Journal Information
Vol. 58. Issue 4.
Pages T300-T302 (April 2022)
Download PDF
More article options
Vol. 58. Issue 4.
Pages T300-T302 (April 2022)
Full text access
[Translated article] 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
Ver más
Related content
Arch Bronconeumol. 2022;58:300-210.1016/j.arbres.2021.06.008
Francisco-Javier González-Barcala, Felipe Villar-Álvarez, Federico Martinón-Torres
This item has received
Article information
Full Text
Download PDF
Full Text

Pertussis is not just a disease of children. The incidence and rate of complications is highest in the first few months after birth, but neither natural infection nor vaccination confer protection for life, meaning that reinfection can occur at any time. The incidence of the disease in adults is higher than usually thought. 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.1 In another study in Germany that included patients over 18 years of age (median age 50 years) with cough of more than 7 days’ duration, a diagnosis of pertussis was established in 5.6% of the cases.2 These infections require the prescription of various drugs, including antibiotics, and visits to the family doctor and the emergency department with the consequent increase in health expenditure.3 In a recent study in 7 states in the US that included adult patients hospitalized for pertussis, 12% of those aged 21–64 years, and 10% of those over 65 years, were admitted to intensive care.4

Pertussis is a highly contagious respiratory disease that has a basic reproduction number estimated at between 12 and 17.5–7 The typical clinical presentation in adults prompting a possible diagnosis of pertussis usually involves cough lasting more than 2 weeks, associated with any of the following symptoms: paroxysmal cough, inspiratory whooping, and post-tussive vomiting.6,8 It has a wide spectrum of severity, ranging from mild cough to severe symptoms of pneumonia, encephalopathy, and respiratory failure.4,5 In adults, the presence of paroxysmal cough and absence of fever have high sensitivity but low specificity for the diagnosis of pertussis, while inspiratory whooping and post-tussive vomiting have high specificity but low sensitivity. Patients may also present other symptoms, such as dyspnea, sleep disturbance, and rib pain, and complications, such as sinusitis, pneumonia, urinary incontinence, or rib fractures.4 Atypical clinical presentations are becoming more frequent, especially in adults and previously vaccinated subjects, who tend to have milder forms, with cough often being the only symptom. Since cough is a very common, nonspecific symptom with multiple possible etiologies, diagnostic delays can occur that can promote the spread of infection.8,9 Another important factor is subclinical infection, detected by positive PCR in asymptomatic patients, that also contributes to the spread of infection.10

PCR or culture of the patient's biological samples may be performed to confirm diagnosis, but these are only useful within the first 3 weeks after onset of cough, and after this period, serologies should be used.3,7 Time to medical consultation in adults is around 17 days, which is at the limit of the period during which PCR or culture retain diagnostic utility. This diagnostic delay also increases infectious outbreaks with attack rates that can exceed 90%.6,11

The pertussis vaccine, introduced in the middle of the last century, led to a significant reduction in the incidence of the disease. In recent years, however, there appears to be a global resurgence of pertussis. In Italy, the number of cases tripled between 2008 and 2017 after a significant decline in the preceding decade.12,13 Various explanations have been suggested for this increase in incidence, but there is no clear consensus as to the reason. It could be related to asymptomatic transmission by infected vaccinated subjects, a lower vaccination rate in some populations, a progressive loss of immunity acquired by vaccination or previous infection, genetic variations of Bordetella pertussis that make it more virulent or capable of evading the vaccine response, a shorter duration of protection obtained with acellular vaccines, an increase in the awareness of the disease among both the population and medical professionals, or the increased availability and sensitivity of diagnostic methods, among other factors.1,2,5,7,8

