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Diphtheria, Tetanus, Pertussis

Ask the Experts: Diseases & Vaccines

Diphtheria, Tetanus, Pertussis

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Diphtheria, Tetanus, Pertussis
Disease Issues Scheduling Vaccines
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Vaccine Products Tetanus and Wound Management
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Disease Issues
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; however, multiple factors have likely contributed to the increase, including waning immunity from the acellular vaccine (DTaP), increased recognition of pertussis, and improved diagnostic testing and reporting.
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 life-long. 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. 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 (see www.cdc.gov/pertussis/outbreaks/guide/index.html). 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.
Vaccine Recommendations Back to top
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 in children and adults ages 7 and older?
In response to an increased incidence of pertussis in the U.S., ACIP has issued 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 single dose of Tdap (instead of Td) at the 11–12-year-old visit.
  Adolescents and adults who have not received a dose of Tdap, or for whom vaccine status is unknown, should receive a single dose of Tdap as soon as feasible. As stated above, Tdap can be administered regardless of interval since the previous Td dose.
  Children ages 7 through 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 single dose of Tdap. If needed, they should complete their series with Td.
  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.
  Pregnant teens and women should receive Tdap during each pregnancy, preferably between 27 and 36 weeks' gestation. Women who have never received Tdap and who do not receive it during pregnancy should receive it immediately postpartum. To obtain the recommendations, go to www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm.
My 7-year-old patient has had only 1 dose of tetanus toxoid-containing vaccine at 11 months of age (a dose of DTaP). The catch-up schedule says he needs 3 additional doses of tetanus toxoid-containing vaccine (4 total). Why 4? If he were completely unvaccinated on the seventh birthday, he would only need a total of 3 doses.
If the first dose of a tetanus toxoid-containing vaccine is administered before the first birthday, 4 doses are necessary before beginning the 10-year cycle of booster doses. If the first dose is administered after the first birthday, 3 doses are necessary. The final dose should be spaced 6 months from the previous dose.
When should adolescents who received a dose of Tdap (tetanus-diphtheria, pertussis-containing vaccine; Adacel, sanofi; Boostrix, GSK) at age 11–12 years receive their next dose of Td or Tdap?
Currently, ACIP recommends only one lifetime dose of Tdap for everyone with the exception of pregnant women for whom a dose is recommended during each pregnancy. Someone who received a dose of Tdap at age 11 or 12 should receive a booster dose of Td vaccine ten years later, unless tetanus prophylaxis is required sooner due to an injury.
Aren't the ACIP recommendations for 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.
We have a 63-year-old patient who states she had tetanus as a child. She does not know whether she ever had any tetanus-containing vaccines in her lifetime. Should Tdap be given to this patient, and is it safe?
A history of tetanus disease is not a reason to avoid tetanus-containing vaccines. Tetanus disease does not produce immunity because of the very small amount of toxin required to produce illness. As long as your patient has no other contraindications she should receive Tdap now. If she has no documentation of prior tetanus vaccination, she should receive a complete 3-dose primary series (dose #1 of Tdap, followed by dose #2 of Td 4 to 8 weeks later, and dose #3 of Td 6–12 months after dose #2).
Vaccine Products Back to top
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. If vaccination providers do not know or have available the type of DTaP vaccine previously administered to a child, any DTaP vaccine may be used to continue or complete the series. For vaccines in general, vaccination should not be deferred because the brand used for previous doses is not available or is unknown (see page 10 of the ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf).
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?
If Tdap was inadvertently administered to a child under age 7 years, 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 the vaccine vial at least 3 times before administering any vaccine.
If a six-year-old child is due for the fifth dose of DTaP and inadvertently receives Tdap, I know that this dose counts as the fifth dose of DTaP. But should this child receive another dose of Tdap at age 11–12 years?
Yes. In this situation, a second dose of Tdap should be administered at the recommended age of 11 or 12 years.
We would like to avoid stocking both Tdap and Td vaccines. Is CDC likely to recommend that Tdap completely replace Td in the immunization schedule in the near future?
