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Research

Effectiveness of pertussis vaccination and duration of immunity

Kevin L. Schwartz, Jeffrey C. Kwong, Shelley L. Deeks, Michael A. Campitelli, Frances B. Jamieson, Alex Marchand-Austin, Therese A. Stukel, Laura Rosella, Nick Daneman, Shelly Bolotin, Steven J. Drews, Heather Rilkoff and Natasha S. Crowcroft
CMAJ November 01, 2016 188 (16) E399-E406; DOI: https://doi.org/10.1503/cmaj.160193
Kevin L. Schwartz
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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  • For correspondence: kevin.schwartz@oahpp.ca
Jeffrey C. Kwong
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Shelley L. Deeks
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Michael A. Campitelli
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Frances B. Jamieson
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Alex Marchand-Austin
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Therese A. Stukel
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Laura Rosella
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Nick Daneman
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Shelly Bolotin
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Steven J. Drews
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Heather Rilkoff
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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Natasha S. Crowcroft
Institute for Clinical Evaluative Sciences (Schwartz, Kwong, Campitelli, Stukel, Daneman); Institute of Health Policy, Management, and Evaluation (Schwartz, Stukel, Rosella, Daneman), University of Toronto; The Hospital for Sick Children (Schwartz); Public Health Ontario (Kwong, Deeks, Rosella, Rilkoff, Crowcroft); Dalla Lana School of Public Health (Kwong, Deeks, Bolotin, Crowcroft), University of Toronto; Department of Family and Community Medicine (Kwong), University of Toronto; University Health Network (Kwong); Department of Laboratory Medicine and Pathobiology (Jamieson, Marchand-Austin, Crowcroft), University of Toronto; Public Health Ontario Laboratory Services (Jamieson, Marchand-Austin); Toronto, Ont.; ProvLab Alberta, University of Alberta Hospital (Drews); Department of Pathology and Laboratory Medicine (Drews), University of Alberta, Edmonton, Alta.
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  • Figure 1:
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    Figure 1:

    Pertussis-vaccine effectiveness (blue bars, left axis) and proportion of positive tests (solid line, right axis) by year since last vaccination in participants with up-to-date or partial vaccination. As time from last vaccination increased, vaccine effectiveness decreased, and the proportion of tests positive for pertussis increased. Vaccine effectiveness was calculated from crude odds ratios (ORs) using the formula VE = 1 – OR × 100. Error bars represent 95% confidence intervals. Ref = reference group (unvaccinated population). Results of the Cochran–Armitage trend test for proportion of pertussis cases: p < 0.001.

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    Table 1:

    Characteristics of 5867 participants with a pertussis test result between December 2009 and March 2013

    CharacteristicNo. (%)*
    Pertussis-positive cases
    n = 486
    Pertussis-negative controls
    n = 5381
    Age, yr, mean ± SD7.7 ± 5.75.0 ± 5.0
    Age
     3–11 mo80 (16.5)1268 (23.6)
     1–3 yr100 (20.6)1794 (33.3)
     4–6 yr52 (10.7)891 (16.6)
     7–13 yr165 (34.0)988 (18.4)
     14–21 yr89 (18.3)440 (8.2)
    Birth year
     1992–199649 (10.1)340 (6.3)
     1997–2000110 (22.6)517 (9.6)
     2001–200493 (19.1)569 (10.6)
     2005–200875 (15.4)1435 (26.7)
     2009–2012159 (32.7)2520 (46.8)
    Sex, male235 (48.4)2764 (51.4)
    Neighbourhood income quintilen = 478n = 5314
     1 (lowest)90 (18.8)1121 (21.1)
     287 (18.2)954 (18.0)
     395 (19.9)997 (18.8)
     487 (18.2)1162 (21.9)
     5 (highest)119 (24.9)1080 (20.3)
    Rural residencen = 484
    116 (23.9)
    n = 5360
    869 (16.2)
    Year of test
     2009< 6 (< 1)82 (1.5)
     201035 (7.2)1087 (20.2)
     201163 (12.9)1083 (20.1)
     2012366 (75.3)2648 (49.2)
     201320 (4.1)481 (8.9)
    Any complex chronic medical condition9 (1.9)262 (4.9)
    Health care use in previous year
     ≥ 2 emergency department visits123 (25.3)2070 (38.5)
     ≥ 1 hospital admission89 (18.3)1796 (33.4)
     ≥ 8 physician office visits140 (28.8)2916 (54.2)
    • Note: SD = standard deviation.

    • ↵* Unless stated otherwise.

