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acellular pertussis vaccine/diphtheria toxoid/tetanus toxoid; diphtheria, tetanus toxoid & pertussis vaccine (DPT, DTaP, TDaP, DTP, Acel-Immune, Tri-Immunol, Tripedia, Daptacel, INFANRIX, Adacel, Boostrix)

Indication: 1) active immunization of infants & children 2 months-6 years against diphtheria, tetanus & pertussis [10] 2) recommended for primary immunization & routine recall - mandatory for school children in some states [16] 3) acellular pertussis form (INFANRIX) indicated only for children previously immunized 3-4 times with whole cell DPT 4) all adults 19-65+ who have not previously received TDaP; includng elderly > 65 years of age [8,12,13,16], especially if contact with infants < 12 months of age [38] 5) pregnant women during each pregnancy, preferably after 20 weeks' gestation [14]; 27-36 weeks of gestation [33]; if not, then before discharge from the hospital* [19] - Tdap vaccine during pregnancy is associated with reduced risk for pertussis during the infant's 1st year of life, especially in the 1st 2 months [35] 6) adolescents & adults who have not received Tdap & who anticipate close contact with an infant < 12 months of age, preferably 2 weeks before contact with the infant [14] 9) TdaP is acceptable alternative to dT [39] * safe during pregnancy [25,27] * decline in infant pertussis incidence (91%) in the U.K. after introduction of maternal immunization [26] * 3rd trimester maternal immunization 78% effective & 91% effective at preventing pertussis-related hospitalization [37] * tetanus vaccination is associated with reduced occurrence & slower progression of Parkinson's disease Contraindications: 1) patients with cancer 2) immunodeficiency 3) children with a history of neurologic disorders 4) history of serious adverse reactions to pertussis vaccine 5) do not use for treatment of diphtheria, tetanus or pertussis infection 6) does not reduce risk of dementia - may increase incidence of dementia in the elderly after a 2-year lag period [40] pregnancy category: generally safe in pregnancy [27] safety in lactation - Benefit/risk: - number needed to harm: 167 women need to be vaccinated to cause 1 excess case of chorioamionitis [7] Epidemiology: - ~50% of pregnant women receive Tdap vaccine [30] - 20% of pregnant women do not know their Tdap vaccination status [30] Dosage: Children 2 months-6 years 1) 1st dose at 2-3 months recommended 2) when pertussis is common in a community, the 1st dose can be given to infants as early as 6 weeks of age [28] 3) 0.5 mL IM on 3 occasions at 4-8 week intervals 4) reinforcing dose 1 year after 3rd injection 5) booster when child is 6 years of age - along with MMR, required for school entry (2002) - state requirement usually 5 doses [36] Adolecents & adults - Adaacel & Boostrix for adolescents; Adaacel for adults [3,4] - one time dose with Tdap 0.5 mL IM - booster vaccination with dT - wounds, especially puncture wounds: vaccinate with dT - Tdap + immune globulin if incomplete primary series [11] Injection: 1) diphtheria 6.7-12.5 Lf units, tetanus 5-12.5 Lf units, & whole cell pertussis 4 protective units/0.5 mL (7.5 mL vials) 2) diphtheria 7.5 Lf units, tetanus 5 Lf units, & acellular pertussis 4 protective units/0.5 mL (5 mL vials) Tripedia, Infantrix & Daptacel are considered interchangeable Pharmacokinetics: - elimination: liver - 1st dose provides immunity for about 1 year - subsequent doses needed for continued immunity [23] Adverse effects: 1) convulsions, screaming episodes, malaise, sleepiness, focal neurologic signs, shock, collapse, chills, erythema, induration, rash, urticaria, local tenderness, arthralgias, fever, swelling, warmth, increased risk of haemophilus b infections in the week following vaccination, allergic or anaphylactic reactions (rare) 2) all serious adverse reactions must be reported to the FDA 3) local reactions less common in children 1-6 years when DTaP vaccine administered in the thigh rather than the arm [18] 4) no association with type 1 diabetes [24] 5) chorioamnionitis in pregnant women (6.1% vs. 5.5%) [7] 6) Tdap during pregnancy not associated with increased risk for structural birth defects, including microcephaly [34] Drug interactions: - prior immunization (within 5 years) with another tetanus- containing vaccine does not appear to increase risk for adverse outcomes during pregnancy [31] Notes: - if adverse reaction occurs, immunization should be completed with diphtheria & tetanus toxoid (dT, Td). - a nodule may be present at the site of injection for a few weeks - 2012 worst year for pertussis in over 50 years despite mandatory vaccination programs [16] - vaccine 53-64% effective [21] - duration of effectiveness of acellular vaccine in question [16] - TdaP effectiveness 73% after 1 year & 34% after 2-4 years [29] - even more frequent vaccination will likely be proposed [16] - increase in pertussis cases coincides with the shift from whole-cell to acellular pertussis vaccines [17] - pertussis immunity drops soon after last (5th) dose of DTaP is given [20] - children age 3-36 months 30 times more likely to be diagnosed with pertussis if inadequately vaccinated [22]