Currently, ACIP recommends giving only 1 dose of Tdap to adolescents and adults who have not previously received the vaccine, with the exception of pregnant women, who should be vaccinated during each pregnancy. ACIP is unlikely to recommend routine Tdap revaccination for groups other than pregnant women. Therefore, medical settings will need to continue to stock Td vaccine in order to administer it to patients who need to complete the full primary 3-dose tetanus and diphtheria series and also to administer 10-year booster doses of Td throughout the lifetime of those who have completed the primary series. Note that if a person who previously received Tdap needs a booster dose of Td (as a routine booster dose or for wound management) it is acceptable to administer Tdap if Td is not available.
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.
A dose of Kinrix (DTaP-IPV; GSK) should have been administered to a 4-year-old, but Pentacel (DTaP-IPV-Hib; Sanofi Pasteur) was administered instead. Does the dose of DTaP count?
Yes. The DTaP in the Pentacel can be counted. Although Pentacel is licensed as a 4-dose series and this may represent a fifth dose of Pentacel (in which case it would be off-label use), the dose of DTaP counts as the fifth dose of DTaP.
Tdap for Adolescents and Adults Back to top
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 years and older, and Adacel (sanofi pasteur) is licensed for people ages 10 through 64 years. The two vaccines also contain a different number of pertussis antigens and different concentrations of pertussis antigen and diphtheria toxoid.
I am confused about which adults to vaccinate with Tdap vaccine and which product to use. Please help!
CDC published updated recommendations on Tdap vaccination for adults in the MMWR on June 29, 2012. ACIP recommends that ALL adults age 19 years and older who have not yet received a dose of Tdap receive a single dose. Tdap should be administered regardless of interval since the last tetanus or diphtheria toxoid-containing vaccine (e.g., Td). After receiving Tdap, people should receive Td every 10 years for routine booster immunization against tetanus and diphtheria, according to previously published guidelines. Pregnant women should receive Tdap during each pregnancy.
Providers should not miss an opportunity to vaccinate adults age 65 and older with Tdap. Providers may administer any Tdap vaccine they have available. When feasible, providers should administer Boostrix (GSK) to adults age 65 and older as it is licensed for this age group. Adacel (sanofi) is licensed for use in people age 10 through 64. However, ACIP concluded that either vaccine administered to a person age 65 or older is immunogenic and will provide protection. A dose of either vaccine is considered valid.
When a tetanus toxoid-containing vaccine is needed for wound management in a person who has not previously received Tdap, the use of Tdap is preferred over Td.
We see many 10-year-olds for middle school entry immunization. Is one brand of Tdap preferred for this age group?
No. In March 2014, FDA lowered the age indication for Adacel brand Tdap vaccine (sanofi) from age 11 years to age 10 years. Both Tdap products, Adacel and Boostrix (GSK), now have the same lower age indication.
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 addition, ACIP recommends 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 dose of Tdap 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/schedules/index.html).
A 16-year-old has a written record of receiving two doses of DTaP at 2 and 5 months of age and one dose of Tdap at 15 years of age. Since she has had three doses of pertussis-containing vaccine, would she still need two additional doses of Td?
Since the first DTaP was received before 12 months of age and one Tdap dose has been given, this person needs one dose of Td 6 calendar months after the Tdap dose. A routine Td booster should be administered every 10 years. See IAC's new handout: DTaP, Tdap, and Td Catch-up Vaccination Recommendations by Prior Vaccine History and Age.
According to the ACIP recommendations, which healthcare workers should be vaccinated against pertussis with tetanus-diphtheria-acellular pertussis (Tdap) vaccine?
ACIP recommends the following 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. Pregnant HCP should receive additional doses of Tdap during each pregnancy.
  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 view this and other recommendations for healthcare personnel, go to "Immunization of Health-Care Personnel" (MMWR 2011;60[SS-7]:4-46) at www.cdc.gov/mmwr/pdf/rr/rr6007.pdf.
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 of any age 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. 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 single dose of Tdap be given to all adults, including those age 65 years or older, especially adults who have or anticipate having close contact with an infant younger than age 12 months (e.g., grandparents, childcare providers).
Please review the current recommendations for the use of Tdap in adults.
ACIP recommends the following:
All adults ages 19 years and older who have not yet received a dose of Tdap should receive a single dose.
  All pregnant women should receive a dose of Tdap during each pregnancy, preferable between 27 and 36 weeks' gestation. Women who have never received Tdap
and who do not receive it during pregnancy should receive it immediately postpartum.
