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Bordetella pertussis strain lacking pertactin and pertussis toxin.

Pertussis has resurged in the United States in recent decades; >48,000 cases were reported in 2012 (http:// www.cdc.gov/pertussis/surv-reporting/cases-by-year. html). Suggested causes include improved surveillance and diagnostics, waning immune response to acellular vaccines introduced in the United States in the 1990s (DTaP [diphtheria, tetanus, and pertussis]; Tdap, [tetanus, diphtheria, and pertussis]), and changes to circulating B. pertussis strains, which led to a mismatch with vaccine strains (1). Components of acellular pertussis vaccines in the United States are pertactin (Prn), pertussis-toxin (Pt), filamentous hemagglutinin, and sometimes fimbrial proteins 2/3. Since 2010, multiple mutations have been documented in the Prn-encoding gene (prn), which have spread rapidly across the United States and other countries (2,3). Pt-deficient Bordetella pertussis isolates are rare, with 1 report from France (4). To our knowledge, B. pertussis that lacks Pt and an additional acellular vaccine immunogen has not been documented.

The Case

Prodromal pertussis symptoms developed on March 4, 2013, in an 11-month-old white, non-Hispanic infant from New York State while the family was traveling outside the state. Cough reportedly began on March 14, 2013, and 12 days later (March 26) he was brought to his healthcare provider (HCP) with symptoms consistent with pertussis.

Since the child's birth, the diagnosing HCP had seen the child only once; no visits to other HCPs were known. Per parental report, the case-patient was experiencing paroxysmal cough, apnea, and posttussive vomiting. No thoracic radiograph was obtained. A 5-day course of oral azithromycin was prescribed; the parent reported that the infant received treatment for 3 consecutive days, beginning March 26, 2013. The infant was not reported to have any pertussis-associated complications (seizures, pneumonia, or encephalopathy) and had only light coughing as of April 11, 2013.

The infant was unvaccinated because the parents refused administration of all vaccines. Three siblings, ages 12, 10, and 8 years, lived with the infant and were undervaccinated; they had received 2, 1, and 3 doses, respectively, of pertussis-containing vaccines. No coughing illness was reported among the siblings. The mother reported that she received Tdap vaccine during her pregnancy with the case-patient, but receipt of vaccine could not be verified.

A nasopharyngeal swab specimen was collected from the infant on March 26, 2013, for testing at a commercial laboratory. The isolate was also forwarded to New York State's public health laboratory, the Wadsworth Center, where it was found to be positive for B. pertussis by PCR targeting IS481 and BP283 (5). Both laboratories yielded positive culture results for B. pertussis. No other testing was performed.

The Wadsworth Center forwarded the isolate, designated I979, to the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia, USA) for confirmatory identification and molecular typing as part of the Enhanced Pertussis Surveillance program (6). PCR amplification of the gene encoding the first subunit of Pt (ptxA) was unsuccessful while the CDC multitarget real-time PCR diagnostic assay was performed (7). Amplification of the promoter region (ptxP) and ptxA was also unsuccessful during multilocus sequence typing targeting acellular vaccine component genes ptxA, ptxP, prn, and fim3 (8).

Further characterization of I979 and French strain FR3749 (4) was undertaken by multilocus sequence typing, multilocus variable-number tandem-repeat analysis, pulsed-field gel electrophoresis (9), and whole-genome sequencing. Long sequencing reads were obtained with the Pacific Biosciences RS II (Menlo Park, CA, USA) at >120 x coverage and assembled de novo into a single contig by using HGAP v3 and Quiver v1 (Pacific Biosciences). Assembly structure was confirmed with a genome optical map after restriction digestion with Kpnl (OpGen, Gaithersburg, MD, USA). The final sequence was polished with short reads obtained with Illumina MiSeq and CLC Genomics Workbench v7.5.1 (QIAGEN, Valencia, CA, USA) with >90 x coverage. Completed genomes were submitted to the National Center for Biotechnology Information (http://www.ncbi.nlm.nih.gov/) with GenBank accession nos. CP010965 (FR3749) and CP010966 (I979). Basic genome metrics are listed in Table 1.

Prn production was determined by ELISA (2,11). Pt production was examined through Western blot analysis of cultures grown in cyclodextrin-modified StainerScholte liquid medium to optical density (OD) 600 nm = 0.1 (12). Proteins precipitated with trichloroacetic acid were washed, reduced, and separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Pt detection is described in Figure 1.

