|
|
|
|
|
| Is
it true that pertussis in children is increasing? Are more infants
dying from the disease? |
 |
| Since the 1980s, the number of
reported pertussis cases has increased. These increases have been
noted in both infants
younger than age 1 year, particularly among infants younger than age
6 months; adolescents age 11–18 years, and adults. An
increase in the number of reported deaths from pertussis among very
young infants has paralleled the increase in the number
of reported cases. Reasons for the increases in pertussis are not
completely clear; improvements in diagnosis and reporting
of pertussis in adolescents and adults appear to be important
factors contributing to the overall increase. |
|
| As a pediatrician, I am concerned
about protecting my newborn patients from pertussis, especially
given the recent outbreaks in my community where infants have died.
How many doses of pediatric diphtheria-tetanus-acellular pertussis
(DTaP) vaccine does an infant need before she or he is protected
from pertussis? |
|
| Vaccine efficacy is 80%–85%
following 3 doses of DTaP vaccine. Efficacy data following just 1 or
2 doses are lacking but are
likely lower. Therefore, it is especially important that you advise
parents of infants and all people who live with the
infant or who provide care to him or her be protected against
pertussis. It is recommended that the infant's family members
and potential visitors receive a one-time dose of adolescent/adult
tetanus-diphtheria-acellular (Tdap) vaccine if they have
not already done so. |
|
| Can a child or an adult who has
had pertussis get the disease again? |
|
| Reinfection appears to be uncommon,
but does occur. Reinfection may present as a persistent cough rather
than typical pertussis. |
| |
| Should further doses of pertussis
vaccine be given to an infant or child who has had culture-proven
pertussis? |
|
| Immunity to pertussis following
infection is not lifelong. Persons with a history of pertussis
should continue to receive pertussis-containing vaccines according
to the recommended schedule. (Note: This answer is based upon
recommendations of the AAP's Committee on Infectious Diseases.) |
| |
| If an adolescent or adult who has
never received their one-time dose of Tdap is either infected with
or exposed to pertussis, is vaccination with Tdap still necessary,
and if so when? |
|
| Yes. Adolescents or adults who have
a history of pertussis disease generally should receive Tdap
according to the routine
recommendation. This practice is recommended because the duration of
protection induced by pertussis disease is unknown
(waning might begin as early as 7 years after infection) and because
diagnosis of pertussis can be difficult to confirm,
particularly with tests other than culture for B. pertussis.
Administering pertussis vaccine to people with a history of
pertussis presents no theoretical risk. However, if the illness was
recent (less than 5 years) and the diagnosis was certain
(i.e., culture confirmed), it is reasonable to wait 3–5 years before
administration of Tdap, unless tetanus and diphtheria
toxoids are needed. For details, visit CDC's published
recommendations on this topic at
www.cdc.gov/vaccines/pubs/acip-list.htm. |
| |
| If a healthcare worker (HCW)
receives tetanus-diphtheria-acellular pertussis (Tdap) vaccine and
is then exposed to someone with pertussis, do you treat the
vaccinated HCW with prophylactic antibiotics or consider them immune
to pertussis? |
|
| You should follow the post-exposure
prophylaxis protocol for pertussis exposure recommended by CDC (
www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm). Research
is needed to evaluate the effectiveness of Tdap to prevent pertussis
in healthcare settings. Until studies define the optimal management
of exposed vaccinated healthcare personnel, or experts arrive at
consensus, healthcare facilities should continue to follow the
post-exposure prophylaxis protocol for vaccinated HCWs who are
exposed to pertussis. |
|
|
|
|
|
| What are the recommendations for
vaccination of infants and young children with DTaP? |
|
| All children should receive a series
of DTaP at ages 2, 4, and 6 months, with boosters at ages 15-18
months and at 4-6 years. The fourth dose may be given as early as
age 12 months if at least 6 months have elapsed since the third
dose. |
|
| What are the recommendations for
use of Tdap, including those issued by ACIP at its October 2010 and
February 2011 meetings? |
|
| In response to an
increased incidence of pertussis in the U.S., ACIP voted
on several new recommendations for the use of Tdap
vaccine. The complete recommendations follow. |
|
| • |
|
Tdap can
be given regardless of the interval since the last
Td was given. There is NO need to wait 2–5 years to
administer Tdap following a dose of Td. |
| • |
|
Adolescents should receive a one-time dose of Tdap
(instead of Td) at the 11–12-year-old visit. |
| • |
|
Adolescents and
adults younger than age 65 years who have not
received a dose of Tdap, or for whom vaccine status
is unknown, should be immunized as soon as feasible.
