On this page:

Diphtheria, Tetanus, Pertussis

DTP - disease issues Vaccination scheduling issues

Vaccine recommendations Contraindications and precautions to vaccine

Vaccine products - choosing the right one Tetanus and wound management issues

Combination vaccines containing DTaP Vaccine storage and handling

Tdap for adolescents and adults

DTP - disease issues

Is it true that pertussis in children is increasing? Are more infants dying from the disease?

Since the 1980s, the number of reported pertussis cases has increased. These increases have been noted in both infants younger than age 1 year, particularly among infants younger than age 6 months; adolescents age 11-18 years, and adults. An increase in the number of reported deaths from pertussis among very young infants has paralleled the increase in the number of reported cases. Reasons for the increases in pertussis are not completely clear; improvements in diagnosis and reporting of pertussis in adolescents and adults appear to be important factors contributing to the overall increase.

As a pediatrician, I am concerned about protecting my newborn patients from pertussis, especially given the recent outbreaks in my community where infants have died. How many doses of pediatric diphtheria-tetanus-acellular pertussis (DTaP) vaccine does an infant need before she or he is protected from pertussis?

Vaccine efficacy is 80%-85% following 3 doses of DTaP vaccine. Efficacy data following just 1 or 2 doses are lacking but are likely lower. Therefore, it is especially important that you advise parents of infants and all people who live with the infant or who provide care to him or her be protected against pertussis. It is recommended that the infant's family members and potential visitors receive a one-time dose of adolescent/adult tetanus-diphtheria-acellular (Tdap) vaccine if they have not already done so.

Can a child or an adult who has had pertussis get the disease again

Reinfection appears to be uncommon, but does occur. Reinfection may present as a persistent cough rather than typical pertussis.

Should further doses of pertussis vaccine be given to an infant or child who has had culture-proven pertussis?

CDC's Advisory Committee on Immunization Practices (ACIP) states that a child who has had culture-proven pertussis does not need additional doses of pertussis vaccine. The series may be completed with pediatric DT. However, if there is any doubt about the diagnosis (i.e., if the diagnosis was made without a culture), the pertussis vaccine series should be completed on schedule.

If an adolescent or adult who has never received their one-time dose of Tdap is either infected with or exposed to pertussis, is vaccination with Tdap still necessary, and if so when?

Yes. Adolescents or adults who have a history of pertussis disease generally should receive Tdap according to the routine recommendation. This practice is recommended because the duration of protection induced by pertussis disease is unknown (waning might begin as early as 7 years after infection) and because diagnosis of pertussis can be difficult to confirm, particularly with tests other than culture for B. pertussis. Administering pertussis vaccine to people with a history of pertussis presents no theoretical risk. However, if the illness was recent (less than 5 years) and the diagnosis was certain (i.e., culture confirmed), it is reasonable to wait 3-5 years before administration of Tdap, unless tetanus and diphtheria toxoids are needed. For details, visit CDC's published recommendations on this topic at www.cdc.gov/vaccines/pubs/acip-list.htm.

If a healthcare worker (HCW) receives tetanus-diphtheria-acellular pertussis (Tdap) vaccine and is then exposed to someone with pertussis, do you treat the vaccinated HCW with prophylactic antibiotics or consider them immune to pertussis?

You should follow the post-exposure prophylaxis protocol for pertussis exposure recommended by CDC ( www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm). Research is needed to evaluate the effectiveness of Tdap to prevent pertussis in healthcare settings. Until studies define the optimal management of exposed vaccinated healthcare personnel, or experts arrive at consensus, healthcare facilities should continue to follow the post-exposure prophylaxis protocol for vaccinated HCWs who are exposed to pertussis.

Vaccine Recommendations

What are the recommendations for vaccination of infants and young children with DTaP?
All children should receive a series of DTaP at ages 2, 4, and 6 months, with boosters at ages 15-18 months and at 4-6 years. The fourth dose may be given as early as age 12 months if at least 6 months have elapsed since the third dose.

What are the recommendations for use of Tdap, including those issued by ACIP at its October 2010 and February 2011 meetings?

In response to an increased incidence of pertussis in the U.S., ACIP voted on several new recommendations for the use of Tdap vaccine. The complete recommendations follow.

• Tdap can be given regardless of the interval since the last Td was given. There is NO need to wait 2-5 years to administer Tdap following a dose of Td.

• Adolescents should receive a one-time dose of Tdap (instead of Td) at the 11-12-year-old visit.

