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Evaluation of the Diagnostic Utility of the New Clinical Case Definition of Pertussis–Experience from Sentinel and Hospital-Based Pertussis Surveillance

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Evaluation of the Diagnostic Utility of the New Clinical Case Definition of Pertussis–Experience from Sentinel and Hospital-Based Pertussis Surveillance DOI: https://doi.org/10.2298/SARH180413022R UDC: 616.921.8-074 443 ORIGINAL ARTICLE / ОРИГИНАЛНИ РАД Evaluation of the diagnostic utility of the new clinical case definition of pertussis – experience from sentinel and hospital-based pertussis surveillance Mioljub Ristić1,2, Vesna D. Stojanović1,3, Vladimir Petrović1,2, Ulrich Heininger4 1University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; 2Institute of Public Health of Vojvodina, Novi Sad, Serbia; 3Institute for Child and Youth Health Care of Vojvodina, Novi Sad, Serbia; 4University Children’s Hospital Basel (UKBB), Basel, Switzerland SUMMARY Introduction/Objective Global surveillance systems use different clinical case definitions of pertussis. The aim of this study was to identify sign and symptom combinations with best relation with laboratory- confirmed pertussis. Methods A one-year prospective observational study, proposed by the Global Pertussis Initiative (GPI) for three age groups (0–3 months, four months to nine years, and ≥ 10 years) was performed in Novi Sad to evaluate the performance of the clinical case definition of pertussis. Laboratory confirmation of B. pertussis infection was obtained using the DNA polymerase chain reaction (PCR) or ELISA serology tests. Results From October 1, 2013 to September 30, 2014, 103 (32.3%) out of 319 participants with suspected pertussis had laboratory-confirmed pertussis. Combined whooping, post-tussive emesis, and worsening of symptoms at night was the best predictor of pertussis in outpatients aged four months to nine years (positive likelihood ratio (LR+) 11.6), while among inpatients of the same age group it was apnoea (LR+ 13.5). The LR+ in outpatients aged ≥10 years for combinations of apnoea and post-tussive emesis, or a combination of whooping and sweating episodes between paroxysms and post-tussive emesis was 16.8, while among in-patients LR+ was < 2.3 for all combinations in the same age group. Conclusions The GPI case definitions for pertussis are good predictors for laboratory-confirmed pertussis and are useful for the purpose of pertussis surveillance. Keywords: pertussis (whooping cough); Global Pertussis Initiative; case definition; surveillance INTRODUCTION Initiative (GPI) proposed an algorithm based on the most common signs and symptoms of per- Pertussis remains an important cause of mor- tussis for three age groups, i.e. 0–3 months, four bidity and mortality among infants and chil- months to nine years, and ≥ 10 years old [7]. dren, even in countries with high vaccination Until 2012, the epidemiology of pertussis in coverage rates. The World Health Organiza- Novi Sad has not been described well, when an tion (WHO) estimates that 50 million cases improved surveillance method for pertussis was and 300,000 deaths occur every year because introduced following the GPI recommenda- of pertussis, and case-fatality rates of pertus- tions [7]. We then determined that pertussis sis in developing countries are estimated to be was widespread in our population, affecting as high as 4% in infants [1]. Consequently, es- patients of any age [8, 9]. tablishing a reliable diagnosis of pertussis has The aim of this study was to determine the become increasingly important [2, 3]. most predictive signs and symptoms of pertus- Because of the heterogeneity in clinical sis, and to evaluate the diagnostic performance manifestations of pertussis, lack of general of certain combinations of signs and symptoms Received • Примљено: availability of laboratory confirmation of the based on the case definitions of pertussis pro- April 13, 2018 Revised • Ревизија: disease, mixed infections, and a low index of posed by the GPI. January 21, 2019 suspicion among many physicians, pertussis Accepted • Прихваћено: is under-recognized worldwide. In addition, February 22, 2019 the absence of a sensitive clinical case defini- METHODS Online first: March 20, 2019 tion of pertussis has contributed to missed or misdiagnosed pertussis cases [4, 5, 6]. Study design, specimen collection, and Existing clinical case definitions of pertussis laboratory testing Correspondence to: are based on clinical presentation in infants and Mioljub RISTIĆ children, but they are also used for adolescents The recruitment period was from October 1, Institute of Public Health and adults who may manifest distinct signs and 2013 to September 30, 2014 (52 weeks). Ac- of Vojvodina Futoška 121 symptoms. Therefore, in an effort to improve cording to the GPI, methods have previously 21000 Novi Sad, Serbia the diagnosis of pertussis, the Global Pertussis been described in detail [7, 9]. Briefly, we [email protected] 444 Ristić M. et al. simultaneously conducted prospective surveillance at both ly vaccinated,” although the difference was not significant primary (outpatients) and tertiary (inpatients) health care (OR 1.87, 95% CI 0.97–3.60, p = 