Editorial
Pertussis-like illness is not the same as pertussis
Ulrich Heininger
University of Basel Children's Hospital, Division of Pediatric Infectious Diseases and Vaccinology, Basel, Switzerland
Read
3221
Timeswas read the article
1204
Total PDF
2017
Total HTML
Share statistics
array:24 [ "pii" => "S0021755721000322" "issn" => "00217557" "doi" => "10.1016/j.jped.2021.02.001" "estado" => "S300" "fechaPublicacion" => "2021-09-01" "aid" => "967" "copyright" => "Sociedade Brasileira de Pediatria" "copyrightAnyo" => "2021" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "J Pediatr (Rio J). 2021;97:471-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:19 [ "pii" => "S0021755721000334" "issn" => "00217557" "doi" => "10.1016/j.jped.2021.02.002" "estado" => "S300" "fechaPublicacion" => "2021-09-01" "aid" => "968" "copyright" => "Sociedade Brasileira de Pediatria" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "J Pediatr (Rio J). 2021;97:473-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:9 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Discrepant changes of urinary cystatin C and other urinary biomarkers in preterm neonates" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "473" "paginaFinal" => "475" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Guido Filler, Maria E. Díaz-González de Ferris" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Guido" "apellidos" => "Filler" ] 1 => array:2 [ "nombre" => "Maria E. Díaz-González de" "apellidos" => "Ferris" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0021755721000334?idApp=UINPBA000049" "url" => "/00217557/0000009700000005/v1_202109160616/S0021755721000334/v1_202109160616/en/main.assets" ] "asociados" => array:1 [ 0 => array:19 [ "pii" => "S0021755720302576" "issn" => "00217557" "doi" => "10.1016/j.jped.2020.10.018" "estado" => "S300" "fechaPublicacion" => "2021-09-01" "aid" => "957" "copyright" => "Sociedade Brasileira de Pediatria" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "J Pediatr (Rio J). 2021;97:500-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Protective effect of exclusive breastfeeding and effectiveness of maternal vaccination in reducing pertussis-like illness" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "500" "paginaFinal" => "507" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Renata Medeiros do Nascimento, Paulo Neves Baptista, Katiuscia Araújo de Miranda Lopes, Analíria Moraes Pimentel, Fábia da Silva Pereira Cruz, Ricardo Arraes de Alencar Ximenes" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Renata Medeiros do" "apellidos" => "Nascimento" ] 1 => array:2 [ "nombre" => "Paulo Neves" "apellidos" => "Baptista" ] 2 => array:2 [ "nombre" => "Katiuscia Araújo de Miranda" "apellidos" => "Lopes" ] 3 => array:2 [ "nombre" => "Analíria Moraes" "apellidos" => "Pimentel" ] 4 => array:2 [ "nombre" => "Fábia da Silva Pereira" "apellidos" => "Cruz" ] 5 => array:2 [ "nombre" => "Ricardo Arraes de Alencar" "apellidos" => "Ximenes" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0021755720302576?idApp=UINPBA000049" "url" => "/00217557/0000009700000005/v1_202109160616/S0021755720302576/v1_202109160616/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Pertussis-like illness is not the same as pertussis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "471" "paginaFinal" => "472" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Ulrich Heininger" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Ulrich" "apellidos" => "Heininger" "email" => array:1 [ 0 => "ulrich.heininger@ukbb.ch" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "University of Basel Children's Hospital, Division of Pediatric Infectious Diseases and Vaccinology, Basel, Switzerland" "identificador" => "aff0005" ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pertussis, caused by infection with the Gram-negative Bacterium <span class="elsevierStyleItalic">Bordetella pertussis</span>, is a nasty disease at any age, but most serious in young infants. They can suffer from apnea, bradycardia, paroxysmal spells, and life-threatening pulmonary failure associated with hyperleukocytosis caused by the effect of pertussis toxin (PT).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Treatment options are limited and focus on antibiotics to eliminate <span class="elsevierStyleItalic">B. pertussis</span> from the nasopharynx, thereby interrupting the chain of transmission, and symptomatic therapy to ameliorate the course of this disease. The success of treatment is quite variable and fatalities occur regularly. Protecting young infants from <span class="elsevierStyleItalic">B. pertussis</span> infection, therefore, is paramount. Immunizing close contact persons before or shortly after the birth of a child (so-called “cocooning”) is a challenging strategy which has proven to be of suboptimal efficiency.