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Bennai RM, Zouaki A, El Amin G, Rahani A, Zirar J, Seffar M, Soully K, Mahraoui C, Kabbaj H. Pertussis outbreak in children hospitalized in Rabat (Morocco). Diagn Microbiol Infect Dis 2024; 109:116225. [PMID: 38492491 DOI: 10.1016/j.diagmicrobio.2024.116225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Cyclical pertussis epidemics primarily affect young infants. This study aims to estimate pertussis prevalence during the ongoing 2023 outbreak at our institution, focusing on affected age groups and clinical presentations. MATERIEL AND METHODS This retrospective study includes patients admitted to Rabat University Hospital Center from 1st January 2021 to 30th June 2023. Symptomatic patients underwent Multiplex Respiratory Panel PCR testing for respiratory infections. The analysis included cases where RT-PCR identified Bordetella spp., with data analysed using SPSS 15.0. RESULTS Pertussis cases sharply increased from December 2022, constituting 85.4 % of positive samples. Most cases (78.2 %) occurred in infants under 3 months, presenting symptoms such as coughing (94.5 %) and dyspnoea (94.5 %). Pertussis was suspected in 60 % of RT-PCR confirmed cases. B. pertussis DNA was identified in 81.8 % of cases and B. parapertussis DNA in 18.2 % of cases. CONCLUSION The study exposes a significant pertussis outbreak affecting predominantly young infants.
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Affiliation(s)
- Redouane Mammar Bennai
- Mohamed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco; Ibn Sina University Hospital Center, Specialties Hospital, Central Laboratory of Virology, Rabat, Morocco.
| | - Amal Zouaki
- Mohamed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco; Ibn Sina University Hospital Center, Specialties Hospital, Central Laboratory of Virology, Rabat, Morocco
| | - Ghizlane El Amin
- Mohamed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco; Ibn Sina University Hospital Center, Specialties Hospital, Central Laboratory of Virology, Rabat, Morocco
| | - Abdeljalil Rahani
- Mohamed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco; Ibn Sina University Hospital Center, Specialties Hospital, Central Laboratory of Virology, Rabat, Morocco
| | - Jalila Zirar
- Mohamed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco; Ibn Sina University Hospital Center, Specialties Hospital, Central Laboratory of Virology, Rabat, Morocco
| | - Myriam Seffar
- Mohamed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco; Ibn Sina University Hospital Center, Specialties Hospital, Central Laboratory of Virology, Rabat, Morocco
| | - Karim Soully
- Mohamed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco; Ibn Sina University Hospital Center, Central Laboratory of Bacteriology, Rabat, Morocco
| | - Chafik Mahraoui
- Mohamed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco; Ibn Sina University Hospital Center, Children Hospital, Rabat, Morocco
| | - Hakima Kabbaj
- Mohamed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco; Ibn Sina University Hospital Center, Specialties Hospital, Central Laboratory of Virology, Rabat, Morocco
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2
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Adewusi OO, Waldner CL, Hanington PC, Hill JE, Freeman CN, Otto SJG. Laboratory tools for the direct detection of bacterial respiratory infections and antimicrobial resistance: a scoping review. J Vet Diagn Invest 2024; 36:400-417. [PMID: 38456288 PMCID: PMC11110769 DOI: 10.1177/10406387241235968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
Rapid laboratory tests are urgently required to inform antimicrobial use in food animals. Our objective was to synthesize knowledge on the direct application of long-read metagenomic sequencing to respiratory samples to detect bacterial pathogens and antimicrobial resistance genes (ARGs) compared to PCR, loop-mediated isothermal amplification, and recombinase polymerase amplification. Our scoping review protocol followed the Joanna Briggs Institute and PRISMA Scoping Review reporting guidelines. Included studies reported on the direct application of these methods to respiratory samples from animals or humans to detect bacterial pathogens ±ARGs and included turnaround time (TAT) and analytical sensitivity. We excluded studies not reporting these or that were focused exclusively on bioinformatics. We identified 5,636 unique articles from 5 databases. Two-reviewer screening excluded 3,964, 788, and 784 articles at 3 levels, leaving 100 articles (19 animal and 81 human), of which only 7 studied long-read sequencing (only 1 in animals). Thirty-two studies investigated ARGs (only one in animals). Reported TATs ranged from minutes to 2 d; steps did not always include sample collection to results, and analytical sensitivity varied by study. Our review reveals a knowledge gap in research for the direct detection of bacterial respiratory pathogens and ARGs in animals using long-read metagenomic sequencing. There is an opportunity to harness the rapid development in this space to detect multiple pathogens and ARGs on a single sequencing run. Long-read metagenomic sequencing tools show potential to address the urgent need for research into rapid tests to support antimicrobial stewardship in food animal production.
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Affiliation(s)
- Olufunto O. Adewusi
- HEAT-AMR (Human-Environment-Animal Transdisciplinary Antimicrobial Resistance) Research Group, University of Alberta, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Cheryl L. Waldner
- Departments of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Janet E. Hill
- Veterinary Microbiology, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Claire N. Freeman
- Departments of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Simon J. G. Otto
- HEAT-AMR (Human-Environment-Animal Transdisciplinary Antimicrobial Resistance) Research Group, University of Alberta, Edmonton, AB, Canada
- Healthy Environments Thematic Area Lead, Centre for Healthy Communities, University of Alberta, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
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3
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Juscamayta-López E, Valdivia F, Soto MP, Nureña B, Horna H. A pangenome approach-based loop-mediated isothermal amplification assay for the specific and early detection of Bordetella pertussis. Sci Rep 2023; 13:4356. [PMID: 36928221 PMCID: PMC10018623 DOI: 10.1038/s41598-023-29773-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/10/2023] [Indexed: 03/18/2023] Open
Abstract
Despite widespread vaccination, Bordetella pertussis continues to cause pertussis infections worldwide, leaving infants at the highest risk of severe illness and death, while people around them are likely the main sources of infection and rapidly spread the disease. Rapid and less complex molecular testing for the specific and timely diagnosis of pertussis remains a challenge that could help to prevent the disease from worsening and prevent its transmission. We aimed to develop and validate a colorimetric loop-mediated isothermal amplification (LAMP) assay using a new target uvrD_2 informed by the pangenome for the specific and early detection of B. pertussis. Compared to that of multitarget quantitative polymerase chain reaction (multitarget qPCR) using a large clinical DNA specimen (n = 600), the diagnostic sensitivity and specificity of the uvrD_2 LAMP assay were 100.0% and 98.6%, respectively, with a 99.7% degree of agreement between the two assays. The novel colorimetric uvrD_2 LAMP assay is highly sensitive and specific for detecting B. pertussis DNA in nasopharyngeal swabs and showed similar diagnostic accuracy to complex and high-cost multitarget qPCR, but it is faster, simpler, and inexpensive, which makes it very helpful for the reliable and timely diagnosis of pertussis in primary health care and resource-limited settings.
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Affiliation(s)
- Eduardo Juscamayta-López
- Centro Nacional de Salud Pública, Instituto Nacional de Salud, Lima, Perú.
- Facultad de Salud Pública y Administración (GA, AGL), Universidad Peruana Cayetano Heredia, Lima, Perú.
| | - Faviola Valdivia
- Centro Nacional de Salud Pública, Instituto Nacional de Salud, Lima, Perú
| | - María Pía Soto
- Centro Nacional de Salud Pública, Instituto Nacional de Salud, Lima, Perú
| | - Brenda Nureña
- Centro Nacional de Salud Pública, Instituto Nacional de Salud, Lima, Perú
| | - Helen Horna
- Centro Nacional de Salud Pública, Instituto Nacional de Salud, Lima, Perú
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4
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Viswanathan R, Bafna S, Choudhary ML, Reddy M, Katendra S, Maheshwari S, Jadhav S. Looking beyond Pertussis in Prolonged Cough Illness of Young Children. Vaccines (Basel) 2022; 10:1191. [PMID: 36016079 PMCID: PMC9414653 DOI: 10.3390/vaccines10081191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 11/28/2022] Open
Abstract
Pertussis, commonly known as whooping cough, is one of the most poorly controlled vaccine-preventable diseases in the world. South-East Asia is estimated to contribute the most to childhood disease burden while this remains largely unexplored in India. The clinical diagnosis of pertussis in young children is a challenge as the classical four-stage presentation with paroxysmal cough or whoop may be absent. It is also difficult to differentiate from other respiratory infections which can cause pertussis-like illness. Children below two years with prolonged cough illness attending an urban pediatric center in western India, were evaluated for pertussis and viral infections by molecular methods. Bordetella pertussis and B. holmesii were confirmed in three each of 45 suspected cases, and RSV-A and hMPV were the most common viruses that were detected. These organisms can mimic mild cases of pertussis and need to be considered in differential diagnosis of prolonged cough illness in young children. The accurate etiology of prolonged cough illness needs to be detected and documented to ensure appropriate management and accurate estimates of disease burden.
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Affiliation(s)
- Rajlakshmi Viswanathan
- Bacteriology Group, ICMR-National Institute of Virology, 130/1, Sus Road, Pashan, Pune 411021, India; (S.K.); (S.M.)
| | - Sanjay Bafna
- Department of Pediatric Medicine, Jehangir Hospital, 32, Sassoon Road, Pune 411001, India; (S.B.); (M.R.)
| | - Manohar Lal Choudhary
- Influenza Group, ICMR-National Institute of Virology, 20-A, Ambedkar Road, Pune 411001, India; (M.L.C.); (S.J.)
| | - Monika Reddy
- Department of Pediatric Medicine, Jehangir Hospital, 32, Sassoon Road, Pune 411001, India; (S.B.); (M.R.)
| | - Savita Katendra
- Bacteriology Group, ICMR-National Institute of Virology, 130/1, Sus Road, Pashan, Pune 411021, India; (S.K.); (S.M.)
| | - Shradha Maheshwari
- Bacteriology Group, ICMR-National Institute of Virology, 130/1, Sus Road, Pashan, Pune 411021, India; (S.K.); (S.M.)
| | - Sheetal Jadhav
- Influenza Group, ICMR-National Institute of Virology, 20-A, Ambedkar Road, Pune 411001, India; (M.L.C.); (S.J.)
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5
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Kang L, Cui X, Fu J, Wang W, Li L, Li T, Wang X, Xiao F, Jia H, Mi R, Hou X. Clinical characteristics of 967 children with pertussis: a single-center analysis over an 8-year period in Beijing, China. Eur J Clin Microbiol Infect Dis 2021; 41:9-20. [PMID: 34398346 PMCID: PMC8365282 DOI: 10.1007/s10096-021-04336-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/06/2021] [Indexed: 11/26/2022]
Abstract
The purpose of this study is to understand children’s clinical characteristics with pertussis and analyze risk factors on critical pertussis patients. Demographic data from patients with pertussis at Children’s Hospital affiliated to the Capital Institute of Pediatrics between March 2011 and December 2018 were collected. We retrospectively gathered more information with the positive exposure, vaccination, antibiotic usage before diagnosis, clinical manifestation, laboratory tests, therapy, and complications for hospitalized children. We divided the patients into severe and non-severe groups, comparing related factors and clinical characteristics among each group. In particular, we summarize the clinical features of the severe patients before aggravation. A total of 967 pertussis cases were diagnosed, of which 227 were hospitalized. The onset age younger than 3 months old accounted for the highest proportion, and 126 patients received hospitalization. For those patients, the incidence of post-tussive vomiting, paroxysmal cyanosis, post-tussive heart rate decrease, hypoxemia, severe pneumonia, and mechanical ventilation was significantly higher than that in the ≥ 3-month-old group (p < 0.05). Among 227 hospitalized patients, 54 suffered from severe pertussis. Risk factors for severe patients included early age of onset, pathogen exposure, and unvaccinated status. Cough paroxysms, post-tussive vomiting, paroxysmal cyanosis, facial flushing/cyanosis/fever during cough, increased WBC, and chest X-ray revealing pneumonia/consolidation/atelectasis were important indications of severe pertussis. Unvaccinated status was an independent risk factor for severe pertussis. The most vulnerable population was infants < 3 months old to pertussis, and may be on the severe end of the disease. Pediatricians must detect and treat severe cases promptly and recommend timely vaccination for all eligible children.
