Epidemiological burden of pertussis in children in Asia: a review of 1990–2021 data and future projections

Introduction

Pertussis, caused by the bacterium Bordetella pertussis, is a highly contagious respiratory disease characterized by paroxysmal spasmodic coughing and inspiratory “whooping” sounds (1). The pediatric population, particularly unvaccinated or incompletely vaccinated infants, represents the most susceptible demographic, with a higher risk of severe complications such as encephalopathy, cardiopulmonary failure, and even mortality (2,3).

Global epidemiological data (4) from 2019 estimated 19,519,182 cases [95% uncertainty interval (UI): 14,932,850–24,811,999], corresponding to an incidence rate of 252.3 per 100,000 population worldwide. Notably, children exhibit significantly higher rates of severe disease and mortality compared to adults, especially among those lacking primary immunization (5). Recent trends indicate a resurgence of pertussis in pediatric populations (6-8), underscoring its persistent threat as a critical public health concern.

Previous research (9,10) has primarily focused on post-vaccination policy adjustments, clinical manifestations, and prognostic factors, while systematic assessments of disease burden remain limited. Asia, the most populous continent with highly heterogeneous healthcare infrastructure and resource distribution, exhibits substantial interregional disparities. Although studies utilizing the Global Burden of Disease (GBD) database have provided insights into the worldwide pertussis burden (4,11,12), these analyses predominantly adopt a broad, age-stratified approach, lacking granular examination of spatiotemporal trends, sex-specific disparities, and the disproportionate impact on pediatric populations in Asia.

To address these gaps, this study utilizes GBD 2021 data to conduct a comprehensive analysis of pertussis incidence, mortality, and disability-adjusted life years (DALYs) among Asian children from 1990 to 2021 (13). Furthermore, we explored the correlation between the Socio-demographic Index (SDI) and pertussis burden across Asian nations. To project future epidemiological trends, we employed a Bayesian age-period-cohort (BAPC) model to forecast disease burden over the next three decades. Our findings aim to inform evidence-based prevention strategies and enhance understanding of pertussis epidemiology in Asian pediatric populations. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0022/rc).

Methods

Data sources

This study is based on the 2021 GBD data, which was accessed through the Global Health Data Exchange (GHDx) results tool (https://vizhub.healthdata.org/gbd-results/. Accessed on 1 February 2026.). The GBD 2021 provides the most recent population estimate data for 204 countries and regions, spanning from 1950 to 2021. This study primarily focuses on the burden of pertussis among children in Asia from 1990 to 2021. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Due to the secondary analysis of publicly available GBD data, institutional review board approval and informed consent were not required.

Retrieval method

This study extracted data from the GBD database on the incidence, mortality rate, and DALYs of pertussis among the pediatric population across Asian countries and regions. The location scope included six regional groupings: Central Asia, High-income Asia Pacific, South Asia, East Asia, Southeast Asia, and North Africa and the Middle East, as well as all individual Asian countries. Data were stratified by sex, including “both”, “female” and “male”. The pediatric population was defined as individuals aged 0–14 years and further categorized into five age groups: <1 year, 1–2 years, 2–4 years, 5–9 years, and 10–14 years. The study period covered the years from 1990 to 2021.

Statistical analysis

All data analyses in this study were conducted using R software, version 4.4.2. Data extracted from the GBD database were used to calculate the number of pertussis cases, deaths, and DALYs across different regions in Asia. The rates of these indicators per 100,000 population, along with their 95% UIs, were reported as key measures to evaluate the burden of pertussis among children. The estimated annual percentage change (EAPC) was employed to assess temporal trends in disease burden, with positive values indicating an increasing trend and negative values indicating a decreasing trend.

The Spearman rank correlation test was used to analyze the linear association between the SDI and disease burden across various Asian countries and regions (14). For forecasting future trends, the BAPC model was utilized to project the incidence and mortality rates of pediatric pertussis over the next 30 years in four representative Asian countries: China, Japan, South Korea, and India. A P value of less than 0.05 was considered statistically significant.

