| Diphtheria, Tetanus, Pertussis |
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| Disease Issues |
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| Is
it true that pertussis in children is increasing? Are more infants
dying from the disease? |
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| Since the 1980s, the number of reported pertussis cases has
increased. These increases have been noted in both infants younger
than age 1 year, particularly
among infants younger than age 6 months; adolescents age 11–18
years, and adults. An increase in the number of reported deaths from
pertussis among very
young infants has paralleled the increase in the number of reported
cases. Reasons for the increases in pertussis are not completely
clear; however, multiple
factors have likely contributed to the increase, including waning
immunity from the acellular vaccine (DTaP), increased recognition of
pertussis, and
improved diagnostic testing and reporting. |
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| 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? |
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| 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. |
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| Can a child or an adult who has had
pertussis get the disease again? |
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| Reinfection appears to be uncommon, but does occur. Reinfection may
present as a persistent cough rather than typical pertussis. |
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| Should further doses of pertussis
vaccine be given to an infant or child who has had culture-proven
pertussis? |
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| 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.) |
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| 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? |
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| 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. |
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| 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? |
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| You should follow the post-exposure prophylaxis protocol for
pertussis exposure recommended by CDC (see www.cdc.gov/pertussis/outbreaks/guide/index.html).
Research is needed to evaluate the effectiveness of Tdap to prevent
pertussis in healthcare settings. Until studies define the optimal
management of exposed
vaccinated healthcare personnel, or experts arrive at consensus,
healthcare facilities should continue to follow the post-exposure
prophylaxis protocol for
vaccinated HCWs who are exposed to pertussis. |
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| 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. |
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| 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. |
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| What are the recommendations for
vaccination of infants and young children with DTaP? |
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| 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. |
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| What are the
recommendations for use of Tdap in children and adults
ages 7 and older? |
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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.
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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. |
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Adolescents should receive a single dose of Tdap
(instead of Td) at the 11–12-year-old visit. |
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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. |
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Children ages 7
through 10 years who are not fully immunized against
pertussis (i.e., did not complete a series of
pertussis-containing vaccine before
their seventh birthday) should receive a single dose of
Tdap. If needed, they should complete their series with
Td. |
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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. |
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Pregnant teens and
women should receive Tdap during each pregnancy,
preferably between 27 and 36 weeks' gestation. Women
who have never received Tdap and
who do not receive it during pregnancy should receive it
immediately postpartum. To obtain the recommendations, go
to www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm. |
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| 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? |
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| Yes. Footnote 12 of the 2017 child and adolescent immunization schedule (available at
www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html) states that a child who
receives a dose of Tdap between 7 through 10 years of age as part of the catch-up series (as in this case), may receive another dose of Tdap at age 11 or 12 years. |
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| 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? |
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| 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 6 months after the invalid Tdap dose. If Td is not available, Tdap can be used for this
dose. |
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| 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. |
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| 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. |
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| When should adolescents who received a dose of Tdap (tetanus-diphtheria, pertussis-containing vaccine; Adacel, sanofi; Boostrix, GSK) at age 11–12 years receive their next dose of Td or Tdap? |
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| Currently, ACIP recommends only one lifetime dose of Tdap for everyone with the exception of pregnant women for whom a dose is recommended during each pregnancy. Someone who received a dose of Tdap at age 11 or 12 should receive a
booster dose of Td vaccine ten years later, unless tetanus prophylaxis is required sooner due to an injury.