(As stated above, Tdap can be administered
regardless of interval since the previous Td dose.) |
| • |
|
Adults age 65 years
and older who have not previously received a dose of
Tdap, and who have or anticipate having close
contact with children younger than age 12 months
(e.g., grandparents, other relatives, child care
providers), should receive a one-time dose to
protect infants. (As stated above, Tdap can be
administered regardless of interval since the
previous Td dose.) |
| • |
|
Other
adults 65 years and older who are not in contact
with an infant, and who have not previously received
a dose of Tdap, may receive a single dose of Tdap in
place of a dose of Td. |
| • |
|
Children ages 7–10
years who are not fully immunized against pertussis
(i.e., did not complete a series of
pertussis-containing vaccine before their seventh
birthday) should receive a one-time dose of Tdap. |
| • |
|
All healthcare
workers, regardless of age, should receive a single
dose of Tdap as soon as feasible if they have not
previously received Tdap and regardless of the time
since the last dose of Td. |
|
|
| Aren't the October 2010 ACIP
recommendations for expanded use of Tdap vaccine in children ages 7
through 9 years and in adults age 65 years and older different from
what is on the package inserts? |
|
| Yes. Sometimes ACIP makes
recommendations that differ from the FDA-approved package insert
indications, and this is one of those instances. ACIP
recommendations represent the standard of care for vaccination
practice in the United States. In general, to determine
recommendations for use, one should follow the recommendations of
ACIP rather than the information in the package insert. |
|
| I don't remember using a vaccine
off-label before, so the new Tdap recommendations for vaccinating
people older than age 65 make me a bit nervous. What could be the
legal repercussions if we vaccinate a 70-year-old grandparent with
Tdap and he develops a severe side effect? |
|
| We cannot give legal advice.
However, you should keep in mind that ACIP recommendations represent
the standard of care for vaccination practice in the United States.
In general, to determine recommendations for use, one should follow
the recommendations of ACIP rather than the information in the
package insert. |
|
|
|
|
|
| I'm confused about
the various vaccines that contain tetanus, diphtheria, and
pertussis. Can you explain? |
|
| There are two basic
products that can be used in children younger than age 7 years (DTaP
and DT) and two that can be used in older children and adults (Td
and Tdap). Some people get confused between DTaP and Tdap and others
get confused between DT and Td. Here's a hint to help you remember.
The pediatric formulations usually have 3-5 times as much of the
diphtheria component than what is in the adult formulation. This is
indicated by an upper-case "D" for the pediatric formulation (i.e.,
DTaP, DT) and a lower case "d" for the adult formulation (Tdap, Td).
The amount of tetanus toxoid in each of the products is equivalent,
so it remains an upper-case "T." |
|
|
| Can we use the two DTaP products
interchangeably? |
|
| There are two different DTaP
products currently used in the U.S. for the primary series for
children ages 2 months through 6 years (Daptacel by sanofi pasteur
and Infanrix by GlaxoSmithKline). ACIP has recommended that,
whenever feasible, healthcare providers should use the same brand of
DTaP vaccine for all doses in the vaccination series. |
|
| What should we do if we don't
know which brand of DTaP a child had previously? |
|
| If the DTaP brand used for previous
doses is not known or not in stock, use whatever DTaP vaccine you
have available for all subsequent doses. |
|
| Someone gave Tdap to an infant
instead of DTaP. Now what should be done? |
|
This error sometimes happened
because the packaging for the sanofi products (Daptacel [DTaP] and
Adacel [Tdap]) was quite
similar. You'll be glad to know that sanofi pasteur has changed
their packaging and you should notice more distinct tabs, new
package colors and vial labels, and clear use-descriptions next to
the package logos.
