What makes UpToDate so powerful?

  • over 11000 topics
  • 22 specialties
  • 5,700 physician authors
  • evidence-based recommendations
See more sample topics
Find Patient Print
0 Find synonyms

Find synonyms Find exact match

Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age
UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age
View in Chinese
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2017. | This topic last updated: May 30, 2017.

INTRODUCTION — Childhood and adolescent immunizations are one of the most effective means of preventing serious illness. Diphtheria, tetanus, and pertussis immunization in children and adolescents 7 through 18 years of age will be discussed here. Diphtheria, tetanus, and pertussis immunization in children zero through six years of age and other childhood immunizations are discussed separately. (See "Diphtheria, tetanus, and pertussis immunization in infants and children 0 through 6 years of age" and "Standard immunizations for children and adolescents: Overview".)

BACKGROUND — Diphtheria is an acute respiratory or cutaneous illness caused by Corynebacterium diphtheriae. Respiratory diphtheria has a case fatality rate of 5 to 10 percent [1]. (See "Epidemiology and pathophysiology of diphtheria" and "Clinical manifestations, diagnosis, and treatment of diphtheria".)

Tetanus is a nervous system disorder characterized by muscle spasms. It is caused by Clostridium tetani, a toxin-producing anaerobe. Mortality is increased among unvaccinated persons [2]. (See "Tetanus".)

Pertussis, or "whooping cough," is an acute respiratory illness caused by Bordetella pertussis. The case fatality rate for pertussis is approximately 0.2 percent; mortality is increased among infants younger than three months of age. (See "Pertussis infection in adolescents and adults: Clinical manifestations and diagnosis" and "Pertussis infection in infants and children: Clinical features and diagnosis".)

VACCINES — Vaccines for diphtheria, tetanus, and pertussis were introduced into the routine childhood immunization schedule in the United States during the 1940s, with dramatic effects on disease incidence (figure 1A and figure 1B and figure 2) [1-3].

Vaccine preparations — Vaccines for children ≥7 years, adolescents, and adults contain less diphtheria toxoid and pertussis antigen (if they contain pertussis antigens) than the vaccines that are used for children <7 years [1-4]. Vaccines for children ≥7 years also may contain less tetanus toxoid (table 1).

Diphtheria-, tetanus-, and/or pertussis-containing vaccines for children aged 7 through 18 years include:

Tdap – Tdap contains tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. The pertussis antigens that are included vary depending upon the vaccine product (table 1). Two Tdap vaccines are approved by the US Food and Drug Administration (FDA) [5]:

BOOSTRIX, for use in individuals ≥10 years of age [6]. The tip and rubber plunger of the needleless syringe contain latex; the single-dose vial, however, does not contain latex.

Adacel, for use in individuals 10 through 64 years of age [7]; Adacel is available in single-dose vials that are latex free [8].

The Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) recommend off-label use of Tdap for children between 7 and 10 years of age who are not fully vaccinated against pertussis [9,10]. (See '7 to 10 years' below and 'Catch-up schedule' below.)

Tdap vaccines do not contain thimerosal [11].

Care must be taken to distinguish Tdap from the diphtheria toxoid, tetanus toxoid, acellular pertussis vaccine (DTaP) used in children <7 years (table 1). (See "Diphtheria, tetanus, and pertussis immunization in infants and children 0 through 6 years of age", section on 'Vaccines'.)

Td – Td contains tetanus toxoid and reduced diphtheria toxoid. Care must be taken to distinguish Td from the diphtheria toxoid-tetanus toxoid vaccine (DT) used in children <7 years in whom it is desirable to avoid the pertussis vaccine (table 1). Some preparations of Td may contain latex and trace amounts of thimerosal (ie, <0.01 percent) [11].

Immunization with conjugate vaccines that contain diphtheria toxoid or CRM197 protein, a nontoxic variant of diphtheria toxin (eg, the quadrivalent meningococcal conjugate vaccine) is not a substitute for diphtheria toxoid immunization [12].

Single-antigen tetanus toxoid – The single-antigen tetanus toxoid (TT) preparation is approved for use as a booster dose in children ≥7 years or adults when combined-antigen preparations are not indicated (eg, a documented severe allergic reaction to diphtheria toxoid). TT preparations may contain latex and/or trace amounts (≤0.01 percent) of thimerosal [11].

Choice of vaccine — The choice of vaccine depends upon the age of the child or adolescent and whether he or she has received a dose of tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap) vaccine.

7 to 10 years — Acellular pertussis-containing vaccines are not licensed for children 7 to 10 years of age. Children in this age group do not require diphtheria, tetanus, or pertussis immunization if they are fully vaccinated (figure 3). Full vaccination is defined by five doses of diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine [DTaP] or four doses of DTaP if the fourth dose was administered on or after the fourth birthday.