    • View popup
    Table 2:

    Crude and adjusted estimates of vaccine effectiveness, including sensitivity analyses*

    Variable; time since last vaccinationPertussis positive, no. vaccinated/totalPertussis negative, no. vaccinated/totalCrude vaccine effectiveness, % (95% CI)Adjusted† vaccine effectiveness, % (95% CI)
    Up-to-date vaccination
     15–364 d54/2131691/247684 (78 to 89)§80 (71 to 86)§
     1–3 yr46/2051089/187479 (71 to 85)§84 (77 to 89)§
     4–7 yr51/210391/117636 (10 to 54)§62 (42 to 75)§
     ≥ 8 yr42/201213/9983 (−41 to 33)41 (0 to 66)
    Partial vaccination
     15–364 d13/172340/112581 (66 to 89)§75 (54–86)§
     1–3 yr27/186344/112961 (41 to 75)§68 (50 to 80)§
     4–7 yr30/189223/100834 (−1 to 56)56 (30 to 72)§
     ≥ 8 yr64/223305/1090−4 (−43 to 25)36 (−6 to 61)
    Sensitivity analyses for participants with up-to-date vaccination compared with unvaccinated participants
    Exposure misclassification‡
     15–364 d54/2131691/247696 (89 to 100)§95 (87 to 100)§
     1–3 yr46/2051089/187498 (93 to 100)§98 (94 to 100)§
     4–7 yr51/210391/117656 (27 to 80)§63 (35 to 82)§
     ≥ 8 yr42/201213/99814 (−61 to 67)22 (−70 to 73)
    Excluding infants aged < 7 mo with incomplete primary series
     15–364 d26/1581192/176191 (86 to 94)§87 (79 to 92)§
     1–3 yr46/1781089/165882 (74 to 87)§84 (77 to 89)§
     4–7 yr51/183391/96044 (20 to 60)§62 (42 to 75)§
     ≥ 8 yr42/174213/78215 (−24 to 42)42 (0 to 66)
    Indeterminate pertussis PCR considered positive
     15–364 d105/3051691/427676 (69 to 81)§71 (61 to 79)§
     1–3 yr82/2821089/187470 (61 to 78)§79 (72 to 85)§
     4–7 yr68/268391/117632 (8 to 50)§62 (45 to 74)§
     ≥ 8 yr59/259213/9980 (−9 to 24)41 (5 to 63)§
    Indeterminate pertussis PCR considered negative
     15–364 d54/2131742/256884 (78 to 88)§80 (53 to 86)§
     1–3 yr46/2051125/195179 (70 to 85)§83 (76 to 89)§
     4–7 yr51/210408/123435 (9 to 54)§59 (37 to 73)§
     ≥ 8 yr42/201230/10565 (−37 to 35)37 (−7 to 63)
    Restricted to years 2009–2011
     15–364 d22/53839/114474 (55 to 85)§71 (43 to 85)§
     1–3 yr13/44455/76072 (45 to 86)§84 (65 to 92)§¶
     4–7 yr11/42144/44925 (−54 to 63)70 (26 to 87)§
     ≥ 8 yr4/3561/36628 (−70 to 69)79 (28 to 94)§¶
    Restricted to years 2012–2013
     15–364 d32/160852/133286 (79 to 91)§83 (73 to 89)§
     1–3 yr33/161634/111481 (71 to 87)§85 (76 to 90)§¶
     4–7 yr40/168247/72739 (4 to 62)§57 (29 to 73)§
     ≥ 8 yr38/166152/6326 (−41 to 38)24 (−38 to 51)¶
    Excluding outbreak
     15–364 d48/1391578/225078 (68 to 84)§76 (63 to 84)§
     1–3 yr38/129974/164671 (57 to 81)§82 (72 to 88)§
     4–7 yr34/125342/101427 (−12 to 52)§65 (41 to 79)§
     ≥ 8 yr25/116183/855−1 (−62 to 37)55 (13 to 77)§¶
    • Note: CI = confidence interval, PCR = polymerase chain reaction.

    • ↵* Reference group was the unvaccinated population.

    • ↵† Adjusted for age, sex, rural v. urban residence, income quintile, any comorbidity, ambulatory health care use in previous 12 months, emergency health care use in previous 12 months and inpatient health care use in previous 12 months.

    • ↵‡ Additional details in Appendix 2, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.160193/-/DC1.

    • ↵§ p < 0.05.

    • ↵¶ The variable “any comorbidity” was excluded from these models owing to quasi-separation of data points.

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Effectiveness of pertussis vaccination and duration of immunity
Kevin L. Schwartz, Jeffrey C. Kwong, Shelley L. Deeks, Michael A. Campitelli, Frances B. Jamieson, Alex Marchand-Austin, Therese A. Stukel, Laura Rosella, Nick Daneman, Shelly Bolotin, Steven J. Drews, Heather Rilkoff, Natasha S. Crowcroft
CMAJ Nov 2016, 188 (16) E399-E406; DOI: 10.1503/cmaj.160193

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Effectiveness of pertussis vaccination and duration of immunity
Kevin L. Schwartz, Jeffrey C. Kwong, Shelley L. Deeks, Michael A. Campitelli, Frances B. Jamieson, Alex Marchand-Austin, Therese A. Stukel, Laura Rosella, Nick Daneman, Shelly Bolotin, Steven J. Drews, Heather Rilkoff, Natasha S. Crowcroft
CMAJ Nov 2016, 188 (16) E399-E406; DOI: 10.1503/cmaj.160193
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