If Tdap was inadvertently
administered to a child, it should not be counted as
either the first, second, or third dose of DTaP. The
dose should be repeated with DTaP. Continue vaccinating
on schedule. If the dose of Tdap was administered for
the fourth or fifth DTaP dose, the Tdap dose can be
counted as valid. Please remind your staff to always
check and double check the vaccine vial before
administering any vaccine. |
|
| I have a patient who received
single-antigen tetanus (TT) in the emergency room rather than Td or
Tdap. Should he be revaccinated? |
|
| ACIP recommends that patients
needing prophylaxis against tetanus always be given either Td or, if
appropriate, Tdap rather than TT, as long as there is no
contraindication to the other vaccine components. If it's already
been given and the person had not yet received Tdap as an adolescent
or adult, you should make certain that he gets Tdap as soon as
feasible. If he had received Tdap previously, he can wait until the
next scheduled booster dose is due to get his routine Td booster. |
| |
| When should a person receive
tetanus toxoid (TT) alone? |
|
| Single antigen tetanus toxoid should
only be used in rare instances, for example when a person has had a
documented severe allergic response to diphtheria toxoid. |
| |
| In what year did tetanus toxoid
first become available? At what age might most patients never have
received a primary series? |
|
| Tetanus toxoid became commercially
available in 1938, but was not widely used until the military began
routine vaccination in 1941. Routine administration of tetanus
toxoid was recommended by the AAP in 1944. Most World War II
military personnel received at least one dose of tetanus toxoid, but
civilian use, particularly for adults, did not increase until after
the war. You should not assume the tetanus vaccination status for
any person based on their age alone. Only a written record is
acceptable proof of immunization. People without documentation
should be assumed to be unimmunized. |
| |
| If a dose of DTaP or Tdap is
inadvertently given to a patient for whom the product is not
indicated (e.g., wrong age group), how do we rectify the situation? |
|
| The first step is to
inform the parent/patient that you administered the wrong
vaccine. Next, follow these guidelines: |
|
| • |
|
Tdap
given to a child younger than age 7 years as either
dose 1, 2, or 3, is NOT valid. Repeat with DTaP as
soon as feasible. |
| • |
|
Tdap
given to a child younger than age 7 years as either
dose 4 or 5 can be counted as valid for DTaP dose 4
or 5. |
| • |
|
DTaP given to
patients age 7 or older can be counted as valid for
the one-time Tdap dose. |
|
|
|
|
|
|
| What is the difference between
the two Tdap products - Boostrix and Adacel? |
|
| Both of these vaccines provide
protection against diphtheria, tetanus, and pertussis. Boostrix
(GlaxoSmithKline) is licensed for people ages 10–64 years, and
Adacel (sanofi pasteur) is licensed for people ages 11–64 years.
Both are approved for one dose only, not multiple doses in a series.
