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Diphtheria, Tetanus, Pertussis

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Diphtheria, Tetanus, Pertussis

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Diphtheria, Tetanus, Pertussis
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Disease Issues
Is pertussis in children still a problem? Which age groups are affected?
Since the 1980s, the number of reported pertussis cases has increased in children, adolescents and adults. The most recent overall peaks in disease were seen between 2010 and 2014. The incidence in all age groups has decreased since 2014 and preliminary surveillance data indicate that incidence declined precipitously during the COVID-19 pandemic in 2020 and 2021. In 2019, CDC received reports of more than 18,000 cases of pertussis, with preliminary estimates of 5,398 reported cases in 2020 and just 1,609 in 2021. COVID-19 control measures such as wearing masks in public, social distancing, and other interventions designed to reduce the spread of COVID-19 also helped reduce the spread of pertussis and other respiratory infections. However, with the discontinuation of these measures, the prevalence of infections like pertussis that are transmitted by respiratory droplets is likely to increase.
The incidence of pertussis remains highest in young infants. Approximately 1 in 10 U.S. pertussis cases were among infants. Infants are at greatest risk for serious disease and death from pertussis. 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 seen since the 1980s are not completely clear; however, multiple factors have likely contributed to the increase, including waning immunity from the pediatric acellular vaccine (DTaP), increased recognition of pertussis, and improved diagnostic testing and reporting.
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 a 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. 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/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf.
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?
Tdap vaccination status does not change the approach to evaluating postexposure prophylaxis when HCWs are exposed to pertussis. Tdap vaccines have an uncertain role in the prevention of transmission of pertussis and herd protection. Antipertussis antibody levels begin to decline precipitously after the first year following a single Tdap vaccination. Healthcare facilities should follow the post-exposure prophylaxis protocol for pertussis exposure recommended by CDC regardless of a HCW's vaccination status (see www.cdc.gov/pertussis/outbreaks/pep.html). HCW can either receive postexposure prophylaxis or be carefully monitored for 21 days after pertussis exposure. Health care personnel should be treated with antibiotics at the onset of signs and symptoms of pertussis and excluded from work for the first 5 days while receiving appropriate antibiotics. CDC supports targeting postexposure antibiotic use to people at high risk of developing severe pertussis, as well as people who will have close contact with others at high risk of developing severe pertussis.
If a person received a Tdap vaccine and then had a positive pertussis PCR two weeks later, could it be a false positive from the vaccine or should we consider this a case of pertussis? The patient had a cough, nausea, and vomiting for 2–3 days prior to PCR testing.
Recent Tdap vaccination does not affect PCR testing. PCR tests are used to detect DNA sequences of the Bordetella pertussis bacterium. PCR tests are very sensitive and could give a false positive result for other reasons. For more information on the interpretation of pertussis diagnostic tests, see www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-confirmation.html.
Vaccine Recommendations Back to top
Where can I find the most recent recommendations for use of pediatric diphtheria-tetanus-acellular pertussis (DTaP) and adolescent/adult tetanus-diphtheria-acellular pertussis (Tdap) vaccine?
In April 2018, the Advisory Committee on Immunization Practices (ACIP) published a compilation of all previous recommendations for the prevention of pertussis, tetanus, and diphtheria (MMWR 2018;678 [RR-2]:1-31). The document can be accessed on the CDC website at www.cdc.gov/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf.
In January 2020, ACIP published updated Tdap recommendations, stating that either Td or Tdap may be used in situations where Td only was previously recommended. The document can be accessed on the CDC website at www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf.
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 age 7 and older?
The most current ACIP recommendations for Tdap can be accessed here at www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf.
A listing of the recommendations follows:
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 age 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 single dose of Tdap. If needed, they should complete their series with Td or Tdap. If a Tdap dose is administered at age 10 years or older, the Tdap dose may count as the adolescent Tdap dose.
