The Global Pertussis Initiative (GPI) Roundtable Meeting held in

2019, which preceded the COVID-19 pandemic, focused on the

incidence, surveillance, and immunization practices for pertussis in
the Asian region. Participants from China, India, Indonesia,
Malaysia, Pakistan, Philippines, South Korea, Taiwan, and Thailand
presented country-specific information on pertussis prevalence,
diagnosis, surveillance, vaccine administration and schedules,
maternal and neonatal disease rates, and policies and practice of
vaccination during pregnancy. In recent years, many Asian
countries have seen an increase in pertussis cases, although
underreporting of the disease is a concern. Currently, most Asian
countries have only passive surveillance for pertussis in place.
There is a need for improved surveillance to determine the disease
burden and justify vaccination policies and recommendations, such
as essential vaccination, boosters, and vaccination during
pregnancy. Better awareness of the disease in adolescents and
adults is necessary, and infant and childhood vaccination
schedules need to be improved in many countries. Differences
between private versus public sector vaccination schedules and
between whole-cell and acellular pertussis vaccines should
continue to be examined. It can be anticipated that unmet needs in
the prevention and management of pertussis will continue as the
COVID-19 pandemic evolves and that key recommendations
highlighted in this meeting report will be of ongoing importance.
Introduction
Pertussis, also known as whooping cough, is a respiratory infection
caused by Bordetella pertussis [1], [2]. It is characterized by a range
of symptoms, from asymptomatic or mild disease, particularly in
adolescents and adults who were previously vaccinated or acquired
partial immunity by infection, to persistent, progressive coughing
and life-threatening manifestations in young infants [1], [2], [3], [4].
The hallmark of the disease is a violent, frequent, and intense
cough with rapid exhalation followed by a loud inhalation and, at
times, post-tussive emesis [1], [2]. Following infection and an
incubation period typically lasting 9–10 days, the disease course in
infants and young children has 3 stages that each last 1–3 weeks:
catarrhal, paroxysmal, and convalescent [1], [2]. Although the
disease can affect people at any age, those at high risk of catching
the disease include infants who are not yet old enough to be fully
vaccinated and infants who are more likely to require hospitalization
or die from pertussis [1], [5], [6]. Approximately 1 in every 200
infants who contracts pertussis dies, usually from irreversible
pulmonary hypertension resulting from the aggregation of white
blood cells in pulmonary arterioles [7].
Pertussis is an endemic disease found worldwide in both developed
and developing countries [1], [2], [8], [9]. Incidence rates of
pertussis are highest in infants who are also at highest risk of
severe outcomes such as respiratory failure and death [1], [5], [6],
[7]. Globally, it is estimated that there were 24.1 million pertussis
cases and 160,700 deaths from pertussis in children < 5 years of
age in 2014, with periodic epidemics occurring every 3–5 years
[10].
As neither natural infection nor immunization provides lifelong
protection, it is increasingly recognized that individuals who did not
receive booster vaccines beyond 7 years old (older children,
adolescents, and adults, particularly women of childbearing age)
are at risk of pertussis and may be responsible for transmission to
infants [1], [7], [11], [12]. Vaccination programs starting in the 1940s
have reduced the incidence of pertussis globally. In 1980, based on
World Health Organization-United Nations Children’s Fund (WHO-
UNICEF) estimations, there were 1,982,355 cases of pertussis
reported worldwide with an overall diphtheria-tetanus-pertussis
(DTP3) coverage of 20% in young children. In 2019, there were
145,486 total cases remaining after an increase of DTP3 coverage
to 85% [13].
Over the past few decades, however, there has been an increase in
the number of pertussis cases detected in very young infants and
adults and outbreaks continue to occur in many countries [1], [6],
[14], [15], [16], [17]. The causes for the resurgences are multiple
and the weight of each one varies from country to country. Identified
causes include increased awareness of the disease, use of
improved diagnostic tools, inadequate vaccine coverage, waning
immunity following immunization (faster for acellular vaccines) or
natural infection, pathogen adaptation to vaccine-induced immunity,
and the spread of other species of Bordetella that can cause
coughing similar to pertussis [1], [18], [19], [20], [21], [22], [23], [24].
Currently, incidence rates of pertussis and other respiratory
infections have declined owing to substantial impacts of the
measures taken to combat the COVID-19 pandemic. These
declines have been attributed to the adoption of a range of
nonpharmaceutical interventions that have contributed to reducing
transmission not only of SARS-CoV-2 but a number of other
infectious agents, including B. pertussis [25], [26]. At the same time,
however, vaccine coverage rates, including pertussis vaccination,
have also declined sharply worldwide [26]. These global declines
and disruptions in routine vaccination can be expected to result in
widespread increases in vaccine-preventable disease in the coming
years, including pertussis, which remains one of the top causes of
infant mortality globally [27].
In many Asian countries, the burden of disease for pertussis is
unknown, with underreporting due to lack of active surveillance and
inadequate diagnosis caused by less awareness among health
professionals and lack of availability of newer diagnostic tools [28].
The reported cases of pertussis in Asia in 2018 according to WHO
were 17,532 in the South-East Asia region (total population:
1,982,238,000; DTP3 estimate of 89%) and 53,322 in the Western
Pacific region (total population: 1,913,137,000; DTP3 estimate of
93%) [29], [30]. There appears to be significant circulation of B.
pertussis in the Asian population [28]. In a recent sero-surveillance
study of anti-pertussis toxin IgG (anti-PT IgG) in Asian children and
adolescents aged 10–18 years from China, India, Japan, South
Korea, Sri Lanka, Taiwan, and Thailand (N = 1802) from July 2013
to June 2016, 4.8% had anti-PT IgG levels ≥ 62.5 IU/mL,
indicating B. pertussis infection within the previous 12 months [28].
Of those who tested seropositive, 83.9% had received at least 3
doses of DTP vaccination prior to age 6 years [28].