The two vaccines also contain a different number of pertussis
antigens and different concentrations of pertussis antigen and
diphtheria toxoid. |
|
| We have a 13-year-old patient who
was given DT (pediatric) as a preschooler after she had experienced
excessive crying following a dose of DTP. Now, we are wondering if
we can give her Tdap since we know she may not be protected against
pertussis. |
|
| Yes, you can. Many of the
precautions to DTaP (e.g., temperature of 105°F or higher, collapse
or shock-like state, persistent crying lasting 3 hours or longer,
seizure with or without fever) do not apply to Tdap. This issue is
discussed in CDC's Tdap recommendations, available at
www.cdc.gov/mmwr/PDF/rr/rr5503.pdf. |
|
| Should I make an effort to give
teenagers a Tdap dose, even if they've had a dose of Td at age 11–12
years? |
|
| Yes. All adolescents should receive
one dose of Tdap vaccine to protect them from pertussis, even if
they have already received Td. It is important to do this right away
(no minimal interval is required), especially if they are in contact
with an infant younger than age 12 months, work in a healthcare
setting where they have direct contact with patients, or live in a
community where pertussis is occurring. |
|
| We have a 16-year-old patient who
received tetanus-diphtheria (Td) vaccine in the emergency room after
a nail puncture a year ago. Can we give him a tetanus-diphtheria-acellular
pertussis (Tdap) vaccine now? |
|
| Yes. There is no need to observe any
minimum interval between doses of Td and Tdap. |
|
| Some children in my practice are
not up to date on their immunizations, and pertussis is circulating
in our community. Can you guide me in determining how to make the
decision about which vaccine to choose? |
|
| You should use DTaP in children
younger than age 7 years. In October 2010, ACIP voted to give a
single dose of Tdap to children ages 7 through 10 years who did not
finish a minimum 3-dose series of pertussis-containing vaccines
before their 7th birthday (or for whom their pertussis vaccine
status is unknown). Although this is an off-label use of the
vaccines, it's important that you vaccinate these vulnerable
children with Tdap as well as any other adolescent or adult who
hasn't received Tdap previously. |
|
| I need to know how to catch-up a
child who is 12 years old and received 1 dose of DTaP vaccine at age
2 years and a one-time Tdap dose at age 11 years. |
|
| This child needs to complete the
primary series with 1 dose of Td, administered no earlier than 6
months after the Tdap dose given at age 11 years. After that, the
child needs a booster dose of Td every 10 years. An easy way to
determine how to catch up a child is to consult "Recommended
Immunization Schedules for Persons Aged 0 Through 18 Years, U.S."
The schedule is approved by CDC, AAP, and AAFP and is released early
in each calendar year. It includes a catch-up schedule for children
who have fallen behind (see
www.cdc.gov/vaccines/recs/schedules/child-schedule.htm). |
|
| According to the newest ACIP
recommendations, which healthcare workers should be vaccinated
against pertussis with tetanus-diphtheria-acellular pertussis (Tdap)
vaccine? |
|
| On February 23, 2011, ACIP
voted to approve the following recommendations for the use
of Tdap in healthcare personnel. |
|
| • |
|
All
healthcare personnel (HCP), regardless of age,
should receive a single dose of Tdap as soon as
feasible if they have not previously received Tdap
and regardless of the time since last Td dose. |
| • |
|
Tdap is
not currently licensed for multiple administrations.
After receipt of Tdap, HCP should receive routine
booster immunization against tetanus and diphtheria
according to previously published guidelines. |
| • |
|
Hospitals and
ambulatory-care facilities should provide Tdap for
HCP and use approaches that maximize vaccination
rates (e.g., education about the benefits of
vaccination, convenient access, and the provision of
Tdap at no charge). |
|
|
| To obtain a copy of the provisional
recommendations, go to
www.cdc.gov/vaccines/recs/provisional. |
|
| How soon after a dose of Td can a
healthcare worker receive a dose of Tdap, in order to protect
vulnerable infants and others? |
|
| If they have not previously received
Tdap, healthcare personnel in hospitals and ambulatory care settings
should receive a single dose of Tdap as soon as feasible and without
regard to the dosing interval since the last Td. There is no
"minimum interval" one needs to wait between receiving Td and Tdap
when it is given to protect infants or other vulnerable patients. |
|
| Instead of giving
tetanus/diphtheria toxoid and acellular pertussis (Tdap) vaccine to
a father-to-be that needed protection against pertussis, we
mistakenly gave him tetanus/diphtheria (Td) toxoid. How soon after
the Td dose can we give him the dose of Tdap he needs? |
|
| All parents, grandparents,
healthcare workers, and all others who have not already received
Tdap, and especially those who are close contacts of infants younger