  All healthcare personnel, 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 adults should receive Tdap during each pregnancy, preferably between 27- and 36-weeks' gestation. Mothers who have never received Tdap and who do not receive it during pregnancy should receive it immediately postpartum.
  Tdap may be administered in any situations where Td only was previously recommended.
  After receiving an initial dose of Tdap, either Tdap or Td can be used to fulfill the decennial (every 10 years) Td booster dose recommendation.
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. The most effective way to prevent pertussis in early infancy is to vaccinate the mother between 27 and 36 weeks' gestation. Antipertussis antibodies generated by the mother's immune system are passed across the placenta to the fetus. One dose of Tdap should be administered during each pregnancy, preferably between 27 and 36 weeks' gestation. Available data suggest that vaccinating closer to 27 weeks will maximize passive antibody transfer to the infant. A CDC evaluation found Tdap vaccination during the third trimester of pregnancy prevents 78% of pertussis cases in infants younger than 2 months of age and that maternal vaccination reduces the risk of infant hospitalization for pertussis by 90% (www.cdc.gov/pertussis/pregnant/hcp/vaccine-effectiveness.html).
My 11-year-old patient received a dose of Tdap when he was 7 years old. He also received a dose of Td 6 months later in order to finish a primary series of tetanus-toxoid. Can I give him a dose of Tdap now?
Yes. The January 2020 ACIP updated statement on the use of Tdap (available at www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf) states that a child who receives a dose of Tdap from age 7–9 years as part of the catch-up series (as in this case), should receive another dose of Tdap at age 11 or 12 years.
A 16-year-old refugee's record indicates 2 doses of Td separated by 1 month and 1 dose of Tdap given 4 months after the second Td. Is he up to date?
The first two doses of Td are valid because they are separated by at least 4 weeks. However, the minimum interval between the second and third doses of tetanus- containing vaccine is 6 calendar months. So, the Td component of the Tdap dose is not valid because it was given only 4 months after the second dose. The pertussis component can be counted as valid. The patient should receive another dose of Td or Tdap 6 months after the invalid Tdap dose.
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 (Adacel, Sanofi; Boostrix, GSK) at age 11–12 years receive their next dose of Td or Tdap?
As of January 2020, ACIP recommends that Td or Tdap may be administered in any situation when only Td vaccine was previously recommended. Someone who received a dose of Tdap at age 11 or 12 years should receive a booster dose of Td or Tdap vaccine ten years later, unless tetanus prophylaxis is required sooner due to an injury or if Tdap vaccination is needed during pregnancy.
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 or Tdap 4–8 weeks later, and dose #3 of Td or Tdap 6–12 months after dose #2).
My 11-year-old patient inadvertently received a dose of Td instead of Tdap. He received a 5-dose series of DTaP in childhood. Do I need to wait a specific interval before giving him Tdap?
No. Tdap should be administered as soon as possible.
I have a pregnant patient who is 26 weeks along and received a Tdap vaccine 2 1/2 months ago because of healthcare employment. Normally we give our pregnant patients Tdap between 27–36 weeks as recommended. Should we give her another dose of Tdap when she reaches 27 weeks gestation?
The Advisory Committee on Immunization Practices does not recommend Tdap more than once during a pregnancy. The Tdap she received earlier in pregnancy may not provide optimal protection from pertussis for the infant, but some protection is expected. More information can be found at www.cdc.gov/vaccines/pregnancy/pregnant-women/tdap.html.
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 [Sanofi] and Infanrix [GSK]). 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 the ACIP's General Best Practices Guidance for Immunization at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html).
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. May we stock only Tdap vaccine under the updated Tdap CDC recommendations?
Yes. The updated ACIP recommendations for the use of Tdap vaccine state that Tdap or Td may be used in any situation where Td only was previously recommended. The updated guidelines are available at www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf.
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 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 or Tdap 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.
  Tdap or DTaP given to a fully vaccinated child age 7–9 years: the child should receive the routine adolescent Tdap dose at age 11–12 years.
