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Invited Commentary
Infectious Diseases
August 10, 2021

Pertussis Vaccination—A Critical Priority for Us All

Author Affiliations
  • 1Zucker School of Medicine at Hofstra/Northwell, Cohen Children’s Medical Center, Hempstead, New York
  • 2Franny Strong Foundation, West Bloomfield, Michigan
JAMA Netw Open. 2021;4(8):e2119365. doi:10.1001/jamanetworkopen.2021.19365

Infants are most susceptible to severe pertussis disease; complications include encephalopathy, pneumonia, seizures, hospitalization, and death. The Centers for Disease Control and Prevention (CDC) reported 307 deaths from pertussis between 2000 and 2017. Children younger than 2 months accounted for 84% of those deaths. In 2018, pertussis incidence per 100 000 was 72.3 in infants younger than 6 months and 32.7 in infants aged 6 to 12 months, compared with 1.4 in persons aged 20 years or older.1

Since widespread use of the Bordetella pertussis vaccine began, incidence of pertussis cases has decreased more than 75% compared with the prevaccine era.1 A single dose of tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap) vaccine has been recommended by the CDC for adolescents and adults since 2005.2 The CDC also recommends antepartum Tdap vaccination during each pregnancy to protect pregnant women and their very young infants from pertussis.3 Children must receive 3 doses of diphtheria-tetanus–acellular pertussis (DTaP) in the first year of life, a fourth dose in year 2, and a fifth dose at 4 to 6 years of age to enter kindergarten.4

Unfortunately, data show that only about half of pregnant women receive Tdap,5 leaving many women and their very young infants at risk for pertussis. The study by Rane et al6 in this issue of JAMA Network Open further underscores the additional increased risk to infants and children from undervaccination with DTaP. Rane and colleagues6 examined the Washington State Immunization Information system and pertussis surveillance data from Public Health Seattle and King County. Their study revealed important findings. First, undervaccination (receiving fewer than the recommended doses at a given age) and delayed receipt (not receiving doses within the time frames recommended by the CDC) of DTaP vaccine increased risk 4.8-fold for the primary series in infants and young children, 3.2-fold for the second-year reinforcing dose, and 4.6-fold for the prekindergarten booster. Second, a small delay in administration had no apparent effect on risk if the number of doses was received in an age-appropriate manner. Third, the recommendations for the DTaP series in the US from the World Health Organization and Advisory Committee on Immunization Practices are effective in reducing pertussis incidence.

In addition, Rane et al6 documented that pertussis incidence was higher among children aged 2 to 5 years who did not receive the prekindergarten booster. The authors also noted that school-aged children are core spreaders who help sustain pertussis transmission chains due to increased contact rates. Older children and adults can transmit pertussis to those at risk for complications. Parents, most often mothers, are commonly identified as the source of pertussis in infants, as are siblings.7 With waning immunity, vaccinated siblings and caregivers can still transmit pertussis to infants aged 6 months or younger.7

The bottom line is clear, thanks to Rane and colleagues.6 Pertussis vaccination must be a critical priority for everyone because of the increased risk of the disease from undervaccination and delayed vaccination. Decreases in routine vaccination mean children and their communities face an increased risk for outbreaks of vaccine-preventable diseases. With close to 4 million births per year in the US, pregnant women also must receive the Tdap vaccine during the 27th through 36th week of each pregnancy, preferably during the earlier part of this time period, which lowers the risk of pertussis in babies younger than 2 months by 78%.1

There is an urgent need to help children and families be up to date with their vaccines. Like many vaccine-preventable diseases, the risk of pertussis is even higher now among children and adults due to prominent vaccine hesitancy and extra vulnerability from decreased routine vaccination rates during the COVID-19 pandemic.8 Health care professionals should emphasize pertussis vaccination in all of their catch-up efforts. Prevention is key: children, adolescents, and adults, including pregnant women, must all receive their pertussis-containing vaccines as recommended and on time. Infant lives are depending on it.

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Article Information

Published: August 10, 2021. doi:10.1001/jamanetworkopen.2021.19365

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Bernstein H et al. JAMA Network Open.

Corresponding Author: Henry Bernstein, DO, MHCM, Professor of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Cohen Children’s Medical Center, 410 Lakeville Rd, Ste 311, New Hyde Park, NY 11042 (hbernstein@northwell.edu).

Conflict of Interest Disclosures: Dr Bernstein reported receiving personal fees from the Advisory Committee on Immunization Practices and the Centers for Disease Control and Prevention as an Advisory Committee on Immunization Practices member, personal fees for serving as editor of Current Opinion in Pediatrics, personal fees from Takeda as a Data Safety Monitoring Board member of an intrathecal enzyme study for Hurler syndrome, and a breastfeeding promotional grant from the New York State Department of Health outside the submitted work. Ms McNally reported receiving personal fees from the Advisory Committee on Immunization Practices and the Centers for Disease Control and Prevention as an Advisory Committee on Immunization Practices member outside the submitted work.

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Public Health Foundation, 2015.
Broder  KR, Cortese  MM, Iskander  JK,  et al; Advisory Committee on Immunization Practices (ACIP).  Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP).   MMWR Recomm Rep. 2006;55(RR-3):1-34.PubMedGoogle Scholar
Havers  FP, Moro  PL, Hunter  P, Hariri  S, Bernstein  H.  Use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: updated recommendations of the Advisory Committee on Immunization Practices—United States, 2019.   MMWR Morb Mortal Wkly Rep. 2020;69(3):77-83. doi:10.15585/mmwr.mm6903a5 PubMedGoogle ScholarCrossref
Wodi  AP, Ault  K, Hunter  P, McNally  V, Szilagyi  PG, Bernstein  H.  Advisory committee on immunization practices recommended immunization schedule for children and adolescents aged 18 years or younger—United States, 2021.   MMWR Morb Mortal Wkly Rep. 2021;70(6):189-192. doi:10.15585/mmwr.mm7006a1PubMedGoogle ScholarCrossref
Kahn  KE, Black  CL, Ding  H,  et al.  Influenza and Tdap vaccination coverage among pregnant women—United States, April 2018.   MMWR Morb Mortal Wkly Rep. 2018;67(38):1055-1059. doi:10.15585/mmwr.mm6738a3 PubMedGoogle ScholarCrossref
Rane  MS, Rohani  P, Halloran  ME.  Association of diphtheria-tetanus–acellular pertussis vaccine timeliness and number of doses with age-specific pertussis risk in infants and young children.   JAMA Netw Open. 2021;4(8):e2119118. doi:10.1001/jamanetworkopen.2021.19118Google Scholar
Skoff  TH, Kenyon  C, Cocoros  N,  et al.  Sources of infant pertussis infection in the United States.   Pediatrics. 2015;136(4):635-641. doi:10.1542/peds.2015-1120PubMedGoogle ScholarCrossref
Santoli  JM, Lindley  MC, DeSilva  MB,  et al.  Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration—United States, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(19):591-593. doi:10.15585/mmwr.mm6919e2 PubMedGoogle ScholarCrossref
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