The ACIP and the AAP recommend off-label use of Tdap in children aged 7 through 10 years who are not fully vaccinated against pertussis [9,10]. Tdap is preferred to DTaP for this age group because it causes fewer adverse reactions [13-15].

Children age 7 to 10 years who are not fully vaccinated against pertussis and who have no contraindications to pertussis vaccine should receive a single dose of Tdap to provide protection against pertussis. Additional doses of tetanus toxoid-reduced diphtheria toxoid (Td) should be administered as necessary according to the catch-up schedule (table 2). (See 'Contraindications' below and 'Catch-up schedule' below.)

Children 7 through 10 years of age who have never been vaccinated against tetanus, diphtheria, or pertussis or whose vaccination status is unknown should receive a series of three tetanus- and diphtheria-containing vaccines (table 2). The preferred schedule is a single dose of Tdap (if there are no contraindications to pertussis vaccine) followed by a dose of Td ≥4 weeks later and a second dose of Td 6 to 12 months after the first. Tdap can be substituted for either of the Td doses if Tdap is not administered as the first dose in the series. (See 'Contraindications' below and 'Catch-up schedule' below.)

Children who receive Tdap between ages 7 and 10 years as part of a catch-up series may receive Tdap at age 11 through 12 years [10].

10 through 18 years — The ACIP, the AAP Committee on Infectious Diseases, the American Academy of Family Physicians (AAFP), and the Society for Adolescent Health and Medicine (SAHM) recommend a single booster dose of Tdap for adolescents [16,17]. Tdap may be substituted for any indicated dose of Td in a child ≥10 years of age [4,5]. (See 'Indications' below.)

Dose and route — The dose of diphtheria toxoid, tetanus toxoid, and pertussis vaccines is 0.5 mL. The vaccine is administered intramuscularly. The deltoid muscle is the preferred site for administration, but the anterolateral thigh can also be used [18].

Storage and handling — Diphtheria toxoid, tetanus toxoid, and acellular pertussis vaccines should be stored continuously at 36 to 46ºF (2 to 8ºC) [19]. During transport, the vaccine may be out of refrigeration for as long as four days, but it should be refrigerated immediately upon arrival. Freezing reduces the potency of the tetanus component; vaccine exposed to freezing temperature should not be administered.

Efficacy and effectiveness — The efficacy and effectiveness of diphtheria, tetanus, and pertussis immunization vary depending upon the definition used for efficacy (ie, antibody levels correlated with protection or protection from disease) and the number of doses.

Td — After a series of three appropriately spaced doses of tetanus toxoid-reduced diphtheria toxoid (Td) vaccines, approximately 95 percent of adolescents and adults achieve levels of diphtheria antitoxin correlated with protection (>0.1 international unit of antitoxin/mL), and virtually all adolescents and adults achieve levels of tetanus antitoxin correlated with protection (>0.1 international unit of antitoxin/mL) [1,2]. Levels of antibody diminish with time [20]. Booster doses of tetanus toxoid, reduced diphtheria toxoid are necessary every 10 years throughout life. (See 'Routine schedule' below.)

The estimated efficacy of diphtheria toxoid in the prevention of diphtheria disease is 97 percent [1]. The clinical efficacy of tetanus toxoid has not been studied in vaccine trials [2].

The effectiveness of immunization with diphtheria-tetanus toxoid is demonstrated by the decline of these diseases in the United States after the immunizations were added to the routine immunization schedule in the 1940s (figure 1A-B) [1,2,21]. Most cases of diphtheria and tetanus in the United States occur in inadequately immunized persons [1,2].

Tdap — In randomized controlled trials, virtually all adolescent and adult recipients of tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap) developed antibody levels of tetanus and diphtheria antitoxin correlated with protection [5,22,23]. Booster response rates to these antigens were achieved in ≥90 percent.

In a randomized trial, the efficacy of Tdap in preventing laboratory-confirmed pertussis in adolescents and adults was 92 percent (95% CI 32-99 percent) [24]. (See "Pertussis infection in adolescents and adults: Treatment and prevention".)

However, the effectiveness of Tdap appears to wane soon after receipt among adolescents who completed childhood vaccination with acellular pertussis vaccines (ie, the cohort born in the late 1990s) rather than a combination of acellular and whole cell vaccines (ie, those born before 1997) (figure 4) [25-30]. The ACIP began recommending Tdap for adolescents in 2006 [5]. In pertussis outbreaks during 2005 and 2007, reported effectiveness of acellular pertussis vaccine in preventing laboratory confirmed or probably pertussis among vaccinated adolescents ranged from 66 to 85 percent [31,32]. In more recent state-wide outbreaks, Tdap provided similar modest protection during the first year after vaccination (effectiveness of 64 to 75 percent), but effectiveness quickly waned to approximately 10 percent by ≥4 years [33-35].

