Epidemiology of pertussis in French hospitals in 1993 and 1994: thirty years after a routine use of vaccination.

BACKGROUND: Despite widespread vaccination during 30 years, the hypothesis of a resurgence of pertussis in France has been raised by outbreaks and sporadic case reports. No surveillance data were available after 1985. METHODS: A survey was undertaken in 1993 and 1994 in a pediatric hospital network able to confirm cases; the network (22 hospitals) represents 19.6% of pediatric admissions in France. Case definition included clinical (> or = 21 days of paroxysmal cough), laboratory-confirmed (culture or serology by immunoblot) or epidemiologically confirmed pertussis (documented contact with a laboratory-confirmed case). The pattern of transmission was studied in the household. Vaccine status was obtained from health records. RESULTS: during a 15-month period 560 cases (316 index cases, 244 household contact cases) were reported; 49% of index cases and 20% of contact cases were confirmed by culture and/or serology. Sixty-five percent of index cases were younger than 1 year of age (the incidence in this age group could be estimated to be 95/100000) and 66% were hospitalized for a mean duration of 2 weeks. Infection was acquired from parents (34%) and siblings (46%). Seventy-three percent of index cases were unvaccinated. CONCLUSIONS: Although pertussis vaccination coverage is very high in France, the organism is still circulating, affecting, within the pediatric population, mostly non- or incompletely vaccinated infants. These results strongly support the importance of adhering to the immunization schedule and suggest introducing booster dose(s) to prolong vaccine immunity and reduce the exposure to Bordetella pertussis of infants too young to be immunized.

Bordetella holmesii isolated from a patient with sickle cell anemia: analysis and comparison with other Bordetella holmesii isolates.

OBJECTIVES: To analyze a Bordetella holmesii isolate from a patient with sickle cell anemia and to compare it with other B. holmesii strains and isolates and with strains of B. pertussis and B. bronchiseptica, two well-characterized species of the Bordetella genus. METHODS: The bacteriological characteristics and proteins produced by the B. holmesii isolate and the reference strain (ATCC 51541) were analyzed and compared with those of B. pertussis and B. bronchiseptica using sera from patients infected with B. pertussis, B. bronchiseptica or B. holmesii. RESULTS: The bacteriological characteristics of the B. holmesii isolate studied here were similar to those of the B. holmesii reference strain and other isolates. Some of the proteins produced by B. holmesii isolates were similar to those produced by B. pertussis and B. bronchiseptica, but none of these proteins was similar to the toxins and adhesins involved in the pathogenicity of B. pertussis and B. bronchiseptica. The phenotypic diversity of the proteins produced by B. holmesii isolates and the reference strain was striking. CONCLUSIONS: Our results suggest that either, the expression of B. holmesii proteins is regulated as in B. pertussis and B. bronchiseptica, with the B. holmesii strain exhibiting different phases, or the proteins produced in B. holmesii are different.

Evolution of French Bordetella pertussis and Bordetella parapertussis isolates: increase of Bordetellae not expressing pertactin.

Bordetella pertussis and Bordetella parapertussis are closely related bacterial agents of whooping cough. Whole-cell pertussis (wP) vaccine was introduced in France in 1959. Acellular pertussis (aP) vaccine was introduced in 1998 as an adolescent booster and was rapidly generalized to the whole population, changing herd immunity by specifically targeting the virulence of the bacteria. We performed a temporal analysis of all French B. pertussis and B. parapertussis isolates collected since 2000 under aP vaccine pressure, using pulsed-field gel electrophoresis (PFGE), genotyping and detection of expression of virulence factors. Particular isolates were selected according to their different phenotype and PFGE type and their characteristics were analysed using the murine model of respiratory infection and in vitro cell cytotoxic assay. Since the introduction of the aP vaccines there has been a steady increase in the number of B. pertussis and B. parapertussis isolates collected that are lacking expression of pertactin. These isolates seem to be as virulent as those expressing all virulence factors according to animal and cellular models of infection. Whereas wP vaccine-induced immunity led to a monomorphic population of B. pertussis, aP vaccine-induced immunity enabled the number of circulating B. pertussis and B. parapertussis isolates not expressing virulence factors to increase, sustaining our previous hypothesis.