Results

Incidence, mortality, and DALYs of pertussis among children in Asia

Incidence

In 2021, the total number of new pertussis cases among children in Asia was estimated at 2,527,252.453 (95% UI: 1,388,456.829–4,272,388.470), corresponding to an incidence rate of 231.868 per 100,000 population (95% UI: 127.387–391.979). Among them, 1,195,026.246 cases (95% UI: 654,439.001–2,023,033.881) were male and 1,332,226.207 (95% UI: 733,984.284–2,249,354.589) were female. The number of male cases was approximately 0.90 times that of female cases, and the incidence rate among females (255.798/100,000) was higher than that among males (209.970/100,000) (see Table 1).

Between 1990 and 2021, the overall incidence rate in Asia showed a significant decline (see Figure 1), from 1,838.795 per 100,000 (95% UI: 1,402.351–2,342.577) to 231.868 per 100,000 (95% UI: 127.387–391.979), with an EAPC of –3.43 (95% CI: –4.34 to –2.52). The decline was similar between sexes (female EAPC: –3.42; male EAPC: –3.44).

Figure 1 Epidemiological trends in the incidence rate (A-C), mortality rate (D-F), and DALYs rate (G-I) of childhood pertussis by sex across various Asian regions from 1990 to 2021. Values are presented as rates per 100,000 population. DALYs, disability-adjusted life years.

Age-specific analysis revealed the most pronounced decline in incidence among children aged 12–23 months (EAPC: –4.98; 95% CI: –5.83 to –4.13), followed by infants under 1 year of age (EAPC: –3.33). Age-specific analysis shows that the highest incidence rate in Asia is observed among children aged 12–23 months, followed by infants under 1 year of age (see Figure 2A).

Figure 2 Incidence rate (A), mortality rate (B), and DALYs rate (C) associated with the burden of childhood pertussis across different age groups in Asian countries in 2021. Values are presented as rates per 100,000 population. DALYs, disability-adjusted life years.

Mortality

In 2021, there were an estimated 14,934.880 pertussis-related deaths among children in Asia (95% UI: 4,686.788–34,416.276), with an estimated mortality rate of 1.370 per 100,000 population (95% UI: 0.430–3.158). Male deaths totaled 7,969.409 (95% UI: 2,444.766–18,430.743), and female deaths totaled 6,965.471 (95% UI: 2,200.708–16,187.058). The male mortality rate (1.530/100,000) was slightly higher than that of females (1.224/100,000) (see Table 1).

From 1990 to 2021, the mortality rate declined from 15.251 per 100,000 (95% UI: 5.920–35.135) to 1.370 per 100,000 (95% UI: 0.430–3.158), with an EAPC of –4.64 (see Figure 1D-1F). The most significant reduction was observed in the 2–4 years age group (EAPC: –12.25), followed by the 5–9 years group (EAPC: –4.76; 95% CI: –5.65 to –3.86). Age-specific analysis shows that the highest mortality rate in Asia is observed among children aged 12–23 months, followed by infants under 1 year of age (see Figure 2B).

DALYs

In 2021, the total DALYs attributable to pediatric pertussis in Asia were 1,321,933.610 (95% UI: 423,870.119–3,040,926.211), with a DALY rate of 33.345 per 100,000 (see Table 1). The DALY rate for males (108.402/100,000) was slightly lower than that for females (135.361/100,000). Between 1990 and 2021, the DALY rate decreased from 612.561 per 100,000 to 33.345 per 100,000, with an EAPC of –9.17 (see Figure 1G-1I). The greatest reduction was observed in the 2–4 years age group (EAPC: –4.97; 95% CI: –5.81 to –4.11), followed by the 5–9 years group (EAPC: –4.74; 95% CI: –5.63 to –3.85). Age-specific analysis shows that the highest DALYs rate in Asia is observed among children aged 12–23 months, followed by infants under 1 year of age (see Figure 2C).

Regional burden of pertussis among children in Asia

Incidence

In 2021, South Asia had the highest incidence rate (400.595 per 100,000), while the High-income Asia Pacific region had the lowest (0.300 per 100,000). The most rapid decline in incidence was observed in the High-income Asia Pacific region (EAPC: –9.97) (see Table 1).

