalisation In the 1970s, the UK, Germany and Sweden saw increases in the number of cases whooping cough after immunisation campaigns were stopped after a scare over the safety of the vaccine. There were 100,000 cases of whooping cough in the UK between 1977 and 1979, including a number of deaths.
Whooping cough resurfaces in county
BY JOYCE GODWIN
Pertussis, more commonly known as whooping cough, was once essentially eradicated in Texas through vaccination, but its resurgence is a threat in Grayson County according to the Grayson County Health Department. "We have been fortunate so far and have not had the very high numbers seen in other parts of the state," said Dr. Carolyn Fruthaler, director of the Grayson County Health Department. "However, with winter on the way, and people spending more time in close quarters, we expect to see more."
Whooping cough cases have been increasing in Texas according to the Texas Department of Health since 2000 when 327 confirmed cases were reported over 45 counties throughout Texas, more than doubling the number reported the previous year. In 2001, 615 cases of whooping cough were reported in 70 Texas counties and this has been the largest number since the 802 cases reported in 1968.
In lightly populated Burnet County, with 86 cases in a population of only 40,000, health officials have been battling a continuing outbreak of whooping cough that began in May. The Central Texas county, which includes the cities of Marble Falls and Burnet, had no cases reported last year according to the Texas Department of Health. This year between January and July, the Texas Department of Health reports a total of 378 cases of whooping cough recorded over 41 Texas counties, including four infant deaths. The report also states 30 percent of all patients have been children under one-year-old. Immunizations will wane with age leaving teens and adults susceptible to the disease, Fruthaler said.
"An adult who has a cough for two weeks or more should be evaluated by a physician," she said. "We have had normal amounts of (whooping cough) vaccine and have not had to postpone doses; children should be up to date on that vaccine." Dr. Sharilyn Stanley, TDH associate commissioner for disease control and prevention said a lot of youth don't cover their mouths and noses when they cough or sneeze, increasing the risk of transmission in school. "Older children, teen-agers and adults usually have a milder case of whooping cough, but that is more likely to cause pneumonia, seizures, brain damage and death in infants," Stanley said. "The elderly and persons with weakened immune systems also are more likely to have severe complications. Any infant with a cough or difficulty breathing should be seen by a physician."
Complete vaccination against pertussis includes a series of four primary doses and a fifth booster dose of DTaP, a combination vaccine that also protects against diphtheria and tetanus. The first dose should be given at six weeks to two months of age, with subsequent doses at four months, six months and 15-to-18 months, and the booster dose at four years. Protection increases after each dose. The vaccine is not authorized for people seven and older.
Stanley said TDH is advising physicians to consider giving antibiotics immediately to patients with whooping cough symptoms and to their family members, instead of waiting for results of lab tests to confirm the illness. Noting that the vaccine's effectiveness may diminish after a few years, Stanley added that physicians should not rule out whooping cough as a possible diagnosis simply because the patient has been vaccinated.
Three stages of whooping cough
The Texas Department of Health says whooping cough is a bacterial respiratory illness spread from person to person through respiratory droplets from coughing and sneezing. The illness is most likely to be spread in household situations where opportunities for continual close contact with an infected family member are greater. There are three stages of whooping cough. The first is marked by a runny nose, sneezing, low-grade fever and a mild cough and usually lasts for one to two weeks. The second stage, typically lasting from one-to-six weeks, includes prolonged spasms of rapid coughs usually accompanied by high-pitched whoops as the person gasps for air. Vomiting often follows the coughing bouts. In the third stage, coughing spells occur less frequently as the patient recovers over a two-to-three week span, but coughing spasms can recur for several months.
Problems with control
"One of the biggest problems in controlling the spread of whooping cough is that it's often not suspected or diagnosed in the first stage when the symptoms are so similar to those of colds and allergies," Stanley said. "It's usually not until the second stage, with the trademark coughing spells and whooping, that diagnosis and treatment occur," she said. "But someone with whooping cough can infect others throughout their illness." The incubation period, or time from exposure to the appearance of symptoms, is typically seven-to-10 days but can range from four-to-21 days and longer. People who have had whooping cough are not likely to have it again.
Possible Causes of resurgence
A July 18 press release from the Texas Department of Health discussed the reasons this disease is making a comeback. Citing the lack of effective immunization as one culprit, the report explained that children who are immunized often miss at least one of the series of five recommended vaccines. This weakens their immunity over time. Many infants are not receiving immunizations at all. Texas ranks 50th in the nation in the percentage of children 19-to-35 months of age completing the recommended doses of several vaccines, including the one for pertussis, according to Texas Medicine, the official news magazine of the Texas Medical Association providing timely information on medical issues that affect Texas patients and their physicians.
Another possible cause is a reformulation of the vaccine, which may have reduced its strength. Pharmaceutical companies began manufacturing a partial cell vaccine, rather than one made from whole pertussis cells, in 1991. That year pertussis cases began to spike higher, though they had trended upward for more than a decade.
For more information about Pertussis or immunizations call the Grayson County Health Department at (903) 893-0131 in Sherman or (903) 465-2878 in Denison or go to the Texas Department of Health web site at http://www.tdh.state.tx.us/immunize/pertussis.htm.
J Child Neurol 2002 Sep;17(9):700-2
Fiumara A, Polizzi A, Mazzei R, Conforti L, Magariello A, Sorge G, Pavone L.
Department of Pediatrics, University of Catania, Italy.