Bordetella parapertussis isolates not expressing pertactin circulating in France.

Surprisingly, most Bordetella parapertussis isolates collected in France since 2007 do not express pertactin, owing to mutations in the structural gene encoding this protein. We used a 454 pyrosequencing strategy to study and compare the genetics of two B. parapertussis isolates (one expressing pertactin and one not expressing pertactin) and the reference strain. No region of difference was detected between the genomes of the two isolates and the genome of the reference strain. No increase in repeated sequences between both isolates was found, and there were very few sequence differences. Using cellular and animal models, we found no substantial difference between the pathogenicity of these B. parapertussis isolates, which is consistent with clinical data. The emergence of these isolates, indicating that pertactin expression is not essential for virulence for B. parapertussis, is discussed.

[The re-emergence of pertussis in Tunisia]. / La réémergence de la coqueluche en Tunisie.

OBJECTIVE: The authors had for aim to analyze pertussis epidemiology in Tunisia by studying nasopharyngeal specimens of infants hospitalized in Tunis. METHODS: Between march 2007 and march 2008, clinical nasopharyngeal samples were collected from infants with a suspected diagnosis of whooping cough, pertussoid cough, or pertussis-like syndrome, admitted at the Tunis children's hospital. The laboratory diagnostic criteria were culture isolation of Bordetella species on Bordet-Gengou medium and real-time PCR. RESULTS: Fifty-nine percent of the 74 investigated children with suspected pertussis were less than two months of age. The diagnosis of pertussis was proved positive by real-time PCR for 41%. Culture was negative in all cases. CONCLUSIONS: Whooping cough is still prevalent in Tunisia despite an important vaccination coverage. Real-time PCR is an invaluable tool for the rapid diagnosis of pertussis, however culture must also be associated.

Investigation on a pertussis outbreak in a military school: risk factors and approach to vaccine efficacy.

INTRODUCTION: Pertussis (whooping cough) is a toxic bacterial infection caused mainly by Bordetella pertussis. In mid-January 2006, several cases of pertussis were diagnosed in a military boarding-school. An investigation was carried out at the end of January to identify the risk factors for infection and to evaluate the efficacy of vaccination. SUBJECTS AND METHODS: Three definitions were used to distinguish the cases; confirmed biologically, confirmed epidemiologically and suspected cases. The risk factor study was carried out after the exclusion of suspect cases. Vaccine efficacy (VE) was evaluated from a case-control study where only biologically confirmed cases were included. For each case, five controls were matched according to age, sex and class. A logistic regression and a conditional logistic regression were performed for the risk factor study and vaccine efficacy, respectively. Statistical analysis was carried out using Stata 9.2 software. RESULTS: A total of 206 cases were included, 17 of them biologically confirmed, 66 epidemiologically and 123 suspected cases. The attack rate was 17.8 per 100. Girls were 1.8 times more likely to catch pertussis (p=0.04), pupils in the first year of college, as well as those in high school were at 5 times greater risk of catching pertussis (p=0.008) than those in the second year of college. For pupils who benefited from at least 5 doses, the VE was at 80% when the last dose dated from less than 6 years earlier. DISCUSSION/CONCLUSION: The attack rate observed in our study was similar to those normally seen during epidemics occurring within a community. Vaccine efficacy declined depending on the time lapse since the last vaccination. Since April 2008, the Public Health Authorities have planned to provide pertussis booster vaccinations for children aged 16-18 who missed those for 11-13-year-old, and for adults aged 26-27 and those who have not been vaccinated for more than 10 years.

First report and detailed characterization of B. pertussis isolates not expressing Pertussis Toxin or Pertactin.

Bordetella pertussis isolates not expressing Pertussis Toxin (PT) or Pertactin (PRN) have been collected, for the first time in 2007, in France, a highly vaccinated country with acellular vaccines. Non-expression was due to deletion of the entire ptx locus, to IS481 insertion in the prn gene or deletion of a part of this gene. Genome sequencing does not indicate any regions of differences when compared to other circulating isolates. It nevertheless shows some sequence differences and an increased number of repeated sequences. The infant infected by the isolate not expressing pertussis toxin, did not present hyperlymphocytosis. All isolates were found less pathogen in animal or cellular models; their circulation raises the problem of clinical and biological diagnoses.

