Pertussis antibodies in postpartum women and their newborns

(2010) 30, 93 97 r 2010 Nature Publishing Group All rights reserved. 0743-8346/10 $32 www.nature.com/jp ORIGINAL ARTICLE Pertussis antibodies in postpartum women and their newborns JH Shakib 1, S Ralston 2, HH Raissy 2, GJ Stoddard 1, KM Edwards 3 and CL Byington 1 1 General Pediatric Division, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA; 2 Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA and 3 Vanderbilt Vaccine Research Program, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA Objective: To (1) determine the proportion of mothers and infants who had levels of IgG antibody to pertussis antigens predicted to be potentially protective at delivery; (2) evaluate the efficiency of maternal infant antibody transport; (3) extrapolate infant antibody titers at 6 weeks; and (4) identify maternal factors associated with potentially protective infant antibodies. Study Design: Sera from mother infant pairs from February 2006 through to April 2007 were tested for antibody to pertussis antigens by standardized ELISA (enzyme-linked immunosorbent assay). Potentially protective antibody levels were defined as >5 ELISA units (EU) for pertussis toxin (PT), and >10 EU for fimbriae (FIM) and pertactin (PRN). Serological evidence of previous maternal infection was defined from antibody to four antigens by k-means cluster analysis. Result: In total, 21% (17/81) of mothers and 26% (21/81) of infants had potentially protective antibody levels at delivery. Mean infant maternal antibody ratios for PT, FIM and PRN were 1.26, 1.36 and 1.31, respectively. At 6 weeks, 11% (9/81) of infants were predicted to have potentially protective antibody levels. Using cluster analysis, 9% (7/81) of mothers had evidence of previous pertussis infection. Infants born to these mothers were predicted to be more likely to have potentially protective antibodies at 6 weeks (43%) than those born to mothers without previous infection (8%) (P ¼ 0.03). Conclusion: Approximately 75% of infants were born with pertussis antibody levels lower than the modest levels associated with potential protection. Despite effective antibody transfer, nearly 90% of infants were predicted to have little antibody by 6 weeks. Maternal immunization before or during pregnancy might simulate previous pertussis infection and help protect infants through the first months of life. (2010) 30, 93 97; doi:10.1038/jp.2009.138; published online 8 October 2009 Keywords: pertussis; infection; immunization; transplacental immunity; infants Correspondence: Dr JH Shakib, General Pediatric Division, Department of Pediatrics, University of Utah School of Medicine, PO Box 581289, Salt Lake City, UT 84158, USA. E-mail: julie.shakib@hsc.utah.edu Received 12 April 2009; revised 10 August 2009; accepted 13 August 2009; published online 8 October 2009 Introduction Pertussis, an endemic and common infectious disease, is of particular importance because of a recent striking increase in the incidence of reported cases, and greatest morbidity and mortality in the youngest infants. 1 3 In 2004 2005, a total of 56 deaths from pertussis in children younger than 3 months were reported to the Centers for Disease Control and Prevention (CDC). 4 As infants do not complete the primary immunization series against pertussis until their sixth month of life, they are particularly susceptible to pertussis infection and are dependent on maternal antibodies for protection. 5 Although precise levels of antibody required for protection from acute pertussis infection have been debated, 1,2 modest levels of IgG antibody to fimbriae (FIM), pertactin (PRN) and pertussis toxin (PT) have been associated with disease prevention. 6,7 Although filamentous hemagglutinin (FHA) is a component of all licensed pertussis vaccines and antibody against FHA is associated with natural infection, it has not been proven to have a primary role in prevention of pertussis infection. 6 9 Several articles have postulated that immunizing pregnant women against pertussis may provide protection to their newborns, 10 13 but the CDC s Advisory Committee on Immunization Practices (ACIP) does not currently recommend this practice. 14 Previous studies have also shown that infants born at or near term have higher antibody levels to specific pathogens than their mothers as a result of active transport of maternal IgG. 15,16 A better understanding of the natural history of transplacentally acquired pertussis antibodies in infants is critical for predicting whether maternal immunization might provide protection from infection to newborns. To further elucidate the potential of maternal pertussis antibody to provide protection against pertussis for newborns in the months before their scheduled active immunization, the objectives of our study were to (1) determine the proportion of mothers and infants who had levels of IgG antibody to pertussis antigens predicted to be potentially protective at delivery; (2) evaluate the efficiency of maternal infant antibody transport; (3) extrapolate infant antibody titers at 6 weeks; and (4) identify maternal factors associated with potentially protective infant antibodies.