  Tdap or DTaP given to a fully vaccinated child age 10 years: count this dose as the routine adolescent Tdap dose recommended at age 11–12 years.
  DTaP given to an undervaccinated child age 7–9 years: count this dose as a Tdap dose of the catch-up series. The child should receive the routine adolescent booster dose of Tdap at age 11–12 years.
  DTaP given to an undervaccinated child age 10 years: count this dose as the routine adolescent Tdap dose recommended at age 11–12 years.
  DTaP given to a person age 11 years or older: count this dose as a routine Tdap dose.
Note that DTaP is neither approved nor recommended for people older than 6 years (except hematopoietic stem cell transplant recipients in some situations; see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html).
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.
The same principle applies to Vaxelis (DTaP-IPV-Hib-HepB, MCM), which is licensed for use in children ages 6 weeks through 4 years as a 3-dose series of vaccinations routinely recommended at age 2 months, 4 months, and 6 months. The DTaP in a dose of Vaxelis inadvertently administered after the 5th birthday or as the 4th or 5th dose of DTaP (off-label use) may be counted as valid and does not need to be repeated.
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 (GSK) 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!
Updated ACIP recommendations for the use of Tdap were published in April 2018 (available at www.cdc.gov/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf) and January 2020 (available at www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf). 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 or Tdap every 10 years for routine booster immunization against tetanus and diphtheria, according to previously published guidelines. A dose of Tdap should be administered during each pregnancy, preferably early in the 27 week through 36 week gestation time period.
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.
ACIP states that children up to date on vaccines who receive a Tdap vaccine when 7–9 years old should receive another Tdap dose at age 11 or 12 years old. What about a child who is 10 years old?
Tdap vaccination for adolescents is recommended at age 11–12 years. A 10-year-old who is already up to date on diphtheria/tetanus/pertussis vaccines and gets a Tdap vaccine for any reason does not need to receive another Tdap at age 11–12 years.
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 conditions previously considered to be 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) did not apply to Tdap. These conditions are also no longer considered to be precautions to DTaP. This issue is addressed in the current ACIP statement, available at www.cdc.gov/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf, page 3.
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. He has never had a tetanus-diphtheria-acellular pertussis (Tdap) vaccine. Can we give him a Tdap vaccine now?
Yes. There is no need to observe any minimum interval between doses of Td and Tdap except when administered as part of a catch-up primary series of tetanus vaccine.
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 giving a dose of Tdap to children age 7–10 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. Children age 7–10 who require more than one dose of tetanus-containing vaccine to be up to date may be given either Td or Tdap for doses needed after the initial Tdap dose. 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 or Tdap, 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 or Tdap 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 or Tdap 6 calendar months after the Tdap dose. A routine Td or Tdap booster should be administered every 10 years. See Immunize.org's handout: DTaP, Tdap, and Td Catch-up Vaccination Recommendations by Prior Vaccine History and Age: www.immunize.org/catg.d/p2055.pdf.
According to the ACIP recommendations, which healthcare personnel 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 may be administered in any situations where Td only was previously recommended. After receipt of Tdap, HCP should receive routine booster immunization against tetanus and diphtheria with either Td or Tdap vaccine. Additionally, pregnant HCP should receive a dose 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 updated recommendations on the use of Td or Tdap in situations where only Td was previously recommended, go to www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a5-H.pdf. For details about Tdap 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?
There is no minimum period to wait to correct your error. 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 dose of Tdap be given to all adults, including those age 65 years or older.
Please review the current recommendations for the use of Tdap in adults.
ACIP recommends the following:
All adults age 19 years and older who have not yet received a dose of Tdap should receive a dose.
  All pregnant people should receive a dose of Tdap during each pregnancy, preferably between 27 and 36 weeks' gestation. Mothers who have never received Tdap and who do not receive it during pregnancy should receive it immediately postpartum.
  A person who has not yet received a dose of Tdap can be given a dose of Tdap 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 age 65 years and older with Tdap. When feasible, give Boostrix to adults age 65 and older. However, either vaccine product (Adacel or Boostrix) 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.