Related

Bordetella pertussis diphtheria tetanus

General

vaccine combination

References

  1. Kaiser Permanente Northern California Regional Drug Formulary, 1998
  2. Prescriber's Letter 12(4): 2005
  3. Prescriber's Letter 12(6): 2005 Boostrix Vaccine Detail-Document#: 210614 (subscription needed) http://www.prescribersletter.com
  4. Ward JI, Cherry JD, Chang SJ, Partridge S, Lee H, Treanor J, Greenberg DP, Keitel W, Barenkamp S, Bernstein DI, Edelman R, Edwards K; APERT Study Group. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med. 2005 Oct 13;353(15):1555-63. PMID: 16221778 - Halperin SA. Pertussis--a disease and vaccine for all ages. N Engl J Med. 2005 Oct 13;353(15):1615-7. No abstract available. PMID: 16221785
  5. Prescriber's Letter 13(2): 2006 Detail-Document#: 220213 (subscription needed) http://www.prescribersletter.com
  6. Centers for Disease Control and Prevention (CDC) Recommendations for preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. http://www.cdc.gov/mmwr/early_release.html
  7. American Academy of Pediatrics Commitee on Infectious Diseases. Prevention of pertussis among adolescents: recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Pediatrics. 2006 Mar;117(3):965-78. Epub 2005 Dec 28. PMID: 16382131 (doi:10.1542/peds.2005-3038) http://pediatrics.aappublications.org/cgi/content/short/117/3/965
  8. Kretsinger K, Broder KR, Cortese MM, Joyce MP, Ortega-Sanchez I, Lee GM, Tiwari T, Cohn AC, Slade BA, Iskander JK, Mijalski CM, Brown KH, Murphy TV; Centers for Disease Control and Prevention; Advisory Committee on Immunization Practices; Healthcare Infection Control Practices Advisory Committee. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health- care personnel. MMWR Recomm Rep. 2006 Dec 15;55(RR-17):1-37. Corresponding NGC guideline withdrawn Dec 2011 PMID: 17167397
  9. Murphy TV, Slade BA, Broder KR, Kretsinger K, Tiwari T, Joyce PM, Iskander JK, Brown K, Moran JS; Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008 May 30;57(RR-4):1-51. Review. PMID: 18509304
  10. Prescriber's Letter 15(7): 2008 Detail-Document#: 240705 (subscription needed) http://www.prescribersletter.com
  11. Medical Knowledge Self Assessment Program (MKSAP) 14, 16. American College of Physicians, Philadelphia 2006, 2012
  12. Steenhuysen J Vaccine panel expands whooping cough coverage Reuters, Oct 27, 2010 http://www.reuters.com/article/idUSTRE69Q5UL20101027 - Journal Watch, Massachusetts Medical Society Physician's First Watch for October 28, 2010 FirstWatch@jwatch.org - Prescriber's Letter 18(2): 2011 Update on Pertussis: Outbreaks and Vaccination Detail-Document#: 270211 (subscription needed) http://www.prescribersletter.com
  13. FDA NEWS RELEASE: July 8, 2011 FDA approves Boostrix to prevent tetanus, diphtheria, and pertussis in older people http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm262390.htm
  14. Centers for Disease Control and Prevention Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine (Tdap) in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged <12 Months --- Advisory Committee on Immunization Practices (ACIP), 2011 MMWR October 21, 2011 / 60(41);1424-1426 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6041a4.htm - Associated Press, Oct 24, 2012 Panel: Pregnant women, get whooping cough shot http://news.yahoo.com/panel-pregnant-women-whooping-cough-shot-152229676.html
