The samples of the younger age groups (one to 17 years) were residual sera from diagnostic laboratories, and samples from the adult population (≥18 years of age) were residuals

of sera obtained from healthy blood donors living all over Israel, screened before the use of the blood donations. Both sources excluded repeat samples from the same individuals as well as sera taken from subjects with confirmed or suspected immunological disorders. Each sample had a unique identifier, plus details of age, sex, religion, place of residence (at the level of town), and the year in which the sample was drawn. Pertussis this website has been reported in Israel since the early 1950s. Practitioners are requested to notify each clinical case to the local public health office which reports on a weekly basis to the Ministry of Health. Case classification does not imply laboratory confirmation. National immunization coverage is calculated each year by the district health offices, and submitted to the Everolimus concentration Ministry of Health. The calculation is based on a representative sample of children born in each health district and registered in the public Family Health Centres. Serum samples were stored at −20 °C until they were tested at the Department of Epidemiology and Preventive Medicine Research Laboratory, Tel Aviv University. IgG antibodies to B. pertussis toxin (PT) were determined by

a commercial enzyme-linked immunosorbent assay (ELISA) (Pertusscan PT-G™, Euro-Diagnostica AB, Sweden) in accordance with the manufacturer’s instructions. This assay was validated within the European Sero-Epidemiology Network 2 (ESEN2) project by testing a panel of 150 human control sera provided by the European Pertussis Reference Laboratory (Department of Hygiene and Microbiology, University of Palermo, Italy) [10]. The panel’s results were calibrated against

those from the Reference Centre at the Health Protection Agency Centre for Infections, London. Linear and quadratic regression was fitted and R2 (multiple correlation coefficient) values were calculated. In the standardization process regression lines were selected and standardization equations obtained [10]. These standardization equations were used others to convert the local quantitative results into standardized reference laboratory unitage (ESEN units). Test results are expressed in “ESEN units” per millilitre. The quantitative titers of anti-PT IgG were classified as high titer samples using a cut-off level of 125 ESEN units/ml (equivalent to 225 local units/ml) indicative of recent or active infection with B. pertussis [9]. The sensitivity of this threshold was estimated at 76% and the positive predictive value (PPV) at 80%, assuming a true prevalence of disease of 10% [9]. A second cut-off of 62.5 ESEN units/ml (equivalent to 134 local units/ml) was employed, suggesting B. pertussis infection in the previous 12 months with high probability [9] and [11].