Journal of Infectious Diseases, vol. 179, April 1999; 915-923. "Temporal trends in the population structure of bordetella pertussis during 1949-1996 in a highly vaccinated population "Despite the introduction of large-scale pertussis vaccination in 1953 and high vaccination coverage, pertussis is still an endemic disease in The Netherlands, with epidemic outbreaks occurring every 3-5 years." One factor that might contribute to this is the ability of pertussis strains to adapt to vaccine-induced immunity, causing new strains of pertussis to re-emerge in this well-vaccinated population.
"The epidemiology of pertussis in the Republic of Ireland" (Communicable Disease Report[:] CDR Review, vol. 2, no. 3, February 28, 1992, pp. R31-3): Following adverse publicity in 1973, uptake of the vaccine fell to 30% in 1976. In recent years, it has leveled out at only 40-45%. Yet when large epidemics of pertussis occurred in 1985 and 1989, mortality from pertussis fell to almost negligible levels.
"Severity of whooping cough in England before and after the decline in pertussis immunisation" (Archives of Disease in Childhood, vol. 59, no. 2, February 1984, pp. 162-5): "Since the decline of pertussis immunisation, hospital admission and death rates from whooping cough have fallen unexpectedly The severity of attacks and the complication rates in children [who were] admitted to hospital were virtually unchanged."
O. Tonz and S. Bajc, "Convulsions or status epilepticus in 11 infants after pertussis vaccination" (Schweiz. Med. Wochenschr., vol. 110, no. 51, December 20, 1980, pp. 1965-71): In three of 11 cases, grand mal epilepsy persisted and two children developed infantile epileptic encephalopathy (Lennox Syndrome). "The following conclusions are drawn from these observations: 1) In view of the usually benign course of whooping cough today, current vaccination is hardlysatisfactory. Improvement of the available vaccines is an urgent necessity 2) Parents should be better informed about the risks involved in pertussis vaccination. 3) Booster inoculations should be abandoned. 4) Health authorities should decide whether the current pertussis vaccination program should be abandoned. 5) Complications following vaccination should be registered .."
"Whooping cough and pertussis vaccine: a comparison of risks and benefits in Britain during the period 1968-83" (Development of Biological Standards, vol. 61, 1985, pp. 395-405): "Since 1975, acceptance of pertussis vaccine has fallen from over 70% to 50% or less in most parts of Britain. This permits evaluation of a continuing natural experiment in which the frequency and severity of whooping cough can be compared [with] those of adverse events following injections of pertussis vaccine There is a significant correlation between vaccine-acceptance and hospital admission by district of residence It is concluded that, in children living in non-deprived circumstances in Britain, the risk of pertussis vaccine during the period 1970-83 exceeded those of whooping cough. In some deprived sectors, the risks from whooping cough might have been marginally higher but there was no evidence that this was associated with any increase in deaths or permanent disabilities."
"Vaccination against whooping-cough. Efficacy versus risks" (The Lancet, vol. 1, January 29, 1977, pp. 234-7): Calculations based on the mortality of whooping-cough before 1957 predict accurately the subsequent decline and the present low mortality Incidence [is] unaffected either by small-scale vaccination beginning about 1948 or by nationwide vaccination beginning in 1957 No protection is demonstrable in infants."
Bentsi-Enchill AD, et al. Estimates of the effectiveness of a whole-cell pertussis vaccine from an outbreak in an immunized population. Vaccine. 1997 Feb;15(3):301-6. PMID: 9139490; UI: 97227584.
Bassili WR, Stewart GT.
