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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pertussis is not just a disease of children&#46; The incidence and rate of complications is highest in the first few months after birth&#44; but neither natural infection nor vaccination confer protection for life&#44; meaning that reinfection can occur at any time&#46; The incidence of the disease in adults is higher than usually thought&#46; A French study conducted between June 2013 and August 2014 that included patients over 50 years of age who had cough lasting between 7 and 21 days revealed a diagnosis of pertussis in 30 of the 129 study patients&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> In another study in Germany that included patients over 18 years of age &#40;median age 50 years&#41; with cough of more than 7 days&#8217; duration&#44; a diagnosis of pertussis was established in 5&#46;6&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> These infections require the prescription of various drugs&#44; including antibiotics&#44; and visits to the family doctor and the emergency department with the consequent increase in health expenditure&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> In a recent study in 7 states in the US that included adult patients hospitalized for pertussis&#44; 12&#37; of those aged 21&#8211;64 years&#44; and 10&#37; of those over 65 years&#44; were admitted to intensive care&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Pertussis is a highly contagious respiratory disease that has a basic reproduction number estimated at between 12 and 17&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5&#8211;7</span></a> The typical clinical presentation in adults prompting a possible diagnosis of pertussis usually involves cough lasting more than 2 weeks&#44; associated with any of the following symptoms&#58; paroxysmal cough&#44; inspiratory whooping&#44; and post-tussive vomiting&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6&#44;8</span></a> It has a wide spectrum of severity&#44; ranging from mild cough to severe symptoms of pneumonia&#44; encephalopathy&#44; and respiratory failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#44;5</span></a> In adults&#44; the presence of paroxysmal cough and absence of fever have high sensitivity but low specificity for the diagnosis of pertussis&#44; while inspiratory whooping and post-tussive vomiting have high specificity but low sensitivity&#46; Patients may also present other symptoms&#44; such as dyspnea&#44; sleep disturbance&#44; and rib pain&#44; and complications&#44; such as sinusitis&#44; pneumonia&#44; urinary incontinence&#44; or rib fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> Atypical clinical presentations are becoming more frequent&#44; especially in adults and previously vaccinated subjects&#44; who tend to have milder forms&#44; with cough often being the only symptom&#46; Since cough is a very common&#44; nonspecific symptom with multiple possible etiologies&#44; diagnostic delays can occur that can promote the spread of infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#44;9</span></a> Another important factor is subclinical infection&#44; detected by positive PCR in asymptomatic patients&#44; that also contributes to the spread of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">PCR or culture of the patient&#39;s biological samples may be performed to confirm diagnosis&#44; but these are only useful within the first 3 weeks after onset of cough&#44; and after this period&#44; serologies should be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;7</span></a> Time to medical consultation in adults is around 17 days&#44; which is at the limit of the period during which PCR or culture retain diagnostic utility&#46; This diagnostic delay also increases infectious outbreaks with attack rates that can exceed 90&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6&#44;11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The pertussis vaccine&#44; introduced in the middle of the last century&#44; led to a significant reduction in the incidence of the disease&#46; In recent years&#44; however&#44; there appears to be a global resurgence of pertussis&#46; In Italy&#44; the number of cases tripled between 2008 and 2017 after a significant decline in the preceding decade&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">12&#44;13</span></a> Various explanations have been suggested for this increase in incidence&#44; but there is no clear consensus as to the reason&#46; It could be related to asymptomatic transmission by infected vaccinated subjects&#44; a lower vaccination rate in some populations&#44; a progressive loss of immunity acquired by vaccination or previous infection&#44; genetic variations of <span class="elsevierStyleItalic">Bordetella pertussis</span> that make it more virulent or capable of evading the vaccine response&#44; a shorter duration of protection obtained with acellular vaccines&#44; an increase in the awareness of the disease among both the population and medical professionals&#44; or the increased availability and sensitivity of diagnostic methods&#44; among other factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;7&#44;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Against this background&#44; various vaccination strategies are being proposed to optimize pertussis control&#46; The US Centers