Update on respiratory infection caused by Bordetella parapertussis

Can Comprehensive Respiratory Pathogen Panels be Used to Exclude Pertussis Infection?

BACKGROUND

Pertussis is a serious public health concern and accurate diagnosis is imperative. Comprehensive, multiplex respiratory pathogen polymerase chain reaction (PCR) panels (RPPs) have recently become popular, but their utility in excluding pertussis infection has not been fully explored.

OBJECTIVES

To determine RPP testing results for pertussis using frozen banked samples that previously tested positive on dedicated Bordetella pertussis PCR testing, and to describe positive test rates for other respiratory pathogens on these samples via RPP.

METHODS

Our microbiology laboratory retrieved banked nasopharyngeal samples from inpatient, ambulatory, and emergency department sources that were positive for pertussis using B. pertussis PCR testing from March 2015 to October 2017. RPP was performed on thawed, archived samples. Rate of pertussis identification on RPP was determined, and positive tests for other pathogens were tabulated.

RESULTS

A total of 3482 specimens were submitted for pertussis PCR testing during the study period. Of those, 138 (4%) were positive for B. pertussis, and 102 (74%) samples were banked and available for RPP testing. Fifty-seven of 102 (56%) of the banked samples had positive RPP testing for pertussis. Of the 45 samples negative for pertussis on RPP testing, 20 (44%) tested positive for other respiratory pathogens.

CONCLUSION

Negative testing for B. pertussis and positive testing for other respiratory pathogens on RPP was common in samples that previously tested positive on dedicated B. pertussis PCR testing, both of which could lead to missed diagnoses of pertussis infection. Clinicians should consider using dedicated pertussis PCR testing if pertussis infection is suspected.

Bordetella pertussis

Pertussis is a highly infectious vaccine-preventable cough illness that continues to be a significant source of morbidity and mortality around the world. The majority of human illness is caused by Bordetella pertussis, and some is caused by Bordetella parapertussis. Bordetella is a Gram-negative, pleomorphic, aerobic coccobacillus. In the past several years, even countries with high immunization rates in early childhood have experienced rises in pertussis cases. Reasons for the resurgence of reported pertussis may include molecular changes in the organism and increased awareness and diagnostic capabilities, as well as lessened vaccine efficacy and waning immunity. The most morbidity and mortality with pertussis infection is seen in infants too young to benefit from immunization. Severe infection requiring hospitalization, including in an intensive care setting, is mostly seen in those under 3 months of age. As a result, research and public health actions have been aimed at better understanding and reducing the spread of Bordetella pertussis. Studies comparing the cost benefit of cocooning strategies versus immunization of pregnant women have been favorable towards immunizing pregnant women. This strategy is expected to prevent a larger number of pertussis cases, hospitalizations, and deaths in infants <1 year old while also being cost-effective. Studies have demonstrated that the source of infection in infants usually is a family member. Efforts to immunize children and adults, in particular pregnant women, need to remain strong.

Contribution of pertussis toxin to the pathogenesis of pertussis disease

Pertussis toxin (PT) is a multisubunit protein toxin secreted by Bordetella pertussis, the bacterial agent of the disease pertussis or whooping cough. PT in detoxified form is a component of all licensed acellular pertussis vaccines, since it is considered to be an important virulence factor for this pathogen. PT inhibits G protein-coupled receptor signaling through Gi proteins in mammalian cells, an activity that has led to its widespread use as a cell biology tool. But how does this activity of PT contribute to pertussis, including the severe respiratory symptoms of this disease? In this minireview, the contribution of PT to the pathogenesis of pertussis disease will be considered based on evidence from both human infections and animal model studies. Although definitive proof of the role of PT in humans is lacking, substantial evidence supports the idea that PT is a major contributor to pertussis pathology, including the severe respiratory symptoms associated with this disease.

Lack of cross-protection against Bordetella holmesii after pertussis vaccination

Vaccines for B. pertussis do not protect against circulating strains of a closely related respiratory pathogen.

Bordetella holmesii, a species closely related to B. pertussis, has been reported sporadically as a cause of whooping cough–like symptoms. To investigate whether B. pertussis–induced immunity is protective against infection with B. holmesii, we conducted an analysis using 11 human respiratory B. holmesii isolates collected during 2005–2009 from a highly B. pertussis–vaccinated population in Massachusetts. Neither whole-cell (wP) nor acellular (aP) B. pertussis vaccination conferred protection against these B. holmesii isolates in mice. Although T-cell responses induced by wP or aP cross-reacted with B. holmesii, vaccine-induced antibodies failed to efficiently bind B. holmesii. B. holmesii–specific antibodies provided in addition to wP were sufficient to rapidly reduce B. holmesii numbers in mouse lungs. Our findings suggest the established presence of B. holmesii in Massachusetts and that failure to induce cross-reactive antibodies may explain poor vaccine-induced cross-protection.