• Adolescents and adults younger than age 65 years who have not received a dose of Tdap, or for whom vaccine status is unknown, should be immunized as soon as feasible. (As stated above, Tdap can be administered regardless of interval since the previous Td dose.)

• Adults age 65 years and older who have not previously received a dose of Tdap, and who have or anticipate having close contact with children younger than age 12 months (e.g., grandparents, other relatives, child care providers), should receive a one-time dose to protect infants. (As stated above, Tdap can be administered regardless of interval since the previous Td dose.)

• Other adults 65 years and older who are not in contact with an infant, and who have not previously received a dose of Tdap, may receive a single dose of Tdap in place of a dose of Td.

• Children ages 7-10 years who are not fully immunized against pertussis (i.e., did not complete a series of pertussis-containing vaccine before their seventh birthday) should receive a one-time dose of Tdap.

• All healthcare workers, regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap and regardless of the time since the last dose of Td.

Aren't the October 2010 ACIP recommendations for expanded use of Tdap vaccine in children ages 7 through 9 years and in adults age 65 years and older different from what is on the package inserts?

Yes. Sometimes ACIP makes recommendations that differ from the FDA-approved package insert indications, and this is one of those instances. ACIP recommendations represent the standard of care for vaccination practice in the United States. In general, to determine recommendations for use, one should follow the recommendations of ACIP rather than the information in the package insert.

I don't remember using a vaccine off-label before, so the new Tdap recommendations for vaccinating people older than age 65 make me a bit nervous. What could be the legal repercussions if we vaccinate a 70-year-old grandparent with Tdap and he develops a severe side effect?

We cannot give legal advice. However, you should keep in mind that ACIP recommendations represent the standard of care for vaccination practice in the United States. In general, to determine recommendations for use, one should follow the recommendations of ACIP rather than the information in the package insert.

Vaccine products - choosing the right one

I'm confused about the various vaccines that contain tetanus, diphtheria, and pertussis. Can you explain?

There are two basic products that can be used in children younger than age 7 years (DTaP and DT) and two that can be used in older children and adults (Td and Tdap). Some people get confused between DTaP and Tdap and others get confused between DT and Td. Here's a hint to help you remember. The pediatric formulations usually have 3-5 times as much of the diphtheria component than what is in the adult formulation. This is indicated by an upper-case "D" for the pediatric formulation (i.e., DTaP, DT) and a lower case "d" for the adult formulation (Tdap, Td). The amount of tetanus toxoid in each of the products is equivalent, so it remains an upper-case "T."
Can we use the two DTaP products interchangeably?

There are two different DTaP products currently used in the U.S. for the primary series for children ages 2 months through 6 years (Daptacel by sanofi pasteur and Infanrix by GlaxoSmithKline). ACIP has recommended that, whenever feasible, healthcare providers should use the same brand of DTaP vaccine for all doses in the vaccination series.

What should we do if we don't know which brand of DTaP a child had previously?

If the DTaP brand used for previous doses is not known or not in stock, use whatever DTaP vaccine you have available for all subsequent doses.

Someone gave Tdap to an infant instead of DTaP. Now what should be done?

This error sometimes happened because the packaging for the sanofi products (Daptacel [DTaP] and Adacel [Tdap]) was quite similar. You'll be glad to know that sanofi pasteur has changed their packaging and you should notice more distinct tabs, new package colors and vial labels, and clear use-descriptions next to the package logos.

If Tdap was inadvertently administered to a child, it should not be counted as either the first, second, or third dose of DTaP. The dose should be repeated with DTaP. Continue vaccinating on schedule. If the dose of Tdap was administered for the fourth or fifth DTaP dose, the Tdap dose can be counted as valid. Please remind your staff to always check and double check the vaccine vial before administering any vaccine.

I have a patient who received single-antigen tetanus (TT) in the emergency room rather than Td or Tdap. Should he be revaccinated?

ACIP recommends that patients needing prophylaxis against tetanus always be given either Td or, if appropriate, Tdap rather than TT, as long as there is no contraindication to the other vaccine components. If it's already been given and the person had not yet received Tdap as an adolescent or adult, you should make certain that he gets Tdap as soon as feasible. If he had received Tdap previously, he can wait until the next scheduled booster dose is due to get his routine Td booster.

When should a person receive tetanus toxoid (TT) alone?

Single antigen tetanus toxoid should only be used in rare instances, for example when a person has had a documented severe allergic response to diphtheria toxoid.

In what year did tetanus toxoid first become available? At what age might most patients never have received a primary series?