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Affiliation(s)
- Limin Kang
- Department of Neonatal Medicine, Peking University First Hospital, Beijing, China
- Department of Neonatal Medicine, Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Xiaodai Cui
- Central Lab, Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Jin Fu
- Central Lab, Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Wenpeng Wang
- Department of Epidemiology, Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Li Li
- Department of Neonatal Medicine, Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Tiegeng Li
- Department of Neonatal Medicine, Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Xiaoying Wang
- Department of Neonatal Medicine, Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Fei Xiao
- Central Lab, Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Huixue Jia
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Rong Mi
- Department of Neonatal Medicine, Affiliated Children’s Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Xinlin Hou
- Department of Neonatal Medicine, Peking University First Hospital, Beijing, China
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Edmunds M, Mearkle R, Folliard J, Anderson C, Balasegaram S, Chandra N, Sawyer C, Fry NK, Ribeiro S, Palmer G, Morgan M, Underhill G, Ahmad N, Friar S, Charlett A, Litt D, Brown CS, Amirthalingam G. Retrospective cohort study investigating extent of pertussis transmission during a boarding school outbreak, England, December 2017 to June 2018. ACTA ACUST UNITED AC 2021; 26. [PMID: 34212843 PMCID: PMC8326658 DOI: 10.2807/1560-7917.es.2021.26.26.1900736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
On 1 May 2018, a pertussis outbreak was declared and widespread vaccination recommended at an all-female secondary boarding school in southern England. We conducted a retrospective cohort study to determine the extent of pertussis transmission and identify risk factors in this semi-closed population. Of 504 students and staff assessed before post-exposure vaccination, 48% (n = 240) had evidence of pertussis. A sub-analysis of 409 students found that both residential dormitory (p = 0.05) and school year (p = 0.03) were associated with pertussis, with odds decreasing by 11% for each increase in school year (95% confidence interval: 0.7-20.2). Odds of pertussis were 1.7 times higher in those assumed to have received acellular vaccines for their primary course compared with those assumed to have received whole-cell vaccines (based on date of birth), although this difference was not significant (p = 0.12). Our findings support the need for timely, widespread vaccination following identification of cases among adolescents in a semi-closed United Kingdom (UK) setting and to review the evidence for the introduction of an adolescent pertussis booster to the UK routine vaccination programme.
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Affiliation(s)
- Matt Edmunds
- UK Field Epidemiology Training Programme, PHE National Infection Service, London, England.,Immunisation and Countermeasures Division, PHE National Infection Service, London, England
| | - Rachel Mearkle
- Thames Valley Health Protection Team, Public Health England, Chilton, England
| | - Jennifer Folliard
- Thames Valley Health Protection Team, Public Health England, Chilton, England
| | | | | | | | - Clare Sawyer
- Field Service, PHE National Infection Service, London, England
| | - Norman K Fry
- Immunisation and Countermeasures Division, PHE National Infection Service, London, England.,Respiratory and Vaccine Preventable Bacteria Reference Unit, PHE National Infection Service, London, England
| | - Sonia Ribeiro
- Immunisation and Countermeasures Division, PHE National Infection Service, London, England
| | | | | | - Gill Underhill
- PHE Regional Microbiology Laboratory, Southampton General Hospital, Southampton, England
| | - Nusreen Ahmad
- PHE Regional Microbiology Laboratory, Southampton General Hospital, Southampton, England
| | - Simon Friar
- PHE Regional Microbiology Laboratory, Southampton General Hospital, Southampton, England
| | - Andre Charlett
- Statistics, Modelling and Economics Department, PHE National Infection Service, London, England
| | - David Litt
- Respiratory and Vaccine Preventable Bacteria Reference Unit, PHE National Infection Service, London, England
| | - Colin S Brown
- Respiratory and Vaccine Preventable Bacteria Reference Unit, PHE National Infection Service, London, England.,Healthcare Associated Infections and Antimicrobial Resistance Division, PHE National Infection Service, London, England
| | - Gayatri Amirthalingam
- Immunisation and Countermeasures Division, PHE National Infection Service, London, England
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7
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Taye S, Tigabu Z, Damtie D, Yismaw G, Moodley C, Nicol MP, Tessema B, Gelaw B, Moges F. Pertussis among patients with clinically compatible illness in the Amhara Regional State, Ethiopia. Int J Infect Dis 2021; 106:421-428. [PMID: 33794378 DOI: 10.1016/j.ijid.2021.03.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pertussis is an acute respiratory tract disease caused by Bordetella pertussis. In 2014, 24.1 million pertussis cases, resulting in 160,700 deaths, were estimated to have occurred worldwide. This study aimed to determine the epidemiology of pertussis among patients with clinically compatible illness who visited selected hospitals in the Amhara Regional State of Ethiopia. METHODS A cross-sectional study design was used to review pertussis patients with clinically compatible illness. Nasopharyngeal swabs were collected from 515 patients from July 2018 through February 2019. DNA was extracted from all nasopharyngeal swabs and samples were analyzed using real-time (RT-) PCR. Crude and adjusted odds ratios with corresponding 95% confidence intervals were estimated using bivariable and multivariable logistic regression analysis, respectively. RESULTS The overall prevalence of Bordetella species among the study participants was 156 of 515 (30.3%) [95% CI = 26.4-34.6] as determined by Bordetella RT-PCR, including: 65 (41.7%) B. pertussis, 89 (57.1%) indeterminate B. pertussis, one (0.6%) Bordetella holmesii and one (0.6%) Bordetella parapertussis. CONCLUSIONS This study found that pertussis is potentially endemic and a common health problem among patients visiting health institutions in the Amhara Regional State of Ethiopia. More data regarding pertussis in Ethiopia could inform development of effective prevention strategies.
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Affiliation(s)
- Solomon Taye
- Department of Medical Microbiology, University of Gondar, Gondar, Amhara Regional State, Ethiopia; Department of Medical Laboratory Sciences, Wachemo University, Hossana, South Nations Nationalities and Peoples Regional State, Ethiopia; Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa.
| | - Zemene Tigabu
- Department of Pediatrics and Child Health, University of Gondar, Gondar, Amhara Regional State, Ethiopia
| | - Debasu Damtie
- Department of Immunology and Molecular Biology, University of Gondar, Gondar, Amhara Regional State, Ethiopia; The Ohio State University Global One Health LLC, Eastern Africa Regional Office, Addis Ababa, Ethiopia
| | - Gizachew Yismaw
- Department of Medical Microbiology, University of Gondar, Gondar, Amhara Regional State, Ethiopia
| | - Clinton Moodley
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Mark P Nicol
- Division of Infection and Immunity, University of Western Australia, Perth, Australia
| | - Belay Tessema
- Department of Medical Microbiology, University of Gondar, Gondar, Amhara Regional State, Ethiopia
| | - Baye Gelaw
- Department of Medical Microbiology, University of Gondar, Gondar, Amhara Regional State, Ethiopia
| | - Feleke Moges
- Department of Medical Microbiology, University of Gondar, Gondar, Amhara Regional State, Ethiopia
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8
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Tessier E, Campbell H, Ribeiro S, Andrews N, Stowe J, Nicholls M, Morgan J, Litt D, Fry NK, Amirthalingam G. Investigation of a pertussis outbreak and comparison of two acellular booster pertussis vaccines in a junior school in South East England, 2019. Euro Surveill 2021; 26:2000244. [PMID: 33769247 PMCID: PMC7995557 DOI: 10.2807/1560-7917.es.2021.26.12.2000244] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 09/03/2020] [Indexed: 11/20/2022] Open
Abstract
In March 2019, a pertussis outbreak occurred in children in a junior school (7-11 years) in England who had been offered pertussis-containing booster vaccine at 40 months of age. In a case-control investigation, we assessed the extent of transmission and any difference in protection afforded to those who had previously received a booster 3- or 5-component acellular pertussis vaccine (aP). We took oral fluid specimens from the students to determine IgG antibodies against pertussis toxin (anti-PT). Parents of students attending the school were sent a questionnaire on pertussis symptoms and vaccination status was retrieved from general practitioner records for all students. Of 381 students, 134 (35.2%) were classified as pertussis cases, 133 by demonstration of significant anti-PT IgG titres and one clinically. There was no significant difference in the risk of pertussis between students receiving 3-component (33.7%) or 5-component (32.3%) aP boosters. However, pertussis infection differed significantly in school year 4, with 22.9%, 50.0%, 23.7% and 38.1% pertussis cases in years 3, 4, 5 and 6, respectively. The proportion of students with incomplete vaccinations recorded was higher than the proportion of those not covered according to the national reported coverage, possibly contributing to sustained transmission within the school.
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Affiliation(s)
- Elise Tessier
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom
| | - Helen Campbell
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom
| | - Sonia Ribeiro
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom
| | - Nick Andrews
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom
| | - Julia Stowe
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom
| | - Margot Nicholls
- Surrey and Sussex Health Protection Team (South East), Public Health England, Surrey, United Kingdom
| | - Jaime Morgan
- Surrey and Sussex Health Protection Team (South East), Public Health England, Surrey, United Kingdom
| | - David Litt
- Vaccine Preventable Bacteria Section, National Infection Service, Public Health England, London, United Kingdom
| | - Norman K Fry
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom
- Vaccine Preventable Bacteria Section, National Infection Service, Public Health England, London, United Kingdom
| | - Gayatri Amirthalingam
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom
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9
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Del Valle-Mendoza J, Del Valle-Vargas C, Aquino-Ortega R, Del Valle LJ, Cieza-Mora E, Silva-Caso W, Bazán-Mayra J, Zavaleta-Gavidia V, Aguilar-Luis MA, Cornejo-Pacherres H, Martins-Luna J, Cornejo-Tapia A. Clinical characteristics and molecular detection of Bordetella pertussis in hospitalized children with a clinical diagnosis of whooping cough in Peru. IRANIAN JOURNAL OF MICROBIOLOGY 2021; 13:23-30. [PMID: 33889359 PMCID: PMC8043828 DOI: 10.18502/ijm.v13i1.5488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background and Objectives Pertussis is an infectious disease caused by the Gram-negative bacterium Bordetella pertussis. In Peru, actual public health programs indicate that vaccination against B. pertussis must be mandatory and generalized, besides all detected cases must be reported. The objective of this study was to determine the prevalence of B. pertussis among children under five years of age with a presumptive diagnosis of whopping cough in Cajamarca, a region located in northern Peru. Materials and Methods The population of this cross-sectional study were children under 5 years old hospitalized as presumptive cases of pertussis during December 2017 to December 2018. The nasopharyngeal samples were analyzed by real-time PCR for the detection of B. pertussis. Results B. pertussis was identified as PCR + in 42.3% of our sample (33/78). The clinical presentation that was observed most frequently includes paroxysmal coughing (97%), difficulty breathing (69.7%), cyanosis (72.7%) and post-tussive emesis (60.6%). Additionally, pneumonia was the most observed complication (33.3%). Four of the patients with PCR+ for B. pertussis presented only lymphocytosis, five only leukocytosis, two patients with decreased leukocytosis and lymphocytes and only one patient with leukopenia and relative lymphocytosis. There was a percentage of 84.8% of unvaccinated children in the PCR+ group. Finally, the mother was the most frequent symptom carrier (18.2%). Conclusion In conclusion, in the studied population there is a high rate of PCR+ cases for B. pertussis. Laboratory values may show leukopenia or lymphopenia in patients with pertussis. It is necessary to use appropriate laboratory diagnostic tests in all infants with respiratory symptoms for B. pertussis. Since, the clinical diagnosis overestimates the diagnosis of pertussis.