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| 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? |
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| 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. |
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| 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? |
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| A history of tetanus disease is not a reason to avoid tetanus-containing vaccines. Tetanus disease does not
produce immunity because of the very small amount of toxin required to produce illness. As long as your patient has
no other contraindications she should receive Tdap now. If she has no documentation of prior tetanus vaccination,
she should receive a complete 3-dose primary series (dose #1 of Tdap, followed by dose #2 of Td 4 to 8 weeks later,
and dose #3 of Td 6–12 months after dose #2). |
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| I'm confused about the various
vaccines that contain tetanus, diphtheria, and pertussis. Can you
explain? |
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| 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." |
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| Can we use the two DTaP products
interchangeably? |
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| There are two different DTaP products currently used in the U.S. for
the primary series for children ages 2 months through 6 years (Daptacel
by sanofi
pasteur and Infanrix by GlaxoSmithKline). ACIP has recommended that,
whenever feasible, healthcare providers should use the same brand of
DTaP vaccine for
all doses in the vaccination series. If vaccination providers do not
know or have available the type of DTaP vaccine previously
administered to a child, any
DTaP vaccine may be used to continue or complete the series. For
vaccines in general, vaccination should not be deferred because the
brand used for previous
doses is not available or is unknown (see page 10 of the ACIP's
General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf). |
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| What should we do if we don't know
which brand of DTaP a child had previously? |
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| 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. |
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| Someone gave Tdap to an infant
instead of DTaP. Now what should be done? |
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| 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. |
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| 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? |
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| Yes. In this situation, a second dose of Tdap should be administered at the recommended age of 11 or 12 years. |
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| We would like to avoid stocking both
Tdap and Td vaccines. Is CDC likely to recommend that Tdap
completely replace Td in the immunization schedule in the
near future? |
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| Currently, ACIP recommends giving only 1 dose of Tdap to adolescents and adults who have not previously received the vaccine, with the exception of pregnant women, who should be vaccinated during each pregnancy. ACIP is unlikely to recommend routine Tdap revaccination for groups other than pregnant women. Therefore, medical settings will need to continue to stock Td vaccine in order to administer it to patients who need to complete the full primary 3-dose tetanus and diphtheria series and also to administer 10-year booster doses of Td throughout the lifetime of those who have completed the primary series. Note that if a person who previously received Tdap needs a booster dose of Td (as a routine booster dose or for wound management) it is acceptable to administer Tdap if Td is not available. |
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| I have a patient who received
single-antigen tetanus (TT) in the emergency room rather than Td or
Tdap. Should he be revaccinated? |
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| 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. |
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| When should a person receive tetanus
toxoid (TT) alone? |
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| 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. |
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| In what year did tetanus toxoid
first become available? At what age might most patients never have
received a primary series? |
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| 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. |
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| 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? |
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| The first step is to inform the parent/patient that you
administered the wrong vaccine. Next, follow these
guidelines: |
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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. |
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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. |
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DTaP given
to patients age 7 or older can be counted as valid
for the one-time Tdap dose. |
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| 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? |
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| 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. |
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| What is the difference between the
two Tdap products - Boostrix and Adacel? |
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| Both of these vaccines provide protection against diphtheria,
tetanus, and pertussis. Boostrix (GlaxoSmithKline) is licensed for
people ages 10 years and
older, and Adacel (sanofi pasteur) is licensed for people ages 10
through 64 years. The two vaccines also contain a different number
of pertussis antigens
and different concentrations of pertussis antigen and diphtheria
toxoid. |
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| I am confused about which adults to
vaccinate with Tdap vaccine and which product to use. Please help! |
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| CDC published updated recommendations on Tdap vaccination for adults
in the MMWR on June 29, 2012. ACIP recommends that ALL adults age 19
years and older who
have not yet received a dose of Tdap receive a single dose. Tdap
should be administered regardless of interval since the last tetanus
or diphtheria toxoid-containing vaccine (e.g., Td). After receiving Tdap, people should
receive Td every 10 years for routine booster immunization against
tetanus and diphtheria,
according to previously published guidelines. Pregnant women should
receive Tdap during each pregnancy. |
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| 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. |
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| 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. |
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| The tetanus and diphtheria toxoid Tenivac (Td, Sanofi) is not currently available from the manufacturer and may not be available until later in 2017. What are we to do
when someone is in need of a Td booster dose? |
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Although there is a shortage of Tenivac, there is another Td product available. It is produced by MassBiologics and distributed by Grifols USA LLC. More information,
including prescribing information for Grifols Td vaccine, can be found at
www.GrifolsTdvaccine.com. If Td is unavailable in the work setting, Tdap should be used in its
place whenever Td is indicated (e.g., for 10-year booster dose or wound management). If a person has previously received a dose of Tdap, it is acceptable to give
another Tdap dose in place of Td when Td is not available. |
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| Tenivac Td (Sanofi Pasteur) for adults is expected to be unavailable until the second half of 2017. Another Td vaccine produced by MassBiologics is available at our wholesaler, but it looks like the components are slightly different from Tenivac. Are the two products interchangeable during the shortage? |
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| Yes, the Td products are equivalent and interchangeable. |
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| We see many 10-year-olds for middle
school entry immunization. Is one brand of
Tdap preferred for this age group? |
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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. |
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| 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. |
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| 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. |
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| 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? |
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| 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. |
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| 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? |
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| Yes. There is no need to observe any minimum interval between doses
of Td and Tdap. |
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| 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? |
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| 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. |
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| 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. |
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| This child needs to complete the primary series with 1 dose of Td,
administered no earlier than 6 months after the Tdap dose given at
age 11 years. After
that, the child needs a booster dose of Td every 10 years. An easy
way to determine how to catch up a child is to consult "Recommended
Immunization Schedules
for Persons Aged 0 Through 18 Years, U.S." The schedule is approved
by CDC, AAP, and AAFP and is released early in each calendar year.
