The review, described by its authors as the first narrative policy analysis focused specifically on the role of surveillance in maternal pertussis programmes, drew on peer-reviewed literature and grey literature published between 2012 and 2026, identified through searches of Medline, Embase and Global Health databases, supplemented by snowball searches and input from authors who work directly within national surveillance systems. Attribution of programme decisions to specific surveillance analyses was based on materials cited in National Immunization Technical Advisory Group (NITAG) recommendations and national policy documents.

Pertussis, a respiratory infection caused by Bordetella pertussis, poses the greatest risk of severe disease and death to infants too young to have completed their primary vaccination course. Unlike some other vaccine-preventable diseases targeted during pregnancy, the primary aim of maternal pertussis vaccination is not to protect the mother but to transfer antibodies across the placenta, providing direct passive protection to newborns. The vaccines used have been in circulation for decades, and England became the first of the seven countries to launch a maternal programme, in 2012, with Finland the most recent, in 2024.

Confirmed case numbers and incidence rates in infants under one year of age, compiled from the ECDC Surveillance Atlas of Infectious Diseases and national reports for 2012 to 2025, show large variations across countries and over time. Broad trends align with the cyclical increases in pertussis activity seen every three to five years, disrupted by the COVID-19 pandemic when social mixing restrictions profoundly altered disease dynamics, and followed by larger-scale post-pandemic outbreaks. In 2024, England reported 893 confirmed cases in infants under one year, Germany 1,005, the Netherlands 837 and Italy 773, with incidence rates of 155.6, 149.2, 508.9 and 203.1 per 100,000 infants respectively. Infant deaths also rose during the resurgence: France recorded 21 deaths in infants under one in 2024, Germany 5, the Netherlands 4 and Italy 4.

Excluding post-pandemic resurgence years, the data show reductions in disease burden in infants following maternal programme introduction. The authors caution that these ecological trends may reflect the combined effect of multiple factors, including vaccination, differences in programme design between countries and varying social mixing restrictions during the pandemic. They note, however, that the observed reductions accord with a wider body of real-world evidence consistently demonstrating high maternal vaccine effectiveness against disease and severe outcomes in infants, including during the post-pandemic resurgence.

Beneath the headline figures lie substantial differences in surveillance design. Mandatory notification of pertussis is longstanding in some countries—England has required notification since 1940 and Italy since 1934—while Germany introduced national notification only in 2013, after five of its sixteen federal states had mandated reporting from 2002. France has no national requirement to notify pertussis cases at all. Case definitions also differ: England notifies on clinical diagnosis usually followed by laboratory investigation, Italy notifies on clinical suspicion alone without routine laboratory confirmation, and Finland and the Netherlands include only laboratory-confirmed cases in their central national infectious disease registries. In France, surveillance coordinated by Santé publique France collates non-mandatory reporting from a hospital-based system covering around 30 percent of infants hospitalised with pertussis, from diagnostic laboratories covering roughly 77 percent of laboratories nationwide, and from a primary care network monitoring outpatient consultations since 2017.

Mortality reporting is similarly variable. England, France and the Netherlands combine death registration data with retrospective analysis, while Italy compiles deaths from certificates completed by general practitioners, with potential for misclassification of causes of death. The collection of supplementary information also differs: vaccination status is routinely gathered in some countries, including England, Germany and the Netherlands, but not in all others. The authors argue that this heterogeneity in case definitions, laboratory confirmation, reporting completeness and data linkage limits cross-country comparability and may obscure the true burden of disease.

The timing of programme introduction emerged as a central theme. In England, the proximate driver was surveillance data documenting a large national outbreak in 2011–2012, with a steep rise in hospitalisations and deaths in infants under three months and 14 pertussis-related deaths in that age group during 2012. A temporary programme was introduced in October 2012 as an outbreak response measure, based on evidence of transplacental antibody transfer and the absence of adverse safety signals from long-established use of diphtheria-tetanus vaccines in pregnant women worldwide; epidemiological evidence on impact was noted to be lacking at the time, and cost-effectiveness analysis did not feature centrally in the initial decision. France’s first programme, in 2018, responded to an outbreak in the overseas territory of Mayotte, and Finland’s 2024 introduction followed national surveillance data showing the highest caseload ever reported to the National Infectious Diseases Register, with 84 cases in children under one year, 53 of whom required hospitalisation.

