The unmet need for pertussis prevention in patients with chronic obstructive pulmonary disease in the Italian context

Pertussis epidemiology in adults: Retrospective analysis of pertussis incidence and association with comorbidities among adult populations in Aotearoa New Zealand, using national administrative datasets

BACKGROUND

In New Zealand, approximately half reported pertussis cases are adult. Studies indicate underestimated pertussis burden in this population and probable reservoir for childhood pertussis. Pertussis is linked to chronic obstructive pulmonary disease (COPD) development and increased risk with pre-existing COPD. While acellular pertussis vaccines are available for adults, data on pertussis disease burden in adults and association with COPD remain limited.

AIM

To estimate pertussis incidence in New Zealand adult health service user (HSU) population aged ≥ 18 between 2008-2019 and inform adult pertussis vaccination strategies by assessing disease burden and risk factors in different adult populations.

METHODS

Retrospective observational cohort study using an HSU cohort, formed by linking administrative health data using unique National Health Index identifier. For primary analysis, annual incidence rates were calculated using pertussis hospitalisations and notifications. In secondary analysis, Cox proportional hazards survival analyses explored association between pertussis in adults and chronic comorbidities.

RESULTS

The cohort had 2,907,258 participants in 2008 and grew to 3,513,327 by 2019, with 11,139 pertussis cases reported. Highest annual incidence rate of 84.77 per 100,000 PYRS in 2012, notably affecting females, those aged 30-49 years, and European or Māori ethnicity. Adjusting for sociodemographic variables found no significant risk of prior pertussis notification leading to comorbidity diagnosis (Adjusted-HR: 0.972). However, individuals with prior comorbidity diagnosis had 16 % greater risk of receiving pertussis notification or diagnosis (Adjusted-HR: 1.162).

CONCLUSIONS

Study found significant pertussis burden among the HSU adult cohort and highlighted higher risk of pertussis for those with recent comorbidity diagnoses. Vaccination for pertussis should be recommended for individuals with comorbidities to reduce infection risk and disease severity. GPs must have capability to test for pertussis, given it is notifiable disease with implications for individuals, their families, and broader population. High-quality disease surveillance is crucial for informing policy decisions.

Increased Burden of Pertussis Among Adolescents and Adults With Asthma or COPD in the United States, 2007 to 2019

BACKGROUND

Individuals with chronic respiratory illnesses may be at higher risk of pertussis infection and severe pertussis than those without.

RESEARCH QUESTION

What is the incidence of pertussis and pertussis complications in cohorts with preexisting asthma or COPD vs age- and sex-matched control patients from the general population in the United States?

STUDY DESIGN AND METHODS

This observational, retrospective study included individuals aged ≥ 10 years from an administrative health claims system between 2007 and 2019. Individuals with preexisting asthma or COPD were matched with control patients from the general population. The incidence of pertussis infections and pertussis-related complications were assessed overall and by age. The incidence of asthma or COPD exacerbations was also assessed before and after diagnosis of pertussis.

RESULTS

In the general population, incidence per 100,000 person-years of pertussis infection ranged from 5.33 in 2007 to 13.04 in 2012, with highest (all years) in those aged 10 to 17 years. The risk of pertussis was higher for the asthma (rate ratio, 3.57; 95% CI, 3.25-3.92) and COPD cohorts (rate ratio, 1.83; 95% CI, 1.57-2.12) than the general population. Those with asthma or COPD had a 4.12-fold (95% CI, 3.16-5.38) and 2.82-fold (95% CI, 2.14-3.27) increased risk of pertussis with complications than the general population, respectively. Exacerbations were most frequent 30 days before pertussis diagnosis (incidence rate [IR], 25%) in the asthma cohort and 30 days before (IR, 26%) and after (IR, 22%) pertussis diagnosis, remaining elevated for 180 days after diagnosis, in the COPD cohort.

INTERPRETATION

Among these insured individuals, asthma or COPD increased the risk for pertussis disease and complications vs the general population. COPD and asthma exacerbations were observed most frequently within 30 days of receiving a pertussis diagnosis and remained elevated, suggesting a long-term effect of pertussis in the COPD cohort.

New Vaccines for Chronic Respiratory Patients

Chronic respiratory diseases (CRD) are responsible for more than four million deaths worldwide and have become especially prevalent in developed countries. Although the current therapies help manage daily symptoms and improve patients' quality of life, there is a major need to prevent exacerbations triggered mainly by respiratory infections. Therefore, CRD patients are a prime target for vaccination against infectious agents. In the present manuscript we review the state of the art of available vaccines specifically indicated in patients with CRDs. In addition to pneumococcus, influenza, pertussis, and SARS-CoV-2 vaccines, recently added immunization options like vaccines and monoclonal antibodies against respiratory syncytial virus, are particularly interesting in CRD patients. As new products reach the market, health authorities must be agile in updating immunization recommendations and in the programming of the vaccination of vulnerable populations such as patients with CRDs. Organizational and educational strategies might prove useful to increase vaccine uptake by CRD patients.

