Guidance

Guidelines for pertussis outbreaks in nurseries and educational settings

Published 18 August 2023

Applies to England

Background

Pertussis infection

Pertussis is a disease caused by Bordetella pertussis (B. pertussis). It has a cyclical pattern of incidence with peaks occurring every 3 to 4 years. Incidence is usually higher in England between July and September. Incidence is highest in infants under 3 months of age, followed by adolescents aged 10 to 14 years (1).

Recent vaccine coverage estimates for DTaP/IPV/Hib/HepB immunisation across England was 91.5% for 3 doses at 12 months of age and 85.4% for the booster dose by 5 years of age (evaluated between October to December 2020). These were slightly lower than the coverage estimates for October 2019 to December 2019 when the proportion of children vaccinated at 12 months was 92.8% and 85.5% for the booster dose (1).

Prior to the SARS-CoV-2 pandemic, resurgences of pertussis had been observed in recent years across England, in addition to other countries with longstanding vaccination programmes (such as Wales, Australia and the USA), despite high levels of vaccine uptake (2). A range of potential explanations for the observed increased in pertussis incidence have been proposed.

There is growing evidence that the shorter duration of protection and lower effectiveness against infection conferred by acellular pertussis (aP) vaccines compared with whole cell pertussis (wP) vaccines have been important contributory factors (2 to 5). This is particularly relevant in Europe where a high proportion of countries switched from a whole cell to acellular primary schedule from the mid-1990s and where in 2017, a total of 42,242 cases were reported (6). In the UK, aP vaccines replaced wP vaccines in the accelerated primary infant schedule (2, 3 and 4 months) in 2004, later than many other high-income countries.

In addition to the primary course, a further dose of aP vaccine has been routinely offered to children at preschool age (3 years, 4 months) since 2001. Reported increases in adolescent disease, in part due to improved case ascertainment but also reflecting waning immunity from the childhood programme, have prompted some countries to introduce adolescent boosters. However, adolescent boosters are not offered as part of the routine vaccination schedule in the UK.

In recent years, there have been increases in the number of pertussis outbreaks in educational settings in the UK; from 4 in 2014, to 24 in 2019. Despite the rapid and marked fall in pertussis cases following the introduction of measures to help control the SARS-CoV-2 pandemic, small numbers of outbreaks in educational settings continued to be reported in 2020 and 2021.

Given the high infectivity of pertussis, alongside the recognised limitations of the acellular vaccines, a re-emergence of pertussis is anticipated, and it is important that pertussis is therefore considered in the differential diagnosis of cough.

Aim and scope of guidance

The aim of this guidance is to advise health protection teams (HPTs) in the management of pertussis outbreaks in schools and nurseries.

Guidance for the public health management of pertussis, and specific guidance on management of pertussis in a healthcare setting can be found on GOV.UK.

Evidence for the use of chemoprophylaxis and vaccination

A Cochrane review from 1999 (7), which included 12 trials with 1,720 participants, concluded that antibiotics were effective in eliminating B. pertussis from patients with the disease, rendering them non-infectious, but did not alter the clinical course of the illness. Effective regimens include:

• 3 days of azithromycin
• 7 days of clarithromycin
• 7 or 14 days of erythromycin

Considering microbiological clearance and side effects, 3 days of azithromycin or 7 days of clarithromycin are considered the current best regimens.

Seven days of trimethoprim/sulfamethoxazole also appeared to be effective for the eradication of B. pertussis from the nasopharynx and may serve as an alternative antibiotic treatment for patients who are unable to tolerate a macrolide. This review also concluded that there was insufficient evidence to determine the benefit of prophylactic treatment in contacts exposed to pertussis.

Dodhia and others (8) reviewed the evidence for the use of erythromycin in the management of persons exposed to pertussis. They found weak evidence to support the use of erythromycin prophylaxis based on evidence obtained from well-designed cohort or case-controlled analytical studies. The beneficial effect to household contacts of receiving antibiotic prophylaxis was at best modest when compared with the protection conferred by an effective whole-cell vaccine. There was no evidence of any benefit of antibiotic prophylaxis to contacts other than household-type contacts.

Van Buynder and others (9) looked at all available data sources on disease due to B. pertussis, including notifications, hospital admissions, deaths, and an enhanced laboratory-based surveillance system for the period 1995 to 1997. They concluded that while overall levels of pertussis notifications had declined, vaccination efficacy waned with increasing age, and pertussis remained a significant cause of mortality and severe morbidity in the very young. They concluded that the risk of mortality and morbidity could be reduced by timely administration of a booster vaccination and increased recognition/treatment of mild disease in older cases followed by early antibiotic therapy for very young household contacts.