Despite waning immunity, vaccination continues to be the most effective strategy to reduce pertussis morbidity and mortality [25,36-38]. In a 2010 to 2012 county-wide outbreak, children who received any doses of acellular pertussis vaccine were less likely to have severe illness or require hospitalization than unvaccinated children, and children fully vaccinated with acellular pertussis vaccine had more rapid resolution of coughing [36].

INDICATIONS — The Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians recommend a single booster dose of tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap) (0.5 mL IM) for adolescents age 11 through 18 years and for pregnant adolescents during each pregnancy (as early as possible between 27 and 36 weeks of gestation), regardless of prior vaccination status (figure 3) [10,39]. Thereafter, adolescents and adults should receive a booster dose of tetanus toxoid-reduced diphtheria toxoid (Td) every 10 years.

Indications for diphtheria, tetanus, and/or pertussis immunization in unimmunized or underimmunized individuals (including those who have not yet received a dose of Tdap) include [4,5,9,40]:

Wound management or tetanus disease (see "Tetanus")

Diphtheria disease or close contact of individual with diphtheria disease (see "Clinical manifestations, diagnosis, and treatment of diphtheria")

Increased risk of pertussis (living in an area with a high rate of endemic pertussis or during an outbreak), attending a school or workplace with a high rate of endemic pertussis or during an outbreak, or having close direct contact with a case of pertussis (eg, family, residential facility, school-related activity) (see "Pertussis infection in infants and children: Treatment and prevention", section on 'Immunization')

Increased risk of complications from pertussis (eg, neurologic, muscular, or cardiac disorder; airway or pulmonary disorder)

Anticipated close contact with an infant younger than 12 months of age (eg, household member, out-of-home caregiver)

Health care workers who have direct patient contact in hospitals or clinics

VACCINE SCHEDULE

Routine schedule — In the United States, children generally receive five doses of diphtheria, tetanus, and pertussis vaccine before seven years of age. (See "Diphtheria, tetanus, and pertussis immunization in infants and children 0 through 6 years of age", section on 'Vaccine schedule'.)

A single dose of tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap) vaccine is recommended for individuals between 11 and 18 years of age [10]. Age 11 to 12 years is the preferred age for this dose [4,5]. Children who received Tdap between ages 7 and 10 years as part of a catch-up series may receive the adolescent dose of Tdap at age 11 to 12 years [10]. (See '7 to 10 years' above.)

Immunization with Tdap is encouraged for adolescents who received a tetanus toxoid-reduced diphtheria toxoid (Td) booster at age 11 to 12 years [4,5]. This recommendation is made to protect adolescents against pertussis and to prevent the spread of pertussis disease to infants, young children, and others at risk for pertussis complications. It is particularly important for adolescents who will have, or anticipate having, close contact with an infant younger than 12 months of age [40,41]. (See "Pertussis infection in adolescents and adults: Treatment and prevention".)

The Advisory Committee on Immunization Practices (ACIP) does not recommend a minimum interval between a tetanus- or diphtheria-toxoid-containing vaccine and Tdap when Tdap is otherwise indicated [10]. However, the minimum intervals in the catch-up schedule should continue to be followed (table 2).

After the adolescent booster dose, individuals should receive Td every 10 years [10]. Adults older than 19 years who did not receive a dose of Tdap during adolescence should substitute Tdap for one booster dose of Td. (See "Tetanus-diphtheria toxoid vaccination in adults" and "Pertussis infection in adolescents and adults: Treatment and prevention".)

Administration with other vaccines — Tdap or Td may be administered at the same visit as other recommended vaccines (eg, meningococcal conjugate vaccine, human papillomavirus, influenza) (figure 3) [5,16,42-48].

Catch-up schedule — The catch-up schedule for children ≥7 years and adolescents with lapsed or incomplete diphtheria, tetanus, and/or pertussis immunization is provided in the table (table 2).

Incomplete pertussis — Adolescents with incomplete pertussis immunization (ie, because there was a precaution to administration of pertussis vaccine during childhood) generally should receive Tdap for their adolescent booster dose [4,5]. Precautions to administration of diphtheria toxoid-tetanus toxoid-acellular pertussis (DTaP) vaccine to children <7 years are not necessarily precautions to administration of Tdap [4,5]. (See "Diphtheria, tetanus, and pertussis immunization in infants and children 0 through 6 years of age", section on 'Precautions' and 'Not contraindications or precautions' below.)