It includes a catch-up
schedule for children who have fallen behind (see www.cdc.gov/vaccines/schedules/index.html). |
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| 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? |
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| Since the first DTaP was received before 12 months of age and one Tdap dose has been given, this person needs one dose of Td 6 calendar months after the Tdap dose. A routine Td booster should be administered every 10 years. See IAC's new handout: DTaP, Tdap, and Td Catch-up Vaccination Recommendations by Prior Vaccine History and Age. |
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| According to the ACIP
recommendations, which healthcare workers should be vaccinated
against pertussis with tetanus-diphtheria-acellular pertussis (Tdap)
vaccine? |
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| ACIP recommends the following for the use of Tdap in healthcare
personnel: |
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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. |
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Tdap is
not currently licensed for multiple administrations.
After receipt of Tdap, HCP should receive routine booster immunization
against tetanus and
diphtheria according to previously published guidelines. Pregnant HCP should receive additional doses of Tdap during each pregnancy. |
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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). |
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| To view this and other recommendations for healthcare personnel, go
to "Immunization of Health-Care Personnel" (MMWR 2011;60[SS-7]:4-46) at www.cdc.gov/mmwr/pdf/rr/rr6007.pdf. |
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| 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? |
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| All parents, grandparents, healthcare workers, and all
others of any age who have not already received Tdap, and
especially those who are close contacts of
infants younger than age 12 months, should receive a
single dose of this vaccine as soon as possible to protect
infants from pertussis. For example, if you
had immediately realized that you had mistakenly given the
father-to-be Td instead of Tdap, you could have given him
the needed Tdap dose at the same visit
at which you gave him the erroneous Td dose. |
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| Can a booster dose of Tdap be given
to people age 65 years and older? |
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| Yes. ACIP recommends a single dose of Tdap be given to all adults,
including those age 65 years or older, especially adults who have or
anticipate having
close contact with an infant younger than age 12 months (e.g.,
grandparents, childcare providers). |
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| Please review the current
recommendations for the use of Tdap in adults. |
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| ACIP recommends the following: |
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All
adults ages 19 years and older who have not yet
received a dose of Tdap should receive a single
dose. |
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All
pregnant women should receive a dose of Tdap during
each pregnancy, preferable between 27 and 36 weeks'
gestation. Women who have never received Tdap
and who do not receive it during pregnancy should
receive it immediately postpartum. |
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The Tdap
dose can be given regardless of the interval since
the person last received a tetanus or diphtheria
toxoid-containing vaccine. |
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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. |
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For adults not
previously vaccinated with Tdap who need wound
management care to prevent tetanus, Tdap is
preferred over Td. |
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| Is there an upper age limit for Tdap
administration? For example, should I vaccinate an 85-year-old? |
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| There is no upper age limit for Tdap vaccination. A single dose of
Tdap is recommended for all adults. |
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| For a person entering a long-term-care facility at age 70 or older, if we cannot document that the resident has had a primary series of three doses of tetanus-containing vaccine, is the right course of action upon admission to give a Tdap first, then a Td in 1 to 2 months, followed by a Td in 6 to 12 months, and then a Td booster every 10 years? |
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| Your understanding of the general Td/Tdap recommendation is correct, and this is the schedule that should be followed for persons 7 years old and older who have never received tetanus-containing vaccine or who cannot provide documentation of prior vaccination. Be sure to document doses administered so a primary series does not need to be repeated in the future. |
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| If a teen or adult patient
received a dose of Td vaccine 2 years ago, should I wait
approximately 8 more years before administering a dose of
Tdap to the
patient? |
|
| No. ACIP recommends that people age 11 through 64 who have
not yet received Tdap receive a single dose of Tdap now.