94 Pertussis antibodies in postpartum women and newborns Methods Protection of human subjects Approval to conduct this study was granted by the Institutional Review Boards of the University of New Mexico and the University of Utah. Mothers provided informed consent for themselves and their infants. Study subjects Women aged 18 to 45 years who delivered healthy term infants X37 weeks gestation were enrolled from the University of New Mexico Health Sciences Center from February 2006 through to April 2007. Mother infant pairs were excluded for multiple gestation, antenatal detection of a major birth defect in the infant, or serious underlying neurological, cardiac, renal or pulmonary disease in either mother or infant. Mother infant pairs were also excluded if the infant required neonatal intensive care. Data collection Participants were enrolled by the University of New Mexico General Clinical Research Center (GCRC) pediatric research nurses within 48 h after delivery and before hospital discharge. Demographic data included age, previous pregnancy history, occupation, education, ethnicity, marital status and number of people in the household. In addition, a history of cough greater than 3 weeks in either mother or any household contact during pregnancy was obtained. Women enrolled in 2007 (n ¼ 17) were asked whether they had received pertussis vaccine (Tdap). Immunization status was not documented for women enrolled in 2006. Laboratory methods 2 ml each of maternal and infant sera were collected by venipuncture, centrifuged, and stored at 20 to 40 1C until testing by a standardized enzyme-linked immunosorbent assay (ELISA) in the Pediatric Infectious Disease Research Laboratory at Vanderbilt University School of Medicine in Nashville, Tennessee (KME). Pertussis-specific IgG to PT, FHA, FIM and PRN were quantified by previously described methods. 17 Briefly, Immulon 2 microtiter plates (VWR International, West Chester, PA, USA) were coated with standard quantities of PT, FHA, FIM or PRN. Serial dilutions of mother infant serum pairs were incubated for 2 h at 28 1C and an appropriate dilution of alkaline phosphataseconjugated goat anti-human IgG was added. The reaction was developed and read at 405 nm. The lower limit of detection of each specific antibody was determined by repeated measurements of serially diluted reference material for each antigen and was 1 ELISA unit (EU) for PT, FHA and PRN, and 2 EU for FIM. Rationale for selecting pertussis antibody levels associated with potential protection and statistical analysis On the basis of reports in the literature, the half-life of transplacental pertussis-specific IgG was defined as 6 weeks. 18,19 Antibody levels determined to be potentially protective were based on vaccine efficacy trial data. 6,7 An analysis by Storsaeter et al. 6 fit a logistic model that dichotomized low pertussis antibody levels for FIM, PRN, PT and FHA as <5 EU and high as X5 EU. A similar analysis by Cherry et al. 7 determined high/low cut points for these pertussis antibodies from 1.5 to 8 EU and with a cut point of 5.7 EU for PT. As there was greater variability in cut points for FIM and PRN in previous studies, potentially protective antibody levels for FIM and PRN were defined more conservatively at >10 EU, whereas elevated levels for PT were defined as >5 EU. We hypothesized that mothers with highest antibody levels would give birth to infants with higher antibody levels and that their infants would be more likely to be protected from pertussis infection at birth than infants born to mothers with lower levels. However, because no level of antibody, presence of specific antibodies, or antibody profile has been accepted universally as a quantifiable serologic measure of protection, 14 we performed a cluster analysis of all four pertussis antibodies to identify women with antibody levels that were statistically greater than the study population as a whole. As it was unlikely that any of the women in our study received adult pertussis immunization, women with the highest antibody titers were likely to have had naturally occurring pertussis infection at some time before the delivery. Infection-acquired immunity may persist for 7 to 10 years after infection 20,21 and significant antibody titers have been documented 5 years postimmunization. 