Incomplete records — Serologic testing can be performed in children and adolescents for whom documentation of immunization against diphtheria and tetanus is incomplete despite an adequate history of immunization [5]. If tetanus and diphtheria antibody concentrations are ≥0.1 international units/mL, previous immunization can be presumed and the adolescent booster dose of Tdap administered as indicated. (See 'Routine schedule' above.)

Special circumstances

Wound management — When tetanus prophylaxis is necessary for wound management (table 3), Tdap may be substituted for Td if Tdap is available, the child is older than 10 years, and Tdap and has not been administered previously [4,5]. The meningococcal conjugate vaccine should be administered at the same visit if possible. (See "Tetanus" and 'Administration with other vaccines' above.)

Tdap not available — If tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap) is indicated but not available, and the last dose of tetanus toxoid-containing vaccine was administered ≥10 years previously, Td should be used [5]. If the last dose of tetanus toxoid-containing vaccine was administered <10 years previously, immunization can be deferred pending availability of Tdap if the patient is likely to return for follow-up.

History of diphtheria, tetanus, or pertussis disease — Natural infection with diphtheria or tetanus disease does not induce immunity. Individuals with diphtheria or tetanus disease should receive tetanus toxoid-reduced diphtheria toxoid during their convalescence. (See "Clinical manifestations, diagnosis, and treatment of diphtheria", section on 'Follow-up' and "Tetanus", section on 'Active immunization'.)

Well-documented pertussis disease (eg, positive culture or epidemiologic linkage to a culture-proven case) confers short-term immunity [4,5]. However, the duration of protection is unknown. Adolescents with a history of pertussis infection should receive Tdap [4,5].

Vaccine mix-up

Children aged 7 to 10 years who inadvertently receive Tdap instead of Td may receive the adolescent Tdap dose at age 11 through 12 years [5,10]. The child should receive Td 10 years after the most recent Tdap dose.

Inadvertent administration of DTaP vaccine (rather than Td or Tdap) to a child age 7 to 10 years may count as the adolescent Tdap booster, or the child may receive a Tdap booster dose at age 11 through 12 years [5,10]. The child should receive Td 10 years after the most recent dose of DTaP or Tdap.

Inadvertent administration of DTaP vaccine (rather than Td or Tdap) to a child 11 through 18 years of age should count as the Tdap dose. The child should receive Td 10 years after the inadvertent dose.

Vaccine administration errors should be reported to the Vaccine Adverse Event Reporting System (VAERS, telephone number 1-800-822-7967).

Pregnancy — Immunization during pregnancy is discussed separately. (See "Immunizations during pregnancy".)

CONTRAINDICATIONS AND PRECAUTIONS — Contraindications, precautions, and conditions that are neither contraindications nor precautions (and therefore should not be used to defer immunization) for diphtheria toxoid-, tetanus toxoid-, and/or acellular pertussis-containing vaccines are summarized in the table (table 4).

Contraindications — Absolute contraindications to diphtheria, tetanus, and/or pertussis immunizations include [4,5,49]:

Anaphylactic reaction to the diphtheria, tetanus, and/or pertussis vaccine or vaccine constituent (contraindication to subsequent doses of all components)

Encephalopathy within seven days of the administration of a previous dose of the vaccine without another identifiable cause (this is a contraindication to tetanus toxoid-reduced diphtheria toxoid-acellular pertussis [Tdap]; tetanus toxoid-reduced diphtheria toxoid [Td] should be administered) (see 'Vaccine preparations' above)

Some Tdap and Td vaccines contain latex and are contraindicated in patients with anaphylactic reaction to latex

Precautions — Precautions are conditions that might increase the risk for a serious reaction to immunization, might cause diagnostic confusion, or might compromise the ability of the vaccine to produce immunity [18]. Precautions to immunization with Td or Tdap include [4-6,18]:

Moderate or severe illness with or without fever; immunization may be administered upon recovery

History of Arthus-type hypersensitivity reactions after a previous dose of tetanus or diphtheria-toxoid containing vaccines (including quadrivalent meningococcal conjugate vaccine)

Guillain-Barré syndrome (GBS) within six weeks after previous dose of tetanus toxoid- or diphtheria toxoid-containing vaccine (see 'Adverse reactions' below)

For Tdap only: Progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy

Past cutaneous reactions involving skin necrosis (Arthus-type reaction) — Deferral of tetanus- and/or diphtheria toxoid-containing vaccine (including quadrivalent meningococcal conjugate vaccine) for a minimum of 10 years after the last dose may be warranted for patients with a history of a past cutaneous reaction involving skin hemorrhage or necrosis [4,5]. This type of local reaction may represent an Arthus reaction, although the mechanism has not been proven. The history of the reaction should be reviewed to verify the signs and symptoms; consultation with an allergist or immunologist may be warranted.