Rett syndrome is a progressive neurodevelopmental disorder with a well-defined clinical spectrum and course. Recently, mutations in the gene encoding X-linked methyl-CpG binding protein 2 MECP2) have been identified as the cause of Rett syndrome. Along with the classic form, variant forms of Rett syndrome and Rett syndrome phenotypes are also recognized. We report on a girl who, at age 2 months, developed an acute encephalopathy with destructive brain damage 12 hours after acellular pertussis vaccination. Peripheral lymphocyte subset analysis revealed the existence of T lymphocytes double positive for CD4 and CD8 markers. This pattern normalized over the following 3 months. Months later, the girl manifested a Rett syndrome phenotype. DNA screening of the MECP2 gene was unrevealing in the child and her parents. This previously unreported association emphasizes the notion that Rett syndrome phenotypes can result from different (either genetic or environmental) causes.
Pertussis resurgence in Canada largely caused by a cohort effect.
Ntezayabo B, De Serres G, Duval B.
BACKGROUND Beginning in 1990 Canada experienced a resurgence of pertussis. Changes in incidence and hospitalization according to age in the province of Quebec between 1983 and 1998 were examined to assess the presence of a cohort effect resulting from a poorly protective vaccine. METHODS The source of data on incident cases was pertussis notifications to the Quebec Ministry of Health and Social Services. Hospitalization data were extracted from the administrative database that collects information on each hospitalization.RESULTS The mean annual incidence before 1990 was 3.8 cases per 100 000 population which increased to 37.2 thereafter. Infants had the smallest increase (2.7-fold) when compared with children between 1 and 19 years who experienced a 9- to 15-fold increase and with adults (22.5-fold). The mean annual hospitalization rates increased from 2.7 per 100 000 before 1990 to 5.2 afterward. Ninety percent of hospitalizations occurred in children <5 years of age. The proportion of cases in 0- to 4-year-old children decreased, whereas it increased steadily in all other age groups during the entire study period. Between 1990 and 1998 the median age of cases shifted from 4.4 to 7.8 years. Pertussis affected predominantly children who were immunized with a vaccine introduced in the mid-1980s. The evolution of the age distribution of cases paralleled the aging of this cohort with a slow but steady drift of disease from early childhood to adolescence.CONCLUSION The sudden increase in pertussis incidence in Canada can be largely attributed to a cohort effect resulting from a poorly protective pertussis vaccine used between 1985 and 1998.
Tuesday, 14 January, 2003, 12:13 GMT
Fresh fears over child vaccines
The concerns centre around the DTP vaccine Campaigners have called on ministers to ban a vaccine which is routinely given to newborn babies. They say there is growing concern that a mercury compound in the three-in-one DTP vaccine may cause autism and brain damage. The vaccine, which protects against diphtheria, tetanus and pertussis or whooping cough, is given to infants of eight weeks and older.
We want an immediate end to vaccines containing mercury, particularly for children Bill Welsh, Action Against Autism However, the Department of Health has said there is no cause for concern and that the vaccine is safe for children. Recent studies have found no link between DTP vaccines with thiomersal and autism and brain damage. However, regulators in the United States and European Union have recommended that manufacturers should phase out the use of the compound wherever possible as a precaution. Concerns rejected The Department of Health said the current vaccine would be replaced as soon as a suitable alternative became available. But a spokeswoman added: "All vaccines are tested for their safety and efficacy.
"Recent reviews by the Committee on the Safety of Medicines and the US Institute of Medicine found no evidence of any effect of low doses of thiomersal on childhood development." On Tuesday, Prime Minister Tony Blair also dismissed claims saying there was no evidence to back up calls for the vaccine to be withdrawn. But Bill Welsh, chairman of the pressure group Action Against Autism, urged ministers to ban the vaccine.
"We want an immediate end to vaccines containing mercury, particularly for children. This must stop today, this moment, immediately." Speaking to BBC News Online, he said there were growing fears that the mercury compound in the vaccine could pose a threat to children's health. He suggested that thiomersal in the DTP vaccine could cause mercury poisoning in some infants.
"We want every child who has been diagnosed with autism since 1990 to be properly examined to see if they have actually suffered mercury poisoning. "The symptoms of mercury poisoning and autism are exactly the same." Mr Welsh was speaking after he handed in a petition to the Scottish parliament calling for an inquiry into the safety of the vaccine. He was joined by Dr Gordon Bell, a senior lecturer at Stirling University. He said: "This issue has never been investigated properly. An inquiry is
Rett syndrome phenotype following infantile acute encephalopathy.
Fiumara A, Polizzi A, Mazzei R, Conforti L, Magariello A, Sorge G, Pavone L.
Department of Pediatrics, University of Catania, Italy.
Rett syndrome is a progressive neurodevelopmental disorder with a well-defined clinical spectrum and course. Recently, mutations in the gene encoding X-linked methyl-CpG binding protein 2 (MECP2) have been identified as the cause of Rett syndrome. Along with the classic form, variant forms of Rett syndrome and Rett syndrome phenotypes are also recognized. We report on a girl who, at age 2 months, developed an acute encephalopathy with destructive brain damage 12 hours after acellular pertussis vaccination. Peripheral lymphocyte subset analysis revealed the existence of T lymphocytes double positive for CD4 and CD8 markers. This pattern normalized over the following 3 months. Months later, the girl manifested a Rett syndrome phenotype. DNA screening of the MECP2 gene was unrevealing in the child and her parents. This previously unreported association emphasizes the notion that Rett syndrome phenotypes can result from different (either genetic or environmental) causes.