Vaccination in post-tuberculosis lung disease management: A review of the evidence

INTRODUCTION AND OBJECTIVES

Post-tuberculosis lung disease (PTLD), as other chronic respiratory disorders, may have infectious complications; some of them can be prevented with vaccinations. So far, no document has discussed the potential role of vaccination in PTLD. Therefore, the objective of this review was to describe vaccination recommendations to prevent infections potentially capable of complicating PTLD.

MATERIALS AND METHODS

A non-systematic review of the literature was conducted. The following keywords were used: tuberculosis, vaccination, vaccines and PTLD. PubMed/MEDLINE and Embase were used as the search engine, focusing on English-language literature only.

RESULTS

We identified 9 vaccines potentially useful in PTLD. Influenza, pneumococcal and anti-COVID-19 vaccinations should be recommended. Patients with PTLD can also benefit from vaccination against shingles. Vaccination against pertussis is mainly relevant during childhood. Diphtheria, tetanus and measles vaccination are recommended for general population and should be considered in patients with PTLD not previously vaccinated. Tdap (Tetanus, diphtheria, and pertussis) booster should be repeated in every adult every ten years. Vaccination against BCG retains its importance during early childhood in countries where TB is endemic.

CONCLUSIONS

Vaccination deserves to be considered among the strategies to prevent and/or mitigate PTLD complications. Further evidence is necessary to better understand which vaccines have the greatest impact and cost-benefit.

Immune response to pertussis vaccine in COPD patients

Exacerbation triggered by respiratory infection is an important cause of morbidity and mortality in chronic obstructive pulmonary disease (COPD) patients. Strategies aiming to preventing infection may have significant public health impact. Our previous study demonstrated decreased immunological response to seasonal flu vaccination in COPD patients, questioning the efficiency of other vaccines in this group of patients. We performed a prospective, monocenter, longitudinal study that evaluated the humoral and cellular responses upon pertussis vaccination. We included 13 patients with stable COPD and 8 healthy volunteers. No difference in circulating B and T cell subsets at baseline was noted. Both groups presented similar levels of TFH, plasmablasts and pertussis specific antibodies induction after vaccination. Moreover, monitoring T cell immunity after ex-vivo peptide stimulation revealed equivalent induction of functional and specific CD4+ T cells (IFNγ, TNFα and IL-2-expressing T cells) in both groups. Our results highlight the immunological efficiency of pertussis vaccination in this particularly vulnerable population and challenge the concept that COPD patients are less responsive to all immunization strategies. Healthcare providers should stress the necessity of decennial Tdap booster vaccination in COPD patients.

Available evidence and potential for vaccines for reduction in antibiotic prescriptions

Bacterial antibiotic resistance is a public health issue. It means that drugs become ineffective, infections persist and have a huge impact on the health of patients and their spreading increases. To address a complex threat such as bacterial antibiotic resistance different and integrated approaches are needed including discovery of new antibiotics, improvement of diagnostics tools and improvement of antibiotic stewardship. Absolutely relevant are prevention of infections as well as decrease in the use of antibiotics. Vaccines are an important tool in the fight against bacterial antibiotic resistance and can help prevent it in several ways. Indeed, vaccines are highly effective in preventing diseases that might otherwise require the use of antibiotics to treat symptoms and associated complications. Preventing infections through vaccination helps reduce the need for and widespread and inappropriate use of antibiotics, including for secondary bacterial infections.

Conquering the host: Bordetella spp. and Pseudomonas aeruginosa molecular regulators in lung infection

When bacteria sense cues from the host environment, stress responses are activated. Two component systems, sigma factors, small RNAs, ppGpp stringent response, and chaperones start coordinate the expression of virulence factors or immunomodulators to allow bacteria to respond. Although, some of these are well studied, such as the two-component systems, the contribution of other regulators, such as sigma factors or ppGpp, is increasingly gaining attention. Pseudomonas aeruginosa is the gold standard pathogen for studying the molecular mechanisms to sense and respond to environmental cues. Bordetella spp., on the other hand, is a microbial model for studying host-pathogen interactions at the molecular level. These two pathogens have the ability to colonize the lungs of patients with chronic diseases, suggesting that they have the potential to share a niche and interact. However, the molecular networks that facilitate adaptation of Bordetella spp. to cues are unclear. Here, we offer a side-by-side comparison of what is known about these diverse molecular mechanisms that bacteria utilize to counteract host immune responses, while highlighting the relatively unexplored interactions between them.