  The Tdap dose can be given regardless of the interval since the person last received a tetanus or diphtheria toxoid-containing vaccine.
  Providers should not miss an opportunity to vaccinate adults ages 65 years and older with Tdap. When feasible, give Boostrix to adults age 65 and older.
However, either vaccine product provides protection and is considered valid for use in people in this age group.
  For adults not previously vaccinated with Tdap who need wound management care to prevent tetanus, Tdap is preferred over Td.
Is there an upper age limit for Tdap administration? For example, should I vaccinate an 85-year-old?
There is no upper age limit for Tdap vaccination. A single dose of Tdap is recommended for all adults.
For a person entering a long-term-care facility at age 70 or older, if we cannot document that the resident has had a primary series of three doses of tetanus-containing vaccine, is the right course of action upon admission to give a Tdap first, then a Td in 1 to 2 months, followed by a Td in 6 to 12 months, and then a Td booster every 10 years?
Your understanding of the general Td/Tdap recommendation is correct, and this is the schedule that should be followed for persons 7 years old and older who have never received tetanus-containing vaccine or who cannot provide documentation of prior vaccination. Be sure to document doses administered so a primary series does not need to be repeated in the future.
If a teen or adult patient received a dose of Td vaccine 2 years ago, should I wait approximately 8 more years before administering a dose of Tdap to the patient?
No. ACIP recommends that people age 11 through 64 who have not yet received Tdap receive a single dose of Tdap now. ACIP specifies no waiting interval between administering Td and Tdap to anyone in this age group. Adults age 65 years and older do not need to delay Tdap vaccination following Td either.
If a teen or adult mistakenly received a dose of Td when they should have received Tdap, what is the optimal time to give the missing Tdap dose?
As soon as possible, even if it is the same day.
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.
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. Preferably, they should be vaccinated before the infant is born.
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.
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 as Tdap, but take measures to prevent this error in the future. The patient does not need a repeat dose of Tdap.
A pertussis outbreak is occurring in our town, with many cases happening in the schools. Is there a recommendation for boosting middle-and high-school students with an additional dose of Tdap during an outbreak if students have already had 1 dose?
Currently, ACIP recommends only 1 lifetime dose of Tdap for everyone except pregnant women. Revaccination with Tdap during a pertussis outbreak is currently not recommended.
Tdap and Pregnancy Back to top
Can Tdap be administered to pregnant women?
Yes. In June 2011 ACIP voted to recommend that pregnant women who have never received the Tdap vaccine be vaccinated to optimize the concentration of maternal antibodies transferred to the fetus. ACIP made this recommendation in response to the continuing pertussis outbreak, with the goal of protecting newborns with maternal antibodies and decreasing the risk of transmission from mother to infant after birth. In October 2016, ACIP voted to recommend administering Tdap vaccination early in the 27- through 36-week “window” to maximize passive antibody transfer to the infant. Women who have never received Tdap and who do not receive it during pregnancy should receive it immediately postpartum.
When a woman gets Tdap during pregnancy, maternal pertussis antibodies transfer to the newborn, likely protecting the baby against pertussis in early life, before the baby is old enough to have received at least 3 doses of DTaP. Tdap also protects the mother, making it less likely that she will get infected with pertussis during or after pregnancy and thus less likely that she will transmit it to her infant.

The recommendations for the use of Tdap in pregnancy were published in the February 22, 2013 issue of MMWR. To access the new recommendations, visit www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm.
If a woman did not receive Tdap during pregnancy, and it is uncertain whether she received a dose of Tdap prior to her pregnancy, should she receive a dose of Tdap postpartum?
Yes. If there is no written documentation that she received a dose of Tdap prior to or during pregnancy, a dose of Tdap should be administered to her immediately postpartum.
If there is no documentation of a pregnant woman ever receiving Td or Tdap, what schedule should we follow?
The recommended schedule for the primary series given to an unvaccinated person is dose 1 now, dose 2 in 4 weeks, and dose 3 in 6 to 12 months. Tdap should replace 1 dose of Td, preferably between 27 and 36 weeks' gestation to maximize the maternal antibody response and passive antibody transfer to the infant.
