Assessing the Evidence for Maternal Pertussis Immunization: A Report From the Bill & Melinda Gates Foundation Symposium on Pertussis Infant Disease Burden in Low- and Lower-Middle-Income Countries

Abstract

Implementation of effective interventions has halved maternal and child mortality over the past 2 decades, but less progress has been made in reducing neonatal mortality. Almost 45% of under-5 global mortality now occurs in infants <1 month of age, with approximately 86% of neonatal deaths occurring in low- and lower-middle-income countries (LMICs). As an estimated 23% of neonatal deaths globally are due to infectious causes, maternal immunization (MI) is one intervention that may reduce mortality in the first few months of life, when direct protection often relies on passively transmitted maternal antibodies. Despite all countries including pertussis-containing vaccines in their routine childhood immunization schedules, supported through the Expanded Programme on Immunization, pertussis continues to circulate globally. Although based on limited robust epidemiologic data, current estimates derived from modeling implicate pertussis in 1% of under-5 mortality, with infants too young to be vaccinated at highest risk of death. Pertussis MI programs have proven effective in reducing infant pertussis mortality in high-income countries using tetanus-diphtheria-acellular pertussis (Tdap) vaccines in their maternal and infant programs; however, these vaccines are cost-prohibitive for routine use in LMICs. The reach of antenatal care programs to deliver maternal pertussis vaccines, particularly with respect to infants at greatest risk of pertussis, needs to be further evaluated. Recognizing that decisions on the potential impact of pertussis MI in LMICs need, as a first step, robust contemporary mortality data for early infant pertussis, a symposium of global key experts was held. The symposium reviewed current evidence and identified knowledge gaps with respect to the infant pertussis disease burden in LMICs, and discussed proposed strategies to assess the potential impact of pertussis MI.

Keywords: infants; maternal immunization; neonates; pertussis; vaccines.

Figure 1.

The continuum of care during pregnancy and through the neonatal and early childhood periods. Abbreviations: EPI, Expanded Programme on Immunization; MI, maternal immunization; Vx, vaccination.

Figure 2.

The history of maternal immunization [12]. Abbreviations: ACIP, Advisory Committee on Immunization Practices; FDA, US Food and Drug Administration; GBS, group B Streptococcus; Hib, Haemophilus influenzae type b; MI, maternal immunization; MNTE, maternal neonatal tetanus elimination; RSV, respiratory syncytial virus; Tdap, reduced-dose tetanus-diphtheria-acellular pertussis vaccine; WHO, World Health Organization.

Figure 3.

Under-5 pertussis deaths in the different World Health Organization (WHO) regions in 2015, during and after the first month of life [33].