PMID: 12503649 [PubMed - indexed for MEDLINE]
ASTHMA, CHILDHOOD DISEASES, IMMUNIZATIONS RELATED
A provocative new study in the journal Science (3 Jan 97) suggests that diseases such as tuberculosis and whooping cough may permanently alter a child's immune system in a way that confers lifetime protection against asthma and allergies. If true, the public health victories that have largely eliminated those diseases in developed nations may be making people more susceptible to asthma or other allergies. But, the researchers say, asthma and allergies might be prevented in children or treated in adults by giving a vaccine that substitutes for disease by mimicking a serious lung infection. Immunization with harmless bacteria, related to tuberculosis, might be helpfulin preventing and treating allergy. The research was done in Oxford, England and Japan. It focused on 867 school children in Japan who, like most Japanese,received BCG vaccines (Bacillus CalmetteGuerin) at birth and at 6 and 12years of age. That vaccine is made from a kind of bacteria closely related to the one that causes tuberculosis and is popular in some countries to help prevent that disease. (It is not commonly used in the United States in part because it inexplicably fails to stimulate the immune system in many recipients.)Researchers tested the vaccinated Japanese 12 and 13 year olds to see whether they had developed the intended immune response against tuberculosis. They also checked for a history of asthma or related allergies and performed immunesystem tests.
Children who mounted the strongest immune responses against BCG had about one third the incidence of asthma compared to children with weak or no immune response. The researchers conclude that exposure to tuberculosis or related microbes may help protect against asthma They explain: the immune system uses two main arsenals to protect the body. One system centers on antibodies, which when over produced in the lungs cause allergies and asthma. The other system, cell mediated immunity, centers on white blood cells called macrophages, and is the main response to respiratory infections and BCG vaccinations. When one arm of the system is operating, the other backs off. The researchers propose that in the absence of severe childhood lung infections, youngsters never develop the cell mediated response that might permanently temper the antibody arm. (Unlike the BCG vaccine, vaccines against whooping cough and other childhood diseases in this country stimulate antibodies but not cell mediated immunity.) Without that early cell mediated response, they propose, the antibody generating arm of the immune system is left unbridled and poised to over react to innocuous particles such as dust or pollen. Experts in the US disagree on the significance of this research, some calling the findings controversial, some finding it interesting, saying it should be researched more, some saying it's outright wrong.
"... Barker and Pichichero, in a prospective study of 1232 children in Denver, Colorado, found after DTP that only 7% of those vaccinated were free from untoward reactions, which included pyrexia (53%), acute behavioral changes (82%), prolonged screaming (13%), and listlessness, anorexia and vomiting. 71% of those receiving second injections of DTP experienced two or more of the reactions monitored."
Lancet, May 28, 1983, p. 1217
Doctors miss whooping cough cases
Infants are vaccinated against whooping cough from two months
Doctors are failing to diagnose potentially deadly whooping cough in some children, a study suggests. Researchers have found that one in four infants who were admitted to hospital with whooping cough like illness were not given the drugs they needed. They have also confirmed that some children catch the disease from adults and older brothers and sisters. This is despite the fact that the vast majority of people have been vaccinated against the disease. Whooping cough or pertussis is most dangerous in children less than one year old. It can lead to pneumonia, convulsions and, in rare cases, brain damage or death. Serious complications are less likely in older children and adults. Admitted to hospital Dr Natasha Crowcroft and colleagues at the Health Protection Agency looked at 126 infants under five months and 16 children under the age of 15 who had been admitted to hospitals in London with a whooping cough like illness between 1998 and 2000. They identified 25 infants and eight children with the disease. Two infants subsequently died. In the UK, adults may be transmitting whooping cough to infants
They found that seven of the 25 infants did not receive a macrolide antibiotic, the drug of choice for treating whooping cough. This not only reduced their chances of fighting off the disease but also left other patients and medical staff at risk of infection. Many were in paediatric intensive care units (PICU) with other vulnerable children. Writing in the journal Archives of Disease in Childhood, the researchers said: "Twenty eight per cent of infants with proven pertussis did not receive a macrolide antibiotic and risked transmitting the infection to staff and other patients. "Pertussis is extremely infectious and a missed diagnoses in PICU may lead to outbreaks among extremely vulnerable infants." The researchers said many of these children may not have been diagnosed with whooping cough because they did not have typical symptoms. They said the findings highlighted the need to test all children who show even possible signs of infection. The researchers found that many of the hospitalised infants had not been fully vaccinated against whooping cough because they were too young. The vaccine is usually given to infants after two months. They receive three doses at monthly intervals. Infected by adults The study also found that two out of three children had probably contracted the disease from a parent or older siblings. This was despite the fact that the vast majority of adults and all of the siblings had been vaccinated against the disease. Previous studies have suggested that many children catch whooping cough from other members of their household. In 2001, the government introduced a new vaccine booster programme for children before they go to school to try to reduce the risks of them catching the disease. Figures from the Health Protection Agency show that the number of reported cases of whooping cough have fallen since the booster programme was introduced. In 2001, 800 children under the age of 15 were diagnosed with the disease. Last year, that figure was down to 384. However, some scientists believe parents and adults working with children should also be given a booster to stop them passing it on to children. The authors of this latest study appear to back that proposal. "Any future changes to the immunisation programme may need to take into account the fact that in the UK, adults may be transmitting whooping cough to infants," they said.