Current guidance in the management of pertussis

Public Health England (PHE), now part of the UK Health Security Agency (UKHSA), has published guidance for the public health management of pertussis as well as additional guidance for cases of pertussis in healthcare facilities. Public health management of cases of pertussis includes provision of appropriate exclusion advice and antibiotic treatment of cases. Further action depends on the presence of close contacts that fall into a series of at-risk groups (‘vulnerable’ or ‘transmitters’). See Appendix 1 for case and contact definitions.

In the event of there being close contacts in at-risk groups and the notification being within 21 days of the onset of cough; antibiotic prophylaxis and immunisation (dependent on previous immunisation status and age) is recommended to all close contacts of the index case.

Guidance for outbreaks in healthcare settings recommends vaccination and antibiotic chemoprophylaxis where there has been direct contact of the index case (either a patient or healthcare worker) with pregnant women or vulnerable infants, which is classed as a significant contact, within the previous 21 days.

Current UKHSA pertussis guidance recommends that confirmed and suspected cases are excluded from nursery or school until 48 hours after commencing appropriate antibiotic therapy or for 21 days from onset of symptoms (if they are not treated with antibiotics). Furthermore, where there has been more than one case reported from an educational institution, current guidance recommends raising awareness among parents to improve vaccination uptake among children and encourage timely case finding and reporting.

The guidance also recommends that in certain circumstances, wider chemoprophylaxis and vaccination for a school or nursery outbreak may be considered by the outbreak control team depending on factors such as:

• duration of the outbreak and thus the likely benefit of chemoprophylaxis and/or vaccination
• presence of a clearly defined group who can be identified for chemoprophylaxis and/or vaccination
• practicality and feasibility of widespread chemoprophylaxis and/or vaccination
• likely acceptability and compliance with antibiotics
• involvement of a residential setting, for example, boarding school

In view of the growing number of pertussis outbreaks in educational settings and the specific considerations for management, it was recognised that more detailed guidance for HPTs managing pertussis outbreaks in educational settings would be helpful. This guidance outlines outbreak management options based on a scenario-based approach for nurseries, primary, secondary and boarding schools.

Management of pertussis outbreaks

Definition of an outbreak

An outbreak of pertussis in an educational setting or nursery is defined as 2 or more confirmed (or at least one confirmed and one clinically suspected) cases of pertussis within 42 days (2 incubation periods) where transmission is likely to have occurred in the setting.

Generic management

Outbreak confirmation and case ascertainment

In the event of a suspected outbreak in a nursery or educational setting, the priority is to confirm the diagnosis and improve case finding. Potential cases should be referred to relevant healthcare services for clinical assessment and laboratory testing as appropriate.

Urgent testing using oral fluid or throat swab if more than 14 days, and nasopharyngeal swab (or aspirate) if within 3 weeks, of the onset of symptoms and depending on the age of the patient (see Appendix 2 for advice on lab testing) should be considered. If a diagnosis of B. pertussis is unlikely, testing for other respiratory pathogens at the nearest regional UKHSA laboratory may be indicated. HPTs should consider raising awareness among local primary and secondary care services for enhanced case finding (template letters accompany this guidance).

Note: Although chemoprophylaxis is likely to be more effective when implemented early, it is not 100% effective. Vaccination does not provide 100% protection against disease; immunity takes 1 to 2 weeks to develop and is known to wane over time. Therefore, a diagnosis of pertussis should still be considered in an exposed individual who develops signs and symptoms compatible with pertussis, despite receiving chemoprophylaxis and despite previous vaccination.

Identification and management of cases and vulnerable contacts

Cases of pertussis need to be managed in accordance with existing UKHSA guidance. This may include antibiotic treatment; vaccination and exclusion of cases and identification of close contacts who meet the criteria for being ‘vulnerable’ or ‘transmitters’, which may necessitate wider chemoprophylaxis and vaccination (see Appendix 1 for case and contact definitions).

Consider formation of an incident management team (IMT) or outbreak control team (OCT) and undertake a formal risk assessment

If 2 or more confirmed and epidemiologically linked cases of pertussis occur within 42 days of each other an incident management team (IMT) or outbreak control team (OCT) may be considered. In high-risk settings such as residential or special educational needs and disability (SEND) education settings there might be a more significant need for an IMT/OCT than in mainstream settings. A risk assessment should be undertaken by the IMT/OCT to determine whether further public health action should be undertaken.