Epidemiological evaluation of immunisation and other factors in the control of
whooping-cough. Lancet 1976 Feb 28;1(7957):471-4
The general incidence of whooping-cough is lower in fully immunised children, but present immunisation schedules do not adequately protect the infant below 1 year of age either from contracting infection or from its complications. In a recent outbreak in Glasgow, nearly one-third of notified cases were fully immunised. In Glasgow and probably in the U.K. as a whole, the persistance of whooping-cough in some areas is more strongly correlated with adverse socio-economic conditions that with lack of immunisation. The decline in recent years could be attributable to improvement in these conditions at least as much as to immunisation. There is no epidemiological justification for continuing mass immunisation, but there is a strong case for an intensified eradication policy which might include selective immunisation in high-risk groups and areas.
Stewart, GT; Immunisation against whooping cough; British Medical Journal, 31 January
Sir: In showing that 75% of infants below 3 months of age with whooping cough were admitted to hospital and that 42% of all hospital admissions of children notified as whooping cough were infants or 5 months or younger, Drs. Christina L. Miller and W.B, Fletcher (17 January, p 117) have indeed confirmed the widely-held belief that :in young infants whooping cough is still dangerous". They have not shown that "at all ages previous vaccination reduced the severity of the disease." What they have shown is that, among notified cases, a significantly higher proportion of the more severe cases and of those admitted to hospital were not immunised or were incompletely immunised. This does not mean that immunisation is necessarily protective. Of 8092 cases notified to them, 2940 (36%) were fully immunised while only 2424(30%) were definitely not immunised.
In the same issue (p128) Dr. ND Noah claims that "current vaccines provide young children with substantial protection against whooping cough". What he actually shows, in a single tabulation of notifications uncorrected for age, is that the incidence of whooping cough is lower in immunised than in non-immunised children. But the rate of notified infection was still relatively high (50 per 100,000) in 1974 in children fully immunised with the new vaccine. There is no evidence in either article that immunisation of older children protects younger ones.
Several questions arise:
What kind of immunisation is this for which success is being claimed? It is an immunisation which leaves those at highest risk (that is, below 6 months of age) unprotected and which, even when complete, is associated only with partial protection of those in the lowest risk groups.
What kind of epidemiology is this which advocates immunisation by excluding consideration of factors other than immunisation? It is admitted in both articles and is indeed obvious from the data that factors other than immunisation must influence susceptibility to whooping cough. If immunisation is to be tested for efficacy, the data must be standardised for domestic, demographic and social factors.
Whooping cough is much lower in incidence, hospital admissions are less frequent, and immunisation schedules are often better maintained in districts where socioeconomic conditions are favourable. Thereported association between protection and immunisation could be an expression of better social conditions and child care as much as of biological protection by pertussis vaccine.
What kind of editorial policy is this which publishes incomplete data and promotes far-reaching claims about the efficacy of immunisation but refuses to publish collateral data questioning this efficacy?
Paradoxically, the articles by Drs. Miller and Fletcher and Dr. Noah reinforce the suggestion made in my letter in your issue of 10 January (p 93) that evidence about the efficacy of pertussis vaccine is lacking. But the question remains.
MMWR November 05, 1993 / 42(43);840-841,847 Diphtheria Outbreak -- Russian
Despite high levels of vaccination coverage against diphtheria, an ongoing outbreak of diphtheria has affected parts of the Russian Federation since 1990 (1); as of August 31, 1993, 12,865 cases had been reported. This report summarizes epidemiologic information about this outbreak for January 1990- August 1993, and is based on reports from public health officials in the Russian Federation.
Within the report is also says: "an estimated 90% of children were fully vaccinated with four or more doses of diphtheria toxoid by the time they entered school."URL: http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00022128.htm
The Lancet Volume 353, Number 9150 30 January 1999 Risk of diphtheria among schoolchildren in the Russian Federation in relation to time since last vaccination
In 1993, the Russian Federation reported 15229 cases of diphtheria, a 25-fold increase over the 603 cases reported in 1989.1 The incidence rate among children 7-10 years of age (15ˇ7 per 100000) was twice that of adults aged 18 years or over (7ˇ9 per 100000).4 81% of the affected children aged 7-10 years had been vaccinated with at least a primary series of diphtheria toxoid, and most had received the first booster recommended to be given 12 months after completion of the primary series.