22,23 A marker for previous maternal infection was generated by a multivariable k-means cluster analysis looking for a high and low cluster of the four antibodies simultaneously. Women with all four antibody titers in the highest cluster were classified as likely to have had previous infection. Mean infant maternal antibody ratios were calculated to determine the efficiency of maternal infant antibody transfer. Data were analyzed using Stata Version 10.0 (Stafa Corp LP). Results Enrollment A total of 83 mother infant pairs were enrolled in the study, but two pairs were excluded because of missing infant data, leaving 81 mother infant pairs for analysis. The mean maternal age was 27 years. Self-identified maternal race/ethnicity was: 31% White, 25% Hispanic, 9% Native American, 28% mixed race/ethnicity (most commonly combinations of Hispanic, Native American or White) and 7% others. Maternal pertussis history None of the mothers reported that they or a household contact had had a 3-week cough during the pregnancy, and none of the 17 mothers enrolled in 2007 reported receiving Tdap. Mother and newborn infant antibody titers Of the 81 mother infant pairs with complete data, 21% (17/81) of mothers and 26% (21/81) of infants had PT >5 EU, and FIM and

95 PRN >10 EU at delivery. Mean infant maternal antibody ratios for PT, FIM and PRN were 1.26, 1.36 and 1.31, respectively. There were no differences in maternal age, pregnancy history, occupation, education, ethnicity, marital status or number of household members in infants with higher antibody titers compared with those with lower titers. Predicted antibody titers at 6 weeks Using published half-life data for decline of maternal antibody, 18,19 we predicted that 11% (9/81) of infants would have levels of PT >5 EU, and FIM and PRN >10 EU at 6 weeks. Infant antibody titers analyzed by maternal infection status None of the women enrolled had antibody evidence of acute pertussis infection, as previously defined by PT levels X94 EU. 24 Maternal PT antibody levels ranged from 1 to 40 EU. However, 9% (7/81) had evidence of previous infection (likely within 7 to 10 years of the delivery date) 20,21 based on the k-means cluster analysis (Figure 1). These seven women did not differ from the other mothers with respect to age, ethnicity, employment or family size. The mean levels of FIM, PRN and PT of infants born to the seven mothers with evidence of previous infection were all significantly higher than those of infants born to mothers without serological evidence of infection (145 and 32.9 EU, P<0.001; 43.4 and 16.7 EU, P ¼ 0.01; 21.4 and 9.4 EU, P ¼ 0.01, respectively). We predicted that at 6 weeks, 3 (43%) of the 7 infants born to mothers with titers compatible with previous pertussis infection would have PT antibody >5 EU, and FIM and PRN antibody >10 EU compared with 8% (6/74) of the infants born to mothers without such evidence (P ¼ 0.03). Discussion The most important finding from our study is that only onequarter of infants were born with potentially protective pertussis antibody titers >5 EU for PT and >10 EU for FIM and PRN. In addition, we predicted that by 6 weeks, only about 10% would have such levels. Thus, nearly 90% of infants were likely to be susceptible to pertussis infection by 6 weeks of age, despite effective maternal antibody transfer. The timing of predicted antibody loss is before the initiation of the active infant immunization series. Notably, infants born to mothers with serological evidence of previous pertussis infection were predicted to be more likely to have potentially protective antibody levels at 6 weeks. These data indicate that by simulating previous infection, maternal immunization with acellular pertussis vaccine before or during pregnancy might provide increased transplacental protection to newborns. The majority of infants in our study had low antibody levels to all pertussis antigens at birth. Effective maternal infant antibody transfer was confirmed given that mean infant maternal antibody ratios were 1.26 to 1.36 for the pertussis antigens. In spite of effective antibody transfer, only one-quarter of infants were born with the modest antibody levels that we predicted could confer protection, and by 6 weeks, only 11% were predicted to have antibody levels associated with potential protection. Similarly, Healy et al. 19 measured IgG titers in mothers and infants to three FIM PT PRN FHA 250 RECENT INFECTION 200 IgG (ELISA units/ml) 150 100 50 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 Participant Number 52 55 58 61 64 67 70 73 76 79 Figure 1 Maternal IgG to FIM, PRN, PT and FHA.