The Arthus reaction is a laboratory model of a type III or immune complex mediated hypersensitivity reaction. Arthus reactions can be induced in animals that have been previously immunized to form IgG against an antigen. If the antigen is later injected into the skin, immune complexes may form locally, with symptoms beginning several hours later. These immune complexes cause activation of mast cells, neutrophil recruitment, and occlusion of capillaries with platelets. Local inflammation with hemorrhage at the site and sometimes superficial skin necrosis can ensue. (See 'Adverse reactions' below.)

If such a reaction occurred after immunization with diphtheria toxoid but not tetanus toxoid (eg, after immunization with meningococcal conjugate vaccine, which contains diphtheria toxoid), and it has been more than 10 years since the last dose of tetanus toxoid-containing vaccine, tetanus toxoid (TT) may be administered. Alternatively, serology may be performed to determine whether the adolescent has levels of tetanus antitoxin correlated with protection (≥0.1 international units/mL) [5].

Not contraindications or precautions — The following conditions are neither contraindications nor precautions for Tdap or Td; several of the conditions are precautions to the administration of diphtheria toxoid-tetanus toxoid-acellular pertussis (DTaP) or diphtheria toxoid-tetanus toxoid-whole cell pertussis (DTwP) in children <7 years [4,5,18,50] (see "Diphtheria, tetanus, and pertussis immunization in infants and children 0 through 6 years of age", section on 'Precautions'):

Temperature ≥105ºF (40.5ºC) within 48 hours after DTaP or DTwP (not attributable to another cause)

Hypotonic hyporesponsive episode within 48 hours after DTaP or DTwP

Convulsions with or without fever within three days of DTaP or DTwP

History of extensive limb swelling after DTaP or DTwP that is not an Arthus-type reaction

Stable or resolved neurologic disorder (eg, well-controlled seizures, developmental delay, cerebral palsy)

History of contact latex allergy that is not anaphylactic

Immunosuppression, including human immunodeficiency virus (HIV) infection

Mild acute illness with or without fever

Breast-feeding

Use of antimicrobials

SAFETY — The safety of tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap) was confirmed in postmarketing surveillance of more than 13,000 adolescents [51]. There was no increased risk of medically attended neurologic, hematologic, or allergic reactions on days 0 to 29 after Tdap vaccination compared with days 30 to 59 after vaccination, nor was there an increased risk of new-onset chronic illness in recipients of Tdap compared with historical recipients of tetanus toxoid-reduced diphtheria toxoid (Td).

Adverse reactions — Adverse reactions to the Tdap vaccine include:

Local reactions – Mild local reactions (eg, pain, redness, swelling) may occur after immunization with Td or Tdap. In prelicensure studies, mild local reactions occurred with similar frequency: pain (approximately 70 to 80 percent), erythema (approximately 20 percent), and swelling (approximately 20 percent) [5]. Severe local reactions are less frequent (≤6 percent for either Td or Tdap).

Systemic reactions – Systemic reactions also may occur after immunization with Td or Tdap: fever (3 to 14 percent), headache (approximately 40 percent), fatigue (approximately 30 to 35 percent) [4,5]. Fever >102.2ºF (39°C), severe headache, and severe fatigue occur in less than 4 percent.

Syncope – Syncope following immunization appears to be more common among adolescents and young adults than other age groups [5,18,52-54]. The Advisory Committee on Immunization Practices (ACIP) and American Academy of Pediatrics (AAP) suggest that patients be observed for 15 minutes after immunization and that personnel take appropriate measures to prevent injuries if weakness, dizziness, or loss of consciousness occurs [18,54,55]. Having the recipient sit or lie down for 15 minutes after vaccination may prevent syncopal episodes and secondary injuries. If syncope occurs, patients should be observed until symptoms resolve.

Local reactions with skin hemorrhage and necrosis – Arthus-type reactions can occur after vaccines containing tetanus or diphtheria toxoid [5]. They typically occur 4 to 12 hours after vaccination and are characterized by severe pain, swelling, induration, edema, hemorrhage, and occasionally necrosis at the site of the injection. They generally resolve without sequelae. (See 'Past cutaneous reactions involving skin necrosis (Arthus-type reaction)' above.)

Guillain-Barré syndrome – There have been rare case reports of Guillain-Barré syndrome (GBS) following tetanus toxoid-containing vaccines [5,56-58]. However, an association between GBS and tetanus vaccination has not been demonstrated during active surveillance [5,59,60]. (See "Guillain-Barré syndrome: Pathogenesis", section on 'Vaccination'.)

GBS also has been reported after meningococcal conjugate vaccine, which contains diphtheria toxoid. The possible association between meningococcal conjugate vaccine and GBS is discussed separately. (See "Meningococcal vaccines", section on 'Possible association with Guillain-Barré syndrome'.)

