Vaccines and Preventable Diseases:
Tdap for Pregnant Women: Information for Providers
For Health Care Professionals
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In June 2011, the Advisory Committee on Immunization Practices (ACIP) voted to recommend that women’s health care providers should implement a maternal Tdap vaccination program for women who have not previously received the vaccine. Health care providers should administer Tdap preferably during the third or late second trimester of pregnancy (after 20 weeks gestation).
Pertussis Epidemiology
In 2010, 27,550 cases of pertussis were reported in the United States; 3,350 of those cases were in infants younger than 6 months of age — 25 of those infants died. Studies have shown that when the source of pertussis was identified, mothers were responsible for 30–40% of infant infections.
Seriousness of Pertussis for Mother and Infant
It’s expected that vaccinating your patients with Tdap during pregnancy will prevent more infant hospitalizations and deaths from pertussis than cocooning alone.
Pertussis can cause serious and sometimes life-threatening complications in infants, especially within the first 6 months of life. In infants younger than 1 year of age who get pertussis, more than half must be hospitalized. The younger the infant, the more likely treatment in the hospital will be needed. Of those infants who are hospitalized with pertussis about 1 in 5 will get pneumonia and 1 in 100 will die.
Adolescents and adults can also experience complications from pertussis. They are usually less serious in this age group, especially in those who have been vaccinated. Common complications in adolescents and adults are often caused by the cough itself, including urinary incontinence (28%), syncope (6%) and rib fractures (4%).
Tdap Vaccine Safety for Mother and Infant
In addition to vaccinating your patients with Tdap, you should educate them about encouraging others – including dads, grandparents and other caregivers – to get vaccinated with Tdap at least two weeks before coming into contact with their infants.
ACIP concluded that there is no elevated frequency or an unusual occurrence of adverse events among pregnant women who have received Tdap vaccine, or in their newborns. Tdap vaccine is recommended after 20 weeks gestation because that optimizes antibody transfer and protection at birth. The immune response to the vaccine peaks two weeks after administration.
Both tetanus and diphtheria toxoids (Td) and tetanus toxoid (TT) vaccines have been used extensively in pregnant women worldwide since the 1960s to prevent neonatal tetanus. Td and TT vaccines administered during pregnancy have not been shown to harm either the mother or baby/fetus.
Breastfeeding Safety after Tdap Vaccination
Breastfeeding is not a contraindication for receiving Tdap vaccine. Tdap vaccine can and should be given to women who plan to breastfeed. Breastfeeding is fully compatible with Tdap vaccination, and preventing pertussis in mothers can reduce the chance that the infant will get pertussis. Also, by breastfeeding, mothers can pass antibodies they’ve made in response to the Tdap shot on to their infants, which may reduce an infant’s chances of getting sick with pertussis. This is especially important for infants younger than 6 months of age, who have no other way of receiving enough pertussis antibodies, since they are not fully protected until their third dose of DTaP vaccine at 6 months of age.
Transfer of Pertussis Antibodies to Infant through Maternal Tdap Vaccination
Transplacental transfer of maternal pertussis antibodies from mother to infant may provide protection against pertussis in early life, before beginning the primary DTaP series. There is evidence of efficient transplacental transfer of pertussis antibodies to infants. The effectiveness of maternal antibodies in preventing infant pertussis is not yet known, but pertussis antibodies can protect against some disease and the severe outcomes that come along with it. And, a woman vaccinated with Tdap vaccine during pregnancy will also herself be protected at time of delivery and will be less likely to transmit pertussis to her newborn infant.
Pertussis Vaccine for Infant at Birth
There are currently no pertussis vaccines licensed or recommended for newborns at birth. The best way to prevent pertussis in a young infant is by vaccinating the mother during pregnancy.
DTaP Effectiveness for Infant if Mother Vaccinated with Tdap during Pregnancy
By vaccinating a woman with Tdap during pregnancy her infant will gain pertussis antibodies during the most vulnerable time – before three months of age. However, providing this early immunity may also interfere with the infant’s immune response to DTaP vaccine. The infant’s immune response to DTaP may not be as strong, but the clinical implications may not be significant. The benefits of vaccinating during pregnancy and protecting a newborn outweigh the potential risk of blunting the infant’s response to DTaP vaccine. Since infants are at greatest risk of severe disease and death from pertussis before 3 months of age – when their immune systems are least developed – any protection that can be provided is critical. Infants should receive their DTaP vaccines on schedule, starting at 2 months of age.
Postpartum Tdap Vaccination as an Option
Not all hospitals routinely vaccinate with Tdap postpartum, so you can make sure your patients and their infants are protected.
Vaccination with Tdap during pregnancy is ideal. However, if a woman does not get vaccinated during pregnancy, administer the vaccine immediately postpartum, before she leaves the hospital or birthing center. Also advise your patient that other adults who will be around her newborn, such as husbands grandparents, older siblings, and babysitters, should also be vaccinated.
Cocooning
The strategy of protecting infants from pertussis by vaccinating those in close contact with them is known as “cocooning.” ACIP has recommended cocooning with Tdap vaccine since 2005 and continues to recommend this strategy for all those with expected close contact with newborns. Cocooning enhances maternal vaccination to provide maximum protection to the infant. In addition to vaccinating your patients, you should educate them about encouraging others – including dads, grandparents and other caregivers – to get vaccinated with Tdap at least two weeks before coming into contact with their infants.
Full implementation of cocooning has proven to be a challenge; vaccinating during pregnancy provides the best opportunity to protect infants from pertussis.
Patients with Unknown or Uncertain Tdap Vaccination Status
ACIP recommends that if Tdap vaccination status cannot be confirmed with written, dated records, the patient is considered unvaccinated and is therefore eligible to be vaccinated with Tdap. Tdap should be administered regardless of when Td was last received.
References
- Bisgard KM, Pascual FB, Ehresmann KR, et al. Infant pertussis: who was the source?
Pediatr Infect Dis J. 2004;23:985-89. - CDC. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged Less than 12 Months — Advisory Committee on Immunization Practices (ACIP), 2011. MMWR. 2011;60(41):1424-6.
- Cortese MM, Bisgard KM. Pertussis. In: Wallace RB, Kohatsu N, Kast JM, ed. Maxcy-Rosenau-Last Public Health & Preventive Medicine, Fifteenth Edition. The McGraw-Hill Companies, Inc.; 2008:111-14.
- Tanaka M, Vitek CR, Pascual FB, et al. Trends in pertussis among infants in the United States, 1980-1999. JAMA. 2003;290:2968-75.
- Wendelboe AM, Njamkepo E, Bourillon A, et al. Transmission of Bordetella pertussis to young infants. Pediatr Infect Dis J. 2007;26:293-99.
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Content last reviewed on June 15, 2012
Content Source: National Center for Immunization and Respiratory Diseases