The IMT/OCT should consider the following to inform their risk assessment:

• how many cases are confirmed?
• what is the severity of illness in the cases?
• is transmission likely to have already occurred?
• what was the nature of contact between the cases?
• is there a risk of ongoing transmission in the setting?
• what is the duration of the outbreak and thus the likely benefit of widespread chemoprophylaxis and/or vaccination?
• is there a clearly defined group who can be identified for chemoprophylaxis and/or vaccination?
• how practical and feasible is widespread chemoprophylaxis and/or vaccination?
• how acceptable is widespread chemoprophylaxis and/or vaccination?
• how likely are parents or guardians and staff to comply with advice?
• what is the degree of parental and or staff anxiety?
• what is the age of potential contacts and how vulnerable are potential contacts to significant illness because of pertussis infection (see Appendix 1 for case and contact definitions)?
• what is the level of pre-existing vaccination coverage amongst children and staff?
• are there impending events or holidays which may act to facilitate or interrupt transmission?

Communications

The need to share information within UKHSA and with external partners should be considered and may be guided by the input of regional UKHSA communications colleagues.

The following actions should also be considered:

• providing the UKHSA guidance on health protection in schools and other childcare facilities to the educational setting; this guidance contains advice in relation to generic respiratory Infection Prevention and Control (IPC) measures which are effective in limiting the spread of respiratory infections
• providing warn and inform advice to parents or guardians (template letters accompany this guidance); in addition to providing routine advice regarding exclusion, early assessment for symptoms and vaccination, the OCT may choose to include advice regarding what to do if attending hospital appointments or primary care and requirements of close contacts who are healthcare workers to consider informing their occupational health teams
• drafting a reactive media statement
• informing local healthcare services on case reporting and management recommendations
• informing the local authority public health team
• informing UKHSA national immunisation team (immunisation.lead@ukhsa.gov.uk)
• informing relevant UKHSA laboratories (regional and national) and NHS Laboratories
• liaising early with NHS immunisation services to ascertain and improve vaccination coverage in the at-risk population
• liaising early with field epidemiology colleagues to monitor the epidemiology of the outbreak

Ongoing surveillance

The HPT will also need to advise the school and local healthcare services about passive surveillance amongst staff and children to ensure early detection and management of any further cases.

If further clinically suspected cases arise during the surveillance period (42 days from onset of index case), mass testing may be discussed as part of the IMT. Advice on laboratory testing and interpretation may also be sought from the Pertussis Reference Laboratory, Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU), UKHSA Colindale (020 8327 7887). However, public health action including exclusion and treatment of cases should proceed based on clinical diagnosis.

Pertussis outbreaks: scenario management

The following guidance considers HPT actions in relation to the following scenarios; 2 or more cases in:

• a nursery setting
• a primary (day) school
• a secondary (day) school
• a boarding school

Nursery scenario

Outbreak definition in a nursery setting

An outbreak is defined as 2 or more confirmed or at least one confirmed and one clinically suspected case of pertussis within 42 days where transmission is likely to have occurred in the nursery setting.

Chemoprophylaxis in a nursery setting

In a nursery setting, it may be appropriate to consider more widespread chemoprophylaxis (for staff and children) depending on the severity of illness among those affected, the number of cases and the number of potential contacts, in addition to the age and vaccination status of those exposed.

In settings with a large proportion of incompletely vaccinated infants, the OCT may consider arranging chemoprophylaxis if a clearly defined group can be identified and it is practical and feasible. Find the recommended antibiotic regimen within the Recommended antibiotics for chemoprophylaxis or treatment document.

Vaccination in a nursery setting

The OCT should advise that all nursery attendees (and their siblings) and staff check that they are up to date with their pertussis vaccinations and if not, arrange an appointment with their GP promptly to catch up on missing doses. Given the age group, widespread booster vaccinations are unlikely to be required in this setting. Pregnant nursery staff should be advised to follow routine advice in relation to pertussis vaccination in pregnancy (advised from 16 weeks of pregnancy) and to discuss any specific concerns with their midwife.

Primary (day) school scenario

Outbreak definition in a primary day school setting

An outbreak is defined as 2 or more confirmed or at least one confirmed and one clinically suspected case of pertussis within 42 days where transmission is likely to have occurred in the primary day school setting.