for Disease Control and Prevention make a number of recommendations for different adult population groups&#44; particularly pregnant women and health workers&#44; and a blanket indication for a pertussis booster in adults&#44; especially in individuals over 65 years of age&#46; The Center for Disease Control and Prevention states that any adult over the age of 19 who has never been vaccinated against pertussis should receive a dose as soon as possible&#44; and they also recommend the use of boosters that include the pertussis component&#44; especially in people over 65 years of age&#46; Pregnant women should receive the acellular pertussis vaccine&#44; preferably between 27 and 36 weeks of gestation&#46; This strategy has already been shown to be highly effective and is becoming widespread across multiple Western countries&#44; including Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;14&#8211;16</span></a> The recommendations made for adults are also applied to healthcare workers&#44; with priority being given to workers who are in contact with children under 12 months of age&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> Healthcare workers are particularly exposed to infections in their working environment and may be sources of nosocomial outbreaks&#44; suggesting that vaccination would be particularly efficient in this setting&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Adult vaccination focuses on reducing mortality and transmission to infants&#46; However&#44; although a booster dose at age 65 might solve the problem of tetanus and diphtheria&#44; the best strategy in the case of pertussis would be vaccination every 10 years with DTaP&#44; a vaccine that has already demonstrated a good immunogenicity and safety profile&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Reality&#44; according to Aristotle&#44; is the only truth&#46; Similarly&#44; the available evidence seems to suggest that pertussis is not just a pediatric problem&#44; but also significantly affects the adult population&#46; It seems that prevailing vaccination strategies should be revisited&#44; and that vaccination programs aimed at the entire population should be implemented&#44; focusing particularly on specific groups such as pregnant women or healthcare workers&#46; Recommendations for pertussis vaccination in adults have been drawn up as part of prevention programs for community-acquired pneumonia&#46; These include guidelines developed by the Respiratory Prevention Expert Group that specifically propose the vaccination of adults with chronic disease and a higher risk of pertussis complications due to immunosuppression&#44; COPD or diabetes mellitus&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> A careful review of symptoms and screening for etiological diagnoses can help identify the disease&#44; improve its prognosis&#44; and limit dissemination&#46; But this simply proves that the enemy is only visible if we seek it&#44; and that the cost-benefit ratio clearly supports the greater use of vaccination against this disease in the adult population&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">FM-T receives support for research from the Instituto de Salud Carlos III&#44; but it is not related with this work &#40;Health Research Project&#44; Strategic Health Action&#41;&#58; Health Research Fund &#40;FIS&#59; PI070069&#47;PI1000540&#47;PI1601569&#47;PI1901090&#41; of the national RD&#43;I plan &#8220;FEDER funds&#8221; Proyectos GaIN Rescata-Covid IN845D 2020&#47;23 &#40;GaIN&#44; Government of Galicia&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">F-JG-B has received honoraria for scientific consultancy and&#47;or for lectures and&#47;or research grants from&#58; ALK&#44; Astra-Zeneca&#44; Bial&#44; Boehringer-Ingelheim&#44; Chiesi&#44; Gebro Pharma&#44; GlaxoSmithKline&#44; Laboratorios Esteve&#44; Menarini&#44; Mundipharma&#44; Novartis&#44; Rovi&#44; Roxall&#44; Sanofi&#44; Stallergenes-Greer and Teva&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">FV-A has attended or participated in activities organized or financed by the pharmaceutical laboratories Almiral&#44; AstraZeneca&#44; Bial&#44; Boehringer-Ingelheim&#44; Chiesi&#44; GlaxoSmithKline&#44; Esteve&#44; Ferrer&#44; Menarini&#44; Novartis&#44; Mundipharma&#44; Orion&#44; Pfizer&#44; Teva and Zambon&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">FM-T has received honoraria from Biofabri&#44; GSK&#44; Pfizer Inc&#44; Sanofi Pasteur&#44; MSD&#44; Seqirus&#44; Novavax and Janssen for advisory&#44; consultancy and lecturing roles outside the scope of this work&#46; FMT has worked as principal investigator in clinical trials sponsored by the pharmaceutical companies mentioned above and also Ablynx&#44; Regeneron&#44; Roche&#44; Abbott and MedImmune&#44; with all honoraria being paid to the institution&#46;</p></span></span>"
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Editorial
Whooping Cough: The Visible Enemy
Tosferina en el adulto: el enemigo visible
Francisco-Javier González-Barcalaa,b,c,d,
Corresponding author
, Felipe Villar-Alvarezd,e,f, Federico Martinón-Torresg,h,i
a Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
b Departamento de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
c Grupo de investigación - Traslational Research In Airway Diseases (TRIAD), Santiago de Compostela, Spain
d CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