So, it's pretty hard to ascribe low immunization rates as a cause for the outbreak of Diptheria. A much more likely explanation is the social disruption that was going on at the time of great political upheaval. Breakdown of hygiene, poverty, etc.
de Melker HE, et al. Pertussis in The Netherlands: an outbreak despite high levels of immunization with whole-cell vaccine. Emerg Infect Dis. 1997 Apr-Jun;3(2):175-8. PMID: 9204299; UI: 97348248.Shimoni, Zvi; Dobrousin, Anatoly; Cohen, Jonathan; et al. "Tetanus in an Immunised Patient" British Medical Journal Online (10/16/99) Vol. 319, No. 7216, P. 1049;
Kirchner, Jeffrey T., "Manifestations of Pertussis in Immunized
Children and Adults", American Family Physician, November 1, 1999,
Vol. 60, p. 2150
"Recent epidemiologic studies have shown that the incidence and
prevalence of Bordetella pertussis infection in adults are much
greater that previously reported. In studies of adults with chronic
cough, 20 to 25 percent were found to have serologic evidence of
recent B. pertussis infection. However, pertussis is rarely
considered in adults because the signs and symptoms are nonspecific."
Bykowski, M., "Pertussis in Adults", OB GYN News, November 1, 1999,
Vol. 34, p. 29
"It was formerly believed that infection or immunization conferred
lifetime immunity, but now appears that any resultant immunity is in
fact short lived. Thus, there is a growing interest in the selective
reimmunization of adults, he said. And while pertussis was once
considered uncommon in adults and older adolescents, it's now believed
that the disease is endemic in these populations, who actually serve
as the primary reservoir for pertussis, explained Dr. Ogle, professor
of pediatrics at the University of Colorado, Denver. Studies from
throughout the developed world suggest a 25%-30% of persistent
coughing illness in these age groups is pertussis, he added."
Poland, Gregory A., "Still more questions on pertussis vaccines", The
Lancet, November 29, 1997, Vol. 350, pp. 1564-1565
"Despite sharply reducing severe pertussis and pertussis deaths,
whole-cell vaccines have not stopped circulation of Bordetella in the
population, do not induce sustained protective immunity, and are
precluded from routine use as boosters in adolescents and adults
because of their side-effects. In addition, questions about safety
and efficacy remain."
De Serres, Gaston, MD, MPH, Boulianne N., MSC, Duval, B. MD, Déry, P.
MD, Rodrigquez, A. M., MD, Massé, R., MD, and Halperin, S. MD,
"Effectiveness of whole cell pertussis vaccine in child-care centers
and schools", The Pediatric Infectious Disease Journal,
"Despite the high rate of pertussis vaccine coverage in children
between the 2 and 9 years of age, pertussis was a common illness in
these preschool and school age children. Although the whole cell
vaccine was demonstrated to be effective, estimates of vaccine
effectiveness were lower than the estimated in the United States and
elsewhere. ... In those studies a different whole cell vaccine
manufactured by Connaught Laboratories Inc. (Swiftwater, PA) had an
efficacy of 48% in Sweden and 36% in Italy."
Cherry, James D., MD, Brunell, Philip A. MD, Golden, Gerald A., MD,
and Karzon, David T., MD. "Report of the Task Force on Pertussis and
Pertussis Immunization - 1988", Pediatrics, June 1988, Volume 81,
Number 6, Part 2, Supplement, p. 955
"Reported cases and outbreaks in older children and young adults may
reflect a less durable vaccine-induced protection than seen in natural
disease. The duration of protection has varied in several studies,
depending on the epidemiological setting, ie, prevalence of natural
disease as well as the vaccine product used. A study in Michigan
showed an efficacy of 80% 3 years after the last dose, 50% between 4
and 7 years, and virtually none after 12 years. Breakthrough disease
noted in this study was usually mild."