than age 12 months, should receive a single dose of this vaccine as
soon as possible to protect infants from pertussis. There is no need
to observe a "minimum interval" between giving Td and Tdap. For
example, if you had immediately realized that you had mistakenly
given the father-to-be Td instead of Tdap, you could have given him
the needed Tdap dose at the same visit at which you gave him the
erroneous Td dose. |
|
| Can a booster dose of Tdap be
given to people age 65 years and older? |
|
| Yes. ACIP recommends a one-time dose
of Tdap be given to adults age 65 years or older who have or
anticipate having close contact with an infant younger than age 12
months (e.g., grandparents, childcare providers), or for any other
older adult who merely wants to be protected against pertussis. |
|
| We recently saw a 30-year-old man
who remembers that he received a "tetanus booster" in another state
within the past 2 years. The problem is he can't remember if he
received Tdap or Td, and we can't obtain an immunization record. His
wife is pregnant, and we would like to immunize him against
pertussis as a way to protect their soon-to-be-born child. Should we
give him Tdap in this situation? |
|
| Yes. Whenever you lack vaccination
documentation and vaccination is indicated, give the patient Tdap. |
|
| I want to protect pregnant women
and their unborn children from pertussis. Can I give Tdap to
pregnant women? |
|
| Tdap is not contraindicated during
pregnancy. According to ACIP and the American College of
Obstetricians and Gynecologists, a clinician may choose to
administer Tdap to a pregnant woman in the 2nd or 3rd trimester in
certain circumstances, such as a community pertussis outbreak. If
there is no risk to the pregnant woman of acquiring or transmitting
pertussis, ACIP recommends that Tdap vaccination be deferred until
the immediate postpartum period. AAP has endorsed preferential Tdap
vaccination of pregnant adolescents who were not vaccinated with
Tdap at age 11–12 years (Pediatrics 2006; 117:965-78). Providers can
follow either the AAP or ACIP recommendations. |
|
| If a pregnant woman got a dose of
Td during pregnancy, how soon after birth can she get her postpartum
dose of Tdap? |
|
| The mother is taking home an infant
who is susceptible to pertussis, so she should receive Tdap during
the immediate postpartum period (e.g., before hospital discharge).
There is no minimum interval between Td and Tdap. |
|
| Can the parents of a young infant
be given a dose of Tdap right after birth to protect themselves and,
indirectly, their newborn from pertussis, even though they had a
dose of Td vaccine less than two years ago? |
|
| Yes. Parents should receive a single
dose of Tdap as soon as possible to protect their baby from
pertussis. If a dose of Td was given within the previous 2 years,
parents should still be vaccinated with Tdap as soon as possible
regardless of the time interval since the last dose of Td. Other
household contacts that are not up to date with their
pertussis-containing vaccinations should also be appropriately
vaccinated. |
|
| Can Tdap be given at the same
visit as other vaccines? |
|
| Yes. Tdap can be administered with
all other vaccines that are indicated (e.g., meningococcal conjugate
vaccine, hepatitis B vaccine, MMR). Each vaccine should be
administered at a different anatomic site using a separate syringe. |
|
| How many doses of Tdap can we
give to a patient? |
|
| The vaccine is licensed for just one
dose. Subsequent doses should be Td. |
|
| Someone in our clinic gave DTaP
to a 50-year-old instead of Tdap. How should this be handled? |
|
| The DTaP recipient received the
appropriate amount of tetanus toxoid and MORE diphtheria toxoid and
pertussis antigen than is recommended. Count the dose, but take
measures to prevent this error in the future. |
|
|
|
|
|
| What schedule should I use to
vaccinate adolescents or adults who never received the primary
series of tetanus toxoid-containing vaccine? |
|
| Children, ages 7 years and older,
and adults who have never received tetanus-containing vaccines, or
whose vaccination history is unknown, should receive the 3-dose
series. In this situation, ACIP recommends Tdap for dose #1,
followed 4 weeks later by Td for dose #2, followed at least 6 months
later by Td for dose #3. Tdap can substitute for only one of the 3
Td doses in the series, preferably the first. The amount of
protection provided by a single dose of Tdap in a person who has not
previously received pertussis vaccine is not known. Following the
primary series, booster doses of Td should be given every 10 years
thereafter. |
|
| We are routinely scheduling the
4th dose of DTaP in children at 15–18 months, but occasionally would
like to give it earlier. Is that okay? |
|
| The fourth dose of DTaP may be given
as early as age 12 months if at least 6 months have passed since the
third dose. |
|
| When a child comes in for his
vaccinations at age 4–6 years and presents with an incomplete