RESOURCES — Resources related to immunization in children 7 through 18 years of age include:

The Centers for Disease Control and Prevention

The American Academy of Pediatrics

Vaccine information statement for tetanus toxoid-reduced diphtheria toxoid (Td) and tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap)

Immunization Action Coalition

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pertussis" and "Society guideline links: Immunizations in children and adolescents" and "Society guideline links: Diphtheria, tetanus, and pertussis vaccination".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Whooping cough (The Basics)" and "Patient education: Tetanus (The Basics)" and "Patient education: Tdap vaccine (The Basics)" and "Patient education: Vaccines for children age 7 to 18 years (The Basics)")

Beyond the Basics topics (see "Patient education: Why does my child need vaccines? (Beyond the Basics)" and "Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

In accord with the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians, we recommend a single booster dose of tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap) vaccine for adolescents 11 through 18 years of age (Grade 1A). A single dose of Tdap should also be administered to pregnant adolescents during each pregnancy (as early as possible between 27 and 36 weeks of gestation), regardless of prior vaccination status. (See 'Indications' above.)

Additional indications for tetanus-, reduced diphtheria-, and/or acellular pertussis-containing vaccine in unimmunized or underimmunized individuals (including those who have not yet received a dose of Tdap) include wound management or tetanus disease; diphtheria disease or close contact of individual with diphtheria; increased risk of pertussis or complications from pertussis; and anticipated close contact with an infant younger than 12 months of age. (See 'Indications' above.)

The preferred age for Tdap is 11 to 12 years. Thereafter, individuals should receive a booster dose of tetanus toxoid-reduced diphtheria toxoid (Td) every 10 years. (See 'Routine schedule' above.)

The catch-up schedule for children ≥7 years and adolescents with lapsed or incomplete diphtheria, tetanus, and/or pertussis immunization is provided in the table (table 2). (See 'Catch-up schedule' above.)

Absolute contraindications, precautions, and conditions that are neither contraindications nor precautions to administration of Tdap and Td are listed in the table (table 4). (See 'Contraindications and precautions' above.)

Mild local (pain, redness, swelling) and systemic (fever, headache, fatigue) reactions are the most common adverse events after Tdap or Td. More serious reactions include syncope and Arthus-type reactions. (See 'Adverse reactions' above.)

Use of UpToDate is subject to the  Subscription and License Agreement.

