Trends in Infant Pertussis Hospitalizations in the United States, 2009-2017 | Infectious Diseases | JAMA | JAMA Network
[Skip to Navigation]
Sign In
Figure.  Monthly Infant Pertussis Hospitalizations Between Birth and 2 Months of Age, 2009-2017
Monthly Infant Pertussis Hospitalizations Between Birth and 2 Months of Age, 2009-2017

Circles indicate observed rates; dashed line is the predicted rate.

Table.  Characteristics of Infants in the Study Population, 2009-2017
Characteristics of Infants in the Study Population, 2009-2017
1.
Liang  JL, Tiwari  T, Moro  P,  et al.  Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP).  MMWR Recomm Rep. 2018;67(2):1-44. doi:10.15585/mmwr.rr6702a1PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention.  Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women—Advisory Committee on Immunization Practices (ACIP), 2012.  MMWR Morb Mortal Wkly Rep. 2013;62(7):131-135.PubMedGoogle Scholar
3.
Centers for Disease Control and Prevention. Pertussis (whooping cough) surveillance and reporting. 2017. https://www.cdc.gov/pertussis/surv-reporting.html. Accessed March 19, 2019.
4.
 The Truven Health MarketScan Databases for Health Services Researchers. Ann Arbor, MI: Truven Health Analytics; 2017.
5.
Bozio  C, Skoff  T, Pondo  T, Liang  J.  Epidemiology and trends of pertussis among infants: United States, 2000-2015.  Open Forum Infect Dis. 2017;4(suppl 1):S5. doi:10.1093/ofid/ofx162.010Google ScholarCrossref
6.
Winter  K, Cherry  JD, Harriman  K.  Effectiveness of prenatal tetanus, diphtheria, and acellular pertussis vaccination on pertussis severity in infants.  Clin Infect Dis. 2017;64(1):9-14. doi:10.1093/cid/ciw633PubMedGoogle ScholarCrossref
Research Letter
December 3, 2019

Trends in Infant Pertussis Hospitalizations in the United States, 2009-2017

Author Affiliations
  • 1Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
  • 2Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
JAMA. 2019;322(21):2134-2136. doi:10.1001/jama.2019.15577

Pertussis infection can cause serious complications, particularly among infants younger than 2 months, who are too young to be vaccinated.1 To reduce pertussis morbidity and mortality among young infants, the Advisory Committee on Immunization Practices (ACIP) issued a series of recommendation changes regarding antenatal administration of the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine, the most recent of which was issued in 2012 and recommends administration in every pregnant woman, regardless of prior receipt.2 Pertussis incidence among US infants younger than 1 year decreased after 20123; however, data on trends in young infants are scarce. We examined trends in pertussis hospitalizations among infants younger than 2 months before and after the changes to the ACIP recommendations in 2012.

Methods

We used data from the Truven Health Analytics Marketscan Commercial databases, which contain deidentified patient-level data for individuals enrolled in US employer-sponsored private health insurance.4 The database includes all 50 states and is generally reflective of the privately insured population. We identified infants with a birth hospitalization occurring between January 1, 2009, and October 31, 2017, using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes (V30.xx-V39.xx) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes (Z38.xx). Because infant age in months was not available, we assigned the birth hospitalization admission date as the infant’s date of birth. Infants who were not enrolled for at least 59 days after birth were excluded. We were unable to identify infant deaths.

The outcome of interest was pertussis hospitalization occurring between the date of birth and 2 months (60 days) of age. We defined a pertussis hospitalization as an inpatient admission with report of a pertussis-related code (ICD-9-CM code 033.0 or 033.9 or ICD-10-CM code A37.0x or A39.0x).

We calculated monthly pertussis hospitalization rates by dividing the total number of hospitalizations with a pertussis diagnosis in the first 2 months of life by the total number of infants younger than 2 months during a given month. We used an interrupted time-series design with segmented quasi-Poisson regression models to calculate risk ratios (RRs) and 95% CIs comparing infant pertussis hospitalizations occurring between the 2009-2012 period and the 2013-2017 period. We assumed a level change in pertussis hospitalizations (tested using an interaction term) and no lag. We used SAS statistical software version 9.4 (SAS Institute Inc) for data analysis. A 2-sided P < .05 was considered statistically significant. This study was deemed exempt by Emory University’s institutional review board.