ACIP specifies no waiting interval
between administering Td and Tdap to anyone in this age
group. Adults age 65 years and older do not need to delay
Tdap vaccination following Td either. |
|
|
| If a teen or adult mistakenly
received a dose of Td when they should have received Tdap, what is
the optimal time to give the missing Tdap dose? |
|
| As soon as possible, even if it is the same day. |
|
| We recently saw a 30-year-old man
who remembers that he received a "tetanus booster" in another state
within the past 2 years. The problem is he can't
remember if he received Tdap or Td, and we can't obtain an
immunization record. His wife is pregnant, and we would like to
immunize him against pertussis as
a way to protect their soon-to-be-born child. Should we give him
Tdap in this situation? |
|
| Yes. Whenever you lack vaccination documentation and vaccination is
indicated, give the patient Tdap. |
|
| Can the parents of a young infant be
given a dose of Tdap right after birth to protect themselves and,
indirectly, their newborn from pertussis, even
though they had a dose of Td vaccine less than two years ago? |
|
| Yes. Parents should receive a single dose of Tdap as soon as
possible to protect their baby from pertussis. If a dose of Td was
given within the previous 2
years, parents should still be vaccinated with Tdap as soon as
possible regardless of the time interval since the last dose of Td.
Other household contacts
that are not up to date with their pertussis-containing vaccinations
should also be appropriately vaccinated. Preferably, they should be
vaccinated before
the infant is born. |
|
| Can Tdap be given at the same visit
as other vaccines? |
|
| Yes. Tdap can be administered with all other vaccines that are
indicated (e.g., meningococcal conjugate vaccine, hepatitis B
vaccine, MMR). Each vaccine
should be administered at a different anatomic site using a separate
syringe. |
|
| Someone in our clinic gave DTaP to a
50-year-old instead of Tdap. How should this be handled? |
|
| The DTaP recipient received the appropriate amount of tetanus toxoid
and MORE diphtheria toxoid and pertussis antigen than is
recommended. Count the dose as
Tdap, but take measures to prevent this error in the future. The
patient does not need a repeat dose of Tdap. |
|
| A pertussis outbreak is occurring
in our town, with many cases happening in the schools. Is there a
recommendation for boosting middle-and high-school students with an
additional dose of Tdap during an outbreak if students have already
had 1 dose? |
|
| Currently, ACIP recommends only 1
lifetime dose of Tdap for everyone except pregnant women.
Revaccination with Tdap during a pertussis outbreak is currently not
recommended. |
|
|
|
|
|
| Can Tdap be administered to pregnant
women? |
|
Yes. In June 2011
ACIP voted to recommend that pregnant women
who have never received the Tdap vaccine be
vaccinated to optimize the concentration of
maternal antibodies transferred to the fetus.
ACIP made this recommendation in response to
the continuing pertussis outbreak, with the
goal of protecting newborns with maternal
antibodies and decreasing the risk of
transmission from mother to infant after
birth. In October 2016, ACIP voted to
recommend administering Tdap vaccination early
in the 27- through 36-week �window� to
maximize passive antibody transfer to the
infant. Women who
have never received Tdap and who do not
receive it during pregnancy should receive it
immediately postpartum.
|
When a woman gets Tdap during pregnancy, maternal pertussis
antibodies transfer to the newborn, likely protecting the baby
against pertussis in early life,
before the baby is old enough to have received at least 3 doses of
DTaP. Tdap also protects the mother, making it less likely that she
will get infected
with pertussis during or after pregnancy and thus less likely that
she will transmit it to her infant.
The recommendations for the use of Tdap in pregnancy were published
in the February 22, 2013 issue of MMWR. To access the new
recommendations, visit www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm. |
|
| If a woman did not receive Tdap
during pregnancy, and it is uncertain whether she received a dose of
Tdap prior to her pregnancy, should she receive a
dose of Tdap postpartum? |
|
| Yes. If there is no written documentation that she received a dose
of Tdap prior to or during pregnancy, a dose of Tdap should be
administered to her
immediately postpartum. |
|
| If there is no documentation of a
pregnant woman ever receiving Td or Tdap, what schedule should we
follow? |
|
| The recommended schedule for the primary series given to an
unvaccinated person is dose 1 now, dose 2 in 4 weeks, and dose 3 in
6 to 12 months. Tdap should
replace 1 dose of Td, preferably between 27 and 36 weeks' gestation
to maximize the maternal antibody response and passive antibody
transfer to the infant. |
|
| Some women have closely spaced
pregnancies. Should we give Tdap during each pregnancy, even if it
means such women would get 2 doses within 12 months? |