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Affiliation(s)
- Juana Del Valle-Mendoza
- Molecular and Cell Biology Laboratory, Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Department of Medicine, Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Molecular Biology Laboratory, Instituto de Investigación Nutricional, Lima, Peru
| | | | - Ronald Aquino-Ortega
- Molecular and Cell Biology Laboratory, Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Molecular Biology Laboratory, Instituto de Investigación Nutricional, Lima, Peru
| | - Luis J Del Valle
- Barcelona Research Center for Multiscale Science and Engineering, Departament d'Enginyeria Quıímica, EEBE, Universidad Politècnica de Catalunya (UPC), Barcelona, Spain
| | - Erico Cieza-Mora
- Peditric Unit, Hospital Regional Docente de Cajamarca, Cajamarca, Peru
| | - Wilmer Silva-Caso
- Molecular and Cell Biology Laboratory, Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Department of Medicine, Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Molecular Biology Laboratory, Instituto de Investigación Nutricional, Lima, Peru.,Comité del Médico Joven-Consejo Nacional, Colegio Médico del Perú, Lima, Peru
| | - Jorge Bazán-Mayra
- Molecular Biology Laboratory, Laboratorio Regional de Cajamarca, Dirección Regional de Salud de Cajamarca (DIRESA), Cajamarca, Peru
| | - Victor Zavaleta-Gavidia
- Molecular Biology Laboratory, Laboratorio Regional de Cajamarca, Dirección Regional de Salud de Cajamarca (DIRESA), Cajamarca, Peru
| | - Miguel Angel Aguilar-Luis
- Molecular and Cell Biology Laboratory, Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Department of Medicine, Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Molecular Biology Laboratory, Instituto de Investigación Nutricional, Lima, Peru
| | - Hernán Cornejo-Pacherres
- Molecular Biology Laboratory, Laboratorio Regional de Cajamarca, Dirección Regional de Salud de Cajamarca (DIRESA), Cajamarca, Peru
| | - Johanna Martins-Luna
- Molecular and Cell Biology Laboratory, Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Molecular Biology Laboratory, Instituto de Investigación Nutricional, Lima, Peru
| | - Angela Cornejo-Tapia
- Molecular and Cell Biology Laboratory, Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Department of Medicine, Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
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10
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Pimenova AS, Borisova AB, Gadua NT, Borisova OY, Afanasiev SS, Petrova MS, Afanasiev MS, Mironov AY, Aleshkin VA. PCR-based diagnosis of whooping cough in the Russian Federation. Klin Lab Diagn 2021; 66:52-58. [PMID: 33567174 DOI: 10.18821/0869-2084-2021-66-1-52-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim was to determine how often the PCR method is used in different laboratories in Russia. In 2018, we conducted a questionnaire survey in diagnostic laboratories of medical organizations and the Centers of Hygiene and Epidemiology that performed PCR studies to identify microorganisms of the genus Bordetella in all 85 Russian regions. We found that in 2013 the PCR was used in 33 (38.8%) regions, but in 2017 the number of regions increased to 64 (75.3%). During 2013-2017 the study has not been applied in 21 regions. The number of PCR tests performed in the laboratories of medical organizations was significantly different. There has been an increase in the number of tests for the diagnosis of pertussis among people with clinical signs of infection and among contact persons in foci of infection. Compared to the Centers of Hygiene and Epidemiology, in medical organizations the rate of introduction of the PCR was higher. Between 2013 and 2017 the proportion of samples containing DNA B.pertussis decreased, but the proportion of samples containing DNA of other representatives of the genus Bordetella increased. Moreover, in the case of isolation DNA Bordetella spp. clinicians diagnose «Whooping cough, other unspecified organism», since there is no information on the species of the pathogen. Thus, in order to improve the diagnosis of pertussis, it is necessary to optimize PCR tests by including target genes that allow to identify of currently relevant DNAs of different representatives of the genus Bordetella.
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Affiliation(s)
- A S Pimenova
- G.N. Gabrichevsky Research Institute of Epidemiology and Microbiology
| | - A B Borisova
- G.N. Gabrichevsky Research Institute of Epidemiology and Microbiology
| | - N T Gadua
- G.N. Gabrichevsky Research Institute of Epidemiology and Microbiology
| | - O Yu Borisova
- G.N. Gabrichevsky Research Institute of Epidemiology and Microbiology
| | - S S Afanasiev
- G.N. Gabrichevsky Research Institute of Epidemiology and Microbiology
| | - M S Petrova
- G.N. Gabrichevsky Research Institute of Epidemiology and Microbiology
| | - M S Afanasiev
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation
| | - A Yu Mironov
- G.N. Gabrichevsky Research Institute of Epidemiology and Microbiology
| | - V A Aleshkin
- G.N. Gabrichevsky Research Institute of Epidemiology and Microbiology
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11
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Mihara Y, Yoshino S, Nakatani K, Nishimura T, Kan H, Yamamura Y, Tanaka E, Ishii S, Shimonodan H, Okada K, Nishiguchi T. Bordetella pertussis is a common pathogen in infants hospitalized for acute lower respiratory tract infection during the winter season. J Infect Chemother 2020; 27:497-502. [PMID: 33303359 DOI: 10.1016/j.jiac.2020.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/26/2020] [Accepted: 11/02/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION There is some evidence that Bordetella pertussis (B. pertussis) can co-infect with viral respiratory infections in young infants. METHODS B. pertussis infection was studied by culture, polymerase chain reaction (PCR), and loop-mediated isothermal amplification (LAMP) from nasopharyngeal swabs (NPSs) in 49 infants < 12 months of age, who were admitted for lower respiratory tract infections during the winter season. Seven other possible viral pathogens were documented by antigen detection or PCR in NPSs. The clinical feature of infants with mixed infection of B. pertussis and respiratory viruses were examined. RESULTS Overall, B. pertussis infection was found in 10 (20.4%) cases, nine were less than 6 months of age and seven were unvaccinated. Viral etiology was found in 41 (84%) cases and pertussis-viral co-infection was present in eight patients, five of whom had mixed infection with respiratory syncytial virus. Only the presence of staccato coughing, cyanosis, and lymphocytosis were significantly different in B. pertussis-positive cases compared with B. pertussis-negative cases. Of the 10 pertussis cases, only the culture-positive cases showed the typical symptoms and laboratory findings of pertussis in addition to virus-associated respiratory symptoms with severe hospital course, whereas cases identified as DNA-positive lacked the characteristics of pertussis and their clinical severities were the same as B. pertussis-negative cases. CONCLUSION In the absence of typical paroxysmal cough and lymphocytosis, we should carefully consider diagnosis of pertussis in young children hospitalized for presumed viral respiratory illness according to local epidemiological surveillance.
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Affiliation(s)
- Yuka Mihara
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, 5-30, Kitatakamatsu-cho, Miyazaki-shi, Miyazaki 880-0017, Japan.
| | - Shuji Yoshino
- Miyazaki Prefectural Institute for Public Health and Environment, 2-3-2, Gakuenkibanadainishi, Miyazaki-shi, Miyazaki 889-2155, Japan
| | - Keigo Nakatani
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, 5-30, Kitatakamatsu-cho, Miyazaki-shi, Miyazaki 880-0017, Japan
| | - Toyoki Nishimura
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, 5-30, Kitatakamatsu-cho, Miyazaki-shi, Miyazaki 880-0017, Japan
| | - Hiromi Kan
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, 5-30, Kitatakamatsu-cho, Miyazaki-shi, Miyazaki 880-0017, Japan
| | - Yoshiko Yamamura
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, 5-30, Kitatakamatsu-cho, Miyazaki-shi, Miyazaki 880-0017, Japan
| | - Etsuko Tanaka
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, 5-30, Kitatakamatsu-cho, Miyazaki-shi, Miyazaki 880-0017, Japan
| | - Shigeki Ishii
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, 5-30, Kitatakamatsu-cho, Miyazaki-shi, Miyazaki 880-0017, Japan
| | - Hidemi Shimonodan
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, 5-30, Kitatakamatsu-cho, Miyazaki-shi, Miyazaki 880-0017, Japan
| | - Kenji Okada
- Division of Basic Nursing, Fukuoka Nursing College, 2-15-1, Tamura, Sawara-ku, Fukuoka 814-0193, Japan
| | - Toshihiro Nishiguchi
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, 5-30, Kitatakamatsu-cho, Miyazaki-shi, Miyazaki 880-0017, Japan
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12
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Bordetella pertussis, a reemerging pathogen in pediatric respiratory infections. A study in Quito, Ecuador. Rev Argent Microbiol 2020; 53:27-33. [PMID: 33243445 DOI: 10.1016/j.ram.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 05/11/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022] Open
Abstract
Bordetella pertussis is the causative agent of pertussis, which mainly affects unvaccinated children, while Bordetella parapertussis causes a disease presenting clinical characteristics that are indistinguishable from whooping cough. Despite high vaccination coverage, pertussis remains a public health concern worldwide, with approximately 140000 cases reported annually. Here we determined the prevalence of B. pertussis and B. parapertussis infection among infants under one year of age by polymerase chain reaction (PCR); our aim being to identify whether the data obtained relates to the relevant sociodemographic and clinical data. The study included 86 samples of nasopharyngeal swabs from infants aged between 0-12 months, who were reported as probable cases of whooping cough by the health centers around the Ecuadorian highlands, from August 2016 to July 2017. The nasopharyngeal swabs were cultured and microbiological and molecular analyses were performed. B. pertussis was identified by PCR in 41% of the samples (30/86), more than half of which corresponded to infants aged between 0-3 months. Moreover, a statistically significant correlation (p<0.05) between the identification of bacteria in culture and the catarrhal stage of the disease was observed. The results obtained from the study highlighted the need for an active national surveillance of pertussis, in particular for laboratory testing, to provide a highly sensitive and more specific diagnosis of Bordetella infection.
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13
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Jiang W, Mao L, Wang K, Wang Y, Hao C, Shao X, Xu J. Prevalence of B. pertussis infection in children with clinically suspected pertussis. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2020; 54:693-700. [PMID: 32245724 DOI: 10.1016/j.jmii.2020.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 02/08/2020] [Accepted: 03/06/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pertussis is an important cause of hospitalization in children. Limited data on pertussis have been reported from China. The aim of this study was to characterize clinically suspected pertussis attributable to Bordetella pertussis among children and determine factors associated with longer duration of hospital stay in B. pertussis infection. METHODS Two hundred and seventeen consecutive children with clinically suspected pertussis were prospectively enrolled in the study between Jan 2016 through Aug 2017. Variables assessed included demographics, clinical symptoms and laboratory findings. Cox proportional hazards regression model were used to predict variables associated with longer duration of hospital stay. RESULTS Among the 217 patients with clinically suspected pertussis, B. pertussis was found in 106 (48.8%) patients. Of the 106 children with B. pertussis infection, 63 (59.4%) patients had coinfections with majority due to rhinovirus (HRV) (30.2%), Mycoplasma pneumoniae (29.2%) and human bocavirus (hBoV) (11.3%). Presence of coinfection [odds ratio (OR): 1.73, CI: 1.17-2.54], age ≤ 3 months (OR: 1.51, CI: 1.09 to 2.27), and WBC count ≥30 × 109/L (OR: 1.66, CI: 1.07 to 2.84) were independently associated with a longer hospital stay. CONCLUSIONS B. pertussis infection had a high coinfection rate with the majority of coinfections due to HRV, M. pneumoniae and hBoV. Presence of coinfection, Age ≤3 months and WBC count ≥30 × 109/L were associated with a longer hospital stay. Children admitted with pertussis need close monitoring when they had evidence of coinfection, Age ≤3 months, WBC count ≥30 × 109/L.
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Affiliation(s)
- Wujun Jiang
- Department of Respiratory Medicine, Children's Hospital of Soochow University, China; Department of Internal Medicine, Children's Hospital of Wujiang District, Suzhou, China
| | - Luyi Mao
- Department of Pediatrics, Changshu No.2 People's Hospital, China
| | - Kun Wang
- Department of Respiratory Medicine, Children's Hospital of Soochow University, China
| | - Yuqing Wang
- Department of Respiratory Medicine, Children's Hospital of Soochow University, China.
| | - Chuangli Hao
- Department of Respiratory Medicine, Children's Hospital of Soochow University, China
| | - Xuejun Shao
- Department of Clinical Laboratory, Children's Hospital of Soochow University, China
| | - Jun Xu
- Department of Clinical Laboratory, Children's Hospital of Soochow University, China
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14
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Zhang RQ, Li Z, Li GX, Tie YQ, Li XN, Gao Y, Duan QX, Wang L, Zhao L, Fan GH, Bai XD, Wang RH, Chen ZW, Wang JR, Wu Y, Zhao MC, Feng ZS, Wang J, Ma XJ. A highly sensitive one-tube nested quantitative real-time PCR assay for specific detection of Bordetella pertussis using the LNA technique. Int J Infect Dis 2020; 93:224-230. [PMID: 32045697 DOI: 10.1016/j.ijid.2020.01.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 01/24/2020] [Accepted: 01/28/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Bordetella pertussis is a highly contagious respiratory agent and is the causative pathogen of pertussis, which primarily affects children. Current diagnostic techniques for this pathogen have a variety of limitations including a long culture time, low bacterial load, and lack of specificity. METHODS This article reports the development of a one-tube nested quantitative real-time PCR assay using the locked nucleic acid (LNA) technique (LNA-OTN-q-PCR), targeting the BP485 gene and using a simple inexpensive extraction method. A total of 130 clinical samples from patients with clinically suspected pertussis, collected from the Children's Hospital of Hebei, China, were tested by LNA-OTN-q-PCR assay. RT-PCR and two-step semi-nested PCR assays were performed in parallel for comparison. RESULTS Only strains of B. pertussis were identified as positive, whereas all of the remaining strains were appropriately identified as negative by the LNA-OTN-q-PCR assay. A single copy per reaction can be detected by the LNA-OTN-q-PCR assay. Additionally, the sensitivity of this method was 100 times that of the RT-PCR assay (100 copies per reaction). Sixty-three of the 130 clinical samples were detected positive by LNA-OTN-q-PCR assay; in contrast, RT-PCR was able to detect only 41 positive samples. Following this, all 63 samples were positively identified by two-step semi-nested PCR. Compared with the two-step semi-nested PCR assay, both the specificity and sensitivity of the LNA-OTN-q-PCR assay using purified DNA and crude extract were 100%. CONCLUSIONS This assay was able to detect B. pertussis infection with high sensitivity and specificity. This test shows great potential as a promising technique to detect B. pertussis in both clinical laboratories and public health settings.