I979 and FR3749 share the same multilocus variablenumber tandem-repeat analysis type 27 andprn-2 genotype, the most common recent types (3,13). I979 and FR3749 are fim3-1 andfim3-2, respectively. Thefim3 locus has fluctuated between these 2 alleles recently (3,8). Pulsed-field gel electrophoresis indicated that I979 displays profile CDC306, and FR3749 displays CDC046. I979 and FR3749 both lacked Pt production, as shown by Western blot (Figure 1). I979 also failed to produce Prn, whereas FR3749 was positive for Prn production by ELISA, within the range of negative (OD 0.3-0.6) and positive (OD 1.2-1.6) controls.

Comparison of assembled I979 and FR3749 genomes with that of Tohama I (GenBank accession no. NC_002929.2) (10) indicated that the entire ptx/ptl operon is missing as the result of a putative deletion spanning 28,040 bp (Figure 2). Both genomes contain a conserved, truncated IS481 immediately upstream of the deletion and a single IS481 (FR3749) or 2 tandem IS481 sequences (I979) immediately downstream (Figure 2). Within Tohama I, the region absent from I979 and FR3749 encodes 30 predicted genes bound by 2 NCATGN motifs, the target sequence for IS481 insertion (Table 2). The insertion element IS1002 is located within the 3' end of this region, and shares a GCATGG motif with IS481 immediately downstream. The 3' deletion boundary is between IS1002 and IS481 (Figure 2). Whole-genome alignment, using progressiveMauve (14), of I979 and FR3749 with Tohama I revealed structural variation through genomic rearrangements and inversions. In particular, I979 and FR3749 genomes differ by a single, large inversion, the coordinates of which correspond to 2 conserved insertions of IS481 in opposing orientations (online Technical Appendix Figure). I979 and FR3749 differ by 31 single nucleotide polymorphisms, each differing from Tohama I by 204 and 173 single nucleotide polymorphisms, respectively. FR3749 contains wild-type prn at position 1613, whereas I979 prn contains an IS481 insertion, the most common cause of Prn-deficiency, at position 1613 (2,11).

Conclusions

B. pertussis strain I979, identified in our study, is both Pm- and Pt-deficient. Loss of Pt in B. pertussis is a rare occurrence; only 2 isolates have been documented in 8 years. Both I979 and FR3749 were isolated from unvaccinated infants (11 months and 3 months old, respectively), who exhibited typical pertussis symptoms, although FR3749 had difficulty colonizing and multiplying in respiratory tracts of adult mice (4). B. pertussis isolates with deletions at other sites across the genome, including part or all of prn, were reported previously (4,15). During the past 5 years, US B. pertussis isolates have become nearly 100% Prn-deficient (2,3) (unpub. data), and Prn-deficient isolates have been obtained from vaccinated persons (11). The loss of Pt may represent a higher fitness cost to B. pertussis than the loss of Prn. In addition, the possibility that only the Pt-deficient isolates were recovered from patients who were co-infected with wild-type and mutant B. pertussis cannot be discarded. Further testing in models to understand the clinical relevance of Prn- and Ptdeficient strains in vaccinated and unvaccinated persons is warranted.

Although incidence of combined Pt- and Prn-deficiency in B. pertussis is rare, any increased mutation in these or other acellular vaccine immunogens may have serious implications for the efficacy of current vaccines. Global epidemiologic, culture-based, and molecular-based monitoring of B. pertussis is critical for understanding current trends of the disease it causes.

Members of the CDC Pertussis Working Group: Dhwani Batra, Kanwar Bedi, Katherine E. Bowden, Pamela K. Cassiday, Marsenia J. Harrison, Owen Herzegh, Kristen Knipe, Vladimir Loparev, Lucia C. Pawloski, Yanhui Peng, Lori A. Rowe, Scott Sammons, Mili Sheth.

Margaret M. Williams, Kathryn A. Sen, Michael R. Weigand, Tami H. Skoff, Victoria A. Cunningham, Tanya A. Halse, M. Lucia Tondella, CDC Pertussis Working Group [1]

[1] Members of the CDC Pertussis Working Group are listed at the end of this article.

Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (M.M. Williams, M.R. Weigand, T.H. Skoff, M.L. Tondella); New York State Department of Health, Albany, New York, USA (K.A. Sen); Livingston County Health Department, Mt. Morris, New York, USA (V.A. Cunningham); Wadsworth Center, Albany (T.A. Halse)

DOI: http://dx.doi.org/10.3201/eid2202.151332

Acknowledgments

B. pertussis isolate I979 was contributed by the state of New York through participation in the Enhanced Pertussis Surveillance of the Emerging Infections Program Network. In particular, we thank Kathy Root, Kimberlee Musser, and Tammy Quinlan for providing clinical data and isolate I979 and for performing pertussis PCR testing. We also thank Nicole Guiso, Institut Pasteur, Paris, France, for sharing isolate FR3749.

Funding for genome sequencing was provided internally by CDC as part of its Advanced Molecular Detection Initiative.

Dr. Williams is a research scientist in the Pertussis and Diphtheria Laboratory, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia, USA. She specializes in molecular characterization of bacterial pathogens, with a current focus on pertussis genomics.

References

(1.) Misegades LK, Winter K, Harriman K, Talarico J, Messonnier NE, Clark TA, et al. Association of childhood pertussis with receipt of 5 doses of pertussis vaccine by time since last vaccine dose, California, 2010. JAMA. 2012;308:2126-32. http://dx.doi.org/ 10.1001/jama.2012.14939

(2.) Pawloski LC, Queenan AM, Cassiday PK, Lynch AS, Harrison MJ, Shang W, et al. Prevalence and molecular characterization of pertactin-deficient Bordetella pertussis in the United States. Clin Vaccine Immunol. 2014;21:119-25. http://dx.doi.org/10.1128/ CVI.00717-13

(3.) Bowden KE, Williams MM, Cassiday PK, Milton A, Pawloski L, Harrison M, et al. Molecular epidemiology of the pertussis epidemic in Washington State in 2012. J Clin Microbiol. 2014;52:3549-57. http://dx.doi.org/10.1128/JCM.01189-14

(4.) Bouchez V, Brun D, Cantinelli T, Dore G, Njamkepo E, Guiso N. First report and detailed characterization of B. pertussis isolates not expressing pertussis toxin or pertactin. Vaccine. 2009;27:6034-41. http://dx.doi.org/10.1016/j.vaccine.2009.07.074

(5.) Probert WS, Ely J, Schrader K, Atwell J, Nossoff A, Kwan S. Identification and evaluation of new target sequences for specific detection of Bordetella pertussis by real-time PCR. J Clin Microbiol. 2008;46:3228-31. http://dx.doi.org/10.1128/ JCM.00386-08

(6.) Skoff TH, Baumbach J, Cieslak PR. Tracking pertussis and evaluating control measures through enhanced pertussis surveillance, Emerging Infections Program, United States. Emerging Infect Dis. 2015;21:1568. http://dx.doi.org/10.3201/ eid2109.150023

(7.) Tatti KM, Sparks KN, Boney KO, Tondella ML. Novel multitarget real-time PCR assay for rapid detection of Bordetella species in clinical specimens. J Clin Microbiol. 2011;49:4059-66. http://dx.doi.org/10.1128/JCM.00601-11

(8.) Schmidtke AJ, Boney KO, Martin SW, Skoff TH, Tondella ML, Tatti KM. Population diversity among Bordetella pertussis isolates, United States, 1935-2009. Emerg Infect Dis. 2012;18:1248-55. http://dx.doi.org/10.3201/eid1808.120082

(9.) Hardwick TH, Cassiday P, Weyant RS, Bisgard KM, Sanden GN. Changes in predominance and diversity of genomic subtypes of Bordetella pertussis isolated in the United States, 1935 to 1999. Emerg Infect Dis. 2002;8:44-9. http://dx.doi.org/10.3201/ eid0801.010021

(10.) Parkhill J, Sebaihia M, Preston A, Murphy LD, Thomson N, Harris DE, et al. Comparative analysis of the genome sequences of Bordetella pertussis, Bordetella parapertussis and Bordetella bronchiseptica. Nat Genet. 2003;35:32-40. http://dx.doi.org/10.1038/ng1227

(11.) Martin SW, Pawloski L, Williams M, Weening K, DeBolt C, Qin X, et al. Pertactin-negative Bordetella pertussis strains: evidence for a possible selective advantage. Clin Infect Dis. 2015;60:223-7. http://dx.doi.org/10.1093/cid/ciu788

(12.) Imaizumi A, Suzuki Y, Ono S, Sato H, Sato Y. Effect of heptakis (2,6-0-dimethyl)p-cyclodextrin on the production of pertussis toxin by Bordetella pertussis. Infect Immun. 1983;41:1138-43.

