Diphtheria-Tetanus-Pertussis Vaccine

Diphtheria (D) vaccines contain toxoids prepared from Corynebacterium diphtheriae.

Tetanus (T) vaccines contain toxoids prepared from Clostridium tetani.

Acellular (a) pertussis (P) vaccines contain semipurified or purified components of Bordetella pertussis.

Whole-cell pertussis vaccines are no longer available in the United States because of concerns about adverse effects, but they are still available in other parts of the world.

There are 2 preparations of the diphtheria/tetanus toxoids/pertussis vaccine:There are 2 preparations of the diphtheria/tetanus toxoids/pertussis vaccine:

• Diphtheria-tetanus-acellular pertussis (DTaP) for children < 7 years

• Tetanus-diphtheria-pertussis (Tdap) primarily for adolescents and adults

Tdap contains lower doses of diphtheria and pertussis components (indicated by the lower case d and p).

Combination vaccines with hepatitis B (HepB), inactivated poliovirus (IPV), and Haemophilus b conjugate (Hib) are also available in the United States: DTaP-IPV-HepB, DTaP-IPV, DTaP-IPV-Hib, and DTaP-IPV-Hib-HepB.

DTaP is a routine childhood vaccination (1).

Tdap is routinely administered as a single lifetime dose to children at age 11 or 12 years and to people ≥ 13 years who have never received Tdap (regardless of the interval since the last tetanus-diphtheria [Td] vaccine) or whose vaccine status is unknown. This dose is followed by a Td booster every 10 years to ensure continued protection against tetanus and diphtheria. The Td booster recommendation includes a single dose of Tdap for adults ≥ 65 years (2, 3).

Additional boosters of Tdap are also recommended for the following:

• Pregnant patients during each pregnancy (preferably between 27 and 36 weeks gestation), regardless of the interval since any previous dose of Tdap

• Postpartum patients who have never received Tdap

Adults who require a tetanus toxoid-containing vaccine as part of wound management and who have not previously received Tdap are administered Tdap instead of tetanus-diphtheria (Td). Those who have previously received Tdap may be administered Tdap or Td.

People who have had pertussis should still receive a pertussis-containing vaccine as per routine recommendations.

Contraindications for DTaP and Tdap are the following:

• A severe allergic reaction (eg, anaphylaxis) after a previous dose or to a vaccine component

• For the pertussis component: Encephalopathy (eg, coma, decreased level of consciousness, prolonged seizures) that occurred within 7 days of a previous dose of DTaP or Tdap and that is not attributable to another identifiable cause.

Because tetanus vaccination is important, people who have had an anaphylactic reaction to components in DTaP or Tdap should be referred to an allergist to determine whether they are allergic to tetanus toxoid (TT). If not, they can be vaccinated with TT vaccine. Adults with a history of encephalopathy can be vaccinated with tetanus-diphtheria (Td), and children can be given diphtheria-tetanus (DT) instead of Tdap. In children < 7 years of age who develop a contraindication to pertussis-containing vaccine, the Td vaccine may be used off-label instead. If Td vaccine is used, the same schedule as for DTaP should be followed. Children who receive Td in place of DTaP may have suboptimal protection against diphtheria (1).

Precautions vary depending on the formulation.

For DTaP and Tdap, precautions include the following:

• Moderate or severe acute illness with or without fever (vaccination is postponed until illness resolves if possible)

• Guillain-Barré syndrome within 6 weeks after a previous dose to a vaccine containing tetanus toxoid

• For the pertussis component only: A progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy (vaccination is postponed until a treatment regimen is established and the disorder is stabilized)

For DTaP only, precautions include the following:

• A seizure, with or without fever, within 3 days after a previous dose of DTaP

• ≥ 3 hours of persistent, severe, inconsolable screaming or crying within 48 hours after a previous dose of DTaP

• Collapse or shock-like state (hypotonic hyporesponsive episode) within 48 hours after a previous dose of DTaP

• Temperature of ≥ 40.5° C, unexplained by another cause, within 48 hours after a previous dose of DTaP

For Tdap only, precautions include the following:

• History of type III hypersensitivity reactions (Arthus reactions) after a previous dose of a vaccine containing tetanus or diphtheria toxoid (vaccination is postponed ≥ 10 years since the last dose of tetanus toxoid-containing vaccine)

The dose for DTaP or Tdap is 0.5 mL IM.

The DTaP vaccine is administered as a 5-dose primary series during childhood as follows: at age 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before school entry). The fifth dose is not necessary if the fourth dose was administered at age ≥ 4 years and at least 6 months after the third dose.

A single booster dose of Tdap is administered; however, during pregnancy, patients should have a dose during each pregnancy, preferably between 27 and 36 weeks gestation.

Most adverse effects are mild to moderate and can last from 1 to 3 days and may include the following:

• Injection site erythema, pain, and swelling

• Fever

• Fussiness (in infants and young children)

• Fatigue

• Loss of appetite

• Vomiting

Serious adverse effects are rare and are mostly attributable to the pertussis component. They include the following:

• Encephalopathy within 7 days

• A seizure, with or without fever, within 3 days

• ≥ 3 hours of persistent, severe, inconsolable screaming or crying within 48 hours (in infants and young children)

• Collapse or shock within 48 hours

• Temperature of ≥ 40.5° C, unexplained by another cause, within 48 hours

• Immediate severe or anaphylactic reaction to the vaccine

If the pertussis vaccine is contraindicated, a combined tetanus-diphtheria vaccine is available without the pertussis component.

For more information about adverse effects of these vaccines, refer to the prescribing information.

The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.

1. Advisory Committee on Immunization Practices (ACIP): ACIP Recommendations: Diphtheria, Tetanus and Pertussis (DTaP/Tdap/Td) Vaccines

2. Centers for Disease Control and Prevention (CDC): Diphtheria, Tetanus, and Pertussis Vaccination: For Clinicians

3. European Centre for Disease Prevention and Control (ECDC): Diphtheria: Recommended vaccinations

4. ECDC: Tetanus: Recommended vaccinations

5. ECDC: Pertussis: Recommended vaccinations