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Affiliation(s)
- Rui-Qing Zhang
- Hebei Medical University, Shijiazhuang, 050031, Hebei, China; NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China; Hebei General Hospital, Shijiazhuang, 050051, Hebei, China.
| | - Zheng Li
- Hebei General Hospital, Shijiazhuang, 050051, Hebei, China.
| | - Gui-Xia Li
- Children's Hospital of Hebei Province, Shijiazhuang, 050031, Hebei, China.
| | - Yan-Qing Tie
- Hebei General Hospital, Shijiazhuang, 050051, Hebei, China.
| | - Xin-Na Li
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
| | - Yuan Gao
- Hebei Medical University, Shijiazhuang, 050031, Hebei, China; NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
| | - Qing-Xia Duan
- Hebei Medical University, Shijiazhuang, 050031, Hebei, China; NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
| | - Le Wang
- Children's Hospital of Hebei Province, Shijiazhuang, 050031, Hebei, China.
| | - Li Zhao
- Children's Hospital of Hebei Province, Shijiazhuang, 050031, Hebei, China.
| | - Guo-Hao Fan
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
| | - Xue-Ding Bai
- Tangshan Gongren Hospital, Tangshan, 063000, China.
| | - Rui-Huan Wang
- Hunan Provincial Center for Disease Control and Prevention, Hunan, 410005, China.
| | - Zi-Wei Chen
- The Third Xiangya Hospital of Central South University, Hunan, 410013, China.
| | - Jin-Rong Wang
- Hebei Medical University, Shijiazhuang, 050031, Hebei, China; NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
| | - Yong Wu
- Health Gene Technologies, Ningbo, 315040, China.
| | - Meng-Chuan Zhao
- Children's Hospital of Hebei Province, Shijiazhuang, 050031, Hebei, China.
| | - Zhi-Shan Feng
- Hebei Medical University, Shijiazhuang, 050031, Hebei, China; Hebei General Hospital, Shijiazhuang, 050051, Hebei, China.
| | - Ji Wang
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
| | - Xue-Jun Ma
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
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15
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Rabi A, Rokni T, Bennaoui F, Rada N, El Idrissi Slitine N, Draiss G, Bourouss M, Fadl Mrabih Rabou M, Bouskraoui M, Soraa N. Epidemiology of pertussis in Marrakech and contribution of molecular diagnosis. Infect Dis (Lond) 2019; 51:703-705. [PMID: 31274041 DOI: 10.1080/23744235.2019.1637537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Adil Rabi
- a Microbiology Service, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
| | - Taoufik Rokni
- a Microbiology Service, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
| | - Fatiha Bennaoui
- b Neonatal Service, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
| | - Noureddine Rada
- c Paediatric Service A, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
| | - Nadia El Idrissi Slitine
- b Neonatal Service, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
| | - Ghizlan Draiss
- c Paediatric Service A, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
| | - Mounir Bourouss
- d Paediatric Emergency Department, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
| | - Maoulainine Fadl Mrabih Rabou
- b Neonatal Service, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
| | - Mohamed Bouskraoui
- c Paediatric Service A, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
| | - Nabila Soraa
- a Microbiology Service, University Hospital Centre of Marrakech- Faculty of Medicine and Pharmacy of Marrakech - CADI AYYAD University of Marrakech , Marrakech , Morocco
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Liu Z, Liu S, Shu Y, Yang Z, Peng B, Xu H, Li Q, Luo Z, Dai J, Liu E, Fu Z, Zou L. Severe Bordetella pertussis infection and vaccine issue in Chongqing, from 2012 to 2018. Int J Infect Dis 2019; 84:102-108. [PMID: 31100420 DOI: 10.1016/j.ijid.2019.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Pertussis is a highly contagious respiratory illness mainly caused by the Gram-negative bacterium Bordetella pertussis. The infection of B. pertussis has been increasing and the current diagnosis of pertussis in children is challenging; little is known of B. pertussis infection in Chongqing. METHODS There were 25,441 children (14,863 male and 10,578 female) with suspected pertussis enrolled in our retrospective study from December 2012 to November 2018. Then 800 children with suspected B. pertussis infection were randomly chosen to be evaluated by simultaneous amplification and testing in this prospective study. RESULTS Infants younger than 12 months had the greatest burden of pertussis, and the incidence of pertussis in Chongqing appeared to have a periodic pattern. The problem of vaccine quality in China was more serious than previously reported based on the fluctuation of infection rates from 2012 to 2018. Simultaneous amplification and testing to detect B. pertussis RNA (Area Under Curve: 0.900 and Kappa value: 0.831) had better diagnostic performance than real-time PCR for B. pertussis DNA (Area Under Curve: 0.869 and Kappa value: 0.690). CONCLUSIONS We revealed the characteristics of B. pertussis infection and vaccine issues in Chongqing. Simultaneous amplification and testing could be a potential novel assay for measuring B. pertussis infection in the future.
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Affiliation(s)
- Zhidai Liu
- Center for Clinical Molecular Medicine, Children's Hospital of Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Shan Liu
- Center for Clinical Molecular Medicine, Children's Hospital of Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Yi Shu
- Center for Clinical Molecular Medicine, Children's Hospital of Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Zuqun Yang
- Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China; Department of Preventive Medicine, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China
| | - Bin Peng
- Department of Health Statistics, School of Public Health, Chongqing Medical University, Yuzhong District, Chongqing, China
| | - Hongmei Xu
- Department of Infectious Disease, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Qubei Li
- Department of Respiratory Medicine, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Zhengxiu Luo
- Department of Respiratory Medicine, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Jihong Dai
- Department of Respiratory Medicine, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Enmei Liu
- Department of Respiratory Medicine, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Zhou Fu
- Department of Respiratory Medicine, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Lin Zou
- Center for Clinical Molecular Medicine, Children's Hospital of Chongqing Medical University, Yuzhong District, Chongqing, China; Ministry of Education Key Laboratory of Development and Disorders, Children's Hospital, Chongqing Medical University, Yuzhong District, Chongqing, China; Key Laboratory of Pediatrics in Chongqing, Children's Hospital, Chongqing Medical University, Chongqing, China.
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17
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Validation and Implementation of a Diagnostic Algorithm for DNA Detection of Bordetella pertussis, B. parapertussis, and B. holmesii in a Pediatric Referral Hospital in Barcelona, Spain. J Clin Microbiol 2019; 57:JCM.01231-18. [PMID: 30404946 PMCID: PMC6322476 DOI: 10.1128/jcm.01231-18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/24/2018] [Indexed: 01/04/2023] Open
Abstract
This study aimed to validate a comprehensive diagnostic protocol based on real-time PCR for the rapid detection and identification of Bordetella pertussis, Bordetella parapertussis, and Bordetella holmesii, as well as its implementation in the diagnostic routine of a reference children's hospital. The new algorithm included a triplex quantitative PCR (qPCR) targeting IS481 gene (in B. pertussis, B. holmesii, and some Bordetella bronchiseptica strains), pIS1001 (B. parapertussis-specific) and rnase P as the human internal control. Two confirmatory singleplex tests for B. pertussis (ptxA-Pr) and B. holmesii (hIS1001) were performed if IS481 was positive. Analytical validation included determination of linear range, linearity, efficiency, precision, sensitivity, and a reference panel with clinical samples. Once validated, the new algorithm was prospectively implemented in children with clinical suspicion of whooping cough presenting to Hospital Sant Joan de Deu (Barcelona, Spain) over 12 months. Lower limits of detection obtained were 4.4, 13.9, and 27.3 genomic equivalents/ml of sample for IS481 (on B. pertussis), pIS1001 and hIS1001, and 777.9 for ptxA-Pr. qPCR efficiencies ranged from 86.0% to 96.9%. Intra- and interassay variabilities were <3% and <5%, respectively. Among 566 samples analyzed, B. pertussis, B. holmesii, and B. parapertussis were detected in 11.1%, 0.9% (only in females >4 years old), and 0.2% of samples, respectively. The new algorithm proved to be a useful microbiological diagnostic tool for whooping cough, demonstrating a low rate of other non-pertussis Bordetella species in our surveilled area.
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Stefanelli P. Pertussis: Identification, Prevention and Control. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1183:127-136. [PMID: 31321754 DOI: 10.1007/5584_2019_408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pertussis is a vaccine-preventable disease. Despite the high vaccination coverage among children, pertussis is considered a re-emerging disease for which identification, prevention and control strategies need to be improved. To control pertussis it is important to maintain a high vaccination coverage to protect the age groups considered at high risk for the disease. Laboratory confirmation of Bordetella pertussis infection together with a differential diagnostic test for other Bordetellae are prerequisite for a correct and timely diagnosis of pertussis. Moreover, investigations of antimicrobial susceptibility and whole genome sequencing may permit to monitor the circulation of antimicrobials resistant and/or vaccine-escape strains. Finally, the preventive framework should no longer consider pertussis exclusively as a childhood infectious disease, since adults may play a role in transmission events.
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Affiliation(s)
- Paola Stefanelli
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy.
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19
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Del Valle-Mendoza J, Silva-Caso W, Aguilar-Luis MA, Del Valle-Vargas C, Cieza-Mora E, Martins-Luna J, Aquino-Ortega R, Silva-Vásquez A, Bazán-Mayra J, Weilg P. Bordetella pertussis in children hospitalized with a respiratory infection: clinical characteristics and pathogen detection in household contacts. BMC Res Notes 2018; 11:318. [PMID: 29776433 PMCID: PMC5960213 DOI: 10.1186/s13104-018-3405-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/07/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Describe the prevalence of Bordetella pertussis via PCR in children under 5 years old hospitalized as probable cases of pertussis and report the most common clinical features among them. RESULTS A positive PCR result for B. pertussis was observed in 20.5% of our samples (18/88), one-third of them were from infants between 2 and 3 months old. The most common symptoms were paroxysms of coughing (88.9%), difficulty breathing (72.2%), cyanosis (77.8%) and fever (50%). The mother was the most common symptomatic carrier (27.8%), followed by uncles/aunts (22.2%) among children with pertussis.
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Affiliation(s)
- Juana Del Valle-Mendoza
- Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru. .,Laboratorio de Biología Molecular, Instituto de Investigación Nutricional, Lima, Peru.
| | - Wilmer Silva-Caso
- Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Laboratorio de Biología Molecular, Instituto de Investigación Nutricional, Lima, Peru
| | - Miguel Angel Aguilar-Luis
- Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Laboratorio de Biología Molecular, Instituto de Investigación Nutricional, Lima, Peru.,Instituto de Investigación de Enfermedades Infecciosas, Lima, Peru
| | - Cristina Del Valle-Vargas
- Instituto de Investigación de Enfermedades Infecciosas, Lima, Peru.,Facultad de Medicina, Univesidad de Barcelona, Barcelona, Spain
| | - Erico Cieza-Mora
- Servicio de Pediatría, Hospital Docente Regional de Salud de Cajamarca, Cajamarca, Peru
| | - Johanna Martins-Luna
- Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - Ronald Aquino-Ortega
- Laboratorio de Biología Molecular, Instituto de Investigación Nutricional, Lima, Peru.,Instituto de Investigación de Enfermedades Infecciosas, Lima, Peru
| | | | - Jorge Bazán-Mayra
- Laboratorio de Referencia, Dirección Regional de Salud de Cajamarca (DIRESA), Cajamarca, Peru
| | - Pablo Weilg
- Research and Innovation Centre of the Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.