96 pertussis-specific antibodies and found extremely low levels of maternal and infant pertussis antibody at delivery with a rapid decline in the infant s antibody levels by 2 months. The current pediatric vaccine schedule recommends initiation of pertussis vaccination at 6 to 8 weeks of age; full infant protection is likely not achieved until after the third vaccination at 6 months. Although 75% of infant mortality from pertussis infection has been reported in children <2 months of age, 25 the current recommendation does not protect infants during this vulnerable period. Halasa et al. 26 recently evaluated the effect of an additional dose of Diphtheria, Tetanus and Acellular Pertussis (DTaP) vaccine at birth and found that the additional dose was associated with a significantly lower subsequent antibody response to pertussis and diphtheria vaccine compared with controls. This study shows that immunization strategies focusing on infants may not provide the needed early protection from pertussis infection. As there is no universally accepted serological measure of protection from pertussis infection, we hypothesized that mothers with the highest antibody levels would give birth to infants with higher antibody levels, and used cluster analysis to identify women with highest levels. The infants in our study with higher antibody levels were born to women who were identified by the cluster analysis as having the highest antibody levels. These women likely derived their antibody levels through pertussis infection, as none had a documented history of pertussis immunization. None of the mothers identified as having had evidence of previous pertussis infection met the serological definition of acute pertussis (PTX94), and none had or were exposed to pertussis during pregnancy, making acute infection as a cause for elevated antibody levels unlikely. Modestly elevated pertussis antibody titers may persist for 7 to 10 years after infection or immunization, 20 23 and the higher antibody levels shown are most consistent with infection in the years before delivery. Immunization as a strategy to mimic natural infection offers a potentially safer alternative for increasing maternal antibody. Tetanus, Diphtheria and Acellular Pertussis immunization trials in adolescents and adults showed that 93% of vaccinees achieved PT levels X5 EU for up to 5 years post-immunization. 22,23 ACIP currently recommends that adolescents receive a single dose of Tdap, with preference for 11 to 12-year olds. 4 If protection from immunization lasts for B5 years, then most women of childbearing age, if immunized in early adolescence, would be predicted to have low levels of pertussis antibody. The principle of using transplacental immunity to protect infants from vaccine-preventable diseases is not novel. Vaccination of pregnant women with tetanus toxoids has markedly decreased the global incidence of neonatal tetanus. 10,11,27,28 A small trial of influenza immunization during pregnancy in women in Bangladesh showed a 63% reduction in laboratory-confirmed influenza and a 29% reduction in the incidence of febrile respiratory illness in infants born to mothers who received influenza vaccination in the third trimester of pregnancy. 29 The safety of any vaccine administered during pregnancy is paramount, and there are no published data of Tdap use in pregnant women to document safety in the mother or the fetus. ACIP has cited two potential concerns with respect to Tdap use in pregnancy. 14 First, there is a lack of evidence that transplacental maternal antibody induced by Tdap administered during pregnancy will protect infants against pertussis. Prospective large-scale studies will be needed to address this question. Second is the concern that Tdap administered during pregnancy could blunt an infant s immune response to the primary pediatric pertussis immunization series, resulting in increased disease susceptibility later. We did not examine infant response to the primary pertussis series in this study, but previous studies have shown that infants who receive maternally derived pertussis antibody have either no or only a modestly decreased antibody response to acellular vaccine. 