Long-term humoral and cell-mediated immunity after acellular pertussis vaccination compares favourably with whole-cell vaccines 6 years after booster vaccination in the second year of life.

Humoral and cell-mediated immune responses (CMI) were evaluated in subjects 3 and 6 years after primary and booster vaccination with either three-component acellular (Pa) or whole-cell (Pw) vaccines. Low anti-pertussis toxin (PT) antibody levels confirmed the absence of pertussis disease, consistent with ongoing protection. Anti-pertactin (PRN) antibodies, remained at higher levels in Pa-vaccinated subjects. At year 6, CMI responses continued to be present and were higher in Pa-vaccinated than Pw-vaccinated subjects. Long-term protection with Pa vaccines can be expected to be at least as good as that provided by efficacious Pw vaccines.

Analysis of Bordetella pertussis populations in European countries with different vaccination policies.

Despite the widespread use of pertussis vaccines during the last decades, pertussis has remained an endemic disease with frequent epidemic outbreaks. Currently two types of vaccines are used: whole-cell vaccines (WCVs) and recently developed acellular vaccines (ACVs). The long-term aim of our studies is to assess the effect of different vaccination policies on the population structure of Bordetella pertussis and ultimately on the disease burden in Europe. In the present study, a total of 102 B. pertussis isolates from the period 1998 to 2001 from five European countries (Finland, Sweden, Germany, The Netherlands, and France) were characterized. The isolates were analyzed by typing based on variable number of tandem repeats (VNTR); by sequencing of polymorphic genes encoding the surface proteins pertussis toxin S1 and S3 subunits (ptxA and ptxC), pertactin (prn), and tracheal colonization factor (tcfA); and by fimbrial serotyping. The results reveal a relationship between geographic location and VNTR types, the frequency of the ptxC alleles, and serotypes. We have not observed a relationship between the strain characteristics we studied and vaccination programs. Our results provide a baseline which can be used to reveal changes in the B. pertussis population in Europe in the coming years.

Selective processing of submandibular rat 1 protein at dibasic cleavage sites. Salivary and bloodstream secretion products.

The amino acid sequence of submandibular rat 1 (SMR1) protein, deduced from its cDNA sequence, led to the prediction that the SMR1 gene encodes a hormone-like precursor [Rosinski-Chupin, I., Tronik, D. & Rougeon, F. (1988) Proc. Natl Acad. Sci. USA 85, 8553-8557]. SMR1 contains an N-terminal putative secretory signal sequence and a tetrapeptide (QHNP), located between dibasic amino acids which constitute the most common signal for prohormone processing. We have isolated and characterized from the male rat submandibular gland and its secretions three structurally related peptides, namely an undecapeptide (VRGPRRQHNPR), a hexapeptide (RQHNPR) and a pentapeptide (QHNPR) generated from SMR1 by selective proteolytic cleavages at pairs of arginine residues. The biosynthesis of these peptides is subjected to distinct regulatory pathways depending on the organ, sex and age of the rat. Furthermore, the peptides are differentially distributed in the submandibular gland and in resting or epinephrine-elicited submandibular salivary secretions, suggesting distinct proteolytic pathways for their maturation. The undecapeptide is generated in the gland of both male and female rats, but under basal conditions it is only released into the saliva in male animals. The hexapeptide is produced in large amounts in the gland of adult male rats and released into the saliva in both resting and stimulated conditions. The pentapeptide appears only in the male saliva and is present mostly under stimulated conditions. In addition, administration of epinephrine induces the release of the hexapeptide from the submandibular gland into the bloodstream. The evidence indicates that the rat submandibular gland can function as a dual exocrine and endocrine organ for the SMR1-derived hexapeptide, as has been reported for nerve growth factor, epidermal growth factor, renin and kallikrein. Although the biological activities of the SMR1-derived peptides are not yet known, their high production and adrenergic-induced release only into the saliva and bloodstream of adult male rats, suggest a physiological involvement in some male-specific processes.

