|
|
|
|
|
| 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, 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 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. 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 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 one-time 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
one-time 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 one-time 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. |
| • |
|
All pregnant women
who have not previously received Tdap should receive
a one-time dose of Tdap preferably during the third
trimester or late in the
second trimester (after 20 weeks gestation). If not
administered during pregnancy, it should be
administered immediately postpartum. To obtain the
recommendations, go to pages 1424—1426 of this
document:
www.cdc.gov/mmwr/pdf/wk/mm6041.pdf. |
|
|
| Aren't the recent 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. |
|
| 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. |
|
|
|
|
|
| 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. When feasible, the same brand
of DTaP vaccine should be used for all doses of 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? |
|
| 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. Despite these changes, errors are still
occurring.
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 the vaccine vial at least 3
times 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 years and
older, and Adacel (sanofi pasteur) is licensed for people ages 11
through 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. |
|
| 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 in 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.
|
Providers should not miss an opportunity to vaccinate adults age 65
and older with Tdap. Therefore, 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 11 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 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 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? |
|
| 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. |
| • |
|
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 CDC. Immunization of
Health-Care Personnel. MMWR 2011;60(No. SS-7):4-46 at
www.cdc.gov/mmwr/pdf/rr/rr6007.pdf. |
|
| 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 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.
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 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. |
| • |
|
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 one-time dose of Tdap is recommended for all adults. |
|
| 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 their one-time Tdap dose 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 Tdap be administered to pregnant
women? |
|
| In June 2011, after studying new safety and efficacy data, ACIP
voted to recommend that pregnant women who have never received the
Tdap vaccine be vaccinated
with Tdap during their third trimester or the second half of their
second trimester (after 20 weeks gestation) 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. If the vaccine is not
administered during pregnancy, it
should be administered immediately postpartum. On October 21, 2011,
CDC issued recommendations for use of Tdap in pregnant women. To
obtain the
recommendations, go to pages 1424—1426 of this document:
www.cdc.gov/mmwr/pdf/wk/mm6041.pdf. |
|
| 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 in the third
or late second trimester (after 20 weeks gestation). |
|
| 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. |
|
| How many doses of Tdap can we give
to a patient? |
|
| The vaccine is licensed for just one
dose. Subsequent doses (e.g., to complete the series or as 10-year
boosters) should be Td. |
|
| Who should get a second dose of Tdap
vaccine? |
|
| As of summer 2012, no one is recommended to receive more than 1 dose
of Tdap. In the future, ACIP will discuss the need for administering
additional doses of
Tdap and the timing of revaccinating people who have received Tdap
previously. |
|
| 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. |
|
|
|
|
|
| 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. |
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| 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. |
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| 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. |
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| 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. |
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| 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. |
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| Contraindications
and precautions to vaccine |
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| 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? |
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| 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 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). |
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Do the same precautions
that apply to DTaP also apply to Tdap? |
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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 |
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| 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-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 |
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|
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? |
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| 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? |
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|
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 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. |
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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. |
|
| 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. |
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| Reviewed on 7/12 |
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