Prevention
The childhood and adolescent immunization schedule was updated in January 2007 and is available online at http://www.cdc.gov/nip/recs/child-schedule.htm.
VACCINE
Immunizations for Infants and Children <7 Years of Age
Immunization with acellular pertussis vaccine in combination with diphtheria and tetanus toxoids (DTaP) is recommended (see Tables 8-2 and 8-3). DTaP is not licensed for persons 7 years of age and older. Whole-cell pertussis vaccine (DTwP) is not available in the United States, but is used in other countries.
Three DTaP vaccines are licensed for use and are available in the United States. Immunization for infants and children up to the seventh birthday consists of five doses of DTaP vaccine. The first three doses are usually given at ages 2, 4 and 6 months; the fourth dose at age 15-18 months; and the fifth dose at age 4-6 years. The fifth dose is not necessary if the fourth dose was given after the child’s fourth birthday (4).
At least three doses of DTaP are necessary for protection against pertussis; four doses are preferred. Children younger than 7 years should complete as many doses as possible of the primary series before traveling. If an accelerated schedule is required to complete the series of DTaP vaccine, the schedule may be started as soon as the infant is 6 weeks of age, with the second and third doses given 4 weeks after each preceding dose (Table 8-4). The fourth dose should not be given before the child is 12 months old and should be separated from the third dose by at least 6 months. The fifth dose should not be given before the child is 4 years old. Interruption of the recommended schedule or delay in doses does not lead to a reduction in the level of immunity reached on completion of the primary series. There is no need to restart a series, regardless of the time that has elapsed between doses (4).
Immunizations for Children 7-10 Years of Age
There is no pertussis-containing vaccine licensed for children 7-9 years of age. If a child turns 10 years old during the vaccination series with Td, a single dose of BOOSTRIX may be substituted for one of the Td (tetanus and diphtheria toxoids vaccine) doses.
Immunizations for adolescents and adults 11- 64 Years of Age
In 2005, two tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine products were licensed for use by the FDA. BOOSTRIX (GlaxoSmithKline Biologicals) and ADACEL (sanofi pasteur) are licensed for use in persons aged 10-18 years and 11-64 years, respectively (2).
Adolescents aged 11-18 years who have completed their childhood vaccination series with DT, DTaP, and/or DTwP should receive a single dose of Tdap instead of Td for booster immunization against tetanus, diphtheria, and pertussis. Adolescents who received their last Td 5 years or more previously should also receive a single dose of Tdap (Table 1-1) (2). Adults aged 19-64 who have not previously received Tdap should receive a single dose of Tdap if their last tetanus toxoid-containing vaccine (e.g., Td) was administered 10 years or more prior. Tdap is not licensed nor recommended for adults 65 years or older (5).
Adolescents and adults in special situations may benefit from vaccination with Tdap at intervals as short as 2 years from last Td. These would include, but are not limited to, child-care providers who have close contact with infants younger than 12 months, health-care personnel, persons with underlying medical conditions who may be at risk for pertussis-related complications, and those with increased likelihood of exposure to pertussis, such as during an outbreak (2, 5). Adolescents or adults who have never been immunized against pertussis, tetanus, or diphtheria or whose immunity is uncertain should receive a three-dose series of vaccinations. The preferred schedule is a single Tdap dose, followed by a dose of Td 4-8 weeks after the Tdap dose, and a second dose of Td 6-12 months after the first dose. Tdap can be substituted for any one of the three Td doses in the series (2).
Adolescents and adults with incomplete immunization against tetanus and diphtheria should follow the catch-up schedule established for Td/Tdap. A single dose of Tdap can be substituted for any one of the Td doses in the series.
Adverse Reactions
Local reactions (erythema and induration with or without tenderness) are common after the administration of vaccines containing diphtheria, tetanus, and pertussis antigens. Mild systemic reactions such as drowsiness, fretfulness, and low-grade fever can occur after vaccination with DTaP. These reactions are self-limited and can be managed with symptomatic treatment of acetaminophen or ibuprofen. Swelling involving the entire thigh or upper arm has occurred after the fourth and fifth doses of DTaP. These reactions are also self limited (1). Prelicensure studies support the safety of Tdap, with an overall safety profile of local and systemic events comparable with that of Td.
Anaphylactic and other serious adverse reactions are rare after receipt of preparations containing diphtheria, tetanus or pertussis components, or a combination of these.
Precautions and Contraindications
An immediate anaphylactic reaction to a prior dose of vaccine or vaccine component is a contraindication for further vaccination with DTaP and/or Tdap. Encephalopathy not due to another identifiable cause within 7 days of vaccination is a contraindication to further vaccination with a pertussis-containing vaccine (1).
Moderate or severe acute illness is a precaution to vaccination. Mild illnesses, such as otitis media or upper respiratory infection, are not contraindications. Anyone for whom vaccination is deferred because of moderate or severe acute illness should be vaccinated when the condition improves.
Certain infrequent adverse events following pertussis vaccination are considered precautions (not contraindications) for additional doses of DTaP, but not for Tdap: a seizure, with or without fever, occurring within 3 days of immunization; temperature higher than 40.5° C (105° F) not resulting from another identifiable cause within 48 hours of immunization; collapse or a shock-like state (hypotonic-hyporesponsive episode) within 48 hours of immunization, or persistent, inconsolable crying lasting longer than 3 hours and occurring within 48 hours of immunization. These events have not been proven to cause permanent sequelae. In certain circumstances (e.g., during a communitywide outbreak of pertussis), the benefit of additional childhood vaccination with DTaP or adult vaccination with Tdap may outweigh the risk of another reaction (2). Development of Guillain-Barré syndrome 6 weeks or less after a previous dose of a tetanus toxoid-containing vaccine is considered a precaution.
Progressive neurologic conditions characterized by changing developmental findings are considered contraindications to receipt of pertussis vaccine. Such disorders include infantile spasms or uncontrolled epilepsies. Persons with stable neurologic conditions such as cerebral palsy, controlled seizures, or progressive dementia should be vaccinated (1).