Surveillance from early adopters also shaped decisions elsewhere. Strong systems in England that enabled rapid estimates of vaccine effectiveness against disease and accurate safety monitoring after the 2012 outbreak proved important in influencing recommendations in countries that introduced programmes in peacetime, including the Netherlands, Spain and Germany. The Dutch NITAG, recommending a programme in 2015, found international experience—particularly English vaccine effectiveness and safety data—a stronger driver than analysis of expected effects on disease burden or cost-effectiveness. Germany’s 2020 recommendation drew on evidence of high infant disease burden and significant under-reporting of cases, particularly in states where notification had recently been introduced, alongside assessments of the number needed to vaccinate to prevent cases and hospitalisations. Spain rolled out its programme progressively between 2014 and 2016, starting in Catalonia and Asturias, drawing on national surveillance data from RENAVE including documented caseloads in local outbreaks in 2011 and 2012.

Coverage data reveal marked variation where they are centrally collected. Spain has consistently reported the highest national rates, reaching around 88 percent in 2024, an achievement the review attributes in part to universal access to healthcare, financing and trust in healthcare providers. England’s coverage varied from 74.7 percent in December 2017 to 58.9 percent in April 2024, coinciding approximately with the peak of the 2023/24 epidemic, before a substantial recovery. Finland achieved 72 and 74 percent in the first two years of its programme, while Germany remained below 50 percent until recently. Italy has no national coverage monitoring mechanism, and reported uptake varies widely by geography, from 1 percent to over 60 percent in some studies. Data completeness is an ongoing challenge in England, the Netherlands and France, where not all pregnant women are captured in national uptake surveillance, and England is the only country in the analysis that routinely reports coverage by ethnicity, with data showing large disparities.

From these findings, the authors set out five recommendation areas: harmonising case definitions and laboratory confirmation approaches across Europe, with support from the ECDC and professional networks; strengthening coverage monitoring, potentially through national vaccination registries and mandated reporting by equity dimensions such as socioeconomic status; implementing robustly sampled, regular attitudinal surveys to detect declining vaccine confidence; training healthcare workers to improve disease recognition, data recording and culturally competent communication; and strengthening accountability through public reporting of disease burden and coverage, including a proposed pan-European monitoring framework with generalisable metrics. They note that the European Immunization Agenda 2030 makes little reference to maternal vaccination and includes no indicators relevant to it.

The review also points beyond pertussis. Maternal vaccination is an expanding platform, with candidate vaccines for group B streptococcus likely to be licensed in the near future and trajectories for cytomegalovirus less certain. For pathogens with less mature surveillance systems, the authors conclude, targeted epidemiological studies will be needed to provide NITAGs with robust burden-of-disease estimates. They emphasise that the effectiveness of maternal immunisation also depends on factors such as vaccine availability, timing of delivery within pregnancy, antenatal care access and informed consent, and that without sustained investment in surveillance and post-implementation monitoring, opportunities to prevent severe disease and infant deaths will continue to be missed and inequalities will widen.

Subject of Research: The role of disease surveillance in maternal pertussis vaccination programmes across seven European countries

Article Title: The role of disease surveillance in maternal pertussis vaccination programmes in Europe: lessons for the future

Article References: Ismail, S. A., Farnes, K., Patel, T., El Belghiti, F. A., Brisse, S., Campbell, C. N. J., Campbell, H., Gabutti, G., González-López, J. J., Knuutila, A., van der Maas, N., de Melker, H., Mir-Cros, A., Nohynek, H., Toubiana, J., Wichmann, O., Ladhani, S. N., Khalil, A., & Amirthalingam, G. (2026). The role of disease surveillance in maternal pertussis vaccination programmes in Europe: lessons for the future. The Lancet Regional Health – Europe, 71, Article 101902. https://doi.org/10.1016/j.lanepe.2026.101902

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101902

Keywords: pertussis, maternal vaccination, disease surveillance, Europe, vaccination coverage, NITAG, infant health, ECDC, outbreak response, vaccine policy, whooping cough, public health