|
| Yes. ACIP looked into this issue and included related information in
its recommendations published in MMWR on February 22, 2013 (www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm). ACIP reviewed available data
on birth statistics and found that among U.S. women who have
more than one
pregnancy, a very small percentage (2.5%) have an interval of 12
months or less between births. The majority of women who have two
pregnancies have an
interval of 13 months or more between births. Approximately 5% of
women have four or more pregnancies. ACIP concluded that (1) the interval
between subsequent
pregnancies is likely to be longer than is the persistence of
maternal anti-pertussis antibodies, (2) most women would receive
only 2 doses of Tdap, and (3)
a small proportion of women would receive 4 or more doses. |
|
| A theoretical risk exists for severe local reactions (e.g., arthus
reactions, whole limb swelling) for pregnant women who have
multiple, closely spaced
pregnancies. However, the frequency of side effects depends on the
vaccine's antigen content and product formulation, as well as on
preexisting maternal
antibody levels related to the interval since the last dose and the
number of doses received. The risk for severe adverse events has
likely been reduced with
current vaccine formulations (including Tdap), which contain lower
doses of tetanus toxoid than did older vaccine formulations. ACIP believes the potential
benefit of preventing pertussis morbidity and mortality in infants
outweighs the theoretical concerns of possible severe adverse events
in mothers. |
|
| If a woman received Tdap in early
pregnancy, should she get it again in the third trimester? |
|
| No, it is not recommended to give
another dose of Tdap in such cases. Optimal timing for Tdap
administration is between 27 and 36 weeks' gestation because of transplacental antibody kinetics. |
|
| According to ACIP recommendations
published in MMWR on February 22, 2013, "Tdap may be administered
any time during pregnancy, but vaccination during the third
trimester would provide the highest concentration of maternal
antibodies to be transferred closer to birth." More information is
available at www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm. |
|
| Each time there is a pregnancy in
the family, should fathers and other family members receive a Tdap
booster to ensure adequate protection and boost the cocoon effect to
protect the newborn from pertussis? |
|
| At this time, ACIP does not
recommend additional doses of Tdap for fathers or other family
members or caregivers. The multiple Tdap recommendation to optimize
immunity for the infant applies only to the pregnant woman. |
|
| At what gestational age of
pregnancy should we vaccinate pregnant women with Tdap? |
|
| To maximize maternal antibody response and passive antibody
transfer to the infant, the optimal time to administer Tdap is
between 27 and 36 weeks'
gestation. However, Tdap can be administered at any time during
pregnancy. Previously, CDC had recommended that Tdap vaccination
occur after 20 weeks'
gestation. |
|
| We intend to start vaccinating
family contacts of pregnant women with Tdap to protect the newborn.
Can you tell me how long it takes for the Tdap vaccine to provide
protection? |
|
| To best protect infants, CDC recommends that teens and adults who
haven't been vaccinated receive Tdap 2 weeks or more before having
contact with an infant.
If a 2-week time frame is not available prior to coming into contact
with an infant, administer the vaccine as soon as possible. |
|
| If a pregnant woman got a dose of Td
during pregnancy, how soon can she get her dose of Tdap? |
|
| While she should have been given Tdap rather than Td, she can
receive her Tdap dose at any interval since the Td dose was given
and preferably between 27 and
36 weeks gestation. |
|
| A 17-year-old received a dose of Tdap vaccine when she was 12 years old. She is now pregnant. Should she get another dose of Tdap vaccine? |
|
| Yes. ACIP recommends a dose of Tdap during each pregnancy irrespective of the patient's prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer to the infant, optimal timing for Tdap administration is between 27 and 36 weeks gestation. For more information, see www.cdc.gov/mmwr/pdf/wk/mm6207.pdf, page 131. |
|
| Who should get a second dose of Tdap
vaccine? |
|
| Only pregnant women are recommended to receive more than 1 dose of Tdap. ACIP has not recommended Tdap revaccination for any other group including healthcare providers. |
|
| Is there any contraindication to administering Tdap vaccine and Rhogam at the same time to a pregnant woman? |
|
| No. Tdap is an inactivated vaccine and may be administered at the same time as Rhogam (in a separate site with a separate syringe). |
|
|
|
|
|
| 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. |
|
| 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. ACIP recommends that children
age 7 through 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.