e Servicio de Neumología, IIS Fundación Jiménez Díaz, UAM, Madrid, Spain
f Universidad Autónoma de Madrid, Madrid, Spain
g Servicio de Pediatría, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
h Grupo de Genética, Vacunas, Infecciones y Pediatría (GENVIP), Instituto de Investigación Sanitaria de Santiago, Universidad de Santiago, Santiago de Compostela, Spain
i Centro Colaborador de la Organización Mundial de la Salud en Seguridad Vacunal, Santiago de Compostela, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pertussis is not just a disease of children&#46; The incidence and rate of complications is highest in the first few months after birth&#44; but neither natural infection nor vaccination confer protection for life&#44; meaning that reinfection can occur at any time&#46; The incidence of the disease in adults is higher than usually thought&#46; A French study conducted between June 2013 and August 2014 that included patients over 50 years of age who had cough lasting between 7 and 21 days revealed a diagnosis of pertussis in 30 of the 129 study patients&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> In another study in Germany that included patients over 18 years of age &#40;median age 50 years&#41; with cough of more than 7 days&#8217; duration&#44; a diagnosis of pertussis was established in 5&#46;6&#37; of the cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> These infections require the prescription of various drugs&#44; including antibiotics&#44; and visits to the family doctor and the emergency department with the consequent increase in health expenditure&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> In a recent study in 7 states in the US that included adult patients hospitalized for pertussis&#44; 12&#37; of those aged 21&#8211;64 years&#44; and 10&#37; of those over 65 years&#44; were admitted to intensive care&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Pertussis is a highly contagious respiratory disease that has a basic reproduction number estimated at between 12 and 17&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5&#8211;7</span></a> The typical clinical presentation in adults prompting a possible diagnosis of pertussis usually involves cough lasting more than 2 weeks&#44; associated with any of the following symptoms&#58; paroxysmal cough&#44; inspiratory whooping&#44; and post-tussive vomiting&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6&#44;8</span></a> It has a wide spectrum of severity&#44; ranging from mild cough to severe symptoms of pneumonia&#44; encephalopathy&#44; and respiratory failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#44;5</span></a> In adults&#44; the presence of paroxysmal cough and absence of fever have high sensitivity but low specificity for the diagnosis of pertussis&#44; while inspiratory whooping and post-tussive vomiting have high specificity but low sensitivity&#46; Patients may also present other symptoms&#44; such as dyspnea&#44; sleep disturbance&#44; and rib pain&#44; and complications&#44; such as sinusitis&#44; pneumonia&#44; urinary incontinence&#44; or rib fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> Atypical clinical presentations are becoming more frequent&#44; especially in adults and previously vaccinated subjects&#44; who tend to have milder forms&#44; with cough often being the only symptom&#46; Since cough is a very common&#44; nonspecific symptom with multiple possible etiologies&#44; diagnostic delays can occur that can promote the spread of infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#44;9</span></a> Another important factor is subclinical infection&#44; detected by positive PCR in asymptomatic patients&#44; that also contributes to the spread of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">PCR or culture of the patient&#39;s biological samples may be performed to confirm diagnosis&#44; but these are only useful within the first 3 weeks after onset of cough&#44; and after this period&#44; serologies should be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;7</span></a> Time to medical consultation in adults is around 17 days&#44; which is at the limit of the period during which PCR or culture retain diagnostic utility&#46; This diagnostic delay also increases infectious outbreaks with attack rates that can exceed 90&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6&#44;11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The pertussis vaccine&#44; introduced in the middle of the last century&#44; led to a significant reduction in the incidence of the disease&#46; In recent years&#44; however&#44; there appears to be a global resurgence of pertussis&#46; In Italy&#44; the number of cases tripled between 2008 and 2017 after a significant decline in the preceding decade&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">12&#44;13</span></a> Various explanations have been suggested for this increase in incidence&#44; but there is no clear consensus as to the reason&#46; It could be related to asymptomatic transmission by infected vaccinated subjects&#44; a lower vaccination rate in some populations&#44; a progressive loss of immunity acquired by vaccination or previous infection&#44; genetic variations of <span class="elsevierStyleItalic">Bordetella pertussis</span> that make it more virulent or capable of evading the vaccine response&#44; a shorter duration of protection obtained with acellular vaccines&#44; an increase in the