  For adults who have received an initial dose of Tdap, Tdap may be administered in any situations where Td only was previously recommended, including as the decennial (every 10-years) booster dose.
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 dose of Tdap is recommended for all adults. In addition, Tdap may be administered in any situations where Td only was previously recommended.
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 or Tdap in 1 to 2 months, followed by a Td or Tdap in 6 to 12 months, and then a Td or Tdap 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. ACIP recommends that Tdap or Td may be used in situations when only Td was previously recommended. Be sure to document doses administered in your state's immunization information system so other healthcare providers will have access to the record of immunization and a primary series will not need to be repeated in the future.
If a teen or adult patient never received Tdap but received a dose of Td vaccine 2 years ago, should I wait 8 more years before administering a dose of Tdap to the patient?
No. ACIP recommends that people age 11 years and older who have not yet received Tdap receive a dose of Tdap now. ACIP specifies no waiting interval between administering Td and Tdap.
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.
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?
Vaccination of the parents against pertussis after the baby is born is not optimal, but it may be helpful and should be done if the parents have not previously received Tdap, regardless of when they last received Td vaccination. It takes about 2 weeks after Tdap receipt for the parents to have protection against pertussis. Once the parents have protection, they are is less likely to transmit pertussis to the infant. However, the newborn remains at risk of contracting pertussis from others, including siblings, grandparents, and other caregivers. They should be counseled about the importance of Tdap vaccination of the mother during future pregnancies. See CDC's web page for more information: www.cdc.gov/pertussis/pregnant/hcp/pregnant-patients.html.
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?
Revaccination of individuals who are up to date on Tdap immunization with an additional dose of Tdap during a pertussis outbreak is currently not recommended.
Tdap and Pregnancy Back to top
Can Tdap be administered during pregnancy?
Yes. Tdap vaccination is routinely recommended to be given at 27 through 36 weeks' gestation during every pregnancy. This CDC recommendation is endorsed by the American College of Obstetricians and Gynecologists (ACOG), the American College of Nurse-Midwives (ACNM), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Tdap given during one pregnancy will not provide sufficient protection for subsequent pregnancies. In June 2011 ACIP first voted to recommend that pregnant people who have never received the Tdap vaccine be vaccinated to optimize the concentration of maternal antibodies transferred to the fetus. ACIP made this recommendation with the goal of protecting newborns with maternal antibodies and decreasing the risk of transmission of pertussis to infants shortly 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. Mothers who have never received Tdap and who do not receive it during pregnancy should receive it immediately postpartum.
Fewer babies are hospitalized for pertussis when Tdap is given during pregnancy rather than during the postpartum period. A large U.S. study found an 85% reduction in the risk of pertussis in infants under 2 months of age whose mothers were vaccinated with Tdap at 27 through 36 weeks' gestation, compared to infants whose mothers were vaccinated in the hospital immediately following delivery.
When a mother gets Tdap during pregnancy, maternal pertussis antibodies transfer to the newborn, protecting the baby against pertussis in early life, before the baby is old enough to have received vaccination with DTaP. Tdap also protects the mother, making it less likely that she will get infected with pertussis during or after pregnancy.
Recommendations for the use of Tdap in pregnancy are covered in detail here: www.cdc.gov/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf, pages 22–23.
How effective is giving Tdap during pregnancy at preventing pertussis in early infancy?
A CDC evaluation found Tdap vaccination during the third trimester of pregnancy prevents 78% of pertussis cases in infants younger than 2 months of age. These findings are similar to other studies from the United Kingdom and the United States that suggest that vaccinating the mother during pregnancy is highly effective at protecting infants against pertussis.
When infants do get pertussis, their infection is less severe if their mother received Tdap during pregnancy. A CDC evaluation found maternal vaccination is 90% effective at preventing infant hospitalization from pertussis. Another U.S. study showed that infants whose mothers got Tdap during pregnancy had a significantly lower risk of hospitalization and shorter hospital stays. That same study showed that no infants born to vaccinated mothers required intubation or died of pertussis.