Chemoprophylaxis in a primary day school setting

Chemoprophylaxis is not routinely recommended in this setting except in exceptional circumstances. Chemoprophylaxis may be considered when the uptake of the routine childhood vaccinations in the cohort at risk is known to be particularly low (based on local immunisation coverage data).

Vaccination in a primary day school setting

An offer of booster vaccination may be considered based on the following factors: severity of cases, numbers of children affected, presence of a significant number of vulnerable contacts, and low background vaccination coverage. In this situation, the OCT may decide to offer a booster dose to all children or advise that parents or guardians ensure that all children are up to date with the national vaccination schedule by checking with their GPs.

Secondary (day) school scenario

Outbreak definition in a secondary day school setting

An outbreak is defined as 2 or more confirmed or at least one confirmed and one clinically suspected case of pertussis within 42 days where transmission is likely to have occurred in the secondary school day setting.

Chemoprophylaxis in a secondary day school setting

Chemoprophylaxis is not routinely recommended.

Vaccination in a secondary day school setting

In this situation, it is assumed that all students are likely to be at risk of developing infection given the waning immunity from the vaccine that is frequently observed in this age group. However, there is a low likelihood of severe disease and students of this age may also be less likely to have close contact with those perceived to be more vulnerable to severe pertussis (unvaccinated infants and pregnant women who may transmit to unvaccinated infants, see Appendix 1 for case and contact definitions).

Therefore, widespread vaccination would not be routinely recommended. However, if there were high numbers of hospitalisations, or significantly large numbers of students affected, the OCT might consider booster vaccination as a control measure. Use of the template letter accompanying this guidance to encourage students, parents or guardians to ensure children are up to date with their routine childhood vaccinations is recommended.

Boarding school scenario

Outbreak definition in a boarding school setting

An outbreak is defined as 2 or more confirmed or at least one confirmed and one clinically suspected case of pertussis within 42 days where transmission is likely to have occurred in the boarding school setting.

Chemoprophylaxis in a boarding school setting

Consideration needs to be given to whether the boarding school environment is equivalent to a household setting. In this case, chemoprophylaxis would need to be provided as per household contacts detailed in the current UKHSA guidance . It may also be worth potentially extending this to specific relevant cohorts such as boarding houses for protracted outbreaks.

Vaccination in a boarding school setting

Vaccination is likely to be recommended, but the OCT need to consider the age group affected and timing of school age routine booster vaccine as to whether this is in the form of a mass booster campaign or a catch-up programme. The rationale for this approach is that the outbreak is likely to be protracted and a closed setting means it is perceived to be beneficial to interrupt transmission with potentially large numbers of students affected. However, this may be guided by consideration of the feasibility or practicality, and acceptability or compliance with this approach in addition to the degree of parental and or staff anxiety and any impending events or holidays which may act to facilitate or interrupt transmission.

Table 1. Summary of public health management

Note: see Appendix 3 for case studies

Educational setting	Chemoprophylaxis	Vaccination
Nursery scenario	May be appropriate to consider widespread chemoprophylaxis.	Widespread booster vaccinations are unlikely to be required.
Primary school scenario	Chemoprophylaxis is not recommended in this setting other than in exceptional circumstances.	Widespread administration of a booster vaccination may be appropriate.
Secondary school scenario	Chemoprophylaxis is not normally recommended in this setting.	Widespread vaccination is not normally recommended.
Boarding school scenario	Consideration needs to be given to whether the boarding school environment is considered to be equivalent to a household setting. In this case, chemoprophylaxis should be provided.	Vaccination is likely to be recommended, but the OCT needs to consider whether this is in the form of a mass booster or catch-up programme.

Appendix 1. Case and contact definitions

Suspected case of pertussis

Any person in whom a clinician suspects pertussis infection or any person with an acute cough lasting for 14 days or more, without an apparent cause plus one or more of the following:

• paroxysms of coughing
• post-tussive vomiting
• inspiratory whoop

and:

• absence of laboratory confirmation
• no epidemiological link to a laboratory confirmed case

Confirmed case of pertussis

Any person with signs and symptoms consistent with pertussis with:

• B. pertussis isolated from a respiratory sample (typically an nasopharyngeal aspirate (NPA) or nasopharyngeal swab (NPS)/pernasal swab (PNS) (or throat swab), or:
• A B. pertussis PCR positive result from a respiratory clinical specimen, or:
• a positive serology result based on an elevated titre of anti-pertussis toxin IgG reported in International Units per mL (IU/mL) in the absence of vaccination within the past year, according to manufacturer’s instructions, or:
• a positive oral fluid (OF) result based on an elevated titre (greater than 70 aU) of anti-pertussis toxin IgG in the absence of vaccination within the past year

Epidemiologically linked case of pertussis

A suspected case with signs and symptoms consistent with pertussis, but no laboratory confirmation, who was in contact with a laboratory-confirmed case of pertussis in the 21 days before the onset of symptoms.