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In contrast, providing newborns with a protective amount of anti-PT IgG antibodies via the placenta after immunization of pregnant women with pertussis component vaccines has demonstrated efficacy and safety.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">With this background, Nascimento and colleagues performed a case-control study in sentinel hospitals for pertussis in Recife, Brazil, to investigate the “protective effect of exclusive breastfeeding and effectiveness of maternal vaccination in reducing pertussis-like illness”.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> During the 2 year study period they identified 73 cases with a diagnosis of “pertussis-like illness” (clinically diagnosed in 71 of them) of which 29 were hospitalized, and 194 controls. Forty-seven (64%) of cases were born to mothers vaccinated against pertussis with Tdap combination vaccines during pregnancy as were 144 (74%) of the controls. They found out that, in the univariate analysis, exclusive breastfeeding in children <6 months of age born to unvaccinated mothers demonstrated a protective effect against “pertussis-like illness” with an odds ratio of 0.27 (95% CI; 0.07, 1.00) and in children born to vaccinated mothers the protective effect had an OR of 0.21 (95% CI; 0.06, 0.69). In contrast, the protective effect of pertussis immunization in pregnancy had an insignificant OR of 0.70 (95% CI; 0.40, 1.34).</p><p id="par0015" class="elsevierStylePara elsevierViewall">In Brazil, immunization during pregnancy (a term more precise than “maternal immunization”<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>) is recommended between the 20th and 36th gestational week according to the authors. Unfortunately, however, the authors do not tell us the exact timing of immunization during pregnancy in the mothers of cases and controls and whether there were differences between the 2 groups. This, however, is very important as the transfer of anti-PT antibodies from mother to child is suboptimal if immunization is too close to delivery.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">What do these findings tell us? First, and most importantly, the major shortcoming of this study is the imprecise case definition where infants with “pertussis-like illness” rather than confirmed <span class="elsevierStyleItalic">B. pertussis</span> infections were enrolled. Although most of them demonstrated clinical signs of pertussis such as paroxysmal cough (96%) and posttussive vomiting (53%), these characteristics are not exclusive and specific enough for pertussis caused by <span class="elsevierStyleItalic">B. pertussis</span> infection. It has been shown that a variety of viruses such as adenovirus, parainfluenza viruses 1, 2 and 3, and respiratory syncytial virus and bacteria such as <span class="elsevierStyleItalic">Chlamydia pneumoniae</span> and <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> but also other representatives of the Bordetella species (e.g. <span class="elsevierStyleItalic">B. parapertussis</span> and <span class="elsevierStyleItalic">B. holmesii</span>) can cause this clinical entity and are not preventable by pertussis vaccines.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This is problematic because there is a likelihood of undetermined magnitude that infants with “pertussis-like illness” did, in fact, not have pertussis but had any other infection. This would explain the surprisingly poor effectiveness of Tdap immunization during pregnancy in this study which is in sharp contrast to the estimated 91% determined in England.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> It would also explain the protective effect of breastfeeding which is not specific for one organism but by means of providing broad protection, especially against respiratory tract infections.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Nascimento and colleagues are to be applauded that they studied an important question. Unfortunately, however, the case definition they used was not appropriate to come up with meaningful findings. Prevention of pertussis and death due to pertussis in neonates is a key priority of the Global Pertussis Initiative, which recommends that acellular pertussis immunization in pregnancy should be implemented as a priority in all countries if resources allow.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Hopefully, the findings of this study do not undermine this important health measure in Brazil.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore, the authors should be encouraged to repeat the study and aim to make a firm microbiologically confirmed diagnosis of <span class="elsevierStyleItalic">B. pertussis</span> infection in infants with “pertussis-like illness”. In infants, this means either by culture or specific PCR from nasopharyngeal specimens.