Experts' Opinion for Improving Pertussis Vaccination Rates in Adolescents and Adults: A Call to Action

This article highlights the importance of diphtheria-tetanus-acellular pertussis (with reduced antigen content, dTap) vaccination in preventing pertussis, a respiratory infection that is still widespread and easily transmitted. In particular, it highlights the need to receive a booster vaccination throughout life to maintain high antibody levels, which decrease through time. This document collects the opinions that emerged from the comparison between major Italian experts in the field of vaccination. This working group was created to promote a "call to action", aimed at raising awareness among all institutions, public health authorities, and health workers involved in the vaccination process, about the importance of dTap vaccine administration and with the mindset of implementing the strategic vaccination plan provided by the National Vaccine Plan (NVP). In fact, despite this vaccine being included in the NVP, there are some issues attributable to the practice of vaccination (local health authorities, vaccination centers, occupational health services, gynecology centers, societies of work). Therefore, it is necessary that the Ministry defines the vaccination coverage objectives, identifies the groups of subjects who should receive the booster vaccine (subjects exposed to greater risk of infection, subjects over 60, pregnant women), and applies all the necessary measures to encourage the implementation of this practice.

Improving vaccination rates in older adults and at-risk groups: focus on pertussis

Despite the implementation of effective paediatric vaccination programmes, pertussis remains a global health problem. Disease epidemiology has changed over time, shifting towards the adolescent and adult populations. In adults, the true burden of pertussis is greatly underestimated and pertussis vaccine coverage rates are suboptimal, including individuals with chronic conditions. Here, we report the outcomes of a virtual international scientific workshop to assess the evidence on the burden of pertussis in older adults and identify potential solutions to improve uptake of pertussis vaccines. In adults, pertussis is underdiagnosed in part due to atypical or milder clinical presentation and the lack of testing and case confirmation. However, contemporary epidemiological data denoted an increase in the burden of pertussis among adolescents and adults. This might be related to a variety of reasons including the waning of immunity over time, the lack of booster vaccination, and the improved diagnostic methods that led to increased recognition of the disease in adults. Pertussis sequelae can be severe in older adults, particularly those with existing chronic medical conditions, and the vulnerability of these groups is further enhanced by low pertussis vaccine coverage. Possible measures to increase vaccine uptake include strengthening and harmonisation of immunisation guidelines, healthcare professionals taking a more active role in recommending pertussis vaccination, involvement of vaccination centres and pharmacies in the vaccination process, and improving knowledge of pertussis burden and vaccine efficacy among the general population.

The need for pertussis vaccination among older adults and high-risk groups: a perspective from advanced economies of the Asia Pacific region

INTRODUCTION

Influenza and pneumococcal vaccines are the most regularly prescribed vaccines amongst adults <65 years of age. Pertussis booster vaccines (available as combined diphtheria-tetanus-acellular pertussis, Tdap) uptake is relatively low in many countries in the Asia-Pacific region. Increasing Tdap vaccination is a strategy that may aid healthy aging.Areas Covered: Epidemiology data, including notification reports from 6 advanced economies in Asia (Australia, Hong Kong, New Zealand, Singapore, South Korea, and Taiwan) were reviewed to assess the pertussis disease burden and identify high-risk groups. Existing Tdap vaccination recommendations were reviewed. Current vaccination practices were discussed to benchmark and identify barriers and success factors for Tdap booster vaccination in older adults.Expert Opinion: The available evidence supports Tdap vaccination at an individual level for the prevention of pertussis, along with tetanus and diphtheria in those aged 65+ years, together with influenza and pneumococcal vaccination. Data gaps need to be filled to support the development of national/supranational recommendations for pertussis booster vaccination. Groups at higher risk of pertussis infection and its complications, including those with chronic obstructive pulmonary disease and asthma, could be considered as priority groups. Increasing disease awareness and establishing adult vaccination registries could improve vaccine coverage and promote healthy aging.