(13.) Bart MJ, Harris SR, Advani A, Arakawa Y, Bottero D, Bouchez V, et al. Global population structure and evolution of Bordetella pertussis and their relationship with vaccination. MBio. 2014;5:e01074. http://dx.doi.org/10.1128/mBio.01074-14

(14.) Darling AE, Mau B, Perna NT. progressiveMauve: multiple genome alignment with gene gain, loss and rearrangement. PLoS ONE. 2010;5:e11147. http://dx.doi.org/10.1371/journal. pone.0011147

(15.) King AJ, van Gorkom T, Pennings JL, van der Heide HG, He Q, Diavatopoulos D, et al. Comparative genomic profiling of Dutch clinical Bordetella pertussis isolates using DNA microarrays: identification of genes absent from epidemic strains. BMC Genomics. 2008;9:311. http://dx.doi.org/10.1186/1471-2164-9-311

Address for correspondence: Margaret M. Williams, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30329-4027, USA; email: MWilliams7@cdc.gov

Table 1. Characterization of Bordetella pertussis strains I979 and
FR3749 in comparison to strain Tohama I *

             GenBank                    No.    prn
Strain    accession no.   Length, bp   IS481   type   Prn   Reference

FR3749      CP010965      4,079,396     249     2      +    This study
I979        CP010966      4,082,551     252     2      -    This study
Tohama I   NC_002929.2    4,086,189     238     1      +       (10)

* Prn, pertactin; + positive; -, negative.

Table 2. Genes in Bordetella pertussis vaccine strain Tohama I deleted
from B. pertussis I979 and FR3749 genomes, including the entire
ptx/ptl operon *

Protein ID,
GenBank
accession no.    Gene                        Product

NP 882281.1                           Hypothetical protein
NP 882282.1      ptxA               Pertussis toxin subunit 1
NP 882283.1      ptxB               Pertussis toxin subunit 2
NP 882284.1      ptxD               Pertussis toxin subunit 4
NP 882285.1      ptxE               Pertussis toxin subunit 5
NP 882286.1      ptxC               Pertussis toxin subunit 3
NP 882287.1      ptlA         Type IV secretion system protein PtlA
NP 882288.1      ptlB         Type IV secretion system protein PtlB
NP 882289.1      ptlC         Type IV secretion system protein PtlC
NP 882290.1      ptlD         Type IV secretion system protein PtlD
NP 882291.1      ptlI         Type IV secretion system protein PtlI
NP 882292.1      ptlE         Type IV secretion system protein PtlE
NP 882293.1      ptlF         Type IV secretion system protein PtlF
NP 882294.1      ptlG         Type IV secretion system protein PtlG
NP 882295.1      ptlH         Type IV secretion system protein PtlH
                                            tRNA-Asn
NP 882296.1                             Membrane protein
NP 882297.1                   AraC family transcriptional regulator
NP 882298.1                           Hypothetical protein
NP 882299.1                             Membrane protein
NP 882300.1                           Hypothetical protein
NP 882301.1                 Peptide ABC transporter substrate binding
                                             protein
NP 882302.1                         Transport system permease
NP 882303.1                         Transport system permease
                                           Pseudogene
NP 882304.1      IS481                     Transposase
NP 882305.1      argJ       Bifunctional ornithine acetyltransferase/
                                   N-acetylglutamate synthase
NP 882306.1                           Hypothetical protein
NP 882307.1                           Hypothetical protein
NP 882308.1     IS 1002                    Transposase

* ID, identification; ptx, pertussis toxin gene; ptl, pertussis toxin
liberation gene.
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Article Details
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Title Annotation:DISPATCHES
Author:Williams, Margaret M.; Sen, Kathryn A.; Weigand, Michael R.; Skoff, Tami H.; Cunningham, Victoria A.
Publication:Emerging Infectious Diseases
Geographic Code:1U2NY
Date:Feb 1, 2016
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