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  • Writer's pictureMelanie English

Whooping Cough - the background for maternal vaccination...

You're pregnant and you've been offered the maternal Whooping Cough vaccine. Are you accepting wholeheartedly or have you got questions? Google can be a scary and confusing place, especially when you’re pregnant! So after a recent client asked me for the whys and wherefores I've reviewed the information out there to present it n a clear and logical way (hopefully) .

My hope is that if you do not know if you want to accept the whooping cough vaccine, you can read this and make your decision accordingly. I do not intend to direct you in either direction, the choice is always yours.


Trigger Warning - mentions infant deaths


TL:DR Offering the whooping cough vaccine in pregnancy (before 38 weeks) has been on the table in the UK since October 2012 following a national increase in whooping cough cases, particularly in under 3 month old infants. The maternal vaccination has been found to provide protection to new-born infants in the first few months before the start of the national vaccination programme at 3 months, and has found to be successful in doing that.


There is no evidence to suggest that the whooping cough vaccine is unsafe for you or your baby. (NHS)


Cases have fallen since 2012, and dramatically since the lockdowns from 2020 onwards. The vaccination is still being offered. There is no available evidence currently to show what the prevalence of whooping cough is in the population since the covid lockdowns and restrictions have been eased.


What is Whooping Cough?

Whooping Cough (pertussis) is a highly infectious notifiable disease. It’s a bacterial infection of the lungs and breathing tubes. It is spread by respiratory droplet. Most infants who develop the disease have been infected by a family member.


Symptoms normally develop about 2 weeks after infection. The disease gets its name from the characteristic “Whooping” sound of air being drawn into the lungs after a coughing spasm, even though the Whoop is not always present, particularly in infants and young children. The illness can last about 2-3 months.


In young infants the coughing spasm can be followed by periods of apnoea.


Complications - Whooping Cough may be complicated by bronchopneumonia, repeated vomiting leading to weight loss, and cerebral hypoxia with a resulting risk of brain damage. Severe complications and deaths occur most commonly in infants under six months of age.


How is Whooping Cough treated?

If the case is severe, or a baby with whooping cough is under 6 months old, treatment will usually be in hospital. The treatment is to alleviate the side effects of the symptoms, there is no treatment available that can reverse the disease.


If diagnosed within 3 weeks of the infection, antibiotics are prescribed to help stop it spreading to others. Antibiotics may not reduce symptoms.


If the infection has been present for more than 3 weeks, the patient is no longer considered to be contagious and does not need antibiotics.


How is Whooping Cough prevented?

Whooping Cough is prevented in the UK by vaccination, as part of the childhood vaccination programme:


This chart from the Government’s “Green Book” shows the impact of the introduction of childhood vaccination on Whooping Cough numbers.

The drop in the black “coverage” line in the 1970’s was a result of reduced population confidence in the vaccine at that time - the vaccine given today, is not the same as that one.


The whooping cough vaccine is routinely given as part of:

Why is the whooping cough vaccination offered to pregnant women?

Whooping Cough is a cyclical disease, with increases occurring every 3 to 4 years, with pertussis activity (in England) usually peaking each year in quarter 3 (July to September).

In 2012 after a long period of low and reducing cases, a significantly higher than average number of whooping cough infections were recorded.


“On average, in the 10 years from 2002 to 2011 in England and Wales, 800 cases of whooping cough were reported every year with over 300 babies having to go to hospital and 4 babies dying. During 2012, however, cases of whooping cough rose sharply with nearly 10,000 cases and 14 baby deaths… (reference)

During the 2012 whooping cough outbreak, the highest incidence of disease was among infants <3 months of age.


Most infant cases became ill before they were old enough to receive their first dose of vaccine.

In response to the outbreak in 2012, the Department of Health introduced a temporary programme (from October that year) to offer the Whooping Cough vaccination to pregnant women ideally between 28-32 weeks of their pregnancy.


“This programme passively protects infants, through intrauterine transfer of maternal antibodies, from birth until they can be actively protected by the routine infant vaccination programme.” (reference)

This maternal Whooping Cough immunisation programme, introduced in response to the 2012 outbreak became permanent from June 2019 based on evidence of disease impact, high effectiveness and safety


From 2013 to 2019 (7 years) following the introduction of pertussis vaccination in pregnancy there have been 20 further deaths in babies with confirmed pertussis. (an average of 2.8 deaths per year)


All the deaths in 2012 and those that have occurred following the introduction of the maternal vaccination programme were too young to be fully protected by infant vaccination. (i.e. less than 6 months old) Only two of the infants born after the introduction of the maternal programme had a mother who had been vaccinated during pregnancy. In both cases the vaccination was too close to delivery to confer optimal passive protection in the infant.


So all but 2 of the deaths since 2012 were infants whose mothers had not been vaccinated in pregnancy, and the two who had been, the vaccination was too close to the birth to be optimally protective.


The chart below, taken from the 2022 Q2 update of recorded whooping cough cases (the most recent I can find), shows the 2012 peak, a subsequent 4 year peak in 2016 and the impact of Covid-19 lifestyle restrictions on overall Whooping Cough rates in 2020-2022


2020 did not have an annual or quarter 3 peak largely due to the Covid 19 pandemic lifestyle restrictions which reduced the circulation of other infectious diseases including Whooping Cough.


Since the pandemic restrictions, incidences of Whooping cough have remained very low, there seems to be an expectation that they will rise again, but there is currently no published evidence that I can find (May 2023) that this is the case.

This chart seems to show that the incidence levels for the <3 month babies are similar now to pre 2012 levels, but as described above, the average number of baby deaths per year in the UK as a result of Whooping Cough, has dropped from 4 to 2.8. (This is an observation I do not know if this is statistically significant.)

(In the 2020 version of this graph - all lines point sharply downwards- but as was mentioned above, this is mostly likely due to the Covid-19 measures, so I’ve not included it here because it feels like the numbers in recent years have been outside of the trends shown above.)


Breastfeeding


The general immunological protection of breast milk, when an infant is exclusively breastfed, is well known. But I’ve found several sources that indicate that that isn’t sufficient for protecting against Whooping Cough:


The NHS state

“Unfortunately, breastfeeding won’t provide enough protection for your baby against whooping cough.”
“New-born babies are likely to have little or no protection against whooping cough at delivery. Antibodies passed from the pregnant mother to her unborn child following [her] vaccination, should provide some protection to the baby in the first few weeks of life. Maternal antibody levels will be low unless the mother developed whooping cough during pregnancy and the baby is vulnerable from delivery. It appears that antibodies passing through breastmilk are also unlikely to protect the baby.”

It’s difficult to find accessible information about where this conclusion comes from, but a 2017 study (61 cases and 235 controls) summarises their findings:

“Breastfeeding remains a mainstay of prevention for numerous diseases, though it does not seem to play a role against pertussis. Alternative strategies to protect unvaccinated infants from pertussis should be considered.”

Extra note of interest taken from “The Green Book”

“The reasons for the resurgence in disease in the presence of sustained high vaccine coverage are unclear but potential explanations include improved case ascertainment, the change from whole-cell to acellular vaccines, waning immunity and genetic changes in B. pertussis (Cherry, 2012).”

The decision to accept the offer of the maternal Whooping Cough vaccine is yours and yours alone. Your response to the numbers and information presented here will be different to mine. I'm not trying to convince you of anything, but if you weren't sure either way, I hope this information has helped you to make a decision you're certain of and comfortable with.


If you think I've missed anything do drop us a line and I'll review and amend as necessary.


Doula love

Melanie English, Doula

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