awareness of the disease among both the population and medical professionals&#44; or the increased availability and sensitivity of diagnostic methods&#44; among other factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;7&#44;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Against this background&#44; various vaccination strategies are being proposed to optimize pertussis control&#46; The US Centers for Disease Control and Prevention make a number of recommendations for different adult population groups&#44; particularly pregnant women and health workers&#44; and a blanket indication for a pertussis booster in adults&#44; especially in individuals over 65 years of age&#46; The Center for Disease Control and Prevention states that any adult over the age of 19 who has never been vaccinated against pertussis should receive a dose as soon as possible&#44; and they also recommend the use of boosters that include the pertussis component&#44; especially in people over 65 years of age&#46; Pregnant women should receive the acellular pertussis vaccine&#44; preferably between 27 and 36 weeks of gestation&#46; This strategy has already been shown to be highly effective and is becoming widespread across multiple Western countries&#44; including Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;14&#8211;16</span></a> The recommendations made for adults are also applied to healthcare workers&#44; with priority being given to workers who are in contact with children under 12 months of age&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> Healthcare workers are particularly exposed to infections in their working environment and may be sources of nosocomial outbreaks&#44; suggesting that vaccination would be particularly efficient in this setting&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Adult vaccination focuses on reducing mortality and transmission to infants&#46; However&#44; although a booster dose at age 65 might solve the problem of tetanus and diphtheria&#44; the best strategy in the case of pertussis would be vaccination every 10 years with DTaP&#44; a vaccine that has already demonstrated a good immunogenicity and safety profile&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Reality&#44; according to Aristotle&#44; is the only truth&#46; Similarly&#44; the available evidence seems to suggest that pertussis is not just a pediatric problem&#44; but also significantly affects the adult population&#46; It seems that prevailing vaccination strategies should be revisited&#44; and that vaccination programs aimed at the entire population should be implemented&#44; focusing particularly on specific groups such as pregnant women or healthcare workers&#46; Recommendations for pertussis vaccination in adults have been drawn up as part of prevention programs for community-acquired pneumonia&#46; These include guidelines developed by the Respiratory Prevention Expert Group that specifically propose the vaccination of adults with chronic disease and a higher risk of pertussis complications due to immunosuppression&#44; COPD or diabetes mellitus&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> A careful review of symptoms and screening for etiological diagnoses can help identify the disease&#44; improve its prognosis&#44; and limit dissemination&#46; But this simply proves that the enemy is only visible if we seek it&#44; and that the cost-benefit ratio clearly supports the greater use of vaccination against this disease in the adult population&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">FM-T receives support for research from the Instituto de Salud Carlos III&#44; but it is not related with this work &#40;Health Research Project&#44; Strategic Health Action&#41;&#58; Health Research Fund &#40;FIS&#59; PI070069&#47;PI1000540&#47;PI1601569&#47;PI1901090&#41; of the national RD&#43;I plan &#8220;FEDER funds&#8221; Proyectos GaIN Rescata-Covid IN845D 2020&#47;23 &#40;GaIN&#44; Government of Galicia&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">F-JG-B has received honoraria for scientific consultancy and&#47;or for lectures and&#47;or research grants from&#58; ALK&#44; Astra-Zeneca&#44; Bial&#44; Boehringer-Ingelheim&#44; Chiesi&#44; Gebro Pharma&#44; GlaxoSmithKline&#44; Laboratorios Esteve&#44; Menarini&#44; Mundipharma&#44; Novartis&#44; Rovi&#44; Roxall&#44; Sanofi&#44; Stallergenes-Greer and Teva&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">FV-A has attended or participated in activities organized or financed by the pharmaceutical laboratories Almiral&#44; AstraZeneca&#44; Bial&#44; Boehringer-Ingelheim&#44; Chiesi&#44; GlaxoSmithKline&#44; Esteve&#44; Ferrer&#44; Menarini&#44; Novartis&#44; Mundipharma&#44; Orion&#44; Pfizer&#44; Teva and Zambon&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">FM-T has received honoraria from Biofabri&#44; GSK&#44; Pfizer Inc&#44; Sanofi Pasteur&#44; MSD&#44; Seqirus&#44; Novavax and Janssen for advisory&#44; consultancy and lecturing roles outside the scope of this work&#46; FMT has worked as principal investigator in clinical trials sponsored by the pharmaceutical companies mentioned above and also Ablynx&#44; Regeneron&#44; Roche&#44; Abbott and MedImmune&#44; with all honoraria being paid to the institution&#46;</p></span></span>"
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Article information
ISSN: 03002896
Original language: English
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