history of 0-2 doses of DTaP vaccine, how do we determine how many
more doses are needed? |
|
| You should try to achieve at
least 4 total doses. Give additional doses of DTaP with 4 week
intervals until you achieve 3 total doses. Then, if 6 months pass
and the child has not turned seven years old, give the 4th dose. |
|
| If a child didn't have the
recommended 6-month interval between DTaP doses #3 and #4, should it
be repeated? |
|
|
If DTaP #4 is given with at
least a 4-month interval after DTaP #3, it does not need to be
repeated. Decreasing the interval to less than 6 months, however, is
not recommended. |
|
| If a child has already received 5
doses of DTaP by their fourth birthday (with the appropriate 6 month
intervals between #3 and #4 and also between #4 and #5), is a
booster dose after the fourth birthday necessary? |
|
| In general, a child should receive
no more than four doses of DTaP before 4 years of age (preferably by
2 years of age). The ACIP recommends that a dose of DTaP be given at
4–6 years of age. Many states have school immunization laws which
also require at least one dose of DTP/DTaP on or after the fourth
birthday. This dose is important to boost immunity to pertussis. |
|
| Is there a recommendation about
how many doses of DTaP a child can receive by a certain age? Does
this include half doses? |
|
| ACIP and AAP both recommend that
children receive no more than 6 doses of diphtheria and tetanus
toxoids (e.g., DT, DTaP, DTP) before the seventh birthday because of
concern about adverse reactions, primarily local reactions. Half
doses of DTaP are also not recommended under any circumstances, and
should not be counted as part of the vaccination series. Only
documented doses (i.e., those recorded in an electronic or written
record) count toward the maximum of 6 doses. |
|
| What is the minimum interval
between DTaP #4 and DTaP #5? |
|
| The minimum interval between DTaP #4
and DTaP #5 is six months. Remember that the minimum age for DTaP #5
is age 4 years. |
|
| How should we schedule DTaP for a
child with a history of only DT? |
|
| If the child has not received all of
the age-appropriate doses of pertussis-containing vaccine, it would
be best to try to administer as many doses of DTaP as possible
before the child reaches his 7th birthday in order to confer
protection against pertussis. Give additional doses of DTaP with 4
week intervals until you achieve 3 total doses. Then, give
additional doses with 6-month intervals, not to exceed 6 total doses
of diphtheria- and tetanus-containing vaccine by the child's 7th
birthday. |
|
| ACIP and AAP have different
recommendations for spacing Tdap and meningococcal conjugate vaccine
if they are not given simultaneously. Please discuss. |
|
| The ACIP Tdap recommendations
published in the MMWR (www.cdc.gov/vaccines/pubs/acip-list.htm)
state that Tdap or Td can be administered at any time before or
after meningococcal conjugate vaccine. AAP's Committee on Infectious
Diseases (a.k.a., the "Red Book" Committee) took a somewhat more
conservative approach and suggested these vaccines be separated by a
month if not given at the same visit. Providers may use either
approach. |
|
| I've heard that if
adolescent/adult tetanus-diphtheria-acellular pertussis (Tdap) and
meningococcal conjugate vaccine are not given simultaneously, they
should be spaced 1 month apart. Is this what ACIP recommends? |
|
| No, this is not what ACIP
recommends. Certain experts recommend spacing these two vaccines by
a month if they are not given simultaneously. This is out of a
theoretical safety concern about giving two vaccines that contain
diphtheria toxoid (meningococcal conjugate vaccine contains
diphtheria toxoid) unless they are given simultaneously or are
spaced 1 month apart. However, ACIP believes this theoretical safety
concern does not warrant spacing. Tdap and meningococcal conjugate
vaccines are both inactivated vaccines, and inactivated vaccines can
be administered at any time before or after a different inactivated
vaccine or a live vaccine, unless a contraindication exists. |
|
|
|
| Contraindications
and precautions to vaccine |
Back to top |
|
|
|
| What are the contraindications
for using DTaP, DT, Tdap, and Td? |
|
| As with all vaccines, a severe
allergic reaction (e.g., anaphylaxis) to a vaccine component or to a
prior dose is a contraindication to further doses of that vaccine. A
history of encephalopathy within 7 days of receiving a previous
pertussis-containing vaccine that is not due to another identifiable
cause is a contraindication to both DTaP and Tdap. |
|
| What precautions should be
observed when giving DTaP, DT, Tdap, or Td? |
|
| A history of Guillain-Barrè syndrome
(GBS) within 6 weeks of receiving a tetanus toxoid-containing
vaccine, and a history of arthus-type hypersensitivity reaction
after receiving a previous tetanus toxoid-containing vaccine is a
precaution to further vaccination with any of these vaccines. As
with all vaccines, moderate or severe illness is a precaution.