Definition of close contacts

1. Family members or people living in the same household are considered close ‘household contacts’.
2. Contacts in institutional settings with an overnight stay in the same room, for example, boarding school dormitories, during the infectious period should also be considered close contacts.
3. Other types of contact, for example, contact at work or school, would generally not be considered close contact although each situation would need to be assessed on an individual basis where vulnerable contacts are involved.
4. For the definition of a significant exposure in a healthcare setting, please refer to the Public health management of pertussis incidents in healthcare settings guidance.
5. Definition of contacts considered as priority groups for public health action. These include individuals who are themselves at increased risk of complications following pertussis (group 1) as well as those at risk of transmitting the infection to others at risk of severe disease (group 2).

Priority group 1

Individuals at increased risk of severe complications (‘vulnerable’):

• unimmunised infants (born after 32 weeks gestation) less than 2 months of age whose mothers did not receive pertussis vaccine after 16 weeks of pregnancy and at least 2 weeks prior to delivery
• unimmunised infants (born up to and including 32 weeks) less than 2 months of age regardless of maternal vaccine status
• unimmunised and partially immunised infants (less than 3 doses of vaccine) aged 2 months and above regardless of maternal vaccine status

Priority group 2

Individuals at increased risk of transmitting to ‘vulnerable’ individuals in ‘group 1’ who have not received a pertussis containing vaccine more than one week and less than 5 years ago:

• pregnant women (after 32 weeks gestation)
• healthcare workers working with infants and pregnant women
• people whose work involves regular, close or prolonged contact with infants too young to be fully vaccinated
• people who share a household with an infant too young to be fully vaccinated

Appendix 2. Laboratory testing summary

Laboratory testing of clinically suspected cases

Test (target)	Patient criteria	Sample	Access	RVPBRU
Culture (organism)	Suspected cases in all age groups with cough less than 21 days duration	Nasopharyngeal swab or aspirate; Pernasal swab	NHS laboratories	Confirmed isolates to be sent to RVPBRU
PCR (DNA)	Suspected cases in all age groups with cough less than 21 days duration	Nasopharyngeal swab or pernasal preferred; throat swab acceptable for community patients	Some regional UKHSA laboratories
Oral fluid, OF (antibodies)*	Suspected cases aged 2 up to and including 16 years with cough for more than 14 days duration	Oral fluid kit	Oral fluid kit sent to patient upon notification to UKHSA HPT. Patient sends to RVPBRU, Colindale, by post	Samples tested and reported by RVPBRU
Serology (antibodies)*	Suspected cases in older children or adults with cough for more than 14 days duration	Serum	RVPBRU, Colindale, some NHS and regional UKHSA laboratories	Samples tested and reported by RVPBRU (chargeable service)

*Antibody levels may be confounded by recent vaccination. Recommended for those who have not received a dose of pertussis containing vaccine in the preceding year.

Appendix 3. Case studies

Nursery setting case study

Publication: not published.

Point of contact for further information: immunisation.lead@ukhsa.gov.uk

Setting

Nursery setting with 3 rooms which included:

• 18 children in a room for those aged 1 to 2 years
• 41 children in a room for those aged 2 to 3 years
• 35 children in a room for those aged 3 to 5 years

Epidemiology

Two confirmed cases in the room for children aged 1 to 2 years with onset between 23 July and 7 August 2020. It was also notable that several children in this room had a cough and runny noses. Some children were sent home as a precaution by the nursery with instructions to organise a COVID-19 test. All COVID-19 tests came back negative.

Control measures

A warn and inform letter was sent to parents of all children in the room for those aged 1 to 2 years and staff. The letter was subsequently sent to parents of every child at the nursery highlighting signs and symptoms of pertussis to be aware of, the need to ensure children had received their routine childhood vaccinations and to advise that any pregnant contacts had also accessed the pertussis vaccination as per routine advice. The letter asked for children or staff not to attend the nursery if they were symptomatic and to seek medical advice.