Links to published research on Tdap vaccination during pregnancy are available here: www.cdc.gov/pertussis/pregnant/research.html.
My patient is a woman who recently gave birth. She 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 person 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 at least 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 pregnancies are closely spaced. Should we give Tdap during each pregnancy, even if it means mothers 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 those in the U.S. 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 people who have two pregnancies have an interval of 13 months or more between births. Approximately 5% of mothers 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 mothers would receive only 2 doses of Tdap, and (3) a small proportion of mothers would receive 4 or more doses.
A theoretical risk exists for severe local reactions (e.g., Arthus reactions, whole limb swelling) for pregnant people 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 mother received Tdap in early pregnancy, should another dose be given 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 that stage of pregnancy is best for transplacental antibody movement to the fetus.
More information is available at www.cdc.gov/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf, pages 22–23.
Each time there is a pregnancy in the family, should fathers and other family members receive a Tdap booster?
ACIP does not recommend repeated doses of Tdap for fathers or other family members or caregivers of infants during every pregnancy. The recommendation for Tdap vaccination with each pregnancy to optimize immunity for the infant applies only to the pregnant mother.
The practice of "cocooning" infants by making a particular effort to vaccinate caregivers who have not received Tdap vaccination has been recommended by ACIP since 2005; however, the practice has been difficult to implement fully and may not be effective alone as a strategy for protecting newborns from pertussis exposure. The combined strategy of Tdap vaccination during each pregnancy, cocooning, and administering the childhood DTaP series on schedule provides the best protection to the infant.
At what gestational age of pregnancy should we vaccinate mothers 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, preferably during the early part of that window. However, Tdap can be administered at any time during pregnancy.
If a pregnant person got a dose of Td during pregnancy, how soon can the mother get a dose of Tdap?
While the mother should have been given Tdap rather than Td, the Tdap dose may be given 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 (preferably early in that window). For more information, see www.cdc.gov/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf, pages 22–23.
Is there any contraindication to administering Tdap vaccine and Rhogam at the same time during pregnancy?
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, age 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 or Tdap for dose #2, followed at least 6 months later by Td or Tdap for dose #3. The amount of protection provided by one or more doses of Tdap in a person who has not previously received pertussis vaccine is not known. Following the primary series, booster doses of Td or Tdap 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 of DTaP: if the child has turned seven years old, you may administer a dose of Tdap vaccine at that time.
A 7-year-old has a history of 3 doses of DTaP, appropriately spaced, between 4 years and 6 years of age. Is her DTaP series complete?
Although the child would be considered complete for tetanus and diphtheria toxoids, she is not complete for pertussis vaccine. DTaP vaccines are FDA-approved only through age 6 years so no more DTaP doses are recommended.
However, ACIP recommends that children age 7–10 years who are not fully vaccinated against pertussis (defined as 5 doses of DTaP or 4 doses of DTaP if the fourth dose was administered on or after the fourth birthday) and who do not have a contraindication to pertussis vaccine should receive a single dose of Tdap to provide protection against pertussis. If the child in this case is age 7–9 years at the time of Tdap vaccination, the next dose due will be the routine adolescent dose of Tdap at age 11 or 12 years. If the child is age 10, the dose counts as the adolescent dose and no additional dose at age 11 or 12 years is recommended.
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 DTaP is not contraindicated and 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.
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?
Precautions to these vaccines include:
A history of Guillain-Barré syndrome (GBS) within 6 weeks of receiving a tetanus toxoid-containing vaccine
  A history of Arthus-type hypersensitivity reaction after receiving a previous tetanus or diphtheria toxoid-containing vaccine (defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine)
  A moderate or severe acute illness with or without fever
  For pertussis-containing vaccines (DTaP and Tdap only): an additional precaution is a progressive or unstable neurologic disorder, including infantile spasms, uncontrolled seizures or progressive encephalopathy. DTaP and Tdap should be deferred until the neurologic status of the patient is clarified and stabilized.