The child may also receive an additional dose of Tdap at 11 or 12 years of age. See
MMWR 2011;60(No.1):13�15 and footnote 12 of the 2017 child and
adolescent immunization schedule, available at
www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html. |
|
| If a child didn't have the recommended
6-month interval between DTaP doses #3 and #4, should it be
repeated? |
|
| If DTaP #4 is given with at least a 4-month interval after DTaP #3,
it does not need to be repeated. The minimum age of 12 months for
the fourth dose must be
met. Decreasing the interval to less than 6 months, however, is not
recommended. |
|
| If a child has already received 5
doses of DTaP by their fourth birthday (with the appropriate 6 month
intervals between #3 and #4 and also between #4 and
#5), is a booster dose after the fourth birthday necessary? |
|
| In general, a child should receive no more than four doses of DTaP
before 4 years of age (preferably by 2 years of age). The ACIP
recommends that a dose of
DTaP be given at 4–6 years of age. Many states have school
immunization laws which also require at least one dose of DTP/DTaP
on or after the fourth
birthday. This dose is important to boost immunity to pertussis. |
|
| Is there a recommendation about how
many doses of DTaP a child can receive by a certain age? Does this
include half doses? |
|
| ACIP and AAP both recommend that children receive no more than 6
doses of diphtheria and tetanus toxoids (e.g., DT, DTaP, DTP) before
the seventh birthday
because of concern about adverse reactions, primarily local
reactions. Half doses of DTaP are also not recommended under any
circumstances, and should not be
counted as part of the vaccination series. Only documented doses
(i.e., those recorded in an electronic or written record) count
toward the maximum of 6
doses. |
|
| What is the minimum interval between
DTaP #4 and DTaP #5? |
|
| The minimum interval between DTaP #4 and DTaP #5 is six months.
Remember that the minimum age for DTaP #5 is age 4 years. |
|
| How should we schedule DTaP for a
child with a history of only DT? |
|
| If the child has not received all of the age-appropriate doses of
pertussis-containing vaccine, it would be best to try to administer
as many doses of DTaP
as possible before the child reaches his 7th birthday in order to
confer protection against pertussis. Give additional doses of DTaP
with 4 week intervals
until you achieve 3 total doses. Then, give additional doses with
6-month intervals, not to exceed 6 total doses of diphtheria- and
tetanus-containing
vaccine by the child's 7th birthday. |
|
| I've heard that ACIP and AAP have
different recommendations for spacing Tdap and meningococcal
conjugate vaccine if they are not given simultaneously. Please
discuss. |
|
| This is no longer the case. The ACIP's Tdap recommendations
published in the MMWR (www.cdc.gov/vaccines/pubs/acip-list.htm)
state that Tdap or Td can be
administered at any time before or after meningococcal conjugate
vaccine. The AAP also recently stated that "simultaneous
administration of Tdap and all
other recommended vaccines is recommended when feasible. Vaccines
should not be mixed in the same syringe. Other indicated vaccines
that are not available
and therefore cannot be given at the time of administration of Tdap
can be given at any time thereafter." Some experts, however,
recommend spacing these two
vaccines by a month if they are not given simultaneously. This is
out of a theoretical safety concern about giving two vaccines that
contain diphtheria
toxoid (meningococcal conjugate vaccine contains diphtheria toxoid)
unless they are given simultaneously or are spaced 1 month apart. |
|
| There is a
debate within my clinical department about not
allowing influenza vaccine to be given with
DTaP and PCV13. Are there data that state
these should not be given concomitantly? |
|
| A CDC study has
shown a small increased risk for febrile
seizures during the 24 hours after a child
receives the inactivated influenza vaccine at
the same time as the PCV13 vaccine or DTaP
vaccine. However, the risk of febrile seizure
with any combination of these vaccines is
small and ACIP recommends giving these
vaccines at the same visit if indicated. See
www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html
for more information. |
|
|
|
|
|
| What are the contraindications for
using DTaP, DT, Tdap, and Td? |
|
| As with all vaccines, a severe allergic reaction (e.g., anaphylaxis)
to a vaccine component or to a prior dose is a contraindication to
further doses of that
vaccine. A history of encephalopathy within 7 days of receiving a