12,30 Our study had several limitations. Our sample size was small and may not be representative of other geographical areas, particularly with respect to ethnicity and race. As the 6-week infant antibody titers were extrapolated rather than measured, it is possible that actual levels would differ. However, the half-life of pertussis antibody has been well defined in previous studies, 18,19 and we believe that our extrapolation likely provides a reasonable indication of the proportion of 6-week-old infants who would be susceptible to pertussis. Previous studies have also shown crossreactivity between some pertussis antigens and other infectious agents. 31,32 The inclusion of all four antibodies in the cluster analysis attempts to limit the effect of cross-reactivity by defining previous maternal infection on the basis of four antigens associated with acute pertussis infection. Conclusion 75% of infants were born with pertussis antibody levels lower than the modest levels associated with potential protection. Despite effective antibody transfer, nearly 90% of infants were predicted to have little antibody by 6 weeks. Maternal immunization before or during pregnancy might simulate previous pertussis infection and help protect infants through the first months of life. Conflict of interest Administrative, technical and material support was provided by the University of New Mexico Pediatric Research Committee, the University of New Mexico General Clinical Research Center (5-MO1-RR-00997) and the University of Utah Children s Health Research Center. Drs Shakib and Byington were supported by a Center of Excellence in Public Health Informatics award (CDC 1 PO1 CD000284). Dr Byington was supported by the NIH/Eunice Kennedy Shriver (NICHD K24-HD047249). Dr Edwards receives

97 support from the NIH, CDC, Wyeth, sanofi-pasteur, Novartis and CSL limited. References 1 Cherry JD. The epidemiology of pertussis: a comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. Pediatrics 2005; 115(5): 1422 1427. 2 Edwards KM. Overview of pertussis: focus on epidemiology, sources of infection, and long term protection after infant vaccination. Pediatr Infect Dis J 2005; 24(6 Suppl): S104 S108. 3 Wood N, McIntyre P. Pertussis: review of epidemiology, diagnosis, management and prevention. Paediatr Respir Rev 2008; 9(3): 201 211. 4 Centers for Disease Control and Prevention. In: Atkinson W, Hamborsky J, McIntyre L, Wolfe S (eds). Epidemiology and Prevention of Vaccine-Preventable Diseases, 10th edn, 2nd printing, Public Health Foundation: Washington DC, 2008. 5 Van Rie A, Wendelboe AM, Englund JA. Role of maternal pertussis antibodies in infants. Pediatr Infect Dis J 2005; 24(5 Suppl): S62 S65. 6 Storsaeter J, Hallander HO, Gustafsson L, Olin P. Levels of anti-pertussis antibodies related to protection after household exposure to Bordetella pertussis. Vaccine 1998; 16(20): 1907 1916. 7 Cherry JD, Gornbein J, Heininger U, Stehr K. A search for serologic correlates of immunity to Bordetella pertussis cough illnesses. Vaccine 1998; 16: 1901 1906. 8 Zackrisson G, Arminjon F, Krantz I, Lagergård T, Sigurs N, Taranger J et al. Serum antibody response to filamentous hemagglutinin in patients with clinical pertussis measured by an enzyme-linked immunosorbent assay. Eur J Clin Microbiol Infect Dis 1988; 7(6): 764 770. 9 Zackrisson G, Taranger J, Trollfors B. History of whooping cough in nonvaccinated Swedish children, related to serum antibodies to pertussis toxin and filamentous hemagglutinin. J Pediatr 1990; 116(2): 190 194. 10 Mooi FR, de Greeff SC. The case for maternal vaccination against pertussis. Lancet Infect Dis 2007; 7(9): 614 624. 11 Healy CM, Baker CJ. Prospects for prevention of childhood infections by maternal immunization. Curr Opin Infect Dis 2006; 19(3): 271 276. 