Some women have closely spaced pregnancies. Should we give Tdap during each pregnancy, even if it means such women would get 2 doses within 12 months?
Yes. ACIP looked into this issue and included related information in its recommendations published in MMWR on February 22, 2013 (www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm). ACIP reviewed available data on birth statistics and found that among U.S. women who have more than one pregnancy, a very small percentage (2.5%) have an interval of 12 months or less between births. The majority of women who have two pregnancies have an interval of 13 months or more between births. Approximately 5% of women have four or more pregnancies. ACIP concluded that (1) the interval between subsequent pregnancies is likely to be longer than is the persistence of maternal anti-pertussis antibodies, (2) most women would receive only 2 doses of Tdap, and (3) a small proportion of women would receive 4 or more doses.
A theoretical risk exists for severe local reactions (e.g., arthus reactions, whole limb swelling) for pregnant women who have multiple, closely spaced pregnancies. However, the frequency of side effects depends on the vaccine's antigen content and product formulation, as well as on preexisting maternal antibody levels related to the interval since the last dose and the number of doses received. The risk for severe adverse events has likely been reduced with current vaccine formulations (including Tdap), which contain lower doses of tetanus toxoid than did older vaccine formulations. ACIP believes the potential benefit of preventing pertussis morbidity and mortality in infants outweighs the theoretical concerns of possible severe adverse events in mothers.
If a woman received Tdap in early pregnancy, should she get it again in the third trimester?
No, it is not recommended to give another dose of Tdap in such cases. Optimal timing for Tdap administration is between 27 and 36 weeks' gestation because of transplacental antibody kinetics.
According to ACIP recommendations published in MMWR on February 22, 2013, "Tdap may be administered any time during pregnancy, but vaccination during the third trimester would provide the highest concentration of maternal antibodies to be transferred closer to birth." More information is available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm.
Each time there is a pregnancy in the family, should fathers and other family members receive a Tdap booster to ensure adequate protection and boost the cocoon effect to protect the newborn from pertussis?
At this time, ACIP does not recommend additional doses of Tdap for fathers or other family members or caregivers. The multiple Tdap recommendation to optimize immunity for the infant applies only to the pregnant woman.
At what gestational age of pregnancy should we vaccinate pregnant women with Tdap?
To maximize maternal antibody response and passive antibody transfer to the infant, the optimal time to administer Tdap is between 27 and 36 weeks' gestation. However, Tdap can be administered at any time during pregnancy. Previously, CDC had recommended that Tdap vaccination occur after 20 weeks' gestation.
We intend to start vaccinating family contacts of pregnant women with Tdap to protect the newborn. Can you tell me how long it takes for the Tdap vaccine to provide protection?
To best protect infants, CDC recommends that teens and adults who haven't been vaccinated receive Tdap 2 weeks or more before having contact with an infant. If a 2-week time frame is not available prior to coming into contact with an infant, administer the vaccine as soon as possible.
If a pregnant woman got a dose of Td during pregnancy, how soon can she get her dose of Tdap?
While she should have been given Tdap rather than Td, she can receive her Tdap dose at any interval since the Td dose was given and preferably between 27 and 36 weeks gestation.
A 17-year-old received a dose of Tdap vaccine when she was 12 years old. She is now pregnant. Should she get another dose of Tdap vaccine?
Yes. ACIP recommends a dose of Tdap during each pregnancy irrespective of the patient's prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation. For more information, see www.cdc.gov/mmwr/pdf/wk/mm6207.pdf, page 131.
Who should get a second dose of Tdap vaccine?
Only pregnant women are recommended to receive more than 1 dose of Tdap. ACIP has not recommended Tdap revaccination for any other group including healthcare providers.
Is there any contraindication to administering Tdap vaccine and Rhogam at the same time to a pregnant woman?
No. Tdap is an inactivated vaccine and may be administered at the same time as Rhogam (in a separate site with a separate syringe).
Scheduling Vaccines Back to top
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. The minimum age of 12 months for the fourth dose must be met. 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.
I've heard that ACIP and AAP have different recommendations for spacing Tdap and meningococcal conjugate vaccine if they are not given simultaneously. Please discuss.
