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Brief Summary

GUIDELINE TITLE

Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants. Recommendations of the Advisory Committee on Immunization Practices (ACIP).

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

This is the current release of the guideline.

BRIEF SUMMARY CONTENT

 
RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Use of Tetanus and Diphtheria Toxoids Vaccine (Td) or Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Women Who Have Not Received Tdap Previously

  • Routine postpartum Tdap. Pregnant women (including women who are breastfeeding) who have not received a dose of Tdap previously should receive Tdap after delivery and before discharge from the hospital or birthing center if 2 years or more have elapsed since the most recent administration of Td; shorter intervals may be used (see "Special Situations," below). If Tdap cannot be administered before discharge, it should be administered as soon as feasible thereafter. The dose of Tdap substitutes for the next decennial dose of Td.
  • Simultaneous administration. Tdap should be administered with other vaccines that are indicated. Each vaccine should be administered using a separate syringe at a different anatomic site.

Contraindications to Administration of Td and Tdap

The following conditions are contraindications to administration of Td and Tdap:

  • A history of serious allergic reaction (i.e., anaphylaxis) to any component of the vaccine
  • For Tdap (but not Td), a history of encephalopathy (e.g., coma or prolonged seizures) not attributable to an identifiable cause within 7 days of administration of a vaccine with pertussis components

Precautions and Reasons to Defer Administration of Td or Tdap

The following conditions are reasons to defer administration of Td or Tdap:

  • Guillain-Barré syndrome with onset 6 weeks or less after a previous dose of tetanus toxoid–containing vaccine
  • Moderate or severe acute illness
  • A history of an Arthus reaction to tetanus toxoid– and/or diphtheria toxoid–containing vaccine less than 10 years previously
  • For adults, unstable neurologic conditions (e.g., cerebrovascular events or acute encephalopathic conditions)
  • For adolescents, any progressive neurologic disorder, including progressive encephalopathy or uncontrolled epilepsy (until the condition has stabilized)

Special Situations

Deferring Td During Pregnancy to Substitute Tdap in the Immediate Postpartum Period

Advisory Committee on Immunization Practices (ACIP) recommends administration of Td for booster vaccination during pregnancy if 10 years or more have elapsed since a previous Td booster. To add protection against pertussis, health-care providers may defer the Td vaccination during pregnancy and substitute Tdap as soon as feasible after delivery if the woman is likely to have sufficient tetanus and diphtheria protection until delivery. Sufficient tetanus protection is likely if:

  • A pregnant woman aged <31 years has received a complete childhood series of immunization (4 to 5 doses of pediatric pediatric diphtheria and tetanus toxoids and whole-cell pertussis vaccine [DTP], pediatric diphtheria and tetanus toxoids and acellular pertussis vaccine [DTaP], and/or pediatric diphtheria and tetanus toxoids vaccine [DT]) and >1 Td booster dose during adolescence or as an adult (a primary series consisting of 3 doses of Td (or  tetanus toxoid vaccine [TT]) administered during adolescence or as an adult substitutes for the childhood series of immunization)*
  • A pregnant woman aged >31 years has received a complete childhood series of immunization (4 to 5 doses of pediatric DTP, DTaP, and/or DT) and >2 Td booster doses
  • A primary series consisting of 3 doses of Td (or TT) was administered during adolescence or as an adult substitute for the childhood series of immunization,*
  • A pregnant woman has a protective level of serum tetanus antitoxin (>0.1 IU/mL by enzyme-linked immunoabsorbant assay [ELISA]).

A woman should receive Td during pregnancy if she

  • Does not have sufficient tetanus immunity to protect against maternal and neonatal tetanus, or
  • Requires booster protection against diphtheria (e.g., for travel to an area in which diphtheria is endemic**)

Alternatively, health-care providers may choose to administer Tdap instead of Td during pregnancy (see "Considerations for Use of Tdap in Pregnant Women in Special Situations," below).

* Women who have had a 3-dose series as TT instead of Td will likely have protection against tetanus but might not be protected against diphtheria. A protective titer of diphtheria antitoxin is >0.1 IU/mL by ELISA.

**A list of areas in which diphtheria is endemic is available at www.cdc.gov/travel/diseases/dtp.htm.

Postpartum Tdap When <2 Years Have Elapsed Since the Most Recent Dose of Td

Health-care providers should obtain a history of adverse reaction after previous doses of vaccines containing tetanus and diphtheria toxoids. Limited information is available concerning the risk for local and systemic reactions after Tdap at intervals of <2 years. Providers may choose to administer Tdap to these women postpartum for protection against pertussis after excluding a history of moderate to severe adverse reactions following previous tetanus and diphtheria-toxoids–containing vaccines.

Health-care providers should encourage vaccination of household and child care provider contacts of infants aged <12 months. Women should be advised of the symptoms of pertussis and the effectiveness of early antimicrobial prophylaxis, if pertussis is suspected.