Mortality

South Asia also had the highest mortality rate (2.309 per 100,000), whereas the High-income Asia Pacific region had the lowest (0.001 per 100,000). The steepest decrease in mortality rate was again observed in the High-income Asia Pacific region (EAPC: –12.25) (see Table 1).

DALYs

South Asia bore the heaviest DALY burden (38.904 per 100,000), while the High-income Asia Pacific region had the lowest (10.266 per 100,000). The most substantial decline in DALY rate was seen in Central Asia (EAPC: –9.17; 95% CI: –9.80 to –8.55) (see Table 1).

Country-specific epidemiological patterns of pediatric pertussis in Asia

Incidence

In 2021, there were notable disparities in pertussis incidence among Asian countries. India recorded the highest number of cases (1,579,006; 95% UI: 593,261–3,144,338), while Afghanistan had the highest incidence rate (439.38 per 100,000) and Sri Lanka the lowest (4.561 per 100,000). Bhutan experienced the most rapid decline in incidence from 1990 to 2021 (EAPC: –13.60) (see Figure 3A and Table S1).

Figure 3 Incidence rate (A), mortality rate (B), and DALYs rate (C) associated with the burden of childhood pertussis in Asian countries in 2021. DALYs, disability-adjusted life years.

Mortality

Significant differences in mortality burden were also observed. India reported the highest number of deaths (8,268; 95% UI: 590–25,965), while Afghanistan had the highest mortality rate (5.02 per 100,000). Armenia and Georgia had mortality rates approaching zero. Mauritius had the most substantial decrease in mortality (EAPC: –17.27) (see Figure 3B and Table S2).

DALYs

In 2021, India had the highest total DALYs (732,289.734; 95% UI: 59,624.737–2,291,023.071), whereas countries like Brunei and the Maldives reported fewer than 10. Afghanistan had the highest DALY rate (442.56 per 100,000), while the High-income Asia Pacific region had rates close to zero. The greatest decline in DALY rate occurred in the Democratic People’s Republic of Korea (EAPC: –14.64) (see Figure 3C and Table S3).

Correlation between the burden of pediatric pertussis and the sociodemographic index in Asia

A further analysis was conducted to explore the association between the burden of pertussis among children aged 0–14 years and the SDI in Asia using Spearman rank correlation analysis based on cross-sectional data from the year 2021. The results showed:

At the national level, SDI was significantly negatively correlated with incidence (r=–0.4363, P<0.001), mortality (r=–0.6002, P<0.001), and DALY rate (r=–0.6158, P<0.001) among children aged 0–14 years (see Figure 4A-4C).

Figure 4 Relationship between the SDI and the burden of pertussis in Asian countries (A-C) and regions (D-F) in 2021. The points in panels (A-C) represent countries in 2021, the points in panels (D-F) represent regions in 2021. SDI, Socio-demographic Index.

At the regional level, SDI also showed significant negative correlations with incidence (r=–0.8129, P<0.001), mortality (r=–0.9335, P<0.001), and DALY rate (r=–0.9328, P<0.001) (see Figure 4D-4F).

Projected pertussis burden in children in China, Japan, South Korea, and India (2022–2050)

Asia, approximately 4.759 billion people, accounts for 58% of the global population. However, due to economic and geographic disparities, the burden of diseases varies significantly across different regions and countries. China and India are the world’s two most populous developing nations, while Japan and South Korea represent advanced economies in the Asia-Pacific region. These countries were selected as representative cases to forecast the pediatric pertussis burden over the next three decades.

Projected incidence rates

Using a BAPC model, incidence rates from 2022 to 2050 were projected for China, Japan, South Korea, and India. The projections indicate a continued downward trend in all four countries. Specific year-by-year projections are illustrated in Figure 5A. China: the incidence rate is expected to decline to 1.792758 per 100,000 by 2050, representing a 96.7% reduction compared to 2021. Japan and South Korea: incidence rates are projected to approach zero by 2050. India: the incidence rate is forecast to drop to 95.87571 per 100,000 by 2050, corresponding to an approximately 80.1% decrease from 2021.