12 Edwards KM. Pertussis: an important target for maternal immunization. Vaccine 2003; 21(24): 3483 3486. 13 Gall SA. Vaccines for pertussis and influenza: recommendations for use in pregnancy. Clin Obstet Gynecol 2008; 51(3): 486 497. 14 Murphy TV, Slade BA, Broder KR, Kretsinger K, Tiwari T, Joyce PM et al. Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2008; 57(RR-4): 1 51. 15 Englund JA. The influence of maternal immunization on infant immune responses. J Comp Pathol 2007; 137(Suppl 1): S16 S19. 16 Malek A, Sager R, Schneider H. Maternal-fetal transport of immunoglobulin G and its subclasses during the third trimester of human pregnancy. Am J Reprod Immunol 1994; 32(1): 8 14. 17 Meade BD, Deforest A, Edwards KM, Romani TA, Lynn F, O Brien CH et al. Description and evaluation of serologic assays used in a multicenter trial of acellular pertussis vaccines. Pediatrics 1995; 96: 570 575. 18 Van Savage J, Decker MD, Edwards KM, Sell SH, Karzon DT. Natural history of pertussis antibody in the infant and effect on vaccine response. J Infect Dis 1990; 161(3): 473 479. 19 Healy CM, Munoz FM, Rench MA, Halasa NB, Edwards KM, Baker CJ et al. Prevalence of pertussis antibodies in maternal delivery, cord, and infant serum. J Infect Dis 2004; 190(2): 335 340. 20 Wendelboe AM, Van Rie A, Salmaso S, Englund JA. Duration of immunity against pertussis after natural infection or vaccination. Pediatr Infect Dis J 2005; 24(5 Suppl): S58 S61. 21 Pickering LK, Baker CJ, Long SS, McMillan JA (eds). Red Book: 2006 Report of the Committee on Infectious Diseases (Red Book Report of the Committee on Infectious Diseases). 27th edn. American Academy of Pediatrics: Elk Grove Village, 2006, Pertussis; p 515. 22 Edelman K, He Q, Mäkinen J, Sahlberg A, Haanperä M, Schuerman L et al. Immunity to pertussis 5 years after booster immunization during adolescence. Clin Infect Dis 2007; 44(10): 1271 1277. 23 Barreto L, Guasparini R, Meekison W, Noya F, Young L, Mills E. Humoral immunity 5 years after booster immunization with an adolescent and adult formulation combined tetanus, diphtheria, and 5-component acellular pertussis vaccine. Vaccine 2007; 25(48): 8172 8179. 24 Baughman AL, Bisgard KM, Edwards KM, Guris D, Decker MD, Holland K et al. Establishment of diagnostic cutoff points for levels of serum antibodies to pertussis toxin, filamentous hemagglutinin, and fimbriae in adolescents and adults in the United States. Clin Diagn Lab Immunol 2004; 11(6): 1045 1053. 25 Centers for Disease Control and Prevention (CDC). PertussisFUnited States, 2001 2003. MMWR Morb Mortal Wkly Rep 2005; 54(50): 1283 1286. 26 Halasa NB, O Shea A, Shi JR, LaFleur BJ, Edwards KM. Poor immune responses to a birth dose of diphtheria, tetanus, and acellular pertussis vaccine. J Pediatr 2008; 153(3): 327 332. 27 Healy CM, Baker CJ. Maternal immunization. Pediatr Infect Dis J 2007; 26(10): 945 948. 28 Munoz FM, Englund JA. A step ahead. Infant protection through maternal immunization. Pediatr Clin North Am 2000; 47(2): 449 463. 29 Zaman K, Roy E, Arifeen SE, Rahman M, Raqib R, Wilson E et al. Effectiveness of maternal influenza immunization in mothers and infants. N Engl J Med 2008; 359(15): 1555 1564. 30 Englund JA, Anderson EL, Reed GF, Decker MD, Edwards KM, Pichichero ME et al. The effect of maternal antibody on the serologic response and the incidence of adverse reactions after primary immunization with acellular and whole-cell pertussis vaccines combined with diphtheria and tetanus toxoids. Pediatrics 1995; 96(3 Pt 2): 580 584. 31 Jackson LA, Cherry JD, Wang SP, Grayston JT. Frequency of serological evidence of Bordetella infections and mixed infections with other respiratory pathogens in university students with cough illnesses. Clin Infect Dis 2000; 31(1): 3 6. 32 Watanabe M, Connelly B, Weiss AA. Characterization of serological responses to pertussis. Clin Vaccine Immunol 2006; 13(3): 341 348.