Considerations for Use of Tdap in Pregnant Women in Special Situations

The Advisory Committee on Immunization Practices (ACIP) recommends that Td be administered when booster protection is indicated during pregnancy. Health-care providers may choose to administer Tdap instead of Td during pregnancy to add protection against pertussis in situations when Td cannot be delayed until delivery or when the risk for pertussis is increased. In such cases, the women should be informed of the lack of data on safety, immunogenicity, and pregnancy outcomes for pregnant women who receive Tdap. Whether administration of Tdap to pregnant women results in protection of the infant against pertussis through transplacental maternal antibodies is unknown. Maternal antibodies might interfere with the infant's immune response to infant doses of DTaP or conjugate vaccines containing tetanus toxoid or diphtheria toxoid.

If Tdap is administered, the second or third trimester is preferred unless protection is needed urgently. Providers are encouraged to report Tdap administrations regardless of trimester to the appropriate manufacturers' pregnancy registry: for ADACEL,® to sanofi pasteur, telephone 800-822-2463 (1-800-VACCINE) and for BOOSTRIX,® to GlaxoSmithKline Biologicals, telephone 1-888-825-5249.

Tetanus Prophylaxis for Wound Management

ACIP recommends administration of a Td booster for wound management in pregnant women in certain situations if >5 years have elapsed since the previous Td. Health-care providers may choose to administer Tdap instead of Td during pregnancy to add protection against pertussis in these situations. In such cases, the women should be informed of the lack of data on safety, immunogenicity, and pregnancy outcomes for pregnant women who receive Tdap (see "Considerations for Use of Tdap in Pregnant Women in Special Situations," above).

Pregnant Women with Unknown or Incomplete Vaccination

Pregnant women who have not received 3 doses of a vaccine containing tetanus and diphtheria toxoids should complete a series of three vaccinations, including 2 doses of Td during pregnancy, to ensure protection against maternal and neonatal tetanus. The preferred schedule in pregnant women is 2 doses of Td separated by 4 weeks and 1 dose of Tdap administered 6 months after the second dose (postpartum). Health-care providers may choose to substitute a single dose of Tdap for a dose of Td during pregnancy. In such cases, the women should be informed of the lack of data on safety, immunogenicity, and pregnancy outcomes for pregnant women who receive Tdap (see "Considerations for Use of Tdap in Pregnant Women in Special Situations," above).

Reporting Adverse Events after Vaccination

All clinically significant adverse events should be reported to the Vaccine Adverse Event Reporting System (VAERS) even if a causal relation to vaccination is uncertain. VAERS reporting forms and information are available at http://www.vaers.hhs.gov or by telephone, 1-800-822-7967. Providers are encouraged to report adverse events electronically at https://secure.vaers.org/VaersDataEntryintro.htm.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each recommendation.

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2008 May 30

GUIDELINE DEVELOPER(S)

Centers for Disease Control and Prevention - Federal Government Agency [U.S.]

SOURCE(S) OF FUNDING

United States Government

GUIDELINE COMMITTEE

Advisory Committee on Immunization Practices Pertussis Working Group

Advisory Committee on Immunization Practices

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Advisory Committee on Immunization Practices Pertussis Working Group, Membership List, June 2006

Chairman: Dale Morse, MD, Albany, New York

Members: William L. Atkinson, MD, Atlanta, Georgia; Karen Broder, MD, Atlanta, Georgia; Angela Calugar, MD, Atlanta, Georgia; Allison R. Christ, Falls Church, Virginia; Richard Clover, MD, Louisville, Kentucky; James Cheek, MD, Albuquerque, New Mexico; James D. Cherry, MD, Los Angeles, California; Shelley Deeks, MD, Toronto, Ontario, Canada; Kristen R. Ehresmann, MPH, St Paul, Minnesota; Geoffrey Evans, MD, Rockville, Maryland; Theresa Finn, PhD, Rockville, Maryland; Stanley Gall, MD, Louisville, Kentucky; Janet Gilsdorf, MD, Ann Arbor, Michigan; Andrea D. Gelzer, MD, Bloomfield, Connecticut; Bernard Gonik, MD, Detroit, Michigan; Steve Gordon, MD, Cleveland, Ohio; John Iskander, MD, Atlanta, Georgia; Marion F. Gruber, MD, Rockville, Maryland; Wayne E. Hachey, DO, MPH, Falls Church, Virginia; M. Patricia Joyce, MD, Atlanta, Georgia; David L. Klein, PhD, Bethesda, Maryland; Grace M. Lee, MD, MPH, Boston, Massachusetts; Susan M. Lett, MD, Boston, Massachusetts; Sarah S. Long, MD, Philadelphia, Pennsylvania; Bruce Meade, PhD, Rockville, Maryland; Trudy V. Murphy, MD, Atlanta, Georgia; Kathleen M. Neuzil, MD, Seattle, Washington; Gregory A. Poland, MD, Rochester, Minnesota; Fran Rubin, PhD, Bethesda, Maryland; Abigail Shefer, MD, Atlanta, Georgia; William Schaffner, MD, Nashville, Tennessee; Jane Siegel, MD, Dallas, Texas; Barbara A. Slade, MD, Atlanta, Georgia; Tejpratap Tiwari, MD, Atlanta, Georgia; Gregory Wallace, MD, Atlanta, Georgia; Pat Whitley-Williams, MD, New Brunswick, New Jersey