Against this background, various vaccination strategies are being proposed to optimize pertussis control. The US Centers for Disease Control and Prevention make a number of recommendations for different adult population groups, particularly pregnant women and health workers, and a blanket indication for a pertussis booster in adults, especially in individuals over 65 years of age. 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, and they also recommend the use of boosters that include the pertussis component, especially in people over 65 years of age. Pregnant women should receive the acellular pertussis vaccine, preferably between 27 and 36 weeks of gestation. This strategy has already been shown to be highly effective and is becoming widespread across multiple Western countries, including Spain.3,14–16 The recommendations made for adults are also applied to healthcare workers, with priority being given to workers who are in contact with children under 12 months of age.13 Healthcare workers are particularly exposed to infections in their working environment and may be sources of nosocomial outbreaks, suggesting that vaccination would be particularly efficient in this setting.5

Adult vaccination focuses on reducing mortality and transmission to infants. However, although a booster dose at age 65 might solve the problem of tetanus and diphtheria, the best strategy in the case of pertussis would be vaccination every 10 years with DTaP, a vaccine that has already demonstrated a good immunogenicity and safety profile.17

Reality, according to Aristotle, is the only truth. Similarly, the available evidence seems to suggest that pertussis is not just a pediatric problem, but also significantly affects the adult population. It seems that prevailing vaccination strategies should be revisited, and that vaccination programs aimed at the entire population should be implemented, focusing particularly on specific groups such as pregnant women or healthcare workers. Recommendations for pertussis vaccination in adults have been drawn up as part of prevention programs for community-acquired pneumonia. 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, COPD or diabetes mellitus.18 A careful review of symptoms and screening for etiological diagnoses can help identify the disease, improve its prognosis, and limit dissemination. But this simply proves that the enemy is only visible if we seek it, and that the cost-benefit ratio clearly supports the greater use of vaccination against this disease in the adult population.


FM-T receives support for research from the Instituto de Salud Carlos III, but it is not related with this work (Health Research Project, Strategic Health Action): Health Research Fund (FIS; PI070069/PI1000540/PI1601569/PI1901090) of the national RD+I plan “FEDER funds” Proyectos GaIN Rescata-Covid IN845D 2020/23 (GaIN, Government of Galicia).

Conflict of interests

F-JG-B has received honoraria for scientific consultancy and/or for lectures and/or research grants from: ALK, Astra-Zeneca, Bial, Boehringer-Ingelheim, Chiesi, Gebro Pharma, GlaxoSmithKline, Laboratorios Esteve, Menarini, Mundipharma, Novartis, Rovi, Roxall, Sanofi, Stallergenes-Greer and Teva.

FV-A has attended or participated in activities organized or financed by the pharmaceutical laboratories Almiral, AstraZeneca, Bial, Boehringer-Ingelheim, Chiesi, GlaxoSmithKline, Esteve, Ferrer, Menarini, Novartis, Mundipharma, Orion, Pfizer, Teva and Zambon.

FM-T has received honoraria from Biofabri, GSK, Pfizer Inc, Sanofi Pasteur, MSD, Seqirus, Novavax and Janssen for advisory, consultancy and lecturing roles outside the scope of this work. FMT has worked as principal investigator in clinical trials sponsored by the pharmaceutical companies mentioned above and also Ablynx, Regeneron, Roche, Abbott and MedImmune, with all honoraria being paid to the institution.