0.062) (data not shown). levels in the city of Novi Sad. Participants were identified Pertussis was confirmed in 31.3% (5/16), 27.4% and sampled by the physicians in the two health care levels (34/124) and 35.8% (64/179) in individuals 0–3 months, as a part of their daily routine. Hospital surveillance for four months to nine years, and ≥ 10 years old, respectively. the entire Novi Sad area (341,624 inhabitants) was con- In infants 0–3 months of age, the mandatory signs and ducted in two inpatient facilities: pulmonology clinic of symptoms (MSS) in combination with pneumonia (OR the Institute of Child and Youth Health Care of Vojvodina 6.75, 95% CI 0.64–71.18) and close exposure to a person (pediatric inpatient facility) and the Institute of Pulmo- with a prolonged afebrile cough illness (contact) (OR 2.50, nary Diseases of Vojvodina (adult inpatient facility). We CI 0.12–50.45) had a strong association with pertussis, only included patients who fulfilled one or more criteria of but due to a limited number of participants, differences clinical case definitions for three age groups (0–3 months, between positive and negative cases were not statistically four months to nine years, and ≥ 10 years old) [7]. significant (p > 0.05). Patient data collection, sampling, and transport of pa- In the four months to nine years and ≥ 10 years age tient material, as well as the laboratory testing of samples groups, the MSS accompanied by whoop or apnoea or and interpretation of results was performed according to post-tussive emesis or worsening of the symptoms at night the previously used methodology [7, 9]. were significantly associated with having a laboratory-con- We classified participants as “fully vaccinated” accord- firmed pertussis (p < 0.05). Among the participants aged ing to their age, “partly vaccinated” (cases who had re- four months – nine years, only combination of MSS and ceived ≥ 1 but not all the vaccinations required for their pneumonia was not associated with pertussis, and in the age), and “unvaccinated.” Due to waning immunity after ≥ 10 years age group, only MSS accompanied by sweat- vaccination against pertussis, only vaccination status for ing episodes between paroxysms was not a predictor of participants < 18 years was recorded. All participants aged laboratory-confirmed pertussis (p > 0.05) (Table 1). ≥ 18 years were considered as participants with an un- The diagnostic performance of the selected sign and known vaccination status. symptom combinations for pertussis in the participants Verbal informed consent was obtained from patients aged four months to nine years is shown in Table 2 and before swab taking in accordance with national regula- for those ≥ 10 years in Table 3. tions and written consent from parents or guardians was Among the outpatients, the MSS of pertussis in the obtained. age group from four months–nine years accompanied by whoop, post-tussive emesis and worsening symptoms at Statistical analysis night had the highest diagnostic value of laboratory-con- firmed pertussis (LR+ 11.6, 95% CI 2.6–51.8). A combina- Because we registered only five laboratory-confirmed per- tion of the MSS and apnoea was the strongest predictor of tussis cases in infants aged 0–3 months, we did not perform pertussis among inpatients (LR+ 13.5, 95% CI 1.8–99.6). a validation of certain sings and symptoms in this age group. When stratified by the surveillance sites, the MSS along A two-tailed P value p < 0.05 was considered to indicate with apnoea was significantly more sensitive in the hospital statistical significance for all statistical tests. Data analysis than in the sentinel sites (42.1% vs. 6.7%, p = 0.022). The was performed using the SPSS for Windows, version 22.0 MSS in combination with post-tussive emesis or accompa- software (IBM Corp. NY, USA) and MedCalc for Windows, nied by post-tussive emesis and contact were significantly version 12.3.0 (MedCalc Software, Mariakerke, Belgium). more specific among the outpatients than in the inpatients (77.6% vs. 43.8%, p = 0.001 and 100% vs. 90.6%, p = 0.018, respectively). RESULTS According to the values of LR+ for participants aged ≥ 10 years, among the inpatients there was no combination During the study period, 319 participants with suspected with LR+ greater than 2.3. In the outpatients, including the pertussis were enrolled, and 103 (32.3%) had laboratory- MSS in combination with one or more signs and symptoms confirmed pertussis by PCR or serology. Among the lab- through sentinel surveillance, we have determined that five oratory-confirmed cases, 29, 71, and three patients were different combinations from the proposed case definition positive by PCR and the enzyme-linked immunosorbent were the strongest predictors of pertussis in the ≥ 10 years assay (ELISA) respectively. B. parapertussis or B. bronchi- age group (LR+ above 10). septica infections were not detected. No participant with Compared to the values of sensitivities and specificities suspected pertussis had been vaccinated against pertussis among the participants aged ≥ 10 years in the two surveil- during the 12 months before inclusion into the study, and lance systems, including the MSS of pertussis, post-tussive there were no deaths.
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