Advisory Committee on Immunization Practices Membership List, June 24, 2006

Chairman: Jon Abramson, MD, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Executive Secretary: Larry Pickering, MD, CDC, Atlanta, Georgia

Members: Ban Mishu Allos, MD, Vanderbilt University School of Medicine, Nashville, Tennessee; Judith Campbell, MD, Baylor College of Medicine, Houston, Texas; Robert Beck, JD, Palmyra, Virginia; Reginald Finger, MD, Focus on the Family, Colorado Springs, Colorado; Janet Gilsdorf, MD, University of Michigan, Ann Arbor, Michigan; Harry Hull, MD, Minnesota Department of Health, St. Paul, Minnesota; Tracy Lieu, MD, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts; Edgar Marcuse, MD, Children's Hospital and Regional Medical Center, Seattle, Washington; Dale Morse, MD, New York State Department of Health, Albany, New York; Julia Morita, MD, Chicago Department of Public Health, Chicago, Illinois; Gregory Poland, MD, Mayo Medical School, Rochester, Minnesota; Patricia Stinchfield, MSN, Children's Hospitals and Clinics of Minnesota, St. Paul, Minnesota; John J. Treanor, MD, University of Rochester, Rochester, New York; Robin Womeodu, MD, University Hospital, Memphis, Tennessee

Ex-Officio Members: James E. Cheek, MD, Indian Health Services, Albuquerque, New Mexico; Wayne Hachey, DO, Department of Defense, Falls Church, Virginia; Geoffrey S. Evans, MD, Health Resources and Services Administration, Rockville, Maryland; Bruce Gellin, MD, National Vaccine Program Office, Washington, DC; Linda Murphy, Centers for Medicare and Medicaid Services, Baltimore, Maryland; George T. Curlin, MD, National Institutes of Health, Bethesda, Maryland; Kristin Lee Nichol, MD, Department of Veterans Affairs, Minneapolis, Minnesota

Liaison Representatives: American Academy of Family Physicians, Jonathan Temte, MD, Madison, Wisconsin, Doug Campos-Outcalt, MD, Phoenix, Arizona; American Academy of Pediatrics, Keith Powell, MD, Akron, Ohio, Carol Baker, MD, Houston, Texas; America's Health Insurance Plans, Andrea Gelzer, MD, Hartford, Connecticut; American College Health Association, James C. Turner, MD, Charlottesville, Virginia; American College of Obstetricians and Gynecologists, Stanley Gall, MD, Louisville, Kentucky; American College of Physicians, Kathleen M. Neuzil, MD, Seattle, Washington; American Medical Association, Litjen Tan, PhD, Chicago, Illinois; American Pharmacists Association, Stephan L. Foster, PharMD, Memphis, Tennessee; Association of Teachers of Preventive Medicine, W. Paul McKinney, MD, Louisville, Kentucky; Biotechnology Industry Organization, Clement Lewin, PhD, Cambridge, Massachusetts; Canadian National Advisory Committee on Immunization, Monica Naus, MD, Vancouver, British Columbia; Health Care Infection Control Practices Advisory Committee, Steve Gordon, MD, Cleveland, Ohio; Infectious Diseases Society of America, Samuel L. Katz, MD, Durham, North Carolina; London Department of Health, David Salisbury, MD, London, United Kingdom; National Association of County and City Health Officials, Nancy Bennett, MD, Rochester, New York, Jeffrey S. Duchin, MD, Seattle, Washington; National Coalition for Adult Immunization, David A. Neumann, PhD, Alexandria, Virginia; National Foundation for Infectious Diseases, William Schaffner, MD, Nashville, Tennessee; National Immunization Council and Child Health Program, Romeo S. Rodriquez, Mexico City, Mexico; National Medical Association, Patricia Whitley-Williams, MD, New Brunswick, New Jersey; National Vaccine Advisory Committee, Gary Freed, MD, Swiftwater, Pennsylvania, Peter Paradiso, PhD, Collegeville, Pennsylvania; Society for Adolescent Medicine, Amy B. Middleman, MD, Houston, Texas; Pharmaceutical Research and Manufacturers of America, Damian A. Araga, Swiftwater, Pennsylvania

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Centers for Disease Control and Prevention (CDC) and content experts have no financial interest or other relationship with the manufacturers of commercial products or suppliers of commercial services mentioned herein.

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and Prevention (CDC) Web site.

Print copies: Available from the Centers for Disease Control and Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325; (202) 783-3238.

AVAILABILITY OF COMPANION DOCUMENTS

None available

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on June 16, 2008.

COPYRIGHT STATEMENT

No copyright restrictions apply.

DISCLAIMER

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