Pentaxim, Hexaxim, India, pertussis, whooping cough, vaccine, 2 component, 5 component. Talk for Chandigarh, India about whole cell pertussis versus acellular pertussis vaccine -

1. Current Challenges in Pertussis Prevention: A Review
Dr Gaurav Gupta. 23 Sept 2016

2. Conflict of Interest
• Received grants from various vaccine
manufacturers including
– Sanofi Pasteur
– GSK
– Abbott
– Novartis

3. Noel Preston (1988)
‘There must be a few medical subjects that have
generated so much controversy & even outright
contradiction, as pertussis’

4. Leila Denmark. Pearl Kendrick. Grace Eldering. Loney Clinton Gordon.
Women Power !

5. Scope of Discussion
• Is pertussis increasing?
• Is aP responsible?
• Pertussis immunity?
• Why not just use wP vaccine?
• Office practice suggestions?

7. Whooping Cough bounces back

8. Possible Reasons for Increasing Pertussis
• Cyclical outbreaks every 3 to 5 years
• Changing epidemiology, waning immunity
• Inadequate vaccination schedules and/or compliance
• Increased awareness, Improved surveillance and diagnostic
methods (PCR etc.)
• Changes in case definitions
• Lower than desired vaccine efficacy
• Potential mutation & antigenic drift
Cherry JD. Epidemic pertussis in 2012--the resurgence of a vaccine-preventable disease. N Engl J Med 2012;367:785-7.
Clark TA, Messonnier NE, Hadler SC. Pertussis control: time for something new? Trends Microbiol 2012;20:211-3

9. Overview of Past Outbreaks
• Several large pertussis outbreaks have been reported in the
past 20 years
– Chicago, USA, 1993
– Cincinati, USA, 1993
– Nova Scotia, Canada, 1994
– Vermont, USA, 1996
– Netherlands, 1996
– Sindh, Pakistan 2011
– California, USA 2010-11
– Washington, USA 2012
USA between 1980-89 had outbreaks almost every year!
Vaccines 5 ed. Plotkin; Emerging infectious diseases. Vol. 6, No. 4,
July–August 2000; CMAJ February 14, 2006 • 174(4)
Whole cell vaccines

10. Global trends of pertussis incidence
Substantial Heterogeneity in annual rates of change of pertussis incidence...
• Pink area  Countries with significantly positive trends in incidence
• White area  Countries for which trends were not significant
• Blue area  Countries with significantly decreasing trends
Source: 1. Jackson D. W. & Rohani P. Review article - Perplexities of pertussis : recent global epidemiological trends & their potential causes.
Epidemiol. Infect. (2014), 142, 672–684.
Inclusion criteria: mean DTP3 vaccine uptake of>80%, populations of>5 million & >80% complete case count records for this period
10

11. Knowledge is the process of piling up facts,
wisdom lies in their simplification

12. Before
generalized use
of pertussis
vaccine in
children
After generalized
use of pertussis
vaccine in
children
Hewlett EL, Edwards KM. Pertussis — Not Just for Kids. N Engl J Med 2005; 352: 1215-22.
Evolution of pertussis epidemiology

13. SAGE working group – 2014
• Between country variance on multiple factors
– Vaccines
– Population
– Surveillance systems and diagnostic methods
• No evidence of global resurgence of pertussis
• Both wP and aP Pertussis vaccines provide effective disease protection
– But evidence of earlier waning of immunity with aP vaccines
• Resurgence seen in 5 of 19 countries
– Australia, Portugal, USA, UK (aP)
– Chile (wP)
| 13
http://www.who.int/immunization/sage/meetings/2014/april/2_SAGE_April
_Pertussis_Miller_Resurgence.pdf?ua=1

14. Colombia
Algeria
Brazil
Poland

15. Exclusive Use of Acellular Vaccines in Sweden Since
1996 Associated with Excellent Pertussis Control
Adapted from Nilsson L, von Segebaden K., Klink A-M, Grünewald M. Pertussis surveillance in Sweden: fourteen year report.
Smittskyddsinstitutets (SMI).

16. More examples of aP using countries with no resurgences
• Norway: changed to aP in 1998 using 3/5/10 month schedule
• Sweden: no vaccination prior to 1996 aP at 3,5 12 months
• Finland: changed to aP in 2005 using 3,5,12 month schedule
• Denmark: changed to aP in 1997 using 3,5 12 month schedule
| 16http://www.who.int/immunization/sage/meetings/2014/april/1_Pertussis_background_FINAL4_web.pdf?ua=1

17. DTaP Efficacy

19. Comparative efficacy of DTwP &
DTaP vaccines
19
Source: 1. Edwards & Decker. In: Vaccines, 4th Edition, 2004. 2. Plotkin & Cadoz. PIDJ, 1997; 16 (5).

20. Components – Do they matter

21. COMPONENT COMPANY EFFICACY
1C Amvax, JNIH 71 TO 78%
2C SKB 59%
2C Pasteur Merieux 85%
3C SKB (GSK) 84 %
4C LEDERLE - an european vacc .
not marketed
79 %
5C Connaught (Pasteur) 85 %
DTwP VARIOUS countries 36 TO 96 %
Summary of vaccine efficacy: Cochrane 2012 (and 14)
Conclusion

22. Once adjusted for this aberration, the authors
have conceded that their reviews would have
found no efficacy difference between the
different licensed DTaP vaccines.