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Aquino-Andrade A, Martínez-Leyva G, Mérida-Vieyra J, Saltigeral P, Lara A, Domínguez W, García de la Puente S, De Colsa A. Real-Time Polymerase Chain Reaction-Based Detection of Bordetella pertussis in Mexican Infants and Their Contacts: A 3-Year Multicenter Study. J Pediatr 2017. [PMID: 28622957 DOI: 10.1016/j.jpeds.2017.05.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To evaluate the usefulness of real-time polymerase chain reaction (RT-PCR) as a diagnostic method for the detection of Bordetella pertussis in hospitalized patients aged <1 year with a clinical diagnosis of whooping cough, as well as to identify the role of household contacts as a source of infection. STUDY DESIGN This was a prospective, multicenter study of infants aged <1 year who were hospitalized with symptoms suggestive of whooping cough. Nasopharyngeal samples were obtained for culture and RT-PCR testing. The clinical and epidemiologic characteristics and outcomes were analyzed. B pertussis detection and symptoms in household contacts of patients diagnosed with pertussis were studied. RESULTS A total of 286 patients were included; of these, 67.1% had B pertussis and 4.5% had Bordetella spp. Complications occurred in 20% of patients, and the mortality rate was 6.7%. Of 434 contacts studied, 111 were mothers of study infants, representing the most frequently B pertussis-infected group and the main symptomatic contact. CONCLUSION The use of RT-PCR permits improved detection and diagnosis of pertussis and a better understanding of the epidemiology of sources of infection. The complications and mortality rate of pertussis continue to be high. Household contacts are confirmed as a frequent source of infection of B pertussis in young children.
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Affiliation(s)
| | - Gabriel Martínez-Leyva
- Molecular Microbiology Laboratory, National Institute of Pediatrics, Mexico City, Mexico
| | - Jocelin Mérida-Vieyra
- Molecular Microbiology Laboratory, National Institute of Pediatrics, Mexico City, Mexico
| | - Patricia Saltigeral
- Department of Pediatric Infectious Diseases, National Institute of Pediatrics, Mexico City, Mexico
| | - Antonino Lara
- Bacteriology Laboratory, National Institute of Pediatrics, Mexico City, Mexico
| | - Wendy Domínguez
- Department of Epidemiology, National Institute of Pediatrics, Mexico City, Mexico
| | | | - Agustín De Colsa
- Molecular Microbiology Laboratory, National Institute of Pediatrics, Mexico City, Mexico; Department of Pediatric Infectious Diseases, National Institute of Pediatrics, Mexico City, Mexico.
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Abstract
BACKGROUND Pertussis immunization programs aim to prevent severe infant disease. We investigated temporal trends in infant pertussis deaths and pediatric intensive care unit (PICU) admissions and associations of changes in disease detection and vaccines used with death and PICU admission rates. METHODS Using national data from New Zealand (NZ), we described infant pertussis deaths and PICU admissions from 1991 to 2013, over which time national immunization coverage at 2 years of age increased from <80% to 92%. In NZ, pertussis became a notifiable disease with polymerase chain reaction (PCR) diagnosis available in 1997 and acellular replaced whole-cell vaccine in 2000. We used Poisson regression to model temporal trends and compared rates in time intervals using rate ratios (RRs) with 95% confidence intervals (CIs). RESULTS There were 10 pertussis deaths and 159 infant PICU admissions with pertussis from 1991 to 2013. The annual number of infant pertussis PICU admissions increased from 1991 to 2013 (P = 0.02) but the number of pertussis deaths did not (P = 0.09). The risk of PICU admission during infancy with pertussis was increased in the notification/PCR versus the non-notification/PCR era (RR: 1.12; 95% CI: 1.02-1.19) and when acellular replaced whole-cell vaccine (RR: 1.19; 95% CI: 1.06-1.31). Median Pediatric Index of Mortality scores during 2001-2013 were lower than during 1991-1999 (P < 0.001). CONCLUSIONS Infant PICU pertussis admission rates have increased in NZ despite improvements in immunization coverage. Higher rates have occurred since pertussis notification/PCR became available and since acellular replaced whole-cell vaccine. The severity of disease in infants admitted to PICU with pertussis has decreased in recent years.
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Survey of Household Contacts of Infants With Laboratory-confirmed Pertussis Infection During a National Pertussis Outbreak in England and Wales. Pediatr Infect Dis J 2017; 36:140-145. [PMID: 27755466 DOI: 10.1097/inf.0000000000001378] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Highest rates of pertussis occur in infants <3 months of age, too young to be fully vaccinated. The 2012 national outbreak provided a valuable opportunity to study sources of infection for these infants at highest risk of severe complications and death. METHODS Households of infants <3 months of age with laboratory-confirmed pertussis between August 2012 and October 2013 were invited to complete a questionnaire with information on household members' demographics, relationship with the infant, chronology of cough onset where relevant and vaccination history. Contacts were also invited to provide an oral fluid sample for antipertussis toxin IgG testing. Individuals with laboratory evidence of infection and cough onset up to 3 months before infant onset were considered probable sources of infection. RESULTS In total, 220 contacts from 63 families were included in the analysis. In 86% of households (54/63), at least one positive result was found with 44% (97/220) of all contacts testing positive. Around 29% (31/108) of noncoughers tested positive. A probable source of infection was found for 46% (29/63) of infant cases. Mothers were the probable source in 38% of cases, followed by siblings (31%) and fathers (10%). CONCLUSION Household contacts play an important role in the transmission of pertussis to infants and when identified, mothers were the main sources of infection. Immunization during pregnancy has a key role in preventing infant disease through passive protection from birth and reduced maternal exposure.
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Stefanelli P, Buttinelli G, Vacca P, Tozzi AE, Midulla F, Carsetti R, Fedele G, Villani A, Concato C. Severe pertussis infection in infants less than 6 months of age: Clinical manifestations and molecular characterization. Hum Vaccin Immunother 2017; 13:1073-1077. [PMID: 28129036 PMCID: PMC5443365 DOI: 10.1080/21645515.2016.1276139] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We conducted a study to determine the main traits of pertussis among unimmunized infants less than 6 months of age. From August 2012 to March 2015, 141 nasopharyngeal aspirates (NPAs) were collected from infants with respiratory symptoms attending 2 major hospitals in Rome. Clinical data were recorded and analyzed. Lab-confirmation was performed by culture and realtime PCR. B. pertussis virulence-associated genes (ptxP, ptxA and prn), together with multilocus variable-number tandem repeat analysis (MLVA), were also investigated by the sequence-based analysis on the DNAs extracted from positive samples. Antibiotic susceptibility with Etest was defined on 18 viable B. pertussis isolates. Samples from 73 infants resulted positives for B. pertussis. The median age of the patients was 45 d (range 7–165); 21 infants were treated with macrolides before hospital admission. Cough was reported for a median of 10 d before admission and 18 d after hospital discharge among infected infants, 84% of whom showed paroxysmal cough. No resistance to macrolides was detected. Molecular analysis identified MT27 as the predominant MLVA profile, combined with ptxP3-ptxA1-prn2 associated virulence genes. Although our data may not be generalized to the whole country, they provide evidence of disease severity among infants not vaccinated against pertussis. Moreover, genetically related B. pertussis strains, comprising allelic variants of virulence associated genes, were identified.
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Affiliation(s)
- Paola Stefanelli
- a Department of Infectious Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Gabriele Buttinelli
- a Department of Infectious Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Paola Vacca
- a Department of Infectious Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Alberto E Tozzi
- b Multifactorial Disease and Complex Phenotype Research Area, Bambino Gesù Children Hospital IRCCS , Rome , Italy
| | - Fabio Midulla
- c Departments of Pediatrics . "Sapienza" University of Rome , Rome , Italy
| | - Rita Carsetti
- d Immunology Unit, Immunology and Pharmacotherapy Area, Bambino Gesù Children Hospital IRCSS , Rome , Italy
| | - Giorgio Fedele
- a Department of Infectious Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Alberto Villani
- e Department of Pediatrics and Infectious Disease , Bambino Gesù Children Hospital IRCSS , Rome , Italy
| | - Carlo Concato
- f Virology Unit, Bambino Gesù Children Hospital IRCCS , Rome , Italy
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Vittucci AC, Spuri Vennarucci V, Grandin A, Russo C, Lancella L, Tozzi AE, Bartuli A, Villani A. Pertussis in infants: an underestimated disease. BMC Infect Dis 2016; 16:414. [PMID: 27528377 PMCID: PMC4986228 DOI: 10.1186/s12879-016-1710-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 07/12/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The clinical diagnosis of pertussis is not easy in early infancy since clinical manifestations can overlap with several different diseases. Many cases are often misclassified and underdiagnosed. We conducted a retrospective study on infants to assess how often physicians suspected pertussis and the actual frequency of Bordetella pertussis infections. METHODS We analyzed all infants with age ≤90 days hospitalized from March 2011 until September 2013 for acute respiratory symptoms tested with a Real Time Polymerase Chain Reaction able to detect Bordetella pertussis and with a Real Time Polymerase Chain Reaction for a multipanel respiratory virus. Therefore, we compared patients with pertussis positive aspirate, patients with respiratory virus positive aspirate and patients with negative aspirate to identify symptoms or clinical findings predictive of pertussis. RESULTS Out of 215 patients analyzed, 53 were positive for pertussis (24.7 %), 119 were positive for respiratory virus (55.3 %) and 43 had a negative aspirate (20 %). Pertussis was suspected in 22 patients at admission and 16 of them were confirmed by laboratory tests, while 37 infants with different admission diagnosis resulted positive for pertussis. The sensitivity of clinical diagnosis was 30.2 % and the specificity 96.3 %. Infants with pertussis had more often paroxysmal cough, absence of fever and a higher absolute lymphocyte count than infants without pertussis. CONCLUSIONS Pertussis is a serious disease in infants and it is often unrecognized; some features should help pediatricians to suspect pertussis, but clinical suspicion has a low sensitivity. We suggest a systematic use of Real Time Polymerase Chain Reaction to support the clinical suspicion of pertussis in patients with less than 3 months of age hospitalized with acute respiratory symptoms.
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Affiliation(s)
- Anna Chiara Vittucci
- General Pediatric and Infectious Diseases Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Annalisa Grandin
- General Pediatric and Infectious Diseases Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Cristina Russo
- Virology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Laura Lancella
- General Pediatric and Infectious Diseases Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Andrea Bartuli
- Rare Disease and Medical Genetics Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- General Pediatric and Infectious Diseases Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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25
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Sali M, Buttinelli G, Fazio C, Vacca P, La Sorda M, Carannante A, Spanu T, Valentini P, Stefanelli P. Pertussis in infants less than 6 months of age and household contacts, Italy, April 2014. Hum Vaccin Immunother 2016; 11:1173-4. [PMID: 25874559 DOI: 10.1080/21645515.2015.1019190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
We report pertussis cases in 4 infants less than 6 months admitted with symptoms compatible with pertussis to the intensive care unit of the Università Cattolica del Sacro Cuore in Rome, April 2014. Realtime PCR confirmed pertussis diagnosis for the 4 infants, 2 of them were cousins, and for the household contacts of 1 of them. Analysis of pertussis toxin, its promoter and pertactin was also performed. First of all, this report emphasizes the need to investigate household contact of infants with pertussis; secondly, to evaluate the selective vaccination of household members of newborns as an effective program to reduce pertussis in infants.
