Pan American Health Organization · 1st edition, 2025 · 40 pages
Practical field guide for immunization and surveillance managers on preventing and controlling diphtheria and pertussis outbreaks in the Americas.
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2025
- Audience
- Ministry of Health programme managers in immunization, epidemiological surveillance, and maternal and child health
- Evidence
- WHO and PAHO Technical Advisory Group on Vaccine-Preventable Diseases recommendations
- Reviewed
- 16 Oct 2026 · GMJ
What this guideline says
GMJ summary
This 2025 PAHO field guide provides practical recommendations for preventing and controlling diphtheria and pertussis (whooping cough) in the Americas. It addresses the resurgence of diphtheria driven by vaccination gaps and waning immunity, with Haiti, the Dominican Republic, Brazil, Canada, and Venezuela reporting the highest incidence over the past decade. For pertussis, the guide emphasizes that despite vaccine availability, cyclical outbreaks persist, with over 159,000 cases reported globally in 2023.
The guide prioritizes high vaccination coverage (≥95% DTP3) across all age groups, including booster doses at 12–23 months, 4–7 years, and 9–15 years. Pregnant women should receive Tdap during each pregnancy (second or third trimester, at least 15 days before delivery) to protect newborns. The document covers clinical features, diagnostic protocols (culture, PCR, serology with specific timing windows), treatment with antibiotics and diphtheria antitoxin (DAT), and outbreak response strategies including contact-tracing and post-exposure prophylaxis.
A key update is the recommendation to introduce the whole-cell pertussis (wP) hexavalent vaccine (DTwP-Hib-HepB-IPV), which reduces injection numbers, costs, and logistics while providing comparable protection and longer duration of immunity than acellular pertussis hexavalent vaccines. The guide emphasizes that a single laboratory-confirmed diphtheria case should trigger public health response, while two temporally and geographically linked pertussis cases (one laboratory-confirmed) constitute an outbreak.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Primary DTP vaccination series: first dose at 2 months/first contact, second at 4 months, third at 6 months; booster doses at 12–23 months, 4–7 years, and 9–15 years
- Pregnant women: Tdap vaccine during each pregnancy (second or third trimester, minimum 15 days before delivery) to protect newborns from pertussis
- Target vaccination coverage: ≥95% for DTP3 and all booster doses to prevent outbreaks
- Diphtheria treatment: immediate diphtheria antitoxin (DAT) without delay for sensitivity testing, plus antibiotics (macrolides preferred; test for penicillin resistance locally); isolate all cases
- Pertussis diagnosis timing: culture in first 2 weeks of cough; PCR up to 4 weeks; serology from 2–8 weeks (for adolescents/adults, not children <1 year)
- Pertussis treatment: macrolides (erythromycin, clarithromycin, azithromycin); isolate for 5 days after starting antibiotics or 3 weeks if untreated
- Outbreak definitions: single laboratory-confirmed diphtheria case triggers response; pertussis outbreak is ≥2 cases within 42 days, geographically linked, with ≥1 laboratory-confirmed
- Hexavalent vaccine (DTwP-Hib-HepB-IPV): recommended introduction to reduce injections, costs, and logistics while providing non-inferior protection with longer immunity duration than acellular pertussis vaccines
Diagnostic methods for Bordetella pertussis (whooping cough)
Table extracted from the guideline
| Test | Objective | Key features | Recommended for |
|---|---|---|---|
| Culture | Evaluate the bacterium and determine antibiotic resistance | Specificity: 100%; Sensitivity: Up to 60%; Requires viable bacteria and no prior antibiotic use | Young children, unvaccinated individuals, and those with recent onset of cough (<2 weeks) |
| PCR | Detect B. pertussis DNA | Highly sensitive, rapid results (sensitivity 70–99%; specificity 80–100%); Positive results even after antibiotic treatment; Results depend on disease stage | Diagnosis within 3–4 weeks of cough onset, regardless of antibiotic treatment |
| Serology | Detect antibodies against B. pertussis antigens | Not recommended for children under 1 year due to immature immune systems and maternal/vaccine antibody interference; Ideal during outbreaks when diagnosis is established retrospectively | Adolescents and adults with prolonged cough (>2 weeks); Retrospective detection in outbreak settings |
Source: Pan American Health Organization, Control of diphtheria and pertussis: Field guide. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Introduction of whole-cell pertussis (wP) hexavalent vaccine (DTwP-Hib-HepB-IPV) in national immunization programmes, providing non-inferior protection to acellular pertussis hexavalent vaccine with similar reactogenicity and longer duration of immunity
- Updated outbreak response surveillance: in moderate outbreaks, after 5 laboratory-confirmed toxigenic diphtheria cases, epidemiological linking can be considered sufficient for 2–3 incubation periods before resuming laboratory confirmation
- Emphasis on Tdap vaccination for pregnant women during each pregnancy (TAG 2019 recommendation) with target coverage >50% for programme effectiveness
- Updated clinical management guidelines emphasizing immediate DAT administration without prior routine sensitivity testing for diphtheria
From the guideline
Verbatim