23. Antibody Response to aP Antigens (PT & FHA):
High rates of seroconversion for anti-PT (82.9 to 100%) and anti-FHA titers (83.9 to 95.9%) after
the 3 dose primary vaccination with Pentaxim regardless of study population and primary
vaccination schedule
Pentaxim licensed for use in over 100 countries, in NIP of 23 countries, over 100 million
doses used

24. How long does immunity last?

25. Number of subjects: 263496 subjects (8-20 years of age)
Clin Infect Dis 2013;56:1248-54

26. The comparison of pertussis cases in wcP- vs acP vaccinated subjects
is really a comparison of pertussis in adolescents vaccinated with wcP
vs young children vaccinated with acp and since pertussis is much
more common in younger children they suggested that this finding may
have been confounded by age

27. Misegades LK, Winter K, Harriman K, et al. Association of childhood pertussis with receipt of 5 doses of pertussis
vaccine by time since last vaccine dose, California, 2010. JAMA 2012;308:2126-32.

28. Overall DTaP-induced vaccine effectives (VE) and duration
of protection estimates, California 2010
Case Control study in California (2010: 15 counties) to determine the vaccine
effectiveness (VE) at different intervals after 5th dose of DTaP vaccine
Cases (n) Controls (n) VE, % 95% CI
Overall
0 doses 53 19 Reference --
5 doses 629 1,997 88.7 79.4 – 93.8
Time since
5th dose in
months
0 doses 53 19 Reference --
< 12 m 19 354 98.1 96.1 – 99.1
12 – 23 m 51 391 95.3 91.2 – 97.5
24 – 35 m 79 366 92.3 86.6 – 95.5
36 – 47 m 108 304 87.3 76.2 – 93.2
48 – 59 m 141 294 82.8 68.7 – 90.6
60+ m 231 288 71.2 45.8 – 84.8
Adapted from Misegades LK et al. Association of childhood pertussis with receipt of 5 doses of pertussis vaccine by time since last vaccine dose, California, 2010. JAMA
2012;308:2126-32.
60+ : 61-83
months

29. Approximate duration of immunity after natural
infection and after vaccination

30. • Both WHO and the CDC found that the
acellular pertussis vaccines were effective at
prevention of the disease,
• but had a limited impact on infection and
transmission, meaning that vaccinated people
could act as asymptomatic reservoirs of
infection.

31. Why not use wP for everyone?

32. Frequency of Common Side Effects with Pertussis
Vaccines
Event Whole cell
pertussis vaccine
Acellular
pertussis vaccine
Average Average Range
Fever < 38.3°C 44.5% 20.8% 16-29.2%
Fever > 38.3°C 15.9% 3.7% 1.6-5.9%
Erythema 56.3% 31.4% 15-44%
> 2.0 cm 16.4% 3.3% 1.4-5.9%
Swelling 38.5% 20.1% 7.5-24.2%
Drowsiness 62.0% 42.7% 29.4-52.2%
There is a very wide range among various aP with varying frequencies for
individual side effects. Impossible to identify an aP with the most (or least)
favourable adverse event profile.
Mathew JL. Acellular Pertussis Vaccines: Pertinent Issues, Indian Pediatrics 2008;
45:727-729

33. Meta-analysis of Serious Adverse Events with Pertussis
vaccines
Event Frequency
with aP
Frequency
with wP
Pooled RR
(95% CI)
Interpretation
High fever
(>40°C)
227/99323
(0.23%)
996/96879
(1.03%)
0.18
(0.08-0.44)
RR is about
80% less with aP than
with wP, but the
absolute
difference is 2%.
Seizures
(within 48 h)
58/106204
(0.05%)
224/103474
(0.22%)
0.28
(0.13-0.61) RR is about
72% less with aP than
with wP, but the
absolute
difference is negligible.
Hypotensive-
hyporesponsive
episode
20/106204
(0.02%)
491/103474
(0.47%)
0.04
(0.01-0.19) RR is about
96% less with aP than
with wP, but the
absolute
difference is negligible.
Mathew JL. Acellular Pertussis Vaccines: Pertinent Issues, Indian Pediatrics 2008; 45:727-729
Relative risk for some events is less with aP, the absolute risk difference is comparable to wP
because such events are very rare with both.

34. • The NIH-Multi Acellular Pertussis Trial
aP backboned vaccines are always better tolerated than
wP vaccines
Decker & al. Pediatrics 1995
Fever Swelling Pain
Introduction of acP vaccine lead to a reduction of the
emergency room admissions and hospital visits
• Approximately 90 emergency visits and 9
admissions per month are avoided by switching to
the acP vaccine, mainly because of febrile and afebrile
convulsions compared to the wcP vaccine period.
The NIH-Multi Acellular Pertussis Trial The Journal of Inf Dis (1996), pp. S270-S275

35. Role of aP vaccines
Basic purpose of Pertussis vaccination – prevent
morbidity and mortality – max in infants and
neonates
Strategies to reduce them
• Adolescent vaccination
• Maternal vaccination
• Cocooning strategy
• Vaccination of health care workers

36. Role of aP vaccines
Basic purpose of Pertussis vaccination – prevent
morbidity and mortality – max in infants and
neonates
Strategies to reduce them
• Adolescent vaccination
• Maternal vaccination
• Cocooning strategy
• Vaccination of health care workers

37. Office practice suggestions?

38. FAQs
• What to do with children having received all
aP?
• How to counsel parents regarding wP & aP
vaccines?

39. Summary
• Pertussis not yet conquered, though there is no global
resurgence
• Outbreaks are not completely understood, and many
studies have important methodological limitations
• Pertussis has been controlled in many countries using either
aP or wP vaccines.
• Health-care providers need to choose pertussis vaccines
that will best serve their patients while supporting public
health goals