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Affiliation(s)
- Michela Sali
- a Institute of Microbiology; Università Cattolica del Sacro Cuore ; Rome , Italy
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26
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Salim AM, Liang Y, Kilgore PE. Protecting Newborns Against Pertussis: Treatment and Prevention Strategies. Paediatr Drugs 2015; 17:425-41. [PMID: 26542059 DOI: 10.1007/s40272-015-0149-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pertussis is a potentially severe respiratory disease, which affects all age groups from young infants to older adults and is responsible for an estimated 195,000 deaths occurred globally in 2008. Active research is ongoing to better understand the pathogenesis, immunology, and diagnosis of pertussis. For diagnosis, molecular assays (e.g., polymerase chain reaction) for detection of Bordetella pertussis have become more widely available and support improved outbreak detection. In children, pertussis vaccines have been incorporated into routine immunization schedules and deployed for pertussis outbreak control. Lower levels of vaccine coverage are now being observed in communities where vaccine hesitancy is rising. Additionally, recognition that newborn babies are at risk of pertussis in the USA and UK has led to recommendations to immunize pregnant women. Among adolescents and older adults in the USA, Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular pertussis (Tdap) Vaccines are recommended, but substantial individual- and system-level barriers exist that will make achieving national Healthy People 2020 targets for immunization challenging. Current antimicrobial regimens for pertussis are focused on reducing the severity of disease, reducing rates of sequelae, and minimizing transmission of infection to susceptible individuals. Continued surveillance for pertussis will be important to identify opportunities for reducing young infants' exposure and reducing the impact of outbreaks among school-aged children. Laboratory-based surveillance for newly emerging strains of B. pertussis will be important to identify strains that may evade protection elicited by currently available vaccines. Efforts to develop new-generation pertussis vaccines should be considered now in anticipation of vaccine development programs, which may require ten or more years to deliver a licensed vaccine.
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Affiliation(s)
- Abdulbaset M Salim
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA.
| | - Yan Liang
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA. .,Institute of Medical Biology, Chinese Academy of Medical Science, Peking Union Medical College, Kunming, China.
| | - Paul E Kilgore
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA.
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Brotons P, de Paz HD, Esteva C, Latorre I, Muñoz-Almagro C. Validation of a loop-mediated isothermal amplification assay for rapid diagnosis of pertussis infection in nasopharyngeal samples. Expert Rev Mol Diagn 2015; 16:125-30. [PMID: 26565672 DOI: 10.1586/14737159.2016.1112741] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To develop and validate a novel loop-mediated amplification (LAMP) assay for rapid diagnosis (<1 hour) of whooping cough in nasopharyngeal samples versus the gold standard: real-time PCR. METHODS The study included all nasopharyngeal samples (n = 213) collected from children with clinical suspicion of pertussis admitted to Children's University Hospital Sant Joan de Déu (Barcelona, Spain) during July-December 2014. Fresh samples were routinely analyzed by real-time PCR and stored for retrospective LAMP analysis, following an easy 30 minute DNA extraction step by Chelex-100. RESULTS Performance results of the LAMP assay were: linearity, 10(5)-10(1) CFU/ml; Limit of Detection, 2 CFU/ml; precision (mean CV), 7.38%; diagnostic sensitivity, 96.55%; diagnostic specificity, 99.46%; time to detection, 12-30 minutes. CONCLUSION The new test was shown to be 2.5-fold faster than real-time PCR while maintaining similar levels of analytical and clinical performance. Therefore it could become a useful diagnostic tool for molecular point-of-care testing.
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Affiliation(s)
- Pedro Brotons
- a Department of Molecular Microbiology , Hospital Sant Joan de Déu, University of Barcelona , Barcelona , Spain
| | - Hector D de Paz
- a Department of Molecular Microbiology , Hospital Sant Joan de Déu, University of Barcelona , Barcelona , Spain
| | - Cristina Esteva
- a Department of Molecular Microbiology , Hospital Sant Joan de Déu, University of Barcelona , Barcelona , Spain
| | - Irene Latorre
- a Department of Molecular Microbiology , Hospital Sant Joan de Déu, University of Barcelona , Barcelona , Spain
| | - Carmen Muñoz-Almagro
- a Department of Molecular Microbiology , Hospital Sant Joan de Déu, University of Barcelona , Barcelona , Spain
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Laboratory-based surveillance of pertussis using multitarget real-time PCR in Japan: evidence for Bordetella pertussis infection in preteens and teens. New Microbes New Infect 2015; 8:70-4. [PMID: 27076914 PMCID: PMC4815931 DOI: 10.1016/j.nmni.2015.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 10/05/2015] [Accepted: 10/05/2015] [Indexed: 11/20/2022] Open
Abstract
Between January 2013 and December 2014, we conducted laboratory-based surveillance of pertussis using multitarget real-time PCR, which discriminates among Bordetella pertussis, Bordetella parapertussis, Bordetella holmesii and Mycoplasma pneumoniae. Of 355 patients clinically diagnosed with pertussis in Japan, B. pertussis, B. parapertussis and M. pneumoniae were detected in 26% (n = 94), 1.1% (n = 4) and 0.6% (n = 2), respectively, whereas B. holmesii was not detected. It was confirmed that B. parapertussis and M. pneumoniae are also responsible for causing pertussis-like illness. The positive rates for B. pertussis ranged from 16% to 49%, depending on age. Infants aged ≤ 3 months had the highest rate (49%), and children aged 1 to 4 years had the lowest rate (16%, p < 0.01 vs. infants aged ≤ 3 months). Persons aged 10 to 14 and 15 to 19 years also showed high positive rates (29% each); the positive rates were not statistically significant compared with that of infants aged ≤ 3 months (p ≥ 0.06). Our observations indicate that similar to infants, preteens and teens are at high risk of B. pertussis infection.
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Abstract
The introduction of vaccination in the 1950s significantly reduced the morbidity and mortality of pertussis. However, since the 1990s, a resurgence of pertussis has been observed in vaccinated populations, and a number of causes have been proposed for this phenomenon, including improved diagnostics, increased awareness, waning immunity, and pathogen adaptation. The resurgence of pertussis highlights the importance of standardized, sensitive, and specific laboratory diagnoses, the lack of which is responsible for the large differences in pertussis notifications between countries. Accurate laboratory diagnosis is also important for distinguishing between the several etiologic agents of pertussis-like diseases, which involve both viruses and bacteria. If pertussis is diagnosed in a timely manner, antibiotic treatment of the patient can mitigate the symptoms and prevent transmission. During an outbreak, timely diagnosis of pertussis allows prophylactic treatment of infants too young to be (fully) vaccinated, for whom pertussis is a severe, sometimes fatal disease. Finally, reliable diagnosis of pertussis is required to reveal trends in the (age-specific) disease incidence, which may point to changes in vaccine efficacy, waning immunity, and the emergence of vaccine-adapted strains. Here we review current approaches to the diagnosis of pertussis and discuss their limitations and strengths. In particular, we emphasize that the optimal diagnostic procedure depends on the stage of the disease, the age of the patient, and the vaccination status of the patient.
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Affiliation(s)
- Anneke van der Zee
- Molecular Diagnostics Unit, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Frits R Mooi
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands Laboratory of Pediatric Infectious Diseases, Department of Pediatrics, Radboud University Medical Centre, Nijmegen, The Netherlands
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30
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The contribution of PCR testing to influenza and pertussis notifications in Australia. Epidemiol Infect 2015; 144:306-14. [DOI: 10.1017/s0950268815001004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
SUMMARYInfluenza and pertussis are the two most common vaccine-preventable infections notified in Australia. We assessed the role of polymerase chain reaction (PCR) diagnosis in influenza and pertussis cases notified to the Australian National Notifiable Diseases Surveillance System (NNDSS). There were a total of 2 10 786 notified influenza cases (2001–2013) and 2 55 866 notified pertussis cases (1991–2013). After 1 January 2007, the majority of influenza and pertussis notifications were PCR-based (80·5% and 59·6%, respectively). Before 31 December 2006, PCR-based notifications were limited (29·1% and 11·7%, respectively). By 2013, PCR-based notifications had largely replaced all other diagnostic methods, with the exception of serology-based notifications in pertussis cases in adults aged ⩾25 years.
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31
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Gambhir M, Clark TA, Cauchemez S, Tartof SY, Swerdlow DL, Ferguson NM. A change in vaccine efficacy and duration of protection explains recent rises in pertussis incidence in the United States. PLoS Comput Biol 2015; 11:e1004138. [PMID: 25906150 PMCID: PMC4408109 DOI: 10.1371/journal.pcbi.1004138] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 01/16/2015] [Indexed: 01/27/2023] Open
Abstract
Over the past ten years the incidence of pertussis in the United States (U.S.) has risen steadily, with 2012 seeing the highest case number since 1955. There has also been a shift over the same time period in the age group reporting the largest number of cases (aside from infants), from adolescents to 7–11 year olds. We use epidemiological modelling and a large case incidence dataset to explain the upsurge. We investigate several hypotheses for the upsurge in pertussis cases by fitting a suite of dynamic epidemiological models to incidence data from the National Notifiable Disease Surveillance System (NNDSS) between 1990–2009, as well as incidence data from a variety of sources from 1950–1989. We find that: the best-fitting model is one in which vaccine efficacy and duration of protection of the acellular pertussis (aP) vaccine is lower than that of the whole-cell (wP) vaccine, (efficacy of the first three doses 80% [95% CI: 78%, 82%] versus 90% [95% CI: 87%, 94%]), increasing the rate at which disease is reported to NNDSS is not sufficient to explain the upsurge and 3) 2010–2012 disease incidence is predicted well. In this study, we use all available U.S. surveillance data to: 1) fit a set of mathematical models and determine which best explains these data and 2) determine the epidemiological and vaccine-related parameter values of this model. We find evidence of a difference in efficacy and duration of protection between the two vaccine types, wP and aP (aP efficacy and duration lower than wP). Future refinement of the model presented here will allow for an exploration of alternative vaccination strategies such as different age-spacings, further booster doses, and cocooning. Over the past ten years the incidence of pertussis in the United States (U.S.) has risen steadily, with 2012 seeing the highest case number since 1955. There has also been a shift over the same time period in the age group reporting the largest number of cases (aside from infants), from adolescents to 7–11 year olds. We investigate several hypotheses for the upsurge in pertussis cases by fitting a suite of epidemiological models to incidence data from the National Notifiable Disease Surveillance System (NNDSS) between 1990–2009. We find that: 1) the best-fitting model is one in which the vaccine efficacy and duration of protection of the acellular pertussis vaccine is lower than that of the whole-cell vaccine, 2) increasing the rate at which disease is reported to NNDSS is not sufficient to explain the upsurge and 3) 2010–2012 disease incidence is predicted well. These results demonstrate that the resurgence in pertussis in the U.S. can be explained by past changes in vaccination policy. However, our findings suggest that the efficacy of the currently-used acellular vaccine is not much lower than that of the whole-cell vaccine, and booster doses may be sufficient to curtail epidemics while vaccine research continues.
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Affiliation(s)
- Manoj Gambhir
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Modeling Unit, National Center for Immunization and Respiratory Diseases (NCIRD), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
- IHRC, Inc., Atlanta, Georgia, United States of America
- * E-mail:
| | - Thomas A. Clark
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, NCIRD, CDC, Atlanta, Georgia, United States of America
| | - Simon Cauchemez
- Medical Research Council Centre for Outbreak Analysis and Modelling, Imperial College London, London, United Kingdom
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Paris, France
| | - Sara Y. Tartof
- Kaiser Permanente Southern California, Kaiser Permanente Research, Department of Research & Evaluation, Pasadena, California, United States of America
| | - David L. Swerdlow
- Modeling Unit, National Center for Immunization and Respiratory Diseases (NCIRD), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
- Office of Science and Integrative Programs, NCIRD, CDC, Atlanta, Georgia, United States of America
| | - Neil M. Ferguson
- Medical Research Council Centre for Outbreak Analysis and Modelling, Imperial College London, London, United Kingdom
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Campbell H, Amirthalingam G, Fry NK, Litt D, Harrison TG, Wagner K, Crowcroft NS, Miller E. Oral fluid testing for pertussis, England and wales, june 2007-august 2009. Emerg Infect Dis 2015; 20:968-75. [PMID: 24856627 PMCID: PMC4036755 DOI: 10.3201/eid2006.131069] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Existing pertussis surveillance systems tend to underidentify less severe cases among older children and adults. For routine follow-up of notified, nonconfirmed, clinically diagnosed pertussis cases, use of an oral fluid test was pilot tested in England and Wales during June 2007–August 2009. During that period, 1,852 cases of pertussis were confirmed by established laboratory methods and another 591 by oral fluid testing only. Although introduction of serologic testing in 2002 led to the greatest increase in ascertainment of pertussis, oral fluid testing increased laboratory ascertainment by 32% overall; maximal increase (124%) occurred among children 5–9 years of age. Patients whose pertussis was confirmed by oral fluid testing were least likely to be hospitalized, suggesting that milder community cases were being confirmed by this method. Oral fluid testing is an easily administered, noninvasive surveillance tool that could further our understanding of pertussis epidemiology and thereby contribute to decisions on vaccination strategies.