Is it acceptable to give breastfeeding mothers Tdap vaccine?
Yes. Mothers 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 Best Practice Guidelines for Immunization at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html for more information on this issue.
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, GSK) 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 DTaP as a child?
This depends on the contraindication or precaution the person had to DTaP.
The contraindications are (1) severe allergic reaction (e.g., anaphylaxis after a previous dose or to a vaccine component) and (2) encephalopathy within 7 days of a previous dose of DTaP or DTP; in these cases, give Td instead of Tdap.
The precautions for which Tdap vaccination may be delayed or for which the balance of individual risks and benefits should be weighed are
moderate or severe acute illness (defer until recovered);
  history of an Arthus-type hypersensitivity reaction following a previous dose of tetanus or diphtheria toxoid-containing vaccines, including MenACWY-D or MenACWY-TT (Menactra or MenQuadfi, Sanofi Pasteur) (defer vaccination until at least 10 years have elapsed since the last tetanus-toxoid-containing vaccine);
  Guillain-Barré syndrome (GBS) 6 weeks or sooner after a previous dose of tetanus toxoid-containing vaccine; and
  progressive or unstable neurologic disorder, uncontrolled seizures or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized.
ACIP has published a Guide to Vaccine Contraindications and Precautions in its General Best Practice Guidelines for Immunization, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html.
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 Immunize.org'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/hcp/acip-recs/general-recs/contraindications.html.
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 severe allergy (e.g., anaphylaxis) 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
What is the dosing for tetanus immune globulin for an adult with suspected tetanus?
ACIP recommends a single dose of tetanus immune globulin (TIG) for treatment of persons with tetanus. Although the optimal therapeutic dose has not been established, experts recommend 500 international units (IU), which appears to be as effective as higher doses ranging from 3,000 to 6,000 IU and causes less discomfort. Available preparations must be administered intramuscularly; TIG preparations available in the United States are not licensed or formulated for intrathecal or intravenous use. Infiltration of part of the dose locally around the wound is usually recommended if feasible, although the efficacy of this approach has not been proven. If TIG is not available, intravenous immune globulin (IGIV) can be used at a dose of 200 to 400 milligrams per kilogram (mg/kg). However, the Food and Drug Administration (FDA) has not approved IGIV for this use. In addition, anti-tetanus antibody content varies from lot to lot. See www.cdc.gov/tetanus/clinicians.html for more information on this issue.
When a patient seen in the ER needs tetanus protection, which type of tetanus vaccine should be given?
Children age 7–10 years should receive Tdap if they are not fully vaccinated for prevention of pertussis. Otherwise they may receive Td or Tdap. If additional doses are necessary for full tetanus protection, they may be administered as Td or Tdap. Adolescents, and adults age 11 years and older should receive a single dose of Tdap, if they have not received a dose of Tdap after the 11th birthday, otherwise they may receive Td or Tdap. If additional doses are necessary for full tetanus protection, they may be administered as Td or Tdap.
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 an adult 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 Tetanus Prophylaxis for Wound Management section of the current ACIP statement, available at www.cdc.gov/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf, pages 27–28. 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 the person has not had a full series of 3 doses of tetanus-containing vaccine. People with HIV infection or severe immunodeficiency who have contaminated wounds (including minor wounds) should also receive TIG, regardless of their history of tetanus immunizations. TIG should be given as soon as possible after the injury. The dose is 250 IU administered intramuscularly. See CDC's web page for details: www.cdc.gov/tetanus/clinicians.html#wound-management.
How long after a wound occurs is tetanus immune globulin (TIG) no longer recommended?
The incubation period of tetanus ranges from 3 to 21 days, averaging about 10 days. In general, the further the injury site is from the central nervous system, the longer the incubation period. 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 with TIG.
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.
Back to top
This page was updated on April 24, 2022.
This page was reviewed on March 31, 2022.
 
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