Several additional precautions apply only to DTaP (see next
question). |
|
| Do the same precautions that
apply to DTaP also apply to Tdap? |
|
| No, many of the precautions to DTaP
(e.g., temperature of 105°F or higher, collapse or shock-like state,
persistent crying lasting 3 hours or longer, seizure with or without
fever) do not apply to Tdap. This issue is discussed in the Tdap
ACIP recommendations, available at
www.cdc.gov/vaccines/pubs/acip-list.htm |
|
| Can an adult receive Tdap if they
had a contraindication or precaution to DTP as a child? |
|
| Tdap has two contraindications and
four precautions. The contraindications are (1) anaphylactic
reaction to a prior dose of the vaccine or any of its components and
(2) encephalopathy within 7 days of a previous dose of DTaP or DTP;
in this case, give Td instead of Tdap. The precautions are (1)
moderate or severe acute illness; (2) history of an arthus-type
hypersensitivity reaction following a previous dose of a tetanus
toxoid-containing vaccine; (3) Guillain-Barrè syndrome (GBS) 6 weeks
or sooner after a previous dose of tetanus toxoid-containing
vaccine; and (4) progressive or unstable neurologic disorder,
uncontrolled seizures or progressive encephalopathy until a
treatment regimen has been established and the condition has
stabilized. CDC has published a Guide to Vaccine Contraindications
and Precautions in its "General Recommendations on Immunization"
published in MMWR on January 28, 2011. A 2-page user-friendly
version, created by IAC, can be found at
www.immunize.org/catg.d/p3072a.pdf |
|
| When assessing for precautions
for administering DTaP in an infant, is the 105°F cutoff for DTaP a
rectal, oral, or axillary temperature? |
|
| A temperature of 105°F or higher
recorded from any of these body sites following a dose of DTaP
without another known cause constitutes a precaution to further
doses of any pertussis-containing vaccine. |
|
| A 2-month old received her first
dose of DTaP and then had inconsolable crying for greater than 3
hours. Should we give additional doses of DTaP or should we give
just DT? |
|
| Persistent crying following DTaP (as
well as other vaccines) has been observed far less frequently than
it was following the use of DTP. When it occurred after DTP, it was
considered to be an absolute contraindication to further doses of
pertussis-containing vaccine. When it occurs following DTaP, it is
considered a "precaution" (or warning). If you believe the benefit
of the pertussis vaccine exceeds the risk of more crying (which,
although unnerving, is otherwise benign), you can administer DTaP.