Tetanus toxoid became commercially available in 1938, but was not widely used until the military began routine vaccination in 1941. Routine administration of tetanus toxoid was recommended by the AAP in 1944. Most World War II military personnel received at least one dose of tetanus toxoid, but civilian use, particularly for adults, did not increase until after the war. You should not assume the tetanus vaccination status for any person based on their age alone. Only a written record is acceptable proof of immunization. People without documentation should be assumed to be unimmunized.

If a dose of DTaP or Tdap is inadvertently given to a patient for whom the product is not indicated (e.g., wrong age group), how do we rectify the situation?

The first step is to inform the parent/patient that you administered the wrong vaccine. Next, follow these guidelines:

• Tdap given to a child younger than age 7 years as either dose 1, 2, or 3, is NOT valid. Repeat with DTaP as soon as feasible.

• Tdap given to a child younger than age 7 years as either dose 4 or 5 can be counted as valid for DTaP dose 4 or 5.

• DTaP given to patients age 7 or older can be counted as valid for the one-time Tdap dose.

Tdap for adolescents and adults Back to top
What is the difference between the two Tdap products - Boostrix and Adacel?
Both of these vaccines provide protection against diphtheria, tetanus, and pertussis. Boostrix (GlaxoSmithKline) is licensed for people ages 10-64 years, and Adacel (sanofi pasteur) is licensed for people ages 11-64 years. Both are approved for one dose only, not multiple doses in a series. The two vaccines also contain a different number of pertussis antigens and different concentrations of pertussis antigen and diphtheria toxoid.
We have a 13-year-old patient who was given DT (pediatric) as a preschooler after she had experienced excessive crying following a dose of DTP. Now, we are wondering if we can give her Tdap since we know she may not be protected against pertussis.
Yes, you can. Many of the precautions to DTaP (e.g., temperature of 105°F or higher, collapse or shock-like state, persistent crying lasting 3 hours or longer, seizure with or without fever) do not apply to Tdap. This issue is discussed in CDC's Tdap recommendations, available at www.cdc.gov/mmwr/PDF/rr/rr5503.pdf.

Should I make an effort to give teenagers a Tdap dose, even if they've had a dose of Td at age 11-12 years?

Yes. All adolescents should receive one dose of Tdap vaccine to protect them from pertussis, even if they have already received Td. It is important to do this right away (no minimal interval is required), especially if they are in contact with an infant younger than age 12 months, work in a healthcare setting where they have direct contact with patients, or live in a community where pertussis is occurring.

We have a 16-year-old patient who received tetanus-diphtheria (Td) vaccine in the emergency room after a nail puncture a year ago. Can we give him a tetanus-diphtheria-acellular pertussis (Tdap) vaccine now?

Yes. There is no need to observe any minimum interval between doses of Td and Tdap.
Some children in my practice are not up to date on their immunizations, and pertussis is circulating in our community. Can you guide me in determining how to make the decision about which vaccine to choose?

You should use DTaP in children younger than age 7 years. In October 2010, ACIP voted to give a single dose of Tdap to children ages 7 through 10 years who did not finish a minimum 3-dose series of pertussis-containing vaccines before their 7th birthday (or for whom their pertussis vaccine status is unknown). Although this is an off-label use of the vaccines, it's important that you vaccinate these vulnerable children with Tdap as well as any other adolescent or adult who hasn't received Tdap previously.

I need to know how to catch-up a child who is 12 years old and received 1 dose of DTaP vaccine at age 2 years and a one-time Tdap dose at age 11 years.

This child needs to complete the primary series with 1 dose of Td, administered no earlier than 6 months after the Tdap dose given at age 11 years. After that, the child needs a booster dose of Td every 10 years. An easy way to determine how to catch up a child is to consult "Recommended Immunization Schedules for Persons Aged 0 Through 18 Years, U.S." The schedule is approved by CDC, AAP, and AAFP and is released early in each calendar year. It includes a catch-up schedule for children who have fallen behind (see www.cdc.gov/vaccines/recs/schedules/child-schedule.htm).
According to the newest ACIP recommendations, which healthcare workers should be vaccinated against pertussis with tetanus-diphtheria-acellular pertussis (Tdap) vaccine?

On February 23, 2011, ACIP voted to approve the following recommendations for the use of Tdap in healthcare personnel.

• All healthcare personnel (HCP), regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap and regardless of the time since last Td dose.

• Tdap is not currently licensed for multiple administrations. After receipt of Tdap, HCP should receive routine booster immunization against tetanus and diphtheria according to previously published guidelines.

• Hospitals and ambulatory-care facilities should provide Tdap for HCP and use approaches that maximize vaccination rates (e.g., education about the benefits of vaccination, convenient access, and the provision of Tdap at no charge).