Figure 5 Projected incidence and mortality rates of pertussis in China, Japan, Republic of Korea, and India from 1990 to 2050. (A) The predicted trends for incidence rates. (B) The predicted trends for mortality rates. The vertical dashed line indicates the transition point in the model projections. Color coding is used to differentiate between the historical data (blue) and future projections (red).

Projected mortality rates

The BAPC model also projects a consistent decline in mortality rates across the same period. China: the pediatric pertussis mortality rate is expected to decrease to 0.03694731 per 100,000 by 2050, representing a 92.8% reduction from 2021. Japan and South Korea: mortality rates are predicted to approach zero, reflecting effective disease control and healthcare access. India: the mortality rate is projected to fall to 0.2594091 per 100,000 by 2050, an 89.7% reduction compared to 2021 (see Figure 5B).

Discussion

This study systematically assessed the disease burden of pertussis among Asian children from 1990 to 2021 using 2021 GBD data, focusing on incidence, mortality, and DALYs. The results demonstrated a significant overall decline in pertussis incidence, mortality, and DALYs across Asia, though substantial burdens persist in South and Southeast Asia. Infants bear the heaviest disease burden, exhibiting the highest morbidity and mortality rates. Our analysis revealed an inverse correlation between SDI levels and pertussis burden across Asian nations. Using BAPC modeling, we projected disease trends for the next three decades. These findings may provide valuable scientific evidence for optimizing regional pertussis control strategies in Asia, particularly regarding vaccine prioritization and enhanced surveillance of high-risk populations.

In the GBD framework, North Africa and West Asia are classified as a single region and reported as an integrated dataset. Several countries within these areas share similar linguistic, cultural, and socioeconomic characteristics as Arab countries, as well as comparable health system structures and epidemiological patterns. Therefore, their joint presentation in this study follows the original GBD regional classification and was intended to maintain regional comparability across analyses.

The study showed a sustained decline in Asia’s pediatric pertussis burden (1990–2021 incidence EAPC =−3.43, mortality EAPC =−4.64), primarily attributable to the continued expansion of the Expanded Program on Immunization (EPI) (15). Notably, the decline accelerated during 2020–2021 (Figure 1), likely due to COVID-19 containment measures that inadvertently reduced pertussis transmission. However, pandemic-related disruptions to routine immunization services may have increased the population of unvaccinated children, with potential lingering effects on vaccination rates (16). Recent global trends suggest a pertussis resurgence (6,17,18), compounded by the emergence of macrolide-resistant Bordetella pertussis strains (19,20), warranting vigilance for potential localized outbreaks.

Our study also revealed significant regional disparities in the burden of pertussis among children in Asia. South Asian countries such as India and Pakistan bear the heaviest burden, which may be largely attributed to weak primary healthcare infrastructure and fluctuating vaccination coverage rates (e.g., DTP3 coverage in 2017 was only 88% in India and 75% in Pakistan) (21). Notably, there is a strong inverse correlation between rapid socioeconomic development and disease burden. For instance, in China, following the economic reforms of 1978, improvements in healthcare accessibility and diagnostic capabilities were driven by rapid economic growth. Consequently, the incidence rate of pertussis dropped from 947.684 per 100,000 in 1990 to 48.784 per 100,000 in 2021 (EAPC =−3.43). However, even within the same country, substantial regional disparities persist; in western rural China, delayed and missed vaccinations remain common, potentially contributing to localized outbreaks (22).

This study found that infants under one year of age exhibit significantly higher incidence and mortality rates compared to other age groups (e.g., <1-year mortality rate =8.963 per 100,000 vs. 10–14 years =0.12 per 100,000), likely due to the immaturity of their immune systems and the waning of maternal antibodies. Although the age of first dose may differ between countries, typically ranging from 6 to 12 weeks of age, infants remain insufficiently protected before six months, rendering this period a high-risk window for severe disease. A meta-analysis (23) including 17 studies identified age <30 days as an independent risk factor for fatal pertussis. This finding aligns with our results and underscores the heightened mortality risk among unvaccinated neonates. Additionally, the 2–4 years age group demonstrated the greatest reduction in disease burden (mortality EAPC =−4.98), likely reflecting the widespread implementation of booster immunization, further underscoring the critical importance of full vaccine coverage. In high-income countries, the recent introduction of maternal immunization could create further discrepancies in vaccination coverage between low- and high-income countries, which should be taken into consideration when discussing the BAPC model for China, Japan, India, and South Korea.