The HPT sent a batch of nose and throat swabs to the nursery for parents and staff to pick up and swab anyone symptomatic. The used swabs were posted back to the Public Health Laboratory for whole viral respiratory panel testing. The HPT advised that symptomatic children and staff remain away from the nursery until they received a negative swab result or at least 48 hours of a course of antibiotics, if positive for pertussis.

Movement of children into older age group rooms was scheduled but this was postponed whilst the investigation was ongoing. Of 31 swabs processed by the lab for pertussis and COVID-19 none were positive for either but there was a single positive result for Bordetella Para pertussis.

Primary school setting case study

Publication: Investigation of a pertussis outbreak and comparison of 2 acellular booster pertussis vaccines in a junior school in South East England, 2019

Point of contact for further information immunisation.lead@ukhsa.gov.uk

Setting

Local primary (infant and junior closely linked) school in England with 427 students aged 7 to 11 years.

Epidemiology

One serologically confirmed case of pertussis was notified in mid-March 2019. This case had symptom onset in February 2019. Six further (suspected or confirmed) cases were identified in the following days; one was the sibling of case 1 (who attended the linked infant school), the class teacher of case 1 and 4 other pupils in the same class. All of whom had seen the same GP.

Control measures

Following the first case and the head teacher reporting many cough absences at school, a letter was sent to all parents of pupils attending the junior school to raise awareness of the signs and symptoms of pertussis infection. This prompted further reports of students absent with cough illness and 4 additional students were subsequently notified as possible cases with onset dates from late January 2019. By the end of March 2019, 4 confirmed cases and 17 probable cases of pertussis in students who had presented to their GP had been identified.

An incident management team meeting was convened at the beginning of April 2019. All students in the junior school were offered a booster dose of pertussis-containing vaccine regardless of their vaccine status at the school on 1 and 2 May 2019.

As this was the first outbreak in a primary school setting that had been notified since the pre-school booster dose was introduced in 2001 enhanced case finding was undertaken. Parents of all students in the junior school were asked to complete a clinical questionnaire and for their consent for their child to have an oral fluid sample taken. A total of 134 of 381 (35.2%) students at the school were classified as pertussis cases during the outbreak (133 based on oral fluid testing and one clinically diagnosed). Thirty-nine (29.1%) of the confirmed cases were asymptomatic and did not report any cough.

Secondary school setting case study

Publication: not published.

Point of contact for further information: immunisation.lead@ukhsa.gov.uk

Setting

Local secondary school.

Epidemiology

Three confirmed cases across 3 school year groups, with onset in December 2019 (year 7 pupil) and March 2020 (year 9 and 10 pupil). This was in the context of increased local pertussis activity, particularly in the group of those aged under 16 years in this community.

Control measures

The situation was discussed with the school, a warn and inform letter was disseminated to parents through the school in early March 2020. The school was advised to have a low threshold for further cases and to contact the local HPT if there were any further suspected cases. No further cases were reported to the HPT.

A GP letter was disseminated to inform local primary care services about the increased number of confirmed pertussis cases in the area and to stress the importance of:

• ensuring that children and pregnant women were fully vaccinated
• prompt notification of suspected cases
• consideration of a diagnosis of pertussis in persons presenting with prolonged cough
• requesting for testing early enough so that effective public health action could be implemented, including highlighting the age group eligible for oral fluid testing

A letter for maternity units to encourage good uptake of the maternal pertussis programme and encouraging pregnant women with symptoms to avoid settings where they may be in contact with other people until 48 hours after starting antibiotic treatment was also shared.

Boarding school setting case study

Publication: Retrospective cohort study investigating extent of pertussis transmission during a boarding school outbreak, England, December 2017 to June 2018

Point of contact for further information: immunisation.lead@ukhsa.gov.uk

Setting

All-female boarding school in England with students aged 11 to 18 years.

Epidemiology

Two serologically confirmed cases between 21 March and 1 May 2018. Further investigation identified 2 further confirmed cases and 1 suspected case across year groups 9 to 13 and with onsets between 25 February and 16 April 2018. Investigations in the setting identified widespread transmission with 48% of the 504 individuals tested having evidence of carriage or recent infection.