To obtain a copy of the provisional recommendations, go to www.cdc.gov/vaccines/recs/provisional.

How soon after a dose of Td can a healthcare worker receive a dose of Tdap, in order to protect vulnerable infants and others?

If they have not previously received Tdap, healthcare personnel in hospitals and ambulatory care settings should receive a single dose of Tdap as soon as feasible and without regard to the dosing interval since the last Td. There is no "minimum interval" one needs to wait between receiving Td and Tdap when it is given to protect infants or other vulnerable patients.
Instead of giving tetanus/diphtheria toxoid and acellular pertussis (Tdap) vaccine to a father-to-be that needed protection against pertussis, we mistakenly gave him tetanus/diphtheria (Td) toxoid. How soon after the Td dose can we give him the dose of Tdap he needs?

All parents, grandparents, healthcare workers, and all others who have not already received Tdap, and especially those who are close contacts of infants younger than age 12 months, should receive a single dose of this vaccine as soon as possible to protect infants from pertussis. There is no need to observe a "minimum interval" between giving Td and Tdap. For example, if you had immediately realized that you had mistakenly given the father-to-be Td instead of Tdap, you could have given him the needed Tdap dose at the same visit at which you gave him the erroneous Td dose.

Can a booster dose of Tdap be given to people age 65 years and older?
Yes. ACIP recommends a one-time dose of Tdap be given to adults age 65 years or older who have or anticipate having close contact with an infant younger than age 12 months (e.g., grandparents, childcare providers), or for any other older adult who merely wants to be protected against pertussis.

We recently saw a 30-year-old man who remembers that he received a "tetanus booster" in another state within the past 2 years. The problem is he can't remember if he received Tdap or Td, and we can't obtain an immunization record. His wife is pregnant, and we would like to immunize him against pertussis as a way to protect their soon-to-be-born child. Should we give him Tdap in this situation?

Yes. Whenever you lack vaccination documentation and vaccination is indicated, give the patient Tdap.

I want to protect pregnant women and their unborn children from pertussis. Can I give Tdap to pregnant women?

Tdap is not contraindicated during pregnancy. According to ACIP and the American College of Obstetricians and Gynecologists, a clinician may choose to administer Tdap to a pregnant woman in the 2nd or 3rd trimester in certain circumstances, such as a community pertussis outbreak. If there is no risk to the pregnant woman of acquiring or transmitting pertussis, ACIP recommends that Tdap vaccination be deferred until the immediate postpartum period. AAP has endorsed preferential Tdap vaccination of pregnant adolescents who were not vaccinated with Tdap at age 11-12 years (Pediatrics 2006; 117:965-78). Providers can follow either the AAP or ACIP recommendations.

If a pregnant woman got a dose of Td during pregnancy, how soon after birth can she get her postpartum dose of Tdap?

The mother is taking home an infant who is susceptible to pertussis, so she should receive Tdap during the immediate postpartum period (e.g., before hospital discharge). There is no minimum interval between Td and Tdap.

Can the parents of a young infant be given a dose of Tdap right after birth to protect themselves and, indirectly, their newborn from pertussis, even though they had a dose of Td vaccine less than two years ago?

Yes. Parents should receive a single dose of Tdap as soon as possible to protect their baby from pertussis. If a dose of Td was given within the previous 2 years, parents should still be vaccinated with Tdap as soon as possible regardless of the time interval since the last dose of Td. Other household contacts that are not up to date with their pertussis-containing vaccinations should also be appropriately vaccinated.

Can Tdap be given at the same visit as other vaccines?

Yes. Tdap can be administered with all other vaccines that are indicated (e.g., meningococcal conjugate vaccine, hepatitis B vaccine, MMR). Each vaccine should be administered at a different anatomic site using a separate syringe.

How many doses of Tdap can we give to a patient?
The vaccine is licensed for just one dose. Subsequent doses should be Td.
Someone in our clinic gave DTaP to a 50-year-old instead of Tdap. How should this be handled?
The DTaP recipient received the appropriate amount of tetanus toxoid and MORE diphtheria toxoid and pertussis antigen than is recommended. Count the dose, but take measures to prevent this error in the future.

Vaccination scheduling issues

What schedule should I use to vaccinate adolescents or adults who never received the primary series of tetanus toxoid-containing vaccine?