Rapid diagnosis of pertussis in young infants: comparison of culture, PCR, and infant's and mother's serology.

The contribution of maternal pertussis serology comparing prepartum serum to serum collected during the infant's disease to the diagnosis of pertussis in infants was evaluated for 28 pairs of young infants with pertussis syndrome and their mothers and was compared to those of culture and PCR. Infants had a nasopharyngeal aspiration tested by PCR, and acute and convalescent sera were collected during their disease. Mothers had a first acute serum collected concomitantly with the infant's acute serum, and both acute sera were compared to a prepartum serum. Sera were analyzed by immunoblotting for the detection of anti-pertussis toxin (PT) antibodies. Serological evidence of pertussis in infants was assessed as either an increase in anti-PT antibody levels between the mother's prepartum and acute sera or the presence of antibodies in the infant's acute serum and their absence in both the mother's acute and prepartum sera. Culture and PCR sensitivity were 43 and 89%, respectively. Most infants (18 of 24) had no pertussis antibody detectable in their acute sera, confirming a delayed immune response at this age. A comparison of infant's and mother's serology, using prepartum serum, rapidly confirmed the diagnosis in 57% of the cases. Although less sensitive than PCR, this serological method should be used for a rapid diagnosis of pertussis in young infants when culture and PCR are either not available or negative.

Thirty-five years' experience with the whole-cell pertussis vaccine in France: vaccine strains analysis and immunogenicity.

A resurgence in infant and adult pertussis cases has been observed in many countries around 25 years after the introduction of generalised vaccination. An antigenic differences between circulating isolates and vaccinal strains, due to changes in vaccine procedures, could be due to this resurgence. In this study, we analysed the genome and antigenic expression of vaccinal strains of the Aventis Pasteur whole-cell pertussis vaccine from multiple lots stored since 1984. Despite lyophilisation having been performed on these strains for over 30 years, their genome remain conserved, and they still express the major toxins and adhesins. A study in mice confirmed that vaccine lots were highly immunogenic. In conclusion, there is no evidence to suggest that many years of production have resulted in alteration in the French vaccinal strains which quality has remained consistent since its introduction, this can explain its continued efficacy, effectiveness and the lack of epidemics in France.

Adaptive responses of human monocytes infected by bordetella pertussis: the role of adenylate cyclase hemolysin.

The activation/adaptive responses of human monocytes exposed to Bordetella pertussis parental or mutant strains were evaluated and correlated to the expression of two bacterial toxins: adenylate cyclase-hemolysin and pertussis toxin. The marked rise in intracellular cyclic adenosine monophosphate (cAMP) observed in monocytes infected by B. pertussis parental strain, inversely correlated with (1) the production of tumor necrosis factor alpha; (2) the release of superoxide anion; and (3) the expression of the 72-kDa heat shock/stress protein, Hsp70. Experiments performed with mutants deficient in adenylate cyclase-hemolysin or with purified bacterial toxins confirmed the key role of adenylate cyclase-hemolysin in the control of monocytes' response to infection by B. pertussis. This bacterial strategy primarily involves evasion from antimicrobial defenses and, eventually, the sacrifice of the host cell.

Long-term human serum antibody responses after immunization with whole-cell pertussis vaccine in France.

Three hundred sixty children were tested for pertussis serology 0.5 to 1.58 months after complete whole-cell pertussis vaccination. An immunoblot assay was used to detect serum antibodies to pertussis toxin, filamentous hemagglutinin, adenylate cyclase-hemolysin, and pertactin, and agglutination was used for detection of anti-agglutinogen antibodies. Antibodies against pertussis toxin, pertactin, and agglutinogens decreased rapidly after vaccination but increased secondarily, suggesting exposure to infected persons. In contrast, anti-filamentous hemagglutinin antibodies persisted and anti-adenylate cyclase-hemolysin antibodies increased continuously, suggesting either cross-reaction with non-Bordetella antigens or exposure to Bordetella isolates expressing these two antigens, including Bordetella pertussis. These data suggest that unrecognized pertussis is common in France despite massive and sustained immunization in infants and that vaccinated children become susceptible to infection more than 6 years after their last vaccination.