Recommendations of the Italian society for infectious and tropical diseases (SIMIT) for adult vaccinations

Vaccination prevents 2-3 million deaths worldwide every year. Nevertheless, vaccine-preventable diseases (VPDs) still cause a considerable number of deaths especially in subjects belonging to "risk groups." These are represented by older adults, immunocompromised individuals and all subjects with underlying chronic medical conditions (cardiovascular, pulmonary, renal and liver chronic diseases, diabetes, immunodeficiency disorders). They have a weaker immune system and, if infected, are more likely to develop severe complications of their condition or of the preventable-infectious disease. This document summarizes the recommendations for vaccination of the main Global Institutional Organizations and analyses the risks of comorbidities associated with infectious disease and the benefits of vaccination for each specific group. The document provides a clear, practical and authoritative guide to adult vaccination.

Manifesto on the Value of Adult Immunization: "We Know, We Intend, We Advocate"

Immunization through vaccination is a milestone achievement that has made a tremendous contribution to public health. Historically, immunization programs aimed firstly to protect children, who were disproportionally affected by infectious diseases. However, vaccine-preventable diseases can have significant impacts on adult mortality, health, and quality of life. Despite this, adult vaccinations have historically been overlooked in favor of other health priorities, because their benefits to society were not well recognized. As the general population is aging, the issue of vaccination in older adults is gaining importance. In high-income countries, recommendations for the routine vaccination of older adults have been gradually introduced. The Italian National Immunization Plan is considered to be among the most advanced adult vaccination plans in Europe. However, available data indicate there is low adherence to vaccination recommendations in Italy. The COVID-19 pandemic has exposed the damage that can be caused by an infectious disease, especially among adults and individuals with comorbidities. The aim of this “Manifesto”, therefore, is to provide an overview of the existing evidence on the value of adult vaccination, in the Italian context, with a call to action to healthcare providers and health authorities.

Survey among Italian experts on existing vaccines' role in limiting antibiotic resistance

Antimicrobial resistance (AMR) is a major public health problem threatening to reverse the progress made against infectious diseases. The rapid increase of AMR exposes Italian hospitals at increased risk of untreatable infections. Vaccinations can potentially limit AMR by reducing the number of infected cases in need of antibiotics. We conducted a survey among Italian vaccine experts to record their opinion regarding the role of vaccinations against antibiotic resistance (ABR). Among 80 invited experts, 51 answered all questions. Most respondents were experts in hygiene and preventive medicine (56.9%) and aged >50 years (72.6%). ABR was a priority concern in the daily professional activity of 82.4% of respondents. Overall, 47.1% of respondents believed that all vaccinations included in the vaccination calendar played a role against ABR: 92.2% for pertussis vaccination followed by 88.2%, 74.5%, and 70.6% for meningococcus, measles, and varicella vaccinations, respectively. Almost all respondents agreed that the role of vaccinations against ABR should be clearly expressed in the national vaccination guidelines (96.1%) and Scientific Societies should take an explicit position on the issue (92.2%). These results show that Italian experts have recognized the vaccinations’ potential role in limiting ABR and guidelines from the appropriate scientific and governmental authorities are needed.

CONQUEST Quality Standards: For the Collaboration on Quality Improvement Initiative for Achieving Excellence in Standards of COPD Care

Background

Chronic obstructive pulmonary disease (COPD) are managed predominantly in primary care. However, key opportunities to optimize treatment are often not realized due to unrecognized disease and delayed implementation of appropriate interventions for both diagnosed and undiagnosed individuals. The COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST) is the first-of-its-kind, collaborative, interventional COPD registry. It comprises an integrated quality improvement program focusing on patients (diagnosed and undiagnosed) at a modifiable and higher risk of COPD exacerbations. The first step in CONQUEST was the development of quality standards (QS). The QS will be imbedded in routine primary and secondary care, and are designed to drive patient-centered, targeted, risk-based assessment and management optimization. Our aim is to provide an overview of the CONQUEST QS, including how they were developed, as well as the rationale for, and evidence to support, their inclusion in healthcare systems.

Methods

The QS were developed (between November 2019 and December 2020) by the CONQUEST Global Steering Committee, including 11 internationally recognized experts with a specialty and research focus in COPD. The process included an extensive literature review, generation of QS draft wording, three iterative rounds of review, and consensus.

Results

Four QS were developed: 1) identification of COPD target population, 2) assessment of disease and quantification of future risk, 3) non-pharmacological and pharmacological intervention, and 4) appropriate follow-up. Each QS is followed by a rationale statement and a summary of current guidelines and research evidence relating to the standard and its components.

Conclusion

The CONQUEST QS represent an important step in our aim to improve care for patients with COPD in primary and secondary care. They will help to transform the patient journey, by encouraging early intervention to identify, assess, optimally manage and followup COPD patients with modifiable high risk of future exacerbations.