N. Guiso, J.L. Gallais, G. Gavazzi, D. Pinquier, J. Gaillat.
Incidence of pertussis in subjects aged 50 years and older in France in 2013–2014.
Med Mal Infect, 48 (2018), pp. 30-36
R. Weinberger, M. Riffelmann, N. Kennerknecht, C. Hülße, M. Littmann, J. O’Brien, et al.
Long-lasting cough in an adult German population: incidence, symptoms, and related pathogens.
Eur J Clin Microbiol Infect Dis, 37 (2018), pp. 665-672
R.N.F. Leong, J.G. Wood, B. Liu, P.B. McIntyre, A.T. Newall.
High healthcare resource utilisation due to pertussis in Australian adults aged 65 years and over.
Vaccine, 38 (2020), pp. 3553-3559
S.A. Mbayei, A. Faulkner, C. Miner, K. Edge, V. Cruz, S.A. Peña, et al.
Severe pertussis infections in the United States, 2011–2015.
Clin Infect Dis, 69 (2019), pp. 218-226
V.A. Jenkins, M. Savic, W. Kandeil.
Pertussis in high-risk groups: an overview of the past quarter-century.
Hum Vaccin Immunother, 16 (2020), pp. 2609-2617
F. Martinón-Torres, U. Heininger, A. Thomson, C.H. Wirsing von König.
Controlling pertussis: how can we do it? A focus on immunization.
Expert Rev Vac, 17 (2018), pp. 289-297
F. Martinón-Torres, Expected and unexpected effects of vaccination.
Pediatric vaccines and vaccinations, pp. 3-13
E. Aris, L. Harrington, A. Bhavsar, J.C. Simeone, A. Ramond, A. Papi, et al.
Burden of pertussis in COPD: a retrospective database study in England.
B.A. Randi, O.N.E. Sejas, K.T. Miyaji, V. Infante, A.N. Lara, K.Y. Ibrahim, et al.
A systematic review of adult tetanus-diphtheria-acellular (Tdap) coverage among healthcare workers.
Vaccine, 37 (2019), pp. 1030-1037
K. Rubin, S. Glazer.
The pertussis hypothesis: Bordetella pertussis colonization in the etiology of asthma and diseases of allergic sensitization.
Med Hypotheses, 120 (2018), pp. 101-115
H. Martini, C. Rodeghiero, C. Van den Poel, M. Vincent, D. Pierard, K. Huygen.
Pertussis. diagnosis in Belgium: results of the National Reference Centre for Bordetella anno 2015.
Epidemiol Infect, 145 (2017), pp. 2366-2373
S. Marchi, E. Montomoli, E.J. Remarque, G.T. Monteverde Spencer, A. Azzarello, S. Viviani, et al.
Pertussis over two decades: seroepidemiological study in a large population of the Siena Province, Tuscany Region Central Italy.
BMJ Open, 9 (2019), pp. e032987
S. Brugueras, C. Rius, J.P. Millet, M. Casals, J.A. Caylà, Barcelona Pertussis Working Group.
Does the economic recession influence the incidence of pertussis in a cosmopolitan European city?.
BMC Public Health, 19 (2019), pp. 144
D. Langsam, E. Anis, E.J. Haas, R. Gosinov, M. Yechezkel, I. Grotto, et al.
Tdap vaccination during pregnancy interrupts a twenty-year increase in the incidence of pertussis.
Vaccine, 38 (2020), pp. 2700-2706
B. Abu-Raya, K. Maertens, K.M. Edwards, S.B. Omer, J.A. Englund, K.L. Flanagan, et al.
Global perspectives on immunization during pregnancy and priorities for future research and development: an international consensus statement.
Front Immunol, 11 (2020), pp. 1282
Pertussis: summary of vaccine recommendations for healthcare professionals. [consultado 01 Jun 2021]
M. Campins, D. Moreno-Pérez, A. Gil-de Miguel, F. González-Romo, F.A. Moraga-Llop, J. Arístegui-Fernández, et al.
Tos ferina en España Situación epidemiológica y estrategias de prevención y control. Recomendaciones del Grupo de Trabajo de Tos ferina [Whooping cough in Spain. Current epidemiology, prevention and control strategies. Recommendations by the Pertussis Working Group].
Enferm Infecc Microbiol Clin, 31 (2013), pp. 240-253
Redondo E, Rivero-Calle E, Mascarós E, Yuste JE, Fernández-Prada M, Ocaña D, et al. Vacunación frente a la neumonía adquirida en la comunidad del adulto. Actualización 2021 del posicionamiento del Grupo de Neumoexpertos en Prevención. SEMERGEN. 2021;47:411-25.
Copyright © 2021. SEPAR
Archivos de Bronconeumología
Article options

Are you a health professional able to prescribe or dispense drugs?