Our analysis also demonstrated a strong negative correlation between the SDI and the pertussis burden in children, suggesting that socioeconomic development influences disease transmission through multiple pathways. High-SDI regions benefit from vaccination coverage exceeding 95% (24), proactive surveillance systems, advanced pathogen detection capabilities, and high-quality care for critically ill children—all contributing to a significantly reduced disease burden (22). Maternal immunization has also been recently introduced in high-income countries, but it may not have been widely implemented by 2021. Conversely, low-SDI areas face persistent challenges such as poverty, inadequate healthcare investment, and armed conflict, which hinder sustainable immunization programs and timely treatment. This highlights that medical advancements alone are insufficient; economic equity reforms are equally essential to eliminate pertussis.

For future projections, we selected China, Japan, South Korea, and India. Based on the BAPC model, the incidence of pediatric pertussis is expected to decline by 96.7%, nearly 100%, nearly 100%, and 80.1% in these countries, respectively, by 2050. Although countries like Japan and South Korea may achieve elimination goals, shifting public health priorities, driven by low birth rates, aging populations, and stagnating economic growth, could weaken efforts in childhood infectious disease control. Furthermore, the emergence of macrolide-resistant pertussis strains may hinder eradication efforts (19,25,26). For populous nations like India and China, despite anticipated mortality reductions of 80–90%, their large population sizes mean the absolute number of cases and deaths will likely remain significantly higher than in other countries. Therefore, developing countries, particularly China and India, must closely monitor pertussis strain evolution and continue strengthening vaccine accessibility and coverage.

Vaccination programs play a critical role in shaping the burden of pertussis and are highly relevant to the policy implications of our findings. Although the GBD database does not provide detailed country-level vaccine coverage data, available evidence suggests substantial heterogeneity across Asian countries. In China, coverage of the three-dose diphtheria-tetanus-pertussis (DTP) vaccine has remained above 99% over the past decade (6), while Japan has also achieved pertussis vaccination coverage of approximately 99% (27). In contrast, India has reported an average pertussis vaccine coverage of about 89%, slightly below the World Health Organization-recommended threshold of 90%, despite most regions exceeding this level (28). In South Korea, childhood coverage for the first dose of DTaP vaccine reached 98.9% in 2020, whereas vaccine uptake among adults and pregnant women remained substantially lower (29). These differences in vaccine coverage and target populations may contribute to the heterogeneous pertussis burden observed across countries and highlight the importance of strengthening vaccination strategies beyond early childhood.

This study has several limitations. First, GBD data rely on national reporting systems, which may lead to underreporting in conflict zones or remote rural areas, thereby underestimating disease burden. Second, the COVID-19 pandemic likely suppressed pertussis transmission during 2020–2021, while also increasing rates of missed vaccinations, potentially affecting the accuracy of BAPC model projections for 2050. These factors introduce uncertainties into both the EAPC and the model-based projections. Therefore, we interpret the results with caution, and we emphasize that the projections are based on current assumptions and may not represent definitive future trajectories.

Conclusions

Despite a significant decline in the burden of pertussis among children in Asia over the past three decades, it remains a major vaccine-preventable threat to child health. There are marked disparities in disease burden across SDI levels, age groups, and geographic regions, with particular concern for ongoing challenges in low- and middle-income countries. Through enhanced vaccine coverage, protection of high-risk populations, and socioeconomic development, Asia may accelerate its progress toward the elimination of pertussis.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0022/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0022/prf

Funding: This study was supported by the Yunnan Provincial Clinical Medicine Research Center for Gynecological and Obstetric Diseases (No. 202505AJ310008; 2026YJZX-FC22), the Xingdian Healthcare Talents Program (2025), Yunnan Provincial Ten-Thousand Talents Program for Famous Medical Experts (No. KH-2025-XDYC-YLWS-07), and the Open Project of NHC Key Laboratory of Healthy Birth and Birth Defect Prevention in Western China (No. 2024XBYSKF018).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0022/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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