Control measures

Initial outbreak response – single dose of pertussis-containing vaccine recommended for all student boarders in years 9 to 13 who were housed separately from younger boarders. Vaccine was also offered to selected staff members (between 11 and 15 May 2018).

Active case-finding through a short questionnaire, throat swabbing, and oral fluid swabbing was undertaken before initial vaccination in collaboration with UKHSA Immunisation Division and the reference laboratory. This indicated extensive transmission and vaccination was extended to the younger school years.

Learning from this outbreak

There should be a low index of suspicion when multiple pertussis cases are notified in the same secondary school; symptoms are often mild in this age group, so the scale of the outbreak is likely to be larger than the number of notified cases. In semi-closed settings such as this boarding school (where most pupils were boarding) careful consideration should be made of the cohorts of students that appear unaffected but who have opportunities to mix with affected students.

Appendix 4. Guideline development group membership: consultation and approval process

Members of the guideline development group included:

• Dr Gayatri Amirthalingam – Consultant Epidemiologist, Immunisations, UKHSA

• Dr Joanne Darke – Consultant in Health Protection, North East HPT, UKHSA

• Kelly Stoker – Senior Health Protection Nurse, North East HPT, UKHSA

• Sonia Ribeiro – Scientist, UKHSA

• Dr Helen Campbell – Senior Scientist, UKHSA

• Dr Colin Brown – Consultant Medical Microbiologist, UKHSA

• Dr Rachel Mearkle – Consultant in Health Protection, South East Thames Valley HPT, UKHSA

• Jaime Morgan – Senior Health Protection Nurse, South East Surrey and Sussex HPT, UKHSA

• Dr Rebecca Cordery – Consultant in Health Protection, South East London HPT, UKHSA

• Dr Margot Nicholls – Consultant in Health Protection, South East Surrey and Sussex HPT, UKHSA

• Dr Karthik Paranthaman – Consultant Epidemiologist, Field Epidemiology Service South East and London, UKHSA

• Elise Tessier – Scientist, UKHSA

• Dr Norman Fry – Consultant Clinical Scientist, Immunisation and Vaccine Preventable Diseases and Specialised Microbiology and Laboratories Directorate, UKHSA

Case study information

Case study information was kindly provided by the following individuals:

• Fiona Neely – Consultant in Health Protection, South West HPT, UKHSA

• Toyin Ejidokun – Consultant in Health Protection, South West HPT, UKHSA

Governance of project

The guidelines were agreed by the pertussis guidelines development group on 15 February 2023.

The Vaccine Preventable Diseases (VPD) leads group approved the guidance on 22 February 2023.

The guidance was approved by the Vaccine Science and Surveillance Group (VSSG) on 21 April 2023.

References

1. Public Health England (PHE). Laboratory confirmed cases of pertussis (England): annual report for 2020

2. Choi YH, Campbell H, Amirthalingam G, van Hoek AJ, Miller E. ‘Investigating the pertussis resurgence in England and Wales, and options for future control’ BMC Medicine 2016

3. Schwartz KL, Kwong JC, Deeks SL, Campitelli MA, Jamieson FB, Marchand-Austin A and others. ‘Effectiveness of pertussis vaccination and duration of immunity’ Canadian Medical Association Journal (CMAJ) 2016

4. Celentano LP, Massari M, Paramatti D, Salmaso S, Tozzi AE. ‘Resurgence of pertussis in Europe’ Pediatric Infectious Disease Journal 2005

5. World Health Organization (WHO). ‘Summary of the Pertussis Vaccines: WHO position paper - September 2015’ Accessed 9 May 2019

6. European Centre for Disease Prevention and Control (ECDC). Pertussis Annual Epidemiological Report for 2017 Key facts (cited 14 August 2019)

7. Altunaiji S, Kukuruzovic R, Curtis N, Massie J. ‘Antibiotics for whooping cough (pertussis)’ Cochrane database of systematic reviews 2007: issue 3, CD004404

8. Dodhia H, Miller E. ‘Review of the evidence for the use of erythromycin in the management of persons exposed to pertussis’ Epidemiology and Infection 1998: volume 120, issue 2

9. Van Buynder PG, Owen D, Vurdien JE, Andrews NJ, Matthews RC, Miller E. ‘Bordetella pertussis surveillance in England and Wales: 1995 to 1997’ Epidemiology and Infection 1999: volume 123, issue 3

10. PHE. Guidelines for the public health management of pertussis in England May 2018

11. PHE. Guidelines for the public health management of pertussis in healthcare settings November 2016