“WHO strongly recommends that DAT be administered promptly, without prior routine sensitivity testing, emphasizing that treatment should not be delayed.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia, I recognize that diphtheria and pertussis control depends fundamentally on sustained high vaccination coverage, an area where Georgia and neighboring countries have faced challenges in recent years. The recommendation I would stress most to Georgian clinicians is the immediate administration of diphtheria antitoxin upon clinical suspicion without waiting for laboratory confirmation—this requires that healthcare facilities maintain adequate antitoxin stocks and train emergency department staff in recognition and response protocols. The introduction of the whole-cell pertussis hexavalent vaccine represents a practical advance that could improve coverage by reducing injection burden and simplifying cold chain logistics, particularly valuable for our rural areas. One realistic implementation caveat: establishing the recommended case-based surveillance with laboratory confirmation for every suspected case will require strengthening laboratory capacity for culture and PCR diagnosis beyond the current network, and developing clear protocols for specimen transport from peripheral regions to reference laboratories within the diagnostic window.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 16 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and the South Caucasus region face similar challenges to other areas with vaccination coverage gaps. Georgia’s national immunization programme would need to assess current DTP3 coverage (regional target: 95%) and consider introducing the wP hexavalent vaccine to streamline delivery and reduce dropout rates. The guide’s outbreak response protocols are directly applicable, particularly the emphasis on contact-tracing and post-exposure prophylaxis. Countries in the region should strengthen laboratory capacity for culture and PCR diagnosis, establish surveillance systems for case-based reporting, and implement Tdap vaccination for pregnant women as part of antenatal care. The recommendation to classify a single laboratory-confirmed diphtheria case as triggering public health response is critical for early outbreak control in settings with historically low incidence but potential for importation from neighboring endemic areas.
Questions this guideline answers
Quick answers
When should pregnant women receive Tdap vaccine?
During each pregnancy in the second or third trimester, at least 15 days prior to delivery. This transfers protective antibodies to the newborn, providing temporary immunity until the infant can be vaccinated. Countries should aim for >50% coverage among pregnant women for this strategy to be effective.
What is the optimal timing for pertussis diagnostic tests?
Culture is recommended in the first 2 weeks from cough onset; PCR can be used up to 4 weeks; serology is suitable from 2–8 weeks for adolescents and adults with prolonged cough (not for children <1 year due to maternal/vaccine antibody interference).
When should diphtheria antitoxin be administered?
Immediately upon clinical suspicion, without waiting for laboratory confirmation or routine sensitivity testing. WHO strongly recommends prompt DAT administration as it neutralizes circulating toxin but does not reverse existing tissue damage. Treatment should not be delayed.
What defines a diphtheria or pertussis outbreak?
Diphtheria: a single laboratory-confirmed case triggers public health response; two temporally and geographically linked cases (at least one laboratory-confirmed) constitute an outbreak. Pertussis: two or more cases within 42 days, geographically linked, with at least one laboratory-confirmed, or an increase over baseline incidence.
Related on GMJ
Interconnected resources
Dictionary of Public Health
Drugs A–Z
GMJ News coverage
Quality & accreditation
- ASF PHC — Standard 4 — Acute & Same-Day Care · Primary Health Clinic
- ASF PHC — Standard 7 — Governance & Staffing · Primary Health Clinic
- ASF Hospital — Standard 5 — Safety & Emergency Preparedness
- ASF Hospital — Standard 11 — Critical Care
- ASF Medical Transport — Standard 6 — Emergency Response During Transport
Other guidelines on this topic
- Technical guide on the use of maternal vaccine and long-acting monoclonal antibodies against respiratory syncytial virus to protect infants
- Guidelines for surveillance of congenital rubella syndrome in the Region of the Americas
- Technical guidance for an integrated approach to routine surveillance of respiratory viruses in the Americas
- Minimum operational standards and typology for rapid response mobile laboratories
- Consolidated guidance for strengthening national routine surveillance systems: updated HIV case definitions, advanced HIV disease indicators and surveillance checklist
- Issuer
- Pan American Health Organization
- Type
- Guidelines and Technical Manuals
- Edition
- 1st edition, 2025
- Status
- Current
- Published
- 2025-12-03
- Languages
- English
- Scope
- Diphtheria and pertussis epidemiology, clinical features, diagnosis, treatment, vaccination, surveillance, and outbreak response
- Audience
- Ministry of Health programme managers in immunization, epidemiological surveillance, and maternal and child health
- Pages
- 40
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-13058-2 (PDF)
- Evidence
- WHO and PAHO Technical Advisory Group on Vaccine-Preventable Diseases recommendations
- Record history
- Created 16 Oct 2026 · updated 16 Oct 2026 · next check Apr 2027
Pan American Health Organization. Control of diphtheria and pertussis: Field guide. Washington, D.C.: PAHO; 2025. Available from: https://doi.org/10.37774/9789275130582GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
Was this article helpful?