Many providers choose to administer pertussis-containing vaccine if
this is the only precaution the child has experienced. You and the
parent will need to make this judgment. |
|
| Can we give further doses of DTaP
to an infant who had an afebrile seizure within 3 hours of a
previous dose? |
|
| An infant who experiences an
afebrile seizure following a dose of DTaP requires further
evaluation. An infant with a recent seizure or an evolving
neurologic condition should not receive further doses of DTaP, or DT
until the condition has been evaluated and stabilized. Other
indicated vaccines may be administered on schedule. To assure that
the child is at least protected against tetanus and diphtheria, the
decision to give either DTaP or DT should be made no later than the
first birthday. |
|
| Does tetanus toxoid contain horse
serum? |
|
| Tetanus toxoid has never contained
horse serum or protein. Equine tetanus antitoxin (horse derived) was
the only product available for the prevention of tetanus prior to
the development of tetanus toxoid in the 1940s. Equine antitoxin was
also used for passive postexposure prophylaxis of tetanus (e.g.,
after a tetanus-prone wound) until the development of human tetanus
immune globulin in the late 1950s. Equine tetanus antitoxin has not
been available in the U.S. for at least 40 years. |
|
| Can Tdap be given to a pregnant
teen or woman? |
|
| ACIP and AAP have different
recommendations on the use of Tdap in pregnancy. ACIP voted to
recommend using Td (not Tdap) during pregnancy if the woman is due
for a routine tetanus booster. If she is not due for the routine
booster (i.e., the previous Td booster was given within the
preceding 10 years), the new mother should receive Tdap immediately
postpartum. However there are situations when a clinician can
consider the use of Tdap for a pregnant woman, such as if there is a
risk of exposure because of a pertussis outbreak. Tdap is not
contraindicated for pregnant women. The infant's other household
contacts ages 10 through 64 years should also receive 1 dose of
Tdap, if not already given. AAP has endorsed preferential use of the
Tdap vaccine during pregnancy in adolescents who were not vaccinated
at the visit at age 11–12 years (Pediatrics 2006; 117:965-78).
Providers can follow either the AAP or ACIP recommendation. |
|
|
|
|
|
| When a patient seen in the ER
needs tetanus protection, which type of tetanus vaccine should be
given? |
|
| For children younger than age 7
years, give DTaP. Children and adults age 10 through 64 years should
receive a single dose of Tdap instead of Td, if they have not
previously received Tdap. Children who are ages 7 through 9 years
and haven't had at least 3 doses of pertussis-containing vaccine
prior to their seventh birthday (or are unsure), should be given
Tdap. Adults ages 65 or older, especially those who have or
anticipate having contact with an infant, and haven't had Tdap
before (or are unsure), should also be given a dose of Tdap. If Tdap
is not available, or was previously administered, these people
should receive Td. |
|
| If a person gets a puncture wound
or laceration on Friday night, does the person need to receive
tetanus wound management that night or can it wait until Monday? |
|
| ACIP has not addressed this issue
specifically. Puncture wounds, however, should be attended to as
soon as possible. The decision to delay a booster dose of tetanus
toxoid-containing vaccine following an injury should be based on the
nature of the injury and likelihood that the injured person is
susceptible to tetanus. The more likely the person is to be
susceptible, the more quickly that tetanus prophylaxis should be
administered. A person with a tetanus-prone wound (e.g., punctures,
wounds contaminated with soil or fecal material) and who has no
history of tetanus immunization must be vaccinated and given tetanus
immune globulin (TIG) as soon as possible. A person with a
documented series of at least three tetanus toxoid-containing
products, with a booster dose within the previous 10 years ago is
less likely to be susceptible to tetanus, and the need for a booster
dose is not as urgent, particularly if the wound can be thoroughly
cleaned. The more likely a person is to be completely susceptible to
tetanus (i.e., unvaccinated or incompletely vaccinated), the sooner
that TIG and Td/Tdap should be administered, even if it means a trip
to the emergency department. |
|
| When should tetanus immune
globulin (TIG) be administered as part of wound management? |
|
| TIG is recommended for any wound
other than a clean minor wound if the person's vaccination history
is either unknown, or s/he has had less than a full series of 3
doses of Td vaccine. TIG should be given as soon as possible after
the injury. |
|
| How long after a wound occurs is
tetanus immune globulin no longer recommended? |
|
| In the opinion of the tetanus
experts at the CDC, for a person who has been vaccinated but is not
up to date, there is probably little benefit in giving TIG more than
a week or so after the injury. For a person believed to be
completely unvaccinated, it is suggested to increase this interval
to 3 weeks (i.e., up to day 21 post injury). Td or Tdap should be
given concurrently. |
|
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|
| How should DTaP, DT, Tdap, and Td
vaccines be stored? |
|
| Each of these products must be
stored at 35° to 46°F (2° to 8°C). They should not be frozen or
exposed to freezing temperatures. |
|
| Reviewed on 4/11 |
|
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