Section snippets
The Global Pertussis Initiative
The Global Pertussis Initiative (GPI) is an international collaboration
of multidisciplinary experts, established in 2001 [31] in order to (i)
evaluate and communicate the need for improved pertussis control
and for appropriate vaccination strategies, (ii) develop and
communicate recommendations on pertussis immunization, disease
surveillance, and strategies to control pertussis disease that are
acceptable at national, regional, and local levels, (iii) advocate the
importance of primary

Clinical case definitions and diagnosis

The diagnosis of pertussis is largely clinical, but established
diagnostic methods such as polymerase chain reaction (PCR) of B.
pertussis DNA, culture, and serology are used to varying degrees in
different Asian countries for the diagnosis and surveillance of
pertussis (Table 1). The Centers for Disease Control and
Prevention (CDC) 2020 clinical criteria for a diagnosis of pertussis
include a cough and illness lasting at least 2 weeks with at least
one of the following symptoms: paroxysms of

Pertussis vaccination
Recommended pertussis prevention by immunization according to
WHO consists of either inactivated wP or aP pertussis vaccines
combined with diphtheria and tetanus toxoid and administered
intramuscularly in at least 3 primary doses in infants [33], [34].
Additional vaccination strategies recommended by the GPI and
other organizations include booster doses in toddlers, preschool
children, and adolescents as well as vaccination of pregnant
women and health care workers [34], [35], [36]. The

Disease awareness in community physicians

Awareness of pertussis among various age groups by community
physicians is the first step in passive surveillance, but awareness
levels vary across the Asian region. It has been a traditional
misconception that pertussis is a disease of childhood. Awareness
about its existence as a disease or a carrier state in older age
groups may be lacking in some community physicians and therefore
is likely to be missed. For example, this awareness may be limited
among community doctors in China, although

Pertussis incidence and mortality

Pertussis incidence and mortality data were presented at the GPI
2019 Roundtable Meeting by participants from the individual
countries. It should be kept in mind that country-level data are
compromised by a lack of robust surveillance and reporting, leading
to an underestimation of the true burden of disease.

GPI recommendations
The general discussions and country-specific presentations at the
most recent GPI Roundtable Meeting, held in 2019, provided
information to reinforce and build upon prior recommendations. Key
highlights and recommendations are summarized in Table 3.
Previous pertussis vaccination recommendations from the GPI were
developed for high-income countries [73]. More recently, the GPI
recommendations were updated for low- and middle-income
countries (LMICs) [72]. Many LMICs aim for higher coverage of

Discussion
The burden of pertussis remains a worldwide issue with
underreporting an ongoing concern [74]. Reports of pertussis
resurgence and outbreaks mainly come from the developed world
with sophisticated diagnostic facilities and infectious disease
surveillance systems [62]. We understand that pertussis is greatly
underreported in Asian countries such as China, India, Indonesia,
Pakistan, and other countries with large populations [62]. A true
picture of pertussis resurgence in developing countries

Author contributions
All authors were responsible for idea generation, critical review, and
input into the manuscript drafts, as well as approval of the final draft
for submission. All authors had full access to the study data and
take full ownership for the integrity of the data and accuracy of the
data analysis.

Funding
GPI is funded by an unrestricted educational grant from Sanofi
Pasteur. Sanofi Pasteur had no input in the content of this article.
Editorial support in the preparation of this manuscript was provided
by Phase Five Communications, supported by Sanofi Pasteur.

Declaration of Competing Interest

The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to
influence the work reported in this paper.