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Berti E, Venturini E, Galli L, de Martino M, Chiappini E. Management and prevention of pertussis infection in neonates. Expert Rev Anti Infect Ther 2014; 12:1515-31. [PMID: 25371322 DOI: 10.1586/14787210.2014.979156] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite the fact that universal immunization against pertussis led to a dramatic decrease in the incidence and mortality in high-income countries, it has left a window of vulnerability for newborns. Although specific guidelines concerning management of neonatal whooping cough have not yet been developed, the present review summarizes the main available recommendations on diagnostic work-up and treatment of neonatal pertussis. Additionally, new prevention strategies are explored, including the use of an additional booster dose of vaccine to adolescents and adults, vaccination of healthcare workers, immunization of household contacts and caregivers (cocooning strategy), vaccination of pregnant women and, finally, neonatal immunization with novel vaccines. These strategies are analyzed and discussed in terms of efficacy, safety and cost-effectiveness.
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Affiliation(s)
- Elettra Berti
- Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini 24, I-50139, Florence, Italy
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Wang Z, Cui Z, Li Y, Hou T, Liu X, Xi Y, Liu Y, Li H, He Q. High prevalence of erythromycin-resistant Bordetella pertussis in Xi'an, China. Clin Microbiol Infect 2014; 20:O825-30. [DOI: 10.1111/1469-0691.12671] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 05/04/2014] [Accepted: 05/04/2014] [Indexed: 11/29/2022]
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Dabrera G, Amirthalingam G, Andrews N, Campbell H, Ribeiro S, Kara E, Fry NK, Ramsay M. A case-control study to estimate the effectiveness of maternal pertussis vaccination in protecting newborn infants in England and Wales, 2012-2013. Clin Infect Dis 2014; 60:333-7. [PMID: 25332078 DOI: 10.1093/cid/ciu821] [Citation(s) in RCA: 270] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Infants with pertussis infection are at risk of severe clinical illness and death. Several countries, including the United Kingdom, have introduced maternal pertussis vaccination during pregnancy to protect infants from infection following national increases in pertussis notifications. The objective of this study was to estimate the effectiveness of maternal pertussis vaccination in protecting infants against laboratory-confirmed pertussis infection. METHODS A case-control study was undertaken in England and Wales between October 2012 and July 2013. Cases were infants aged <8 weeks at onset with pertussis infection tested by real-time polymerase chain reaction or culture. Family doctors of each case were asked to identify healthy infants born consecutively after the case in each practice, to act as controls. Fifty-eight cases and 55 controls were included in this study. Odds ratios (ORs) were calculated for the association between maternal vaccination and infant pertussis infection. The vaccine effectiveness (VE) was calculated as 1 - OR. This was adjusted for sex, geographical region, and birth period. RESULTS Mothers of 10 cases (17%) and 39 controls (71%) received pertussis vaccine in pregnancy. This gave an unadjusted VE of 91% (95% confidence interval [CI], 77%-97%). Adjusted VE was 93% (95% CI, 81%-97%). CONCLUSIONS Maternal pertussis vaccination is effective in preventing pertussis infection in infants aged <8 weeks and may be considered in other countries experiencing high levels of pertussis notifications.
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Affiliation(s)
- Gavin Dabrera
- Field Epidemiology Training Programme, Public Health England, London, United Kingdom European Programme for Intervention Epidemiology Training, European Centre for Disease Prevention and Control, Stockholm, Sweden Immunisation, Hepatitis and Blood Safety Department
| | | | - Nick Andrews
- Statistics, Modelling and Economics Department, Centre for Infectious Disease Surveillance and Control
| | | | | | - Edna Kara
- Immunisation, Hepatitis and Blood Safety Department
| | - Norman K Fry
- Respiratory and Vaccine Preventable Bacteria Reference Unit, Public Health England, London, United Kingdom
| | - Mary Ramsay
- Immunisation, Hepatitis and Blood Safety Department
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Abstract
In all vaccinated populations, infections with Bordetella pertussis and Bordetella parapertussis continue to cause infections in unvaccinated infants and children, as well as in adolescents and adults with waning immunity. Thus in patients with longer lasting coughs a diagnosis of pertussis should be entertained irrespective of their vaccination status. Due to the non-specific clinical symptoms, clinically suspected cases of pertussis must be verified by laboratory methods. Hyperleukocytosis may be helpful in diagnosis for young infants, but in most cases, nonspecific laboratory tests have no role in pertussis diagnosis. Specific laboratory tests include direct detection of the bacteria or their DNA by culture or PCR, whereas serology serves as an indirect method to diagnose pertussis in those patients who present late in the development of the disease. Serology results can be interpreted in relation to reference values for different populations, but serology is unable to distinguish between vaccination and infection.
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Pittet LF, Emonet S, Schrenzel J, Siegrist CA, Posfay-Barbe KM. Bordetella holmesii: an under-recognised Bordetella species. THE LANCET. INFECTIOUS DISEASES 2014; 14:510-9. [PMID: 24721229 DOI: 10.1016/s1473-3099(14)70021-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Bordetella holmesii, first described in 1995, is believed to cause both invasive infections (bacteraemia, meningitis, endocarditis, pericarditis, pneumonia, and arthritis) and pertussis-like symptoms. Infection with B holmesii is frequently misidentified as being with B pertussis, the cause of whooping cough, because routine diagnostic tests for pertussis are not species-specific. In this Review, we summarise knowledge about B holmesii diagnosis and treatment, and assess research needs. Although no fatal cases of B holmesii have been reported, associated invasive infections can cause substantial morbidities, even in previously healthy individuals. Antimicrobial treatment can be problematic because B holmesii's susceptibility to macrolides (used empirically to treat B pertussis) and third-generation cephalosporins (often used to treat invasive infections) is lower than would be expected. B holmesii's adaptation to human beings is continuing, and virulence might increase, causing the need for better diagnostic assays and epidemiological surveillance.
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Affiliation(s)
- Laure F Pittet
- Department of Paediatrics, Division of General Paediatrics, Children's Hospital, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
| | - Stéphane Emonet
- Department of Genetics and Laboratory Medicine, Department of Medical Specialties, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
| | - Jacques Schrenzel
- Department of Genetics and Laboratory Medicine, Department of Medical Specialties, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
| | - Claire-Anne Siegrist
- Department of Paediatrics, Division of General Paediatrics, Children's Hospital, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland; Neonatal Immunology, Departments of Pathology-Immunology and Paediatrics, University of Geneva, Geneva, Switzerland
| | - Klara M Posfay-Barbe
- Department of Paediatrics, Division of General Paediatrics, Children's Hospital, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland.
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Haslam N, Hoang U, Goldacre MJ. Trends in hospital admission rates for whooping cough in England across five decades: database studies. J R Soc Med 2014; 107:157-62. [PMID: 24526463 DOI: 10.1177/0141076813519439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Our aim was to report on trends in hospitalisation rates for pertussis in England from the 1960s to 2011; and to provide context for the recent unexpected activity of Bordetella pertussis in the UK. DESIGN A retrospective analysis of English national Hospital Episode Statistics (HES, 1968-2011) and the Oxford Record Linkage Study (ORLS, 1963-2011) for people admitted to hospital with whooping cough. SETTING England and the Oxford Record Linkage Study area. MAIN OUTCOME MEASURES Age- and gender-specific hospital admission rates, and summary age- and sex-standardised rates, for people aged under 25 years per 100,000 population in each age group. RESULTS Admission rates declined from the 1960s to the early 1970s. For example, the standardised rates were 12.8 (95% confidence interval 11.2-14.5) per 100,000 in England in 1968 and 4.0 (3.0-4.9) per 100,000 in 1973. They then increased to reach 45.0 (41.4-48.6) per 100,000 in 1978 and 47.4 (43.7-51.1) in 1982. From the late 1980s, admission rates continued to decline, falling to between 1 and 4 per 100,000 in each of the years between 2003 and 2011. While the trend in hospital admissions closely followed that in notifications, the annual ratio between these two measures was not consistent ranging from 1.07 (95% confidence interval 1.00-1.14) to 4.03 (3.79-4.27) notifications per admission over the last 10 years. CONCLUSIONS Epidemics of whooping cough in the late 1970s and early 1980s were associated with a significant rise in hospital admission rates. Current admission rates are low, by historical comparison. Vaccine programmes must continue to be fully implemented in order to improve control of pertussis activity.
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Maltezou HC, Ftika L, Theodoridou M. Nosocomial pertussis in neonatal units. J Hosp Infect 2013; 85:243-8. [PMID: 24156850 DOI: 10.1016/j.jhin.2013.09.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 09/19/2013] [Indexed: 11/25/2022]
Abstract
Pertussis remains a public health concern in many countries despite high vaccination coverage rates. Nosocomial outbreaks of pertussis continue to occur in neonatal units. Neonates and young infants admitted to neonatal intensive care units constitute a pool of susceptible high-risk patients given their prematurity, inadequate immune response and the fact that they are too young to have completed their primary vaccination series against pertussis. This article reviews nosocomial pertussis in neonates and infants, focusing on the role of healthcare workers (HCWs). Outbreaks in neonatal units are often traced to HCWs and are associated with serious morbidity or even a fatal outcome among susceptible young infants. A high index of suspicion is required for early recognition and isolation of patients admitted with suspected or proven pertussis, as well as for HCWs with a compatible clinical syndrome, regardless of vaccination status. Contact investigation is also essential in order to guide administration of post-exposure prophylaxis. Recommendations for a booster vaccination for HCWs are in place in several countries; however, the need of HCWs for lifelong immunity against pertussis cannot be fulfilled by the current vaccine.
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Affiliation(s)
- H C Maltezou
- Department for Interventions in Health-Care Facilities, Hellenic Center for Disease Control and Prevention, Athens, Greece.
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41
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Fry NK, Litt DJ, Duncan J, Vaghji L, Warrener L, Samuel D, Andrews N, Harnden A, Harrison TG. Modelling anti-pertussis toxin IgG antibody decay following primary and preschool vaccination with an acellular pertussis vaccine in UK subjects using a modified oral fluid assay. J Med Microbiol 2013; 62:1281-1289. [DOI: 10.1099/jmm.0.062000-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Recent vaccination with pertussis vaccine can confound serological and oral fluid (OF) assays targeting anti-pertussis toxin (anti-PT) IgG antibodies as a marker of recent infection. This study sought to establish the minimum potentially confounding time period based on experimental data to assist interpretation from such samples submitted from UK subjects for pertussis diagnosis. Anti-PT IgG antibody response and decay were measured post-vaccination using a modified OF IgG antibody-capture ELISA (GACELISA). Data were obtained from 72 infants after the third acellular pertussis vaccine dose in the primary schedule (4 months of age) and from 119 children after the single dose at preschool age (3 years 4 months to 5 years 8 months of age). Specimens were taken at approximately 1 month intervals for 9 months post-primary immunization (third dose) and 13 months post-preschool booster (PSB). The modified GACELISA demonstrated a sensitivity of 52/56 (92.9 %: 95 % CI 82.7–98.0) and a specificity of 120/128 (93.8 %: 95 % CI 88.0–97.3) and showed good agreement with the National Reference Laboratory standard anti-PT IgG serum ELISA (rank correlation = 0.80) and the original OF assay (rank correlation = 0.79). Modelling of the decline in antibody titres showed a reduction of 54 % and 34 % for each doubling of time after day 14 for the post-third primary dose and post-PSB subjects, respectively. These data suggest that the minimum confounding time period is approximately 300 days for samples obtained post-primary immunization and at least 3 years for samples submitted from UK children following immunization with the PSB. These data will greatly assist the interpretation of single high diagnostic anti-PT IgG titres by allowing an estimate of the positive predictive value, when the number of days post-immunization and prevalence are known or assumed.
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Affiliation(s)
- Norman K. Fry
- Public Health England–Respiratory and Vaccine Preventable Bacteria Reference Unit, Colindale, London, UK
| | - David J. Litt
- Public Health England–Respiratory and Vaccine Preventable Bacteria Reference Unit, Colindale, London, UK
| | - John Duncan
- Public Health England–Respiratory and Vaccine Preventable Bacteria Reference Unit, Colindale, London, UK
| | - Lalita Vaghji
- Public Health England–Respiratory and Vaccine Preventable Bacteria Reference Unit, Colindale, London, UK
| | - Lenesha Warrener
- Public Health England–Virus Reference Department, Colindale, London, UK
| | - Dhanraj Samuel
- Public Health England–Virus Reference Department, Colindale, London, UK
| | - Nick Andrews
- Public Health England–Statistics, Modelling and Economics Department, Health Protection Services, Colindale, London, UK
| | - Anthony Harnden
- University of Oxford, Department of Primary Care Health Sciences, Oxford, UK
| | - Timothy G. Harrison
- Public Health England–Respiratory and Vaccine Preventable Bacteria Reference Unit, Colindale, London, UK
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Tarr GAM, Eickhoff JC, Koepke R, Hopfensperger DJ, Davis JP, Conway JH. Using a bayesian latent class model to evaluate the utility of investigating persons with negative polymerase chain reaction results for pertussis. Am J Epidemiol 2013; 178:309-18. [PMID: 23735308 DOI: 10.1093/aje/kws465] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pertussis remains difficult to control. Imperfect sensitivity of diagnostic tests and lack of specific guidance regarding interpretation of negative test results among patients with compatible symptoms may contribute to its spread. In this study, we examined whether additional pertussis cases could be identified if persons with negative pertussis test results were routinely investigated. We conducted interviews among 250 subjects aged ≤18 years with pertussis polymerase chain reaction (PCR) results reported from 2 reference laboratories in Wisconsin during July-September 2010 to determine whether their illnesses met the Centers for Disease Control and Prevention's clinical case definition (CCD) for pertussis. PCR validity measures were calculated using the CCD as the standard for pertussis disease. Two Bayesian latent class models were used to adjust the validity measures for pertussis detectable by 1) culture alone and 2) culture and/or more sensitive measures such as serology. Among 190 PCR-negative subjects, 54 (28%) had illnesses meeting the CCD. In adjusted analyses, PCR sensitivity and the negative predictive value were 1) 94% and 99% and 2) 43% and 87% in the 2 types of models, respectively. The models suggested that public health follow-up of reported pertussis patients with PCR-negative results leads to the detection of more true pertussis cases than follow-up of PCR-positive persons alone. The results also suggest a need for a more specific pertussis CCD.
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Affiliation(s)
- Gillian A M Tarr
- Department of Pediatrics, School ofMedicine and Public Health, University of Wisconsin–Madison, Madison,WI 53792, USA
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Abstract
In recent years, quantitative real-time PCR tests have been extensively developed in clinical microbiology laboratories for routine diagnosis of infectious diseases, particularly bacterial diseases. This molecular tool is well-suited for the rapid detection of bacteria directly in clinical specimens, allowing early, sensitive and specific laboratory confirmation of related diseases. It is particularly suitable for the diagnosis of infections caused by fastidious growth species, and the number of these pathogens has increased recently. This method also allows a rapid assessment of the presence of antibiotic resistance genes or gene mutations. Although this genetic approach is not always predictive of phenotypic resistances, in specific situations it may help to optimize the therapeutic management of patients. Finally, an approach combining the detection of pathogens, their mechanisms of antibiotic resistance, their virulence factors and bacterial load in clinical samples could lead to profound changes in the care of these infected patients.
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Affiliation(s)
- Max Maurin
- Laboratoire de Bactériologie, Département des Agents Infectieux, Institut de Biologie et Pathologie, CHU de Grenoble, Université Joseph Fourier Grenoble 1, France.
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Otsuka N, Yoshino S, Kawano K, Toyoizumi-Ajisaka H, Shibayama K, Kamachi K. Simple and specific detection of Bordetella holmesii by using a loop-mediated isothermal amplification assay. Microbiol Immunol 2012; 56:486-9. [PMID: 22512310 DOI: 10.1111/j.1348-0421.2012.00465.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A loop-mediated isothermal amplification (LAMP) assay for simple detection of Bordetella holmesii was developed. This assay discriminates between B. holmesii and other Bordetella species and successfully detect B. holmesii DNA in nasopharyngeal swab samples from subjects with suspected pertussis. The LAMP assay results were in complete agreement with the results of previously published real-time PCR assay, indicating that the former is a powerful tool for the accurate diagnosis and surveillance of B. holmesii.
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Affiliation(s)
- Nao Otsuka
- Department of Bacteriology II, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashimurayama, Tokyo 208-0011, Japan
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Elumogo T, Booth D, Enoch D, Kuppuswamy A, Tremlett C, Williams C, Shankar A, Morter S. Bordetella pertussis in a neonatal intensive care unit: identification of the mother as the likely source. J Hosp Infect 2012; 82:133-5. [DOI: 10.1016/j.jhin.2012.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 07/12/2012] [Indexed: 10/27/2022]
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Litt DJ, Jauneikaite E, Tchipeva D, Harrison TG, Fry NK. Direct molecular typing of Bordetella pertussis from clinical specimens submitted for diagnostic quantitative (real-time) PCR. J Med Microbiol 2012; 61:1662-1668. [PMID: 22918864 DOI: 10.1099/jmm.0.049585-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Molecular typing of Bordetella pertussis is routinely performed on bacterial isolates, but not on DNA extracted from nasopharyngeal aspirates or pernasal swabs submitted for diagnostic real-time PCR (qPCR). We investigated whether these DNA extracts were suitable for multilocus variable-number tandem repeat analysis (MLVA) and DNA sequence-based typing. We analysed all the available qPCR-positive samples received by our laboratory from patients <1 year of age between January 2008 and August 2010. Eighty-one per cent (106/131) of these generated a complete MLVA profile. This rose to 92 % (105/114) if only samples positive for both of the two targets used for the B. pertussis PCR (insertion element IS481 and pertussis toxin promoter ptxP) were analysed. Sequence-based typing of the pertactin, pertussis toxin S1 subunit and pertussis promoter regions (prn, ptxA and ptxP) was attempted on 89 of the DNA extracts that had generated a full MLVA profile. Eighty-three (93 %) of these produced complete sequences for all three targets. Comparison of molecular typing data from the 89 extracts with those from 111 contemporary bacterial isolates showed that the two sources yielded the same picture of the B. pertussis population [dominated by the MLVA-27 prn(2) ptxA(1) ptxP(3) clonal type]. There was no significant difference in MLVA type distribution or diversity between the two sample sets. This suggests that clinical extracts can be used in place of, or to complement, bacterial cultures for typing purposes (at least, in this age group). With small modifications to methodology, generating MLVA and sequence-based typing data from qPCR-positive clinical DNA extracts is likely to generate a complete dataset in the majority of samples from the <1 year age group. Its success with samples from older subjects remains to be seen. However, our data suggest that it is suitable for inclusion in molecular epidemiological studies of the B. pertussis population or as a tool in outbreak investigations.
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Affiliation(s)
- David J Litt
- Respiratory and Systemic Infection Laboratory, Health Protection Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Elita Jauneikaite
- Respiratory and Systemic Infection Laboratory, Health Protection Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Draga Tchipeva
- Department of Biomedical Sciences, School of Life Sciences, University of Westminster, London W1W 6UW, UK.,Respiratory and Systemic Infection Laboratory, Health Protection Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Timothy G Harrison
- Respiratory and Systemic Infection Laboratory, Health Protection Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Norman K Fry
- Respiratory and Systemic Infection Laboratory, Health Protection Agency, 61 Colindale Avenue, London NW9 5EQ, UK
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Tizolova A, Guiso N, Guillot S. Insertion sequences shared by Bordetella species and implications for the biological diagnosis of pertussis syndrome. Eur J Clin Microbiol Infect Dis 2012; 32:89-96. [PMID: 22886091 DOI: 10.1007/s10096-012-1718-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 07/27/2012] [Indexed: 11/24/2022]
Abstract
The molecular diagnosis of pertussis and parapertussis syndromes is based on the detection of insertion sequences (IS) 481 and 1001, respectively. However, these IS are also detected in the genomes of various Bordetella species, such that they are not specific for either B. pertussis or B. parapertussis. Therefore, we screened the genome of recently circulating isolates of Bordetella species to compare the prevalence of IS481, IS1001 and, also IS1002 with previously published data and to sequence all IS detected. We also investigated whether the numbers of IS481 and IS1001 copies vary in recently circulating isolates of the different Bordetella species. We used the polymerase chain reaction (PCR) method for screening the genome of circulating isolates and to prepare the fragments for sequencing. We used Southern blotting and quantitative real-time PCR for quantification of the numbers of IS. We found no significant diversity in the sequences of the IS harboured in the genomes of the Bordetella isolates screened, except for a 71-nucleotide deletion from IS1002 in B. bronchiseptica. The IS copy numbers in the genome of recently circulating isolates were similar to those in reference strains. Our results confirm that biological diagnosis targeting the IS481 and IS1001 elements are not specific and detect the species B. pertussis, B. holmesii and B. bronchiseptica (IS481), and B. parapertussis and B. bronchiseptica (IS1001).
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Affiliation(s)
- A Tizolova
- Department of Biochemistry and Microbiology, Institute of Chemical Technology, Technicka 5, 166 28 Prague 6, Czech Republic
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Campbell H, Amirthalingam G, Andrews N, Fry NK, George RC, Harrison TG, Miller E. Accelerating control of pertussis in England and Wales. Emerg Infect Dis 2012; 18:38-47. [PMID: 22260989 PMCID: PMC3381681 DOI: 10.3201/eid1801.110784] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Pertussis incidence among infants can be reduced by early completion of the primary vaccination schedule.
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Zouari A, Smaoui H, Brun D, Njamkepo E, Sghaier S, Zouari E, Félix R, Menif K, Ben Jaballah N, Guiso N, Kechrid A. Prevalence of Bordetella pertussis and Bordetella parapertussis infections in Tunisian hospitalized infants: results of a 4-year prospective study. Diagn Microbiol Infect Dis 2012; 72:303-17. [PMID: 22313629 DOI: 10.1016/j.diagmicrobio.2012.01.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 12/23/2011] [Accepted: 01/03/2012] [Indexed: 11/30/2022]
Abstract
The prevalence of pertussis in Tunisia remains undetermined essentially because of the unavailability of a basic laboratory diagnostic service. Specific diagnostic tools were applied for the first time in a Tunisian prospective study in order to get a first estimation of the prevalence of Bordetella pertussis/parapertussis infections and to evaluate their use to determine the epidemiologic characteristics of these infections in Tunisian infants. Between 2007 and 2011, a total of 626 samples from 599 infants aged <1 year with and without pertussoid cough were investigated for the presence of B. pertussis/parapertussis using culture and real-time polymerase chain reaction (PCR). The real-time PCR (RT-PCR) targets include IS481 commonly found in B. pertussis, B. bronchiseptica, and B. holmesii; IS1001 specific of B. parapertussis, in combination with the pertussis toxin promoter region gene (ptx) of B. pertussis; and the recA gene specific of B. holmesii. When possible, patients' household contacts provided nasopharyngeal aspirates (NPAs) for RT-PCR detection of B. pertussis/parapertussis or single-serum samples for anti-PT IgG quantification. All except 1 NPAs were negative by conventional culture, whereas PCR gave positive signals for 126 specimens (21%): B. pertussis, B. parapertussis, and Bordetella spp. were detected in 82%, 6%, and 4% of the samples, respectively. The simultaneous presence of B. pertussis and B. parapertussis was noted in 8% of the cases. Pertussis was reported throughout the year with a peak during the summer of the year 2009. The prevalence of Bordetella infection was 20% between 2007 and 2011. Most of these cases corresponded to patients younger than 6 months who received <3 doses of pertussis vaccine. Among the household contacts enrolled in the study, mothers seemed to be the likely source of infection. This study showed that pertussis is still prevalent in Tunisia and that the disease remains a public health problem affecting not only infants but also adults. Given this situation, sensitive and specific laboratory tests are needed to improve the accuracy of pertussis diagnosis.
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Affiliation(s)
- Asma Zouari
- Microbiology Laboratory, Children's Hospital of Tunis, Tunis, Tunisia.
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