O antigen allows B. parapertussis to evade B. pertussis vaccine-induced immunity by blocking binding and functions of cross-reactive antibodies

Although the prevalence of Bordetella parapertussis varies dramatically among studies in different populations with different vaccination regimens, there is broad agreement that whooping cough vaccines, composed only of B. pertussis antigens, provide little if any protection against B. parapertussis. In C57BL/6 mice, a B. pertussis whole-cell vaccine (wP) provided modest protection against B. parapertussis, which was dependent on IFN-gamma. The wP was much more protective against an isogenic B. parapertussis strain lacking O-antigen than its wild-type counterpart. O-antigen inhibited binding of wP-induced antibodies to B. parapertussis, as well as antibody-mediated opsonophagocytosis in vitro and clearance in vivo. aP-induced antibodies also bound better in vitro to the O-antigen mutant than to wild-type B. parapertussis, but aP failed to confer protection against wild-type or O antigen-deficient B. parapertussis in mice. Interestingly, B. parapertussis-specific antibodies provided in addition to either wP or aP were sufficient to very rapidly reduce B. parapertussis numbers in mouse lungs. This study identifies a mechanism by which one pathogen escapes immunity induced by vaccination against a closely related pathogen and may explain why B. parapertussis prevalence varies substantially between populations with different vaccination strategies.

Clearance of Bordetella parapertussis from the lower respiratory tract requires humoral and cellular immunity

Bordetella parapertussis and Bordetella pertussis are closely related species that cause whooping cough, an acute, immunizing disease. Their coexistence in the same host populations at the same time and vaccine studies showing that B. pertussis vaccines have little effect on B. parapertussis infection or disease suggest that the protective immunity induced by each does not efficiently cross protect against the other. Although the mechanisms of protective immunity to B. pertussis have been well studied, those of B. parapertussis have not. The present study explores the mechanism by which B. parapertussis is cleared from the lower respiratory tract by anamnestic immunity. Serum antibodies are necessary and sufficient for elimination of this bacterium, and CD4(+) T cells, complement, and neutrophils are required for serum antibody-mediated clearance. Mice lacking immunoglobulin A had no defect in their ability to control or clear infection. Interestingly, serum antibody-mediated clearance of B. parapertussis did not require Fc receptors that are required for antibody-mediated clearance of B. pertussis. Together these data support a model for the mechanism of protective immunity to B. parapertussis that is similar but distinct from that of B. pertussis.

Molecular pathogenesis, epidemiology, and clinical manifestations of respiratory infections due to Bordetella pertussis and other Bordetella subspecies

Bordetella respiratory infections are common in people (B. pertussis) and in animals (B. bronchiseptica). During the last two decades, much has been learned about the virulence determinants, pathogenesis, and immunity of Bordetella. Clinically, the full spectrum of disease due to B. pertussis infection is now understood, and infections in adolescents and adults are recognized as the reservoir for cyclic outbreaks of disease. DTaP vaccines, which are less reactogenic than DTP vaccines, are now in general use in many developed countries, and it is expected that the expansion of their use to adolescents and adults will have a significant impact on reducing pertussis and perhaps decrease the circulation of B. pertussis. Future studies should seek to determine the cause of the unique cough which is associated with Bordetella respiratory infections. It is also hoped that data gathered from molecular Bordetella research will lead to a new generation of DTaP vaccines which provide greater efficacy than is provided by today's vaccines.

Efficacies of whole cell and acellular pertussis vaccines against Bordetella parapertussis in a mouse model

Pertussis vaccine development has mainly focused on Bordetella pertussis, and consequently these vaccines contain B. pertussis antigens only. However, the related species Bordetella parapertussis can also cause pertussis, although symptoms associated with the disease are generally considered to be milder. Recent field studies have shown that in some outbreaks B. parapertussis can prevail. Using a mouse model we compared the efficacy against B. parapertussis of two commercially available acellular vaccines and two whole cell vaccines, used in The Netherlands and Finland, respectively. The efficacies of the two whole cell vaccines against B. parapertussis were similar, but much lower compared to the efficacy against B. pertussis. Although, the acellular vaccines conferred some protection against B. parapertussis early in infection, the values were not significant. Later in infection, a highly significant enhancement of colonisation by B. parapertussis was observed in mice vaccinated with acellular vaccines. The whole cell vaccines protected significantly better than the acellular vaccines against B. parapertussis. The possible consequences of a switch from whole cell to acellular vaccines was discussed in the light of our findings.

Challenge of investigating biologically relevant functions of virulence factors in bacterial pathogens

Recent innovations have increased enormously the opportunities for investigating the molecular basis of bacterial pathogenicity, including the availability of whole-genome sequences, techniques for identifying key virulence genes, and the use of microarrays and proteomics. These methods should provide powerful tools for analysing the patterns of gene expression and function required for investigating host-microbe interactions in vivo. But, the challenge is exacting. Pathogenicity is a complex phenotype and the reductionist approach does not adequately address the eclectic and variable outcomes of host-microbe interactions, including evolutionary dynamics and ecological factors. There are difficulties in distinguishing bacterial 'virulence' factors from the many determinants that are permissive for pathogenicity, for example those promoting general fitness. A further practical problem for some of the major bacterial pathogens is that there are no satisfactory animal models or experimental assays that adequately reflect the infection under investigation. In this review, we give a personal perspective on the challenge of characterizing how bacterial pathogens behave in vivo and discuss some of the methods that might be most relevant for understanding the molecular basis of the diseases for which they are responsible. Despite the powerful genomic, molecular, cellular and structural technologies available to us, we are still struggling to come to grips with the question of 'What is a pathogen?'

Fever without apparent source on clinical examination, lower respiratory infections in children, and enterovirus infections

This section focuses on issues in infectious disease that are commonly encountered in pediatric office practice. McCarthy discusses recent literature regarding the evaluation and management of acute fevers without apparent source on clinical examination in infants and children and the evaluation of children with prolonged fevers of unknown origin. Klig reviews recent literature about lower respiratory tract infection in children. Finally, Kennedy and Kahn discuss recent developments in infectious diseases pertinent to office practice.