This is no longer the case. The ACIP's 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. The AAP also recently stated that "simultaneous administration of Tdap and all other recommended vaccines is recommended when feasible. Vaccines should not be mixed in the same syringe. Other indicated vaccines that are not available and therefore cannot be given at the time of administration of Tdap can be given at any time thereafter." Some experts, however, 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.
There is a debate within my clinical department about not allowing influenza vaccine to be given with DTaP and PCV13. Are there data that state these should not be given concomitantly?
A CDC study has shown a small increased risk for febrile seizures during the 24 hours after a child receives the inactivated influenza vaccine at the same time as the PCV13 vaccine or DTaP vaccine. However, the risk of febrile seizure with any combination of these vaccines is small and ACIP recommends giving these vaccines at the same visit if indicated. See www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html for more information.
Contraindications and Precautions 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-Barré 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 or diphtheria toxoid-containing vaccines, including MCV4, 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).
Is it acceptable to give breastfeeding mothers Tdap vaccine?
Yes. Women who have never received Tdap and who did not receive it during pregnancy should receive it immediately postpartum or as soon as possible thereafter. Breastfeeding does not decrease the immune response to routine childhood vaccines and is not a contraindication for any vaccine except smallpox. Breastfeeding is a precaution for yellow fever vaccine and the vaccine can be given for travel when indicated.
Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal visit?
Tdap is an inactivated vaccine and may be given at the same prenatal visit with RhoGam. For more information on this topic, including the timing for the use of other vaccines with regards to RhoGam, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 9.
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.
Mom comes in with her 19-month-old. She reports that her (the mother’s) sibling has a history of a severe reaction to pertussis vaccine in the mid-1990s. Now mom is reluctant to give her child pertussis vaccine although the child received Pediarix (DTaP-HepB-IPV, GlaxoSmithKline) 2 months ago without incident. Should we be concerned about the mother’s family history of a severe reaction to pertussis vaccine?
A family history of a neurologic disorder or reaction to a pertussis-containing vaccine is not a contraindication to vaccination of this child. The child should receive additional DTaP doses as indicated in the catchup schedule.
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 tetanus or diphtheria toxoid-containing vaccines, including MCV4; (3) Guillain-Barré 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.
I have an adult patient with controlled epilepsy who wishes to receive the Tdap vaccine. May I vaccinate him?
Controlled epilepsy is not a contraindication to receipt of Tdap. To access IAC's table of vaccine contraindications and precautions, go to www.immunize.org/catg.d/p3072a.pdf. CDC also makes this information available at www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm.
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.
Is there guidance for pertussis protection for an adult who cannot receive the tetanus portion of the Tdap vaccine because of allergy?
Usually, an "allergy" to tetanus toxoid is anecdotal and not a true anaphylactic reaction to modern tetanus toxoid. Patients often claim to be allergic to tetanus toxoid because of (1) an exaggerated local reaction (which is not an allergy) or (2) a reaction to a tetanus vaccine received many years ago (probably serum sickness from equine tetanus antitoxin). A history of one of these events is not a contraindication to modern tetanus toxoid, Td, or Tdap.
Only an allergist-confirmed anaphylactic allergy to tetanus toxoid should be accepted as a valid contraindication to a modern tetanus-toxoid-containing product. A person who has an allergist-confirmed anaphylactic allergy to tetanus toxoid has no recourse for pertussis vaccination because no single-antigen pertussis vaccine is licensed for use in the United States.
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 post-exposure 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.
Tetanus and Wound Management Back to top
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 and older 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 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.
If a patient is receiving a tetanus-containing vaccine after an injury and there is no history of any prior tetanus vaccine (e.g., an Amish person who has previously declined vaccination), how much tetanus protection will one dose provide? Also, what is the time frame that the tetanus toxoid needs to be given following an injury?
One dose of tetanus toxoid-containing vaccine (Tdap or Td) provides little or no protection. That is why tetanus immune globulin (TIG) is also recommended in this situation. See “The Pink Book” section titled Wound Management at www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html. As far as timing, the toxoid and TIG should be given as soon as possible.
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.
Storage and Handling Back to top
How should DTaP, DT, Tdap, and Td vaccines be stored?
Each of these products must be stored at 2° to 8°C (36° to 46°F). They should not be frozen or exposed to freezing temperatures.
This page was updated on January 19, 2017.
This page was reviewed on December 14, 2016.
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