  15. Associated Press: February 22 All older adults added to vaccine advice for whooping cough by US advisory panel Washington Post http://www.washingtonpost.com/national/health-science/all-older-adults-should-get-vaccinated-against-whooping-cough-us-advisory-panel-says/2012/02/22/gIQAiEsLTR_story.html - Centers for Disease Control and Prevention Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis (Tdap) Vaccine in Adults Aged 65 Years and Older - Advisory Committee on Immunization Practices (ACIP), 2012 MMWR June 29, 2012 / 61(25);468-470 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6125a4.htm
  16. Prescriber's Letter 19(9): 2012 Pertussis Epidemic: Is the Duration of Vaccine Immunity a Factor? Detail-Document#: 280902 (subscription needed) http://www.prescribersletter.com
  17. Klein NP et al. Waning protection after fifth dose of acellular pertussis vaccine in children. N Engl J Med 2012 Sep 13; 367:1012 PMID: 22970945 http://www.nejm.org/doi/full/10.1056/NEJMoa1200850
  18. Jackson LA et al Vaccination Site and Risk of Local Reactions in Children 1 Through 6 Years of Age. Pediatrics. January 14, 2013 PMID: 23319538 http://pediatrics.aappublications.org/content/early/2013/01/08/peds.2012-2617.abstract
  19. Centers for Disease Control and Prevention Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women Advisory Committee on Immunization Practices (ACIP), 2012 MMWR. Feb 22, 2013 / 62(07);131-135 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm
  20. Tartof SY et al Waning Immunity to Pertussis Following 5 Doses of DTap Pediatrics. March 11, 2012 PMID: 23478868 http://pediatrics.aappublications.org/content/early/2013/03/06/peds.2012-1928.full.pdf+html
  21. Baxter R et al Effectiveness of pertussis vaccines for adolescents and adults: case-control study. BMJ 2013;347:f4249 PMID: 23873919 Free full text http://www.bmj.com/content/347/bmj.f4249
  22. Glanz JM et al Association Between Undervaccination With Diphtheria, Tetanus Toxoids, and Acellular Pertussis (DTaP) Vaccine and Risk of Pertussis Infection in Children 3 to 36 Months of Age. JAMA Pediatr. Published online September 09, 2013 PMID: 24019039 http://archpedi.jamanetwork.com/article.aspx?articleid=1735653
  23. Quinn HE et al. Duration of protection after first dose of acellular pertussis vaccine in infants. Pediatrics 2014 Feb 10 Pediatrics. 2014 Mar;133(3):e513-9. PMID: 24515514
  24. Maglione MA et al Safety of Vaccines Used for Routine Immunization of US Children: A Systematic Review. Pediatrics; published online July 1, 2014 PMID: 25086160 http://pediatrics.aappublications.org/content/early/2014/06/26/peds.2014-1079.full.pdf+html - Byington CL Vaccines: Can Transparency Increase Confidence and Reduce Hesitancy? Pediatrics; published online July 1, 2014 PMID: 25086161 http://pediatrics.aappublications.org/content/early/2014/06/26/peds.2014-1494.full.pdf+html
  25. Donegan K et al. Safety of pertussis vaccination in pregnant women in UK: Observational study. BMJ 2014 Jul 11; 349:g4219. PMID: 25015137 http://www.bmj.com/content/349/bmj.g4219
  26. Amirthalingam G et al. Effectiveness of maternal pertussis vaccination in England: An observational study. Lancet 2014 Jul 16; PMID: 25037990 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960686-3/fulltext