previous pertussis-containing vaccine that is not due to another
identifiable cause is a
contraindication to both DTaP and Tdap. |
|
| What precautions should be observed
when giving DTaP, DT, Tdap, or Td? |
|
| A history of Guillain-Barré syndrome (GBS) within 6 weeks of
receiving a tetanus toxoid-containing vaccine, and a history of
arthus-type hypersensitivity
reaction after receiving a previous tetanus or diphtheria
toxoid-containing vaccines, including MCV4, is a precaution to
further vaccination with any of
these vaccines. As with all vaccines, moderate or severe illness is
a precaution. Several additional precautions apply only to DTaP (see
next question). |
|
| Is it acceptable to give breastfeeding
mothers Tdap vaccine? |
|
| Yes. Women who have never received Tdap
and who did not receive it during pregnancy
should receive it immediately postpartum or as
soon as possible thereafter. Breastfeeding
does not decrease the immune response to
routine childhood vaccines and is not a
contraindication for any vaccine except
smallpox. Breastfeeding is a precaution for
yellow fever vaccine and the vaccine can be
given for travel when indicated. |
|
| Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal visit? |
|
| Tdap is an inactivated vaccine and may be given at the same prenatal visit with RhoGam. For more information on this topic, including the timing for the use of other vaccines with regards to RhoGam, see ACIP's General Recommendations on Immunization at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, page 9. |
|
| Do the same precautions that apply to
DTaP also apply to Tdap? |
|
| No, many of the precautions to DTaP (e.g., temperature of 105°F or
higher, collapse or shock-like state, persistent crying lasting 3
hours or longer, seizure
with or without fever) do not apply to Tdap. This issue is discussed
in the Tdap ACIP recommendations, available at www.cdc.gov/vaccines/pubs/acip-list.htm. |
|
| Mom comes in with her 19-month-old. She reports that her (the mother�s) sibling has a history of a severe reaction to pertussis vaccine in the mid-1990s. Now mom is reluctant to give her child pertussis
vaccine although the child received Pediarix (DTaP-HepB-IPV, GlaxoSmithKline) 2 months ago without incident. Should we be concerned about the mother�s family history of a severe reaction to pertussis
vaccine? |
|
| A family history of a neurologic disorder or reaction to a pertussis-containing vaccine is not a contraindication to vaccination of this child. The child should receive additional DTaP doses as indicated in the
catchup schedule. |
|
| Can an adult receive Tdap if they
had a contraindication or precaution to DTP as a child? |
|
| Tdap has two contraindications and four precautions. The
contraindications are (1) anaphylactic reaction to a prior dose of
the vaccine or any of its
components and (2) encephalopathy within 7 days of a previous dose
of DTaP or DTP; in this case, give Td instead of Tdap. The
precautions are (1) moderate or
severe acute illness; (2) history of an arthus-type hypersensitivity
reaction following a previous dose of tetanus or diphtheria
toxoid-containing vaccines,
including MCV4; (3) Guillain-Barré syndrome (GBS) 6 weeks or sooner
after a previous dose of tetanus toxoid-containing vaccine; and (4)
progressive or
unstable neurologic disorder, uncontrolled seizures or progressive
encephalopathy until a treatment regimen has been established and
the condition has
stabilized. CDC has published a Guide to Vaccine Contraindications
and Precautions in its "General Recommendations on Immunization"
published in MMWR on
January 28, 2011. A 2-page user-friendly version, created by IAC,
can be found at www.immunize.org/catg.d/p3072a.pdf. |
|
| I have an adult patient with
controlled epilepsy who wishes to receive the Tdap vaccine. May I
vaccinate him? |
|
| Controlled epilepsy is not a contraindication to receipt of Tdap. To
access IAC's table of vaccine contraindications and precautions, go
to www.immunize.org/catg.d/p3072a.pdf. CDC also makes this information
available at www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm. |
|
| When assessing for precautions for
administering DTaP in an infant, is the 105°F cutoff for DTaP a
rectal, oral, or axillary temperature? |
|
| A temperature of 105°F or higher recorded from any of these body
sites following a dose of DTaP without another known cause
constitutes a precaution to
further doses of any pertussis-containing vaccine. |
|
| A 2-month old received her first dose of
DTaP and then had inconsolable crying for greater than 3 hours.