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">UH is a member of the Global Pertussis Initiative and the «Collaboration of European Experts on Pertussis Awareness Generation» and has received honoraria for participation in associated live meetings from Sanofi Pasteur, the USA, and Sanofi, France, respectively.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">See paper by Nascimento et al. in pages x-y.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Bordetella pertussis</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.J. Nieves" 1 => "U. Heininger" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Microbiol Spectr" "fecha" => "2016" "volumen" => "4" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Protecting newborns from pertussis – the challenge of complete cocooning" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Urwyler" 1 => "U. Heininger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2334-14-397" "Revista" => array:5 [ "tituloSerie" => "BMC Infect Dis" "fecha" => "2014" "volumen" => "14" "paginaInicial" => "397" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25037057" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The protective role of maternally derived antibodies against <span class="elsevierStyleItalic">Bordetella pertussis</span> in young infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "U. Heininger" 1 => "M. Riffelmann" 2 => "G. Bär" 3 => "C. Rudin" 4 => "C.H. von König" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/INF.0b013e318288b610" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2013" "volumen" => "32" "paginaInicial" => "695" "paginaFinal" => "698" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23429559" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Protective effect of exclusive breastfeeding and effectiveness of maternal vaccination in reducing pertussis-like illness" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.M. Nascimento" 1 => "P.N. Baptista" 2 => "K.A. Lopes" 3 => "A.M. Pimentel" 4 => "F.D. Cruz" 5 => "R.A. Ximenes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Pediatr (Rio J)" "fecha" => "2021" "volumen" => "97" "paginaInicial" => "500" "paginaFinal" => "507" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Maternal immunization is not the same as immunization in pregnancy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "U. Heininger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/21645515.2015.1009802" "Revista" => array:5 [ "tituloSerie" => "Hum Vaccin Immunother" "fecha" => "2015" "volumen" => "11" "paginaInicial" => "1074" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25651127" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Maternal immunization earlier in pregnancy maximizes antibody transfer and expected infant seropositivity against pertussis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.S. Eberhardt" 1 => "G. Blanchard-Rohner" 2 => "B. Lemaître" 3 => "M. Boukrid" 4 => "C. Combescure" 5 => "V. Othenin-Girard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/ciw027" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2016" "volumen" => "62" "paginaInicial" => "829" "paginaFinal" => "836" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26797213" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characterization of <span class="elsevierStyleItalic">Bordetella holmesii</span> isolates from patients with pertussis-like illness in The Netherlands" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.R. Mooi" 1 => "S. Bruisten" 2 => "I. Linde" 3 => "F. Reubsaet" 4 => "K. Heuvelman" 5 => "S. van der Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1574-695X.2011.00911.x" "Revista" => array:6 [ "tituloSerie" => "FEMS Immunol Med Microbiol" "fecha" => "2012" "volumen" => "64" "paginaInicial" => "289" "paginaFinal" => "291" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22098551" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An epidemic of a pertussis-like illness caused by Chlamydia pneumoniae" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K. Hagiwara" 1 => "K. Ouchi" 2 => "N. Tashiro" 3 => "M. Azuma" 4 => "K. Kobayashi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00006454-199903000-00013" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "1999" "volumen" => "18" "paginaInicial" => "271" "paginaFinal" => "275" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10093951" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A serologic study of organisms possibly associated with pertussis-like coughing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.H. Wirsing von König" 1 => "H. Rott" 2 => "H. Bogaerts" 3 => "H.J. Schmitt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00006454-199807000-00013" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "1998" "volumen" => "17" "paginaInicial" => "645" "paginaFinal" => "649" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9686733" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics of illness caused by Bordetella parapertussis compared with illness caused by <span class="elsevierStyleItalic">Bordetella pertussis</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "U. Heininger" 1 => "K. Stehr" 2 => "S. Schmitt-Grohé" 3 => "C. Lorenz" 4 => "R. Rost" 5 => "P.D. Christenson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00006454-199404000-00011" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "1994" "volumen" => "13" "paginaInicial" => "306" "paginaFinal" => "309" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8036048" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effectiveness of maternal pertussis vaccination in England: an observational study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Amirthalingam" 1 => "N. Andrews" 2 => "H. Campbell" 3 => "S. Ribeiro" 4 => "E. Kara" 5 => "K. Donegan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(14)60686-3" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2014" "volumen" => "384" "paginaInicial" => "1521" "paginaFinal" => "1528" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25037990" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Breastfeeding and infections in early childhood: a cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Christensen" 1 => "S. Bruun" 2 => "J. Søndergaard" 3 => "H.T. Christesen" 4 => "N. Fisker" 5 => "G. Zachariassen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Pediatrics" "fecha" => "2020" "volumen" => "146" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations to control pertussis prioritized relative to economies: a Global Pertussis Initiative update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.D. Forsyth" 1 => "T. Tan" 2 => "C.W. von König" 3 => "U. Heininger" 4 => "A.J. Chitkara" 5 => "S. Plotkin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.vaccine.2018.10.028" "Revista" => array:6 [ "tituloSerie" => "Vaccine" "fecha" => "2018" "volumen" => "36" "paginaInicial" => "7270" "paginaFinal" => "7275" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30337176" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "What to do and what not to do in serological diagnosis of pertussis: recommendations from EU reference laboratories" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Guiso" 1 => "G. Berbers" 2 => "N.K. Fry" 3 => "Q. He" 4 => "M. Riffelmann" 5 => "C.H. Wirsing von König" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Clin Microbiol Infect Dis" "fecha" => "2011" "volumen" => "30" "paginaInicial" => "307" "paginaFinal" => "312" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00217557/0000009700000005/v1_202109160616/S0021755721000322/v1_202109160616/en/main.assets" "Apartado" => array:4 [ "identificador" => "10177" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorials" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/00217557/0000009700000005/v1_202109160616/S0021755721000322/v1_202109160616/en/main.pdf?idApp=UINPBA000049&text.app=https://jped.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0021755721000322?idApp=UINPBA000049" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 5 | 14 |
| 2024 October | 38 | 33 | 71 |
| 2024 September | 65 | 30 | 95 |
| 2024 August | 82 | 51 | 133 |
| 2024 July | 57 | 47 | 104 |
| 2024 June | 30 | 49 | 79 |
| 2024 May | 39 | 16 | 55 |
| 2024 April | 41 | 21 | 62 |
| 2024 March | 32 | 19 | 51 |
| 2024 February | 41 | 23 | 64 |
| 2024 January | 34 | 25 | 59 |
| 2023 December | 29 | 23 | 52 |
| 2023 November | 48 | 32 | 80 |
| 2023 October | 42 | 31 | 73 |
| 2023 September | 40 | 43 | 83 |
| 2023 August | 31 | 26 | 57 |
| 2023 July | 33 | 27 | 60 |
| 2023 June | 31 | 15 | 46 |
| 2023 May | 38 | 16 | 54 |
| 2023 April | 26 | 11 | 37 |
| 2023 March | 50 | 25 | 75 |
| 2023 February | 37 | 16 | 53 |
| 2023 January | 23 | 38 | 61 |
| 2022 December | 38 | 30 | 68 |
| 2022 November | 42 | 29 | 71 |
| 2022 October | 60 | 38 | 98 |
| 2022 September | 79 | 35 | 114 |
| 2022 August | 88 | 42 | 130 |
| 2022 July | 43 | 32 | 75 |
| 2022 June | 45 | 27 | 72 |
| 2022 May | 64 | 22 | 86 |
| 2022 April | 49 | 33 | 82 |
| 2022 March | 70 | 38 | 108 |
| 2022 February | 56 | 24 | 80 |
| 2022 January | 65 | 28 | 93 |
| 2021 December | 36 | 26 | 62 |
| 2021 November | 40 | 23 | 63 |
| 2021 October | 98 | 40 | 138 |
| 2021 September | 169 | 58 | 227 |
| 2021 August | 19 | 5 | 24 |
| 2021 July | 7 | 8 | 15 |
| 2021 June | 7 | 3 | 10 |
| 2021 May | 6 | 12 | 18 |
| 2021 April | 27 | 22 | 49 |
| 2021 March | 13 | 7 | 20 |
Show all