Children, ages 7 years and older, and adults who have never received tetanus-containing vaccines, or whose vaccination history is unknown, should receive the 3-dose series. In this situation, ACIP recommends Tdap for dose #1, followed 4 weeks later by Td for dose #2, followed at least 6 months later by Td for dose #3. Tdap can substitute for only one of the 3 Td doses in the series, preferably the first. The amount of protection provided by a single dose of Tdap in a person who has not previously received pertussis vaccine is not known. Following the primary series, booster doses of Td should be given every 10 years thereafter.

We are routinely scheduling the 4th dose of DTaP in children at 15-18 months, but occasionally would like to give it earlier. Is that okay?

The fourth dose of DTaP may be given as early as age 12 months if at least 6 months have passed since the third dose.

When a child comes in for his vaccinations at age 4-6 years and presents with an incomplete history of 0-2 doses of DTaP vaccine, how do we determine how many more doses are needed?
You should try to achieve at least 4 total doses. Give additional doses of DTaP with 4 week intervals until you achieve 3 total doses. Then, if 6 months pass and the child has not turned seven years old, give the 4th dose.

If a child didn't have the recommended 6-month interval between DTaP doses #3 and #4, should it be repeated?

If DTaP #4 is given with at least a 4-month interval after DTaP #3, it does not need to be repeated. Decreasing the interval to less than 6 months, however, is not recommended.
If a child has already received 5 doses of DTaP by their fourth birthday (with the appropriate 6 month intervals between #3 and #4 and also between #4 and #5), is a booster dose after the fourth birthday necessary?

In general, a child should receive no more than four doses of DTaP before 4 years of age (preferably by 2 years of age). The ACIP recommends that a dose of DTaP be given at 4-6 years of age. Many states have school immunization laws which also require at least one dose of DTP/DTaP on or after the fourth birthday. This dose is important to boost immunity to pertussis.
Is there a recommendation about how many doses of DTaP a child can receive by a certain age? Does this include half doses?

ACIP and AAP both recommend that children receive no more than 6 doses of diphtheria and tetanus toxoids (e.g., DT, DTaP, DTP) before the seventh birthday because of concern about adverse reactions, primarily local reactions. Half doses of DTaP are also not recommended under any circumstances, and should not be counted as part of the vaccination series. Only documented doses (i.e., those recorded in an electronic or written record) count toward the maximum of 6 doses.

What is the minimum interval between DTaP #4 and DTaP #5?
The minimum interval between DTaP #4 and DTaP #5 is six months. Remember that the minimum age for DTaP #5 is age 4 years.

How should we schedule DTaP for a child with a history of only DT?
If the child has not received all of the age-appropriate doses of pertussis-containing vaccine, it would be best to try to administer as many doses of DTaP as possible before the child reaches his 7th birthday in order to confer protection against pertussis. Give additional doses of DTaP with 4 week intervals until you achieve 3 total doses. Then, give additional doses with 6-month intervals, not to exceed 6 total doses of diphtheria- and tetanus-containing vaccine by the child's 7th birthday.

ACIP and AAP have different recommendations for spacing Tdap and meningococcal conjugate vaccine if they are not given simultaneously. Please discuss.
The ACIP Tdap recommendations published in the MMWR (www.cdc.gov/vaccines/pubs/acip-list.htm) state that Tdap or Td can be administered at any time before or after meningococcal conjugate vaccine. AAP's Committee on Infectious Diseases (a.k.a., the "Red Book" Committee) took a somewhat more conservative approach and suggested these vaccines be separated by a month if not given at the same visit. Providers may use either approach.
I've heard that if adolescent/adult tetanus-diphtheria-acellular pertussis (Tdap) and meningococcal conjugate vaccine are not given simultaneously, they should be spaced 1 month apart. Is this what ACIP recommends?

No, this is not what ACIP recommends. Certain experts recommend spacing these two vaccines by a month if they are not given simultaneously. This is out of a theoretical safety concern about giving two vaccines that contain diphtheria toxoid (meningococcal conjugate vaccine contains diphtheria toxoid) unless they are given simultaneously or are spaced 1 month apart. However, ACIP believes this theoretical safety concern does not warrant spacing. Tdap and meningococcal conjugate vaccines are both inactivated vaccines, and inactivated vaccines can be administered at any time before or after a different inactivated vaccine or a live vaccine, unless a contraindication exists.

Contraindications and precautions to vaccine

What are the contraindications for using DTaP, DT, Tdap, and Td?
As with all vaccines, a severe allergic reaction (e.g., anaphylaxis) to a vaccine component or to a prior dose is a contraindication to further doses of that vaccine. A history of encephalopathy within 7 days of receiving a previous pertussis-containing vaccine that is not due