Adverse events reported after and fifth dose of DT Vaccine
Vaccine 2002 Sep 10;20(27-28):3409-12 Related Articles, Links
Anaphylactic reaction to diphtheria-tetanus vaccine in a child: specific IgE/IgG determinations and cross-reactivity studies.
Martin-Munoz MF, Pereira MJ, Posadas S, Sanchez-Sabate E, Blanca M, Alvarez J.
Allergy Service, University Hospital La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain. email@example.com
The present study describes the occurrence of an anaphylactic reaction after the administration of the fifth booster dose of DT vaccine in a six-year-old child. Skin test, in vitro determinations of specific IgE antibodies and immunoblotting assays showed that the IgE response was directed against tetanus and diphtheria toxoids (Dtx). IgG antibodies were also detected by ELISA and immunoblotting. The RAST and immunoblotting inhibitions showed no cross-reactivity between the two toxoids, indicating the presence of co-existing but non-cross-reacting IgE and IgG antibodies. This was maintained in two subsequent determinations done 18 and 30 months after the episode. To our knowledge, this is the first study of cross-reactivity between tetanus and diphtheria antigens. We show that simultaneous IgE antibodies to two different toxoids may occur, indicating that after an immediate reaction to DT, a search for IgE antibodies to both tetanus and Dtx should be undertaken.
PMID: 12213411 [PubMed - in process]
Adverse events reported after fourth and fifth doses of DTaP
Vol. 49 / No. RR-13 MMWR 3
REACTOGENICITY OF DTaP VACCINES
WHEN ADMINISTERED AS FOURTH
AND FIFTH DOSES OF A SERIES
Data regarding use of a single DTaP vaccine for the complete five-dose series are limited, but available data demonstrate a substantial increase in the frequency and magnitude of local reactions after the fourth and fifth doses. Increases in the frequency of fever after the fourth dose have been reported also, although increased frequencies of other systemic reactions (e.g., fretfulness, drowsiness, or decreased appetite) have not been observed. Despite the increased reactogenicity of the fourth and fifth doses, acellular pertussis vaccines remain the preferred vaccines for preventing pertussis, diphtheria, and tetanus among children because of the improved safety profile when compared with whole-cell pertussis vaccines ( 2-5).
Adverse Reactions After the Fourth Dose
of DTaP When Administered
as a Four-Dose Series
Increases in erythema, swelling, and pain at the injection site and increases in fever have been reported with the fourth dose as compared with the first dose for each of the currently licensed DTaP vaccines. These reactions typically have onset within 2 days of vaccination and resolve completely without sequelae ( 6). During 1991-1994, reactogenicity of ACEL-IMUNE administered as a four-dose series was assessed in an efficacy study in Germany ( 7). DTaP and diphtheria and tetanus toxoids and whole-cell pertussis vaccine (DTP) components of the study were randomized and double-blinded. Local and systemic reactions were reported on standard diary cards for 72 hours after each dose. Of 3,991 children who received the fourth dose of ACEL-IMUNE, 10% experienced erythema >0.9 in. (>2.4 cm), and 9% experienced induration >0.9 in. (>2.4 cm). After the first dose, only 2% of recipients were reported as experiencing erythema or induration of this magnitude. Fever >100.4 F (>38 C) was reported for 7% of recipients of the first dose, but after the fourth dose, 26% of recipients experienced fever >100.4 F (>38 C) ( 4,8). In an open-label trial (i.e., a study in which researchers and subjects know what vaccine and dose is being administered) in the United States, 109 infants who had previously received Tripedia at ages 2, 4, and 6 months received a fourth dose at age 15-20 months ( 9). Reactions were assessed by parents at 6, 24, and 48 hours and daily thereafter for 14 days, and parents were asked to record daily on a standardized diary the presence or absence of injection-site tenderness, redness, or swelling. Of children receiving the fourth dose, 5.5% experienced fever >101 F (>38.3 C) within 72 hours of
vaccination; 30.3%, injection site redness >1 in. (>2.54 cm); 29.4%, injection site swelling >1 in. (>2.54 cm); and 19.3%, injection site pain ( 9). In contrast, during the primary series study of 218 infants, no infants experienced fever >101 F (>38.3 C) after the first dose; 2%, erythema >1 in. (>2.54 cm); 2%, swelling >1 in. (>2.54 cm); and 10%, tenderness at the injection site ( 10). Of 22,505 children who had received three doses of Infanrix® (SmithKline Beecham Biologicals) at ages 3, 4, and 5 months during an open-label safety trial in Germany during April 1993-November 1994, 5,361 received a fourth dose at age 10-36 months
4 MMWR November 17, 2000
( 11). Standardized diaries reporting adverse events occurring within 3 days of vaccination were available for 1,809 children who had received the fourth dose. Age range of this subset of children was 14-28 months. Rates of redness, swelling, pain, and fever increased with successive doses. Redness >0.8 in. (>2 cm) increased from 0% after the first dose to 13.8% after the fourth dose; swelling >0.8 in. (>2 cm), from 0% to 11.4%; pain, from 2.0% to 26.3%; and fever >100.4 F (>38 C), from 6.3% to 26.4% ( 11-13). Increases in the reactogenicity of the fourth dose of Certiva™ (North American Vaccine, Inc.) also have been reported. Fourth-dose data have been reported for 316 infants, a subset of >2,200 who received Certiva as a three-dose primary series during an openlabel trial in the United States ( 14). Safety data were collected using standardized diary cards and telephone follow-up. Fever >100.4 F (>38 C) within 72 hours of vaccination increased in frequency from the first dose to the fourth dose, with fever reported among 1.5% of first-dose recipients and 10.5% of fourth-dose recipients. Frequency of redness >1.2 in. (>3 cm) increased from 0.2% after the first dose to 5.7% after the fourth dose; swelling >1.2 in. (>3 cm), from 0.6% to 4.5%; and tenderness or pain (any), from 5.9% to 19.0% ( 14).