Should we give additional doses of DTaP or should we
give just DT? |
|
| Persistent crying following DTaP (as well as other vaccines) has
been observed far less frequently than it was following the use of
DTP. When it occurred
after DTP, it was considered to be an absolute contraindication to
further doses of pertussis-containing vaccine. When it occurs
following DTaP, it is
considered a "precaution" (or warning). If you believe the benefit
of the pertussis vaccine exceeds the risk of more crying (which,
although unnerving, is
otherwise benign), you can administer DTaP. Many providers choose to
administer pertussis-containing vaccine if this is the only
precaution the child has
experienced. You and the parent will need to make this judgment. |
|
| Can we give further doses of DTaP to
an infant who had an afebrile seizure within 3 hours of a previous
dose? |
|
| An infant who experiences an afebrile seizure following a dose of
DTaP requires further evaluation. An infant with a recent seizure or
an evolving neurologic
condition should not receive further doses of DTaP, or DT until the
condition has been evaluated and stabilized. Other indicated
vaccines may be administered
on schedule. To assure that the child is at least protected against
tetanus and diphtheria, the decision to give either DTaP or DT
should be made no later
than the first birthday. |
|
| Is there guidance for pertussis
protection for an adult who cannot receive the tetanus portion of
the Tdap vaccine because of allergy? |
|
| Usually, an "allergy" to tetanus toxoid is anecdotal and not a true
anaphylactic reaction to modern tetanus toxoid. Patients often claim
to be allergic to
tetanus toxoid because of (1) an exaggerated local reaction (which
is not an allergy) or (2) a reaction to a tetanus vaccine received
many years ago
(probably serum sickness from equine tetanus antitoxin). A history
of one of these events is not a contraindication to modern tetanus
toxoid, Td, or Tdap. |
|
| Only an allergist-confirmed anaphylactic allergy to tetanus toxoid
should be accepted as a valid contraindication to a modern
tetanus-toxoid-containing
product. A person who has an allergist-confirmed anaphylactic
allergy to tetanus toxoid has no recourse for pertussis vaccination
because no single-antigen
pertussis vaccine is licensed for use in the United States. |
|
| Does tetanus toxoid contain horse
serum? |
|
| Tetanus toxoid has never contained horse serum or protein. Equine
tetanus antitoxin (horse derived) was the only product available for
the prevention of
tetanus prior to the development of tetanus toxoid in the 1940s.
Equine antitoxin was also used for passive post-exposure prophylaxis
of tetanus (e.g., after
a tetanus-prone wound) until the development of human tetanus immune
globulin in the late 1950s. Equine tetanus antitoxin has not been
available in the U.S.
for at least 40 years. |
|
|
|
|
|
| When a patient seen in the ER needs
tetanus protection, which type of tetanus vaccine should be given? |
|
| For children younger than age 7 years, give DTaP. Children and
adults age 10 and older should receive a single dose of Tdap instead
of Td, if they have not
previously received Tdap. Children who are ages 7 through 9 years
and haven't had at least 3 doses of pertussis-containing vaccine
prior to their seventh
birthday (or are unsure), should be given Tdap If Tdap is not
available, or was previously administered, these people should
receive Td. |
|
| If a person gets a puncture wound or
laceration on Friday night, does the person need to receive tetanus
wound management that night or can it wait until
Monday? |
|
| ACIP has not addressed this issue specifically. Puncture wounds,
however, should be attended to as soon as possible. The decision to
delay a booster dose of
tetanus toxoid-containing vaccine following an injury should be
based on the nature of the injury and likelihood that the injured
person is susceptible to
tetanus. The more likely the person is to be susceptible, the more
quickly that tetanus prophylaxis should be administered. A person
with a tetanus-prone
wound (e.g., punctures, wounds contaminated with soil or fecal
material) and who has no history of tetanus immunization must be
vaccinated and given tetanus
immune globulin (TIG) as soon as possible. A person with a
documented series of at least three tetanus toxoid-containing
products, with a booster dose within
the previous 10 years ago is less likely to be susceptible to
tetanus, and the need for a booster dose is not as urgent,
particularly if the wound can be
thoroughly cleaned. The more likely a person is to be completely
susceptible to tetanus (i.e., unvaccinated or incompletely
vaccinated), the sooner that TIG
and Td/Tdap should be administered, even if it means a trip to the
emergency department. |
|
| If a patient is receiving a tetanus-containing vaccine after an injury and there is no history of any prior tetanus vaccine (e.g., an Amish person who has previously declined vaccination), how much tetanus
protection will one dose provide? Also, what is the time frame that the tetanus toxoid needs to be given following an injury? |
|
| One dose of tetanus toxoid-containing vaccine (Tdap or Td) provides little or no protection. That is why tetanus immune globulin (TIG) is also recommended in this situation. See �The Pink Book� section
titled Wound Management at
www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html. As far as timing, the toxoid and TIG should be given as soon as possible. |
|
| When should tetanus immune globulin
(TIG) be administered as part of wound management? |
|
| TIG is recommended for any wound other than a clean minor wound if
the person's vaccination history is either unknown, or s/he has had
less than a full
series of 3 doses of Td vaccine. TIG should be given as soon as
possible after the injury. |
|
| How long after a wound occurs is
tetanus immune globulin no longer recommended? |
|
| In the opinion of the tetanus experts at the CDC, for a person who
has been vaccinated but is not up to date, there is probably little
benefit in giving TIG
more than a week or so after the injury. For a person believed to be
completely unvaccinated, it is suggested to increase this interval
to 3 weeks (i.e., up
to day 21 post injury). Td or Tdap should be given concurrently. |
|
|
|
|
|
| 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. |
| |
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