Results

We identified 2 031 775 infants with a birth hospitalization; 94.6% (n = 1 921 892) were enrolled for at least 59 days. Approximately 51.6% of infants were male and 34.3% lived in the South (Table).

Compared with the 2009-2012 rate of pertussis hospitalizations of 8.4 per 100 000 infants (95% CI, 7.2-9.7 per 100 000; 177 of 2.1 million infants), the 2013-2017 rate decreased to 3.3 per 100 000 infants (95% CI, 2.6-4.3 per 100 000; 57 of 1.7 million infants). After adjusting for time, there was a 48% decrease in the rate of pertussis hospitalization (RR, 0.52; 95% CI, 0.31-0.89; Figure). There was no difference in slope between the 2 periods (P = .95).

Discussion

The results of this large national study indicate a decline in pertussis hospitalization rates among young infants after the 2012 recommendation change, adding to the growing body of literature suggesting that maternal Tdap vaccination is associated with lower rates of death5 and hospitalization and reduced disease severity among young infants with pertussis.6

The data used for this study were derived from a privately insured population; findings may not be representative of all infants. Use of ICD codes to identify pertussis hospitalizations may have resulted in misclassification. Infant death data were not available, so pertussis complications were underestimated. Maternal Tdap vaccination status was not assessed; therefore, correlations between maternal vaccination and infant pertussis hospitalization could not be examined. This study examined trends in infant pertussis hospitalizations and could not account for infants with less severe illness who were not hospitalized.

These findings underscore the public health importance of maternal Tdap vaccination in reducing pertussis burden among young infants. Clinicians should continue to promote maternal Tdap vaccination and find ways to overcome barriers to vaccination during pregnancy.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
Back to top
Article Information

Accepted for Publication: September 5, 2019.

Corresponding Author: Sheree L. Boulet, DrPH, MPH, Department of Gynecology and Obstetrics, Emory University School of Medicine, 69 Jesse Hill Jr Dr SE, Glenn Bldg, Fourth Floor, Atlanta, GA 30303 (sboulet@emory.edu).

Author Contributions: Dr Boulet had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Boulet, Jamieson.

Acquisition, analysis, or interpretation of data: Boulet, Chamberlain, Biswas.

Drafting of the manuscript: Boulet, Biswas.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Boulet, Biswas.

Administrative, technical, or material support: Chamberlain.

Conflict of Interest Disclosures: Dr Chamberlain reported receiving personal fees from the American College of Obstetricians and Gynecologists. No other disclosures were reported.

References
1.
Liang  JL, Tiwari  T, Moro  P,  et al.  Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP).  MMWR Recomm Rep. 2018;67(2):1-44. doi:10.15585/mmwr.rr6702a1PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention.  Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women—Advisory Committee on Immunization Practices (ACIP), 2012.  MMWR Morb Mortal Wkly Rep. 2013;62(7):131-135.PubMedGoogle Scholar
3.
Centers for Disease Control and Prevention. Pertussis (whooping cough) surveillance and reporting. 2017. https://www.cdc.gov/pertussis/surv-reporting.html. Accessed March 19, 2019.
4.
 The Truven Health MarketScan Databases for Health Services Researchers. Ann Arbor, MI: Truven Health Analytics; 2017.
5.
Bozio  C, Skoff  T, Pondo  T, Liang  J.  Epidemiology and trends of pertussis among infants: United States, 2000-2015.  Open Forum Infect Dis. 2017;4(suppl 1):S5. doi:10.1093/ofid/ofx162.010Google ScholarCrossref
6.
Winter  K, Cherry  JD, Harriman  K.  Effectiveness of prenatal tetanus, diphtheria, and acellular pertussis vaccination on pertussis severity in infants.  Clin Infect Dis. 2017;64(1):9-14. doi:10.1093/cid/ciw633PubMedGoogle ScholarCrossref
×