Adverse Reactions After the Fifth Dose
of DTaP When Administered
as a Five-Dose Series
Data regarding the reactogenicity of a fifth dose of DTaP administered after four doses of the DTaP vaccine are limited, but are available for three of the four currently licensed DTaP vaccines. These data demonstrate further increases in the local reactogenicity of the fifth dose compared with the fourth dose. No data are available regarding the frequency of adverse events after a fifth dose of Certiva. Data have been summarized from four clinical trials in the United States and Germany, during which 357 infants received a fifth dose of ACEL-IMUNE after having received four previous doses of the same vaccine. Case definitions of substantial erythema and induration varied by protocol, ranging from >0.8 in. (>2 cm) to >0.9 in. (>2.4 cm). However, substantial erythema within 72 hours after the fifth dose was reported for 20% of recipients; substantial induration for 14%; and tenderness for 38% ( 8). In a study in Germany during March-September 1998, of 580 children who received a fifth dose of Tripedia after four previous doses of the same vaccine, 31.0% experienced redness >2 in. (>5 cm) within 3 days of receipt of vaccine; 25.0% experienced swelling >2 in. (>5 cm); and 2.1% experienced severe pain (i.e., crying when the arm was moved) ( 15, Aventis Pasteur, Inc., unpublished data, January 2000). During a safety study in Germany, 413 children received a fifth dose of Infanrix after four previous doses of the same vaccine. During the 3 days after vaccination, redness >2 in. (>5 cm) was reported for 30.3% of recipients; swelling >2 in. (>5 cm), for 20.7%; and grade 3 pain (i.e., pain that prevented everyday activities and necessitated medical advice) for 1.6% of the 376 children for whom symptom sheets were completed (SmithKline Beecham Biologicals, unpublished data, February 2000).
Limb Swelling After Booster Doses of DTaP
Swelling involving the entire thigh or upper arm has been reported after booster doses of different acellular pertussis vaccines. Swelling of the entire thigh was reported
Vol. 49 / No. RR-13 MMWR 5
among recipients of a booster dose of JNIH-6 (a two-component acellular pertussis vaccine produced by Biken [Japan] and comparable to the acellular pertussis component contained in Tripedia). During a study performed in Sweden during the 1980s, children who had previously received two or three doses of Biken acellular pertussis vaccine at age 6-8 months received a booster dose deep subcutaneously of the same vaccine at age 2 years. Certain children experienced substantial local reactions, including swelling of the entire thigh ( 16), although administration of vaccine subcutaneously could have influenced reaction rates in that study. Occurrence of extensive swelling involving the entire thigh of vaccinated children was reported among DTaP recipients in an open-label safety study in Germany during April 1993-November 1994, in which children who had previously received Infanrix at ages 3, 4, and 5 months received a fourth dose at age 10-36 months ( 11). Standardized diaries were available for 1,809 children, with data collected regarding the occurrence of specific solicited symptoms for 3 days after receipt of vaccine. Parents of the remaining 3,498 children were asked to report any symptoms occurring during the 28 days after vaccination; no specific symptoms were solicited. Among 5,361 vaccinees, an increase in thigh circumference was reported as an unsolicited reaction for 62 vaccinees (45 in the first group and 17 in the second group; frequency: 1.2%). One of six centers participating in the study accounted for a majority of these reports; at that center, this reaction was reported for 51 of 1,583 children (3.2%). Among 17 children whose thighs were measured, the mean increase in circumference was 0.9 in. (2.2 cm) (range: 0.2-2.0 in. [0.5-5 cm]). Swelling began within 48 hours of booster dose administration for 51 of 62 children; the mean duration of swelling was 3.9 days (range: 1-7 days). For a limited number of children, the swelling interfered with walking; but for the majority of children, no limitation of activity was experienced. None of the children were febrile. Pain when digital pressure was applied was reported for 51% of the children, and itching was observed among a limited number of children ( 11). In an analysis of the fourth- and fifth-dose follow-up studies from the Multicenter Acellular Pertussis Trial (MAPT) that examined 12 different DTaP vaccines, entire limb swelling was reported as an unsolicited reaction for 20 (2.0%) of 1,015 children who received four consecutive doses of the same DTaP ( 17). Entire thigh swelling was reported for 1 of 16 children receiving four consecutive doses of DTP and for 0 of 246 children receiving a booster dose of DTaP after three doses of DTP. Among children experiencing entire thigh swelling after the fourth dose, 70% were described as irritable, compared with 37% of fourth-dose recipients who did not experience entire thigh swelling. Erythema was reported for 60% of the vaccinees and pain for 60%; the corresponding frequencies among children without entire thigh swelling were 29% and 30%, respectively. Fever >100 F (>37.8 C) was reported for approximately 25% of both groups. Among the 20 children with entire thigh swelling, pain was judged to be mild for 7, moderate for 2, and severe for 3; pain was not reported for 8 of these 20 children. Of eight children whose swelling began on day 1, five experienced moderate or severe pain. A total of 12 children experienced swelling that began on day 2 or 3, none of whom experienced moderate or severe pain. Entire thigh swelling resolved completely and without sequelae among all 20 children (duration: 1-4 days among 11 children for whom duration was known). Among fifth-dose recipients, 0 of 121 children who had received the same DTaP vaccine experienced swelling of the entire upper arm; but such swelling occurred among 4 of 146 children (2.7%) who had received different DTaP vaccines during the five dose series. Although the numbers of children receiving fourth and fifth doses during