REFERENCES

  1. Centers for Disease Control and Prevention. Diphtheria. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook, 13th ed, Hamborsky J, Kroger A, Wolfe S (Eds). Public Health Foundation, Washington, DC 2015. www.cdc.gov/vaccines/pubs/pinkbook/index.html (Accessed on June 03, 2015).
  2. Centers for Disease Control and Prevention. Tetanus. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook, 13th ed, Hamborsky J, Kroger A, Wolfe S (Eds). Public Health Foundation, Washington, DC 2015. www.cdc.gov/vaccines/pubs/pinkbook/index.html (Accessed on June 03, 2015).
  3. Centers for Disease Control and Prevention. Pertussis. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook, 13th ed, Hamborsky J, Kroger A, Wolfe S (Eds). Public Health Foundation, Washington, DC 2015. www.cdc.gov/vaccines/pubs/pinkbook/index.html (Accessed on June 03, 2015).
  4. American Academy of Pediatrics. Pertussis (whooping cough). In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.609.
  5. Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006; 55:1.
  6. BOOSTRIX (tetanus toxoid, reduced diptheria toxoid and acellular pertussis vaccine, adsorbed) prescribing information, 2011. http://us.gsk.com/products/assets/us_boostrix.pdf (Accessed on August 10, 2011).
  7. US Food and Drug Administration. Adacel (Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed). www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm172481.htm (Accessed on April 08, 2014).
  8. Adacel (Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed) prescribing information, 2014. https://www.vaccineshoppe.com/image.cfm?image_type=product_pdf&pi=400-10 (Accessed on April 08, 2014).
  9. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR Morb Mortal Wkly Rep 2011; 60:13.
  10. Robinson CL, Romero JR, Kempe A, et al. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger - United States, 2017. MMWR Morb Mortal Wkly Rep 2017; 66:134.
  11. US Food and Drug Administration. Thimerosal in vaccines. www.fda.gov/CBER/vaccine/thimerosal.htm#t1 (Accessed on August 10, 2011).
  12. American Academy of Pediatrics. Diphtheria. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.325.
  13. Langley JM, Predy G, Guasparini R, et al. An adolescent-adult formulation tetanus and diptheria toxoids adsorbed combined with acellular pertussis vaccine has comparable immunogenicity but less reactogenicity in children 4-6 years of age than a pediatric formulation acellular pertussis vaccine and diphtheria and tetanus toxoids adsorbed combined with inactivated poliomyelitis vaccine. Vaccine 2007; 25:1121.
  14. Meyer CU, Habermehl P, Knuf M, et al. Immunogenicity and reactogenicity of acellular pertussis booster vaccines in children: standard pediatric versus a reduced-antigen content formulation. Hum Vaccin 2008; 4:203.
  15. Scheifele DW, Halperin SA, Ochnio JJ, et al. A modified vaccine reduces the rate of large injection site reactions to the preschool booster dose of diphtheria-tetanus-acellular pertussis vaccine: results of a randomized, controlled trial. Pediatr Infect Dis J 2005; 24:1059.
  16. Cassidy WM, Jones G, Williams K, et al. Safety and immunogenicity of concomitant versus nonconcomitant administration of hepatitis B, tetanus-diphtheria, and measles-mumps-rubella vaccines in healthy eleven- to twelve-year-olds. J Adolesc Health 2005; 36:187.
  17. Middleman AB, Bruner A. Tetanus, diphtheria, and acellular pertussis vaccine: a position statement of the Society for Adolescent Medicine. J Adolesc Health 2009; 45:316.
  18. Kroger AT, Duchin J, Vázquez M. General best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html (Accessed on April 27, 2017).
  19. Centers for Disease Control and Prevention. Storage and handling for diphtheria, tetanus, and pertussis vaccines. Available at: https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/storage-handling.html (Accessed on April 27, 2017).
  20. Sin MA, Zenke R, Rönckendorf R, et al. Pertussis outbreak in primary and secondary schools in Ludwigslust, Germany demonstrating the role of waning immunity. Pediatr Infect Dis J 2009; 28:242.
  21. Roush SW, Murphy TV, Vaccine-Preventable Disease Table Working Group. Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. JAMA 2007; 298:2155.
  22. Pichichero ME, Casey JR. Acellular pertussis vaccines for adolescents. Pediatr Infect Dis J 2005; 24:S117.
  23. Pichichero ME, Rennels MB, Edwards KM, et al. Combined tetanus, diphtheria, and 5-component pertussis vaccine for use in adolescents and adults. JAMA 2005; 293:3003.
  24. Ward JI, Cherry JD, Chang SJ, et al. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med 2005; 353:1555.
  25. Centers for Disease Control and Prevention (CDC). Pertussis epidemic--Washington, 2012. MMWR Morb Mortal Wkly Rep 2012; 61:517.
  26. Witt MA, Arias L, Katz PH, et al. Reduced risk of pertussis among persons ever vaccinated with whole cell pertussis vaccine compared to recipients of acellular pertussis vaccines in a large US cohort. Clin Infect Dis 2013; 56:1248.
  27. Klein NP, Bartlett J, Fireman B, et al. Comparative effectiveness of acellular versus whole-cell pertussis vaccines in teenagers. Pediatrics 2013; 131:e1716.
  28. Sheridan SL, Ware RS, Grimwood K, Lambert SB. Number and order of whole cell pertussis vaccines in infancy and disease protection. JAMA 2012; 308:454.
  29. Phadke VK, Bednarczyk RA, Salmon DA, Omer SB. Association Between Vaccine Refusal and Vaccine-Preventable Diseases in the United States: A Review of Measles and Pertussis. JAMA 2016; 315:1149.