  27. Kharbanda EO et al Evaluation of the Association of Maternal Pertussis Vaccination With Obstetric Events and Birth Outcomes. JAMA. 2014;312(18):1897-1904 PMID: 25387187 http://jama.jamanetwork.com/article.aspx?articleid=1930817
  28. Winter K et al Pertussis Epidemic - California, 2014 MMWR. Weekly December 5, 2014 / 63(48);1129-1132 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6348a2.htm
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  30. Ahluwalia IB et al Tetanus, Diphtheria, Pertussis Vaccination Coverage Before, During, and After Pregnancy - 16 States and New York City, 2011 MMWR. May 22, 2015 / 64(19);522-526 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6419a4.htm - Centers for Disease Control and Prevention (CDC) Pregnancy and Whooping Cough http://www.cdc.gov/pertussis/pregnant/HCP/
  31. Sukumaran L et al Association of Tdap Vaccination With Acute Events and Adverse Birth Outcomes Among Pregnant Women With Prior Tetanus- Containing Immunizations. JAMA. 2015;314(15):1581-1587 PMID: 26501534 http://jama.jamanetwork.com/article.aspx?articleid=2463256
  32. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women--Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep. 2013 Feb 22;62(7):131-5. PMID: 23425962 Free full text
  33. Winter K et al. Effectiveness of prenatal versus postpartum Tdap vaccination in preventing infant pertussis. Clin Infect Dis 2016 Sep 13 PMID: 27624956
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  35. Baxter R, Bartlett J, Fireman B et al Effectiveness of Vaccination During Pregnancy to Prevent Infant Pertussis. Pediatrics. 2017 May;139(5). pii: e20164091. PMID: 28557752 http://pediatrics.aappublications.org/content/early/2017/03/30/peds.2016-4091
  36. Seither R, Calhoun K, Street EJ, et al. Vaccination Coverage for Selected Vaccines, Exemption Rates, and Provisional Enrollment Among Children in Kindergarten - United States, 2016-17 School Year. MMWR Morb Mortal Wkly Rep 2017;66:1073-1080 https://www.cdc.gov/mmwr/volumes/66/wr/mm6640a3.htm
  37. Skoff TH, Blain AE, Watt J et al. Impact of the US maternal tetanus, diphtheria, and acellular pertussis vaccination program on preventing pertussis in infants < 2 months of age: A case-control evaluation. Clin Infect Dis 2017 Sep 28; PMID: 29028938
  38. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  39. Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2019. MMWR Morb Mortal Wkly Rep 2020;69:77-83 https://www.cdc.gov/mmwr/volumes/69/wr/mm6903a5.htm
  40. Douros A et al. Common vaccines and the risk of incident dementia: A population-based cohort study. J Infect Dis 2022 Dec 21; [e-pub]. PMID: 36542511 https://academic.oup.com/jid/advance-article-abstract/doi/10.1093/infdis/jiac484/6948438 - Salmon DA et al. Commentary on "Common vaccines and the risk of dementia: a population-based cohort study": Science can be messy but eventually leads to truths. J Infect Dis 2022 Dec 21; [e-pub] PMID: 36542509 https://academic.oup.com/jid/advance-article/doi/10.1093/infdis/jiac487/6950650
  41. Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020 Jan 24;69(3):77-83 PMID: 31971933 PMCID: PMC7367039 Free PMC article
  42. Israel A et al Anti-tetanus vaccination is associated with reduced occurrence and slower progression of Parkinso's disease. medRxiv. May 21, 2024 https://www.medrxiv.org/content/10.1101/2024.05.03.24306800v2

Components

acellular Pertussis vaccine (Repevax) diphtheria toxoid diphtheria toxoid/tetanus toxoid (dT, Td)