6 MMWR November 17, 2000
MAPT follow-up studies were limited, extensive limb swelling occurred after receipt of a
fourth dose of 9 of the 12 DTaP vaccines included in the study ( 17). Recent studies of the fifth dose of Tripedia and Infanrix have also identified cases of extensive limb swelling. During an open-label trial performed in Germany during March-September 1998, swelling of the entire upper arm was reported as an unsolicited reaction for 14 of 490 children (2.9%) who had received a fifth dose of Tripedia (Aventis Pasteur, Inc., unpublished data, January 2000). For 13 of the 14 children, swelling began within 3 days of vaccination. Associated symptoms included redness for 10 of the 14 (71.4%) vaccinees, pain for 5 (35.7%), and fussiness for 2 (14.3%). Pain was graded as
mild for all children for whom it was reported. No children had fever >100.4 F (>38 C), and only two children were evaluated during an office visit. Median duration of swelling was 4 days (range: 3-6 days) (Aventis Pasteur, Inc., unpublished data, January 2000). During an open-label trial in Germany of Infanrix as a fifth dose after four doses of Infanrix, parents or caretakers were informed of the possibility of limb swelling (SmithKline Beecham Biologicals, unpublished data, February and May 2000). Although limb swelling was not specifically solicited on diary cards, parents or caretakers were asked to contact the investigators if their children experienced such a reaction. Of 413 subjects enrolled, parents of 26 children contacted the investigators to report that their children had experienced swelling. A total of 3 of the 26 children (11%) had fever >99.5 F (>37.5 C) when measured axillarily or orally or >100.4 F (>38 C) when measured rectally. Other associated symptoms included pain for 23 (88.5%) vaccinees, which was diffuse for 6. Redness occurred for 26 (100%) vaccinees and was diffuse for 17. Warmth was experienced by 21 (80.8%) vaccinees and was diffuse for 13. Of the 26 children evaluated, one child experienced swelling extending from shoulder to elbow. That child experienced localized pain at the injection site and diffuse redness and warmth and was afebrile. For one child, swelling was assessed as grade 3 severity (i.e., prevented normal everyday activities and necessitated medical advice). For all vaccinees experiencing swelling, reaction began within 3 days of receipt of vaccine. Mean duration of swelling was 4 days (range: 1-10 days) (SmithKline Beecham Biologicals, unpublished data, February and May 2000).
Pathogenesis of both substantial local reactions and limb swelling is unknown. In an analysis of data from the MAPT fourth- and fifth-dose follow-up studies, swelling >2 in. (>5 cm) after the fourth dose was associated with pertussis toxoid content of the vaccine administered; swelling after the fifth dose was associated with the aluminum content of the vaccine. Entire thigh swelling after the fourth dose was associated with diphtheria toxoid content of the vaccine. Prevaccination antibody levels to diphtheria, tetanus, or pertussis toxins were not predictive of this reaction. The inconsistent pattern of associations of vaccine content and swelling could indicate that the associations were a statistical artifact attributable to a limited sample size or to differential reporting of entire thigh swelling among the DTaP vaccine groups ( 17).
SUPPLEMENTAL ACIP RECOMMENDATIONS
FOR USING DTaP VACCINES
Data are limited regarding differences in reactogenicity among currently licensed acellular pertussis vaccines. Increases in frequency and magnitude of substantial local reactions at the injection site with increasing dose number have been reported for all
Vol. 49 / No. RR-13 MMWR 7
currently licensed DTaP vaccines. Swelling of the thigh or entire upper arm after receipt of fourth and fifth doses of acellular pertussis vaccines has been documented for multiple products from different manufacturers. However, because reports of these reactions have generally not been solicited during safety studies, the frequency is unknown, and the absence of reports does not establish a lack of reaction after receipt of particular DTaP vaccines. Additionally, in the majority of studies of adverse events after receipt of the fourth and fifth doses of DTaP, participants represent a subset (a substantially limited subset in certain studies) of children who received the first three doses. Therefore, the observed frequencies of substantial swelling reactions might have been influenced by selection biases of unknown direction and magnitude. Data are insufficient to establish that mixed sequences of DTaP vaccines from different manufacturers are associated with higher or lower frequencies of these reactions than receipt of a single product for the entire DTaP series. Additional data regarding the reactogenicity of DTaP vaccines when administered as a five-dose series are needed.
Whether children who experience entire limb swelling after a fourth dose of DTaP are at increased risk for this reaction after the fifth dose is unknown. Because reports to date indicate that the reactions are self-limited and in recognition of the benefits of the preschool dose of DTaP, a history of extensive swelling after the fourth dose should not be considered a contraindication for receipt of the fifth dose of the DTaP series.
Parents or caregivers of children receiving the fourth and fifth doses of the DTaP series should be informed of the increases in reactogenicity that have been observed. Although available data demonstrate that these reactions are self-limited and resolve without sequelae, they might be clinically indistinguishable from other conditions (e.g., cellulitis) that require treatment. Therefore, providers must make decisions regarding evaluation and management of children with suspected reactions after DTaP vaccination on a case-by-case basis.
Interchangeable Use of Acellular Pertussis Vaccines
Children who began the series with DTaP at age 2 months began eligibility to receive a fifth dose of DTaP during mid-2000. A child who began the series late and was vaccinated on an accelerated schedule might have become eligible for the fifth dose before then. Data are insufficient to document the safety, immunogenicity, and efficacy of using DTaP vaccines from different manufacturers in a mixed sequence. For this reason, the ACIP recommends that whenever feasible, the same brand of DTaP vaccine should be used for all doses of the vaccination series. However, the vaccine provider might not know or have available the type of DTaP vaccine previously administered to a child. Neither circumstance should present a barrier to administration of DTaP vaccine and any of the available licensed DTaP vaccines can be used to complete the vaccination series.
Are the fourth and fifth doses needed?
Sustained Efficacy During the First 6 Years of Life of 3-Component Acellular Pertussis Vaccines Administered in Infancy: The Italian Experience
Received Mar 28, 2001; accepted Jun 18, 2001.Stefania Salmaso*, Paola Mastrantonio [Dagger ] , Alberto E. Tozzi*, Paola Stefanelli [Dagger ] , Alessandra Anemona*, Marta L. Ciofi degli Atti*, Anna Giammanco§, and the Stage III Working Group
From the Laboratories of * Epidemiology and Biostatistics and [Dagger ] Bacteriology and Medical Mycology, Istituto Superiore di Sanità, Rome, Italy; and § Department of Hygiene and Microbiology, University of Palermo, Palermo, Italy.
Background. In 1992-1993, a randomized, double-blind, placebo-controlled clinical trial of two 3-component acellular pertussis vaccines was started in 4 of Italy's 20 regions. During the trial, the children had been randomized to receive 3 doses of 1 of 2 acellular pertussis vaccines combined with diphtheria and tetanus toxoids (DT) or of a DT vaccine only, at 2, 4, and 6 months of age. Both diphtheria-tetanus-acellular pertussis (DTaP) vaccines, 1 manufactured by SmithKline Beecham (DTaP SB; Infanrix) and 1 manufactured by Chiron Biocine (DTaP CB; Triacelluvax), contain pertussis toxin (PT), filamentous hemagglutinin, and pertactin. The results of the first period of follow-up, which ended in 1994 (stage 1), showed that both vaccines had a protective efficacy of 84% in the first 2 years of life; when the trial's follow-up was extended under partial blinding until the participating children had reached 33 months of age (stage 2 of the follow-up), these high levels of efficacy had persisted. Therefore, the objective of this study was to estimate the persistence of protection from 3 to 6 years of age of the 2 3-component DTaP vaccines administered as primary immunization in infancy.
Methods. An unblinded prospective longitudinal study of vaccinated and unvaccinated children in 4 Italian regions, with active surveillance of cough, was conducted by study nurses, and Bordetella pertussis infections were confirmed laboratory. The present study (stage 3) included those children who completed stage 2 of the follow-up and were still under active surveillance as of October 1, 1995, accounting for 4217 children who had received DTaP SB (representing 94% of the vaccine's recipients in the initial phase of the trial), 4215 who had received DTaP CB (95% of the original recipients), and 266 who had received DT only (18% of the original recipients). Because the parents of most of the original DT placebo group accepted pertussis vaccination during stage 2 in 1995, an additional 856 children were recruited in the DT group at the initiation of stage 3. These additional children were identified from the census list of children born in the same period and living in the same areas as the trial participants but who had been vaccinated in infancy with DT only. Eligible children were included in stage 3 if they had no history of either pertussis or pertussis vaccination and if a serum sample obtained at the time of enrollment had undetectable immunoglobulin G (IgG) against PT. Parental consent to participate in the study was obtained. Active surveillance for pertussis was conducted in the field by 72 study nurses through monthly contact with each family in the study. A cough episode that lasted [>= ] 7 days was considered to be a laboratory-confirmed infection by Bordetella pertussis if at least 1 of the following 5 criteria (listed in hierarchic order) was met: 1) B pertussis was obtained from nasopharyngeal culture (culture-confirmed infection); 2) the enzyme-linked immunosorbent assay (ELISA) IgG or IgA titer against PT in the convalescent-phase serum sample increased by at least 100% compared with the acute-phase sample; 3) the PT-neutralizing titers in Chinese hamster ovary assay in the convalescent-phase sample increased by at least 4-fold compared with the acute-phase sample; 4) the ELISA IgG or IgA titer against filamentous hemagglutinin in the convalescent-phase sample increased by at least 100% and the culture or the polymerase chain reaction assay on the nasopharyngeal aspirate was negative for B parapertussis; and 5) the ELISA IgG PT titer in 1 of the 2 serum samples exceeded the geometric mean titer computed on convalescent sera of the children with a culture-confirmed B pertussis infection in each study group. Incidence of laboratory-confirmed B pertussis infection, using case definitions that varied in terms of duration and type of cough, was computed and the proportion of cases prevented among DTaP recipients in comparison with DT recipients was calculated.
Results. A total of 391 laboratory-confirmed infections were identified in the 3-year follow-up period (138 DTaP SB, 126 DTaP CB, 127 DT recipients, respectively). The mean duration of cough in children with laboratory-confirmed infection was 48, 47, and 70 days for the DTaP SB, DTaP CB, and DT recipients, respectively; the mean duration of spasmodic cough was 15, 13, and 23 days, respectively. When using the primary case definition (ie, laboratory-confirmed B pertussis infection and [>= ] 14 days of spasmodic cough or [>= ] 21 days of any cough), the efficacy was 78% for the DTaP SB vaccine (95% confidence interval [CI]: 71%-83%) and 81% for the DTaP CB vaccine (95% CI: 74%-85%). When using the case definition based on a more severe clinical presentation ( [>= ] 21 days of spasmodic cough), the vaccine efficacy was 86% (95% CI: 79%-91%) for both vaccines. When using the case definition based on milder clinical presentation (any cough for [>= ] 7 days), the efficacy was 76% (95% CI: 69%-81%) for the DTaP SB vaccine and 78% (95% CI: 72%-83%) for the DTaP CB vaccine.
Conclusions. The persistence of protection through 6 years of age suggests that the fourth DTaP dose could be postponed until preschool age in children who received 3-component acellular pertussis vaccines in infancy, provided that immunity to diphtheria and tetanus is maintained. Additional booster doses could be administered at older ages to reduce reactogenicity induced by multiple administrations and to optimize the control of pertussis in adolescents and young adults. Key words: pertussis, acellular vaccine, efficacy, follow-up, prospective study, children.
"168 Given Whooping Cough Protection"
Allentown Morning Call (www.mcall.com) (10/07/03) P. B1; Wlazelek, Ann
At St. Luke's Hospital in Fountain Hill, Pa., officials have been contacting patients and families treated by a pediatrician who did not know he had whooping cough. Antibiotics have already been given to 168 children and family members, and the hospital is still attempting to contact many other patients. No one who received antibiotics tested positive for the disease. The pediatrician contracted the illness from an infected infant. Symptoms of whooping cough include fever, runny nose, and severe coughing fits. Federal officials believe whooping cough is making a comeback due to a vaccine that is only 85 percent effective against the disease with a lifespan lasting only 10 to 12 years.
U.S. IMMUNIZATION NEWS
"Whooping Cough Cases Spread"
New York Times (www.nytimes.com) (10/26/03) P. N5; Kenny, Alice
According to Dr. Michael G. Lasser, a pediatrician in Westchester County, N.Y., who has been treating many of the children involved in an outbreak of whooping cough, the majority of the children have received the vaccine against whooping cough.
The situation that is never addressed in these articles is that often these infants are exposed to other infants who have been recently vaccinated at least once with the DPT or DaPT. Now the vaccinated infants are contagious and have been in contact with the unvaccinated ones...either in the Pediatricians office or in daycare. Or they are exposed to other older toddlers of children who have been recently vaccinated with their fourth or fifth dose of the DPT.. or the DaPT.. ...."vaccine is causing the disease.....!!!!????? It is mentioned that in the mid '70's that the vaccine eliminated the whooping cough but there was an increase in the '80's. If the disease was eliminated then did the continuation of the uses of the vaccine in older and older children bringing on the resurgence of the disease????!!!! Therefore, was it prudent to give boosters of this vaccination? Is is prudent to give this vaccine to older children and adults? Or is there just $$$$$$ involved here?????
The article does mention that older adolescents and adults do not know that they are ill with the whooping cough and then they are passing it onto the infants under the age of 4 months. This is a vaccine failure in these older children and adults.. Is it not? ... The CDC and AAP recommendations are to begin vaccinating at 8 weeks.. This means that most of these babies have had at least one of the DPT vaccines at age 4 months....and now are experiencing the whooping cough that kills them... True????.. Am I missing something here?..... We all know that many babies experience the whooping cough from their first vaccination to the Pertussis. This is just another "scare" tactic here... THEY really don't know what to do here. The vaccine is failing and it is continuing to cause the disease itself. THEY have to put out these articles hoping that the reader is not aware of the truth behind the rouse.
Whooping cough still dangerous for infants even after being vaccinated
By Christi Myers
ABC13 Eyewitness News
(9/06/01) — Fifty to sixty Houston area children will get a disease this year that most of them have been vaccinated against.
What is it? Whooping cough.
6-month-old Audrey De John has almost recovered from whooping cough. Hillary De John/Baby Had Whooping Cough: "She coughed again and started turning blue right under her lip. I turned her over and patted her back and she started screaming crying." Audrey was hospitalized for whooping cough the day after she got her 2nd vaccination against it. Dr. Mark Ward/Texas Children's Hospital: "It's probably the least effective of the vaccines we give routinely to children."
Whooping cough, also called Pertussis, is part of the DTP vaccine. Originally the Pertussis part of the vaccine was controversial because it caused seizures in some children. Now it's been changed to A-cellular Pertussis. It's safer, but it's not as effective as most of us think. The Pertussis vaccine is only about 80 percent effective. That means 2 out of 10 vaccinated children can get whooping cough.
Dr. Mark Ward/Texas Children's Hospital: "However those who have been vaccinated have less severe disease than those who haven't been vaccinated." Audrey is almost over the very distinctive cough. Whooping cough can be dangerous for infants. It's milder in older children and adults. However they're likely to spread this airborne disease. Kathy Barton/Houston Health Department: "It really does require the child complete the full series of 4 immunizations."
By 12- 18 months babies should have 3 DTP shots and a booster. Until then, parents should be aware, that whooping cough is out there and that vaccinated infants can catch it.
Last Updated: Sep 6, 2001