Seroprevalence of Bordetella pertussis Infection in Patients With Chronic Obstructive Pulmonary Disease in England: Analysis of the AERIS Cohort

Pertussis is underdiagnosed and underreported in adults and patients with underlying conditions. Patients with chronic obstructive pulmonary disease (COPD) may be at increased risk of severe pertussis. Understanding the true prevalence of pertussis infections in such patients is important. We therefore evaluated the seroprevalence of anti-pertussis toxin (PT) antibodies in a cohort of 40-85-year-old patients diagnosed with moderate, severe or very severe COPD enrolled (between June 2011 and June 2012) in the prospective, observational "Acute Exacerbation and Respiratory InfectionS in COPD" (AERIS; NCT01360398) study, conducted in England. Serum anti-PT antibodies were measured in 104 patients using an enzyme-linked immunosorbent assay on samples collected 12 months (M12) and 24 months (M24) after enrollment. Overall, 14/104 (13.5%) patients had anti-PT concentrations ≥50 IU/mL at M12 or M24, indicative of exposure to Bordetella pertussis during the preceding 2-3 years. Of these, 6/104 (5.8%) had anti-PT ≥70 IU/mL, of whom 3/104 (2.9%) had anti-PT ≥120 IU/mL, indicative of exposure within 12 and 6 months, respectively. These results show a high circulation of B. pertussis in 40-85-year-old patients with moderate, severe or very severe COPD in England between 2012 and 2014, and call for enhanced immunization to prevent pertussis infections in such patients.

Burden of Pertussis in COPD: A Retrospective Database Study in England

Chronic obstructive pulmonary disease (COPD) may increase the risk and severity of pertussis infection. Health care resource utilization (HCRU) and direct medical costs (DMC) of treating pertussis among patients with COPD are unknown. Reported incidence of pertussis among individuals aged ≥ 50 years with COPD was assessed in Clinical Practice Research Datalink and Hospital Episode Statistics databases during 2009-2018 using a retrospective cohort design. HCRU and DMC from the National Health Service perspective were compared between patients with COPD and pertussis and propensity score-matched patients with COPD without pertussis. Seventy-eight new pertussis events were identified among 387 086 patients with COPD aged ≥ 50 years (incidence rate: 4.73; 95% confidence interval 3.74-5.91 per 100 000 person-years). HCRU and DMC were assessed among 67 patients with COPD and pertussis and 267 matched controls. During the month before the pertussis diagnosis, the rates of general practitioner (GP)/nurse visits (4289 vs. 1774 per 100 patient-years) and accident and emergency visits (182 vs. 18 per 100 patient-years) were higher in the pertussis cohort; GP/nurse visits (2935 vs. 1705 per 100 patient-years) were also higher during the following 2 months (all p < 0.001). During the month before the pertussis diagnosis, annualized per-patient total DMC were £2012 higher in the pertussis cohort (£3729 vs. £1717; p < 0.001); during the following 2 months, they were £2407 higher (£5498 vs. £3091; p < 0.001). In conclusion, a pertussis episode among individuals with COPD resulted in significant increases in HCRU and DMC around the pertussis event.

Seroprevalence of Antibodies against Diphtheria, Tetanus and Pertussis in Adult At-Risk Patients

Patients with chronic diseases are at increased risk of complications following infection. It remains, however, unknown to what extend they are protected against vaccine-preventable diseases. We assessed seroprevalence of antibodies against diphtheria, tetanus and pertussis to evaluate whether current vaccination programs in Belgium are adequate. Antibody titers were assessed with a bead-based multiplex assay in serum of 1052 adults with chronic diseases. We included patients with diabetes mellitus type 1 (DM1) (n = 172), DM2 (n = 77), chronic kidney disease (n = 130), chronic obstructive pulmonary disease (COPD) (n = 170), heart failure (n = 77), HIV (n = 196) and solid organ transplant (SOT) recipients (n = 230). Factors associated with seroprevalence were analysed with multiple logistic regression. We found seroprotective titers in 29% for diphtheria (≥0.1 IU/mL), in 83% for tetanus (≥0.1 IU/mL) and 22% had antibodies against pertussis (≥5 IU/mL). Seroprotection rates were higher (p < 0.001) when vaccinated within the last ten years. Furthermore, diphtheria seroprotection decreased with age (p < 0.001). Tetanus seroprotection was less reached in women (p < 0.001) and older age groups (p < 0.001). For pertussis, women had more often a titer suggestive of a recent infection or vaccination (≥100 IU/mL, p < 0.01). We conclude that except for tetanus, the vast majority of at-risk patients remains susceptible to vaccine-preventable diseases such as diphtheria and pertussis.