  30. Skoff TH, Martin SW. Impact of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccinations on Reported Pertussis Cases Among Those 11 to 18 Years of Age in an Era of Waning Pertussis Immunity: A Follow-up Analysis. JAMA Pediatr 2016; 170:453.
  31. Rank C, Quinn HE, McIntyre PB. Pertussis vaccine effectiveness after mass immunization of high school students in Australia. Pediatr Infect Dis J 2009; 28:152.
  32. Wei SC, Tatti K, Cushing K, et al. Effectiveness of adolescent and adult tetanus, reduced-dose diphtheria, and acellular pertussis vaccine against pertussis. Clin Infect Dis 2010; 51:315.
  33. Acosta AM, DeBolt C, Tasslimi A, et al. Tdap vaccine effectiveness in adolescents during the 2012 Washington State pertussis epidemic. Pediatrics 2015; 135:981.
  34. Klein NP, Bartlett J, Fireman B, Baxter R. Waning Tdap Effectiveness in Adolescents. Pediatrics 2016; 137:e20153326.
  35. Koepke R, Eickhoff JC, Ayele RA, et al. Estimating the effectiveness of tetanus-diphtheria-acellular pertussis vaccine (Tdap) for preventing pertussis: evidence of rapidly waning immunity and difference in effectiveness by Tdap brand. J Infect Dis 2014; 210:942.
  36. Barlow RS, Reynolds LE, Cieslak PR, Sullivan AD. Vaccinated children and adolescents with pertussis infections experience reduced illness severity and duration, Oregon, 2010-2012. Clin Infect Dis 2014; 58:1523.
  37. Cherry JD. Epidemic pertussis in 2012--the resurgence of a vaccine-preventable disease. N Engl J Med 2012; 367:785.
  38. Liko J, Robison SG, Cieslak PR. Pertussis vaccine performance in an epidemic year-Oregon, 2012. Clin Infect Dis 2014; 59:261.
  39. 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; 62:131.
  40. 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 and persons who have or anticipate having close contact with an infant aged <12 months --- Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep 2011; 60:1424.
  41. de Greeff SC, Mooi FR, Westerhof A, et al. Pertussis disease burden in the household: how to protect young infants. Clin Infect Dis 2010; 50:1339.
  42. Vesikari T, Van Damme P, Lindblad N, et al. An open-label, randomized, multicenter study of the safety, tolerability, and immunogenicity of quadrivalent human papillomavirus (types 6/11/16/18) vaccine given concomitantly with diphtheria, tetanus, pertussis, and poliomyelitis vaccine in healthy adolescents 11 to 17 years of age. Pediatr Infect Dis J 2010; 29:314.
  43. Reisinger KS, Block SL, Collins-Ogle M, et al. Safety, tolerability, and immunogenicity of gardasil given concomitantly with Menactra and Adacel. Pediatrics 2010; 125:1142.
  44. Kosalaraksa P, Mehlsen J, Vesikari T, et al. An open-label, randomized study of a 9-valent human papillomavirus vaccine given concomitantly with diphtheria, tetanus, pertussis and poliomyelitis vaccines to healthy adolescents 11-15 years of age. Pediatr Infect Dis J 2015; 34:627.
  45. Schilling A, Parra MM, Gutierrez M, et al. Coadministration of a 9-Valent Human Papillomavirus Vaccine With Meningococcal and Tdap Vaccines. Pediatrics 2015; 136:e563.
  46. Gasparini R, Tregnaghi M, Keshavan P, et al. Safety and Immunogenicity of a Quadrivalent Meningococcal Conjugate Vaccine and Commonly Administered Vaccines After Coadministration. Pediatr Infect Dis J 2016; 35:81.
  47. Tetanus vaccines: WHO position paper – February 2017. Wkly Epidemiol Rec 2017; 92:53.
  48. Pertussis vaccines: WHO position paper - September 2015. Wkly Epidemiol Rec 2015; 90:433.
  49. Centers for Disease Control and Prevention (CDC). Licensure of a diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactivated poliovirus, and haemophilus B conjugate vaccine and guidance for use in infants and children. MMWR Morb Mortal Wkly Rep 2008; 57:1079.
  50. Zepp F, Knuf M, Habermehl P, et al. Safety of reduced-antigen-content tetanus-diphtheria-acellular pertussis vaccine in adolescents as a sixth consecutive dose of acellular pertussis-containing vaccine. J Pediatr 2006; 149:603.
  51. Klein NP, Hansen J, Lewis E, et al. Post-marketing safety evaluation of a tetanus toxoid, reduced diphtheria toxoid and 3-component acellular pertussis vaccine administered to a cohort of adolescents in a United States health maintenance organization. Pediatr Infect Dis J 2010; 29:613.
  52. Braun MM, Patriarca PA, Ellenberg SS. Syncope after immunization. Arch Pediatr Adolesc Med 1997; 151:255.
  53. Woo EJ, Ball R, Braun MM. Fatal syncope-related fall after immunization. Arch Pediatr Adolesc Med 2005; 159:1083.
  54. Centers for Disease Control and Prevention (CDC). Syncope after vaccination--United States, January 2005-July 2007. MMWR Morb Mortal Wkly Rep 2008; 57:457.
  55. American Academy of Pediatrics. Active immunization. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2105. p.13.
  56. Pollard JD, Selby G. Relapsing neuropathy due to tetanus toxoid. Report of a case. J Neurol Sci 1978; 37:113.
  57. Bakshi R, Graves MC. Guillain-Barré syndrome after combined tetanus-diphtheria toxoid vaccination. J Neurol Sci 1997; 147:201.
  58. Newton N Jr, Janati A. Guillain-Barré syndrome after vaccination with purified tetanus toxoid. South Med J 1987; 80:1053.
  59. Tuttle J, Chen RT, Rantala H, et al. The risk of Guillain-Barré syndrome after tetanus-toxoid-containing vaccines in adults and children in the United States. Am J Public Health 1997; 87:2045.
  60. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1996; 45:1.
Topic 2838 Version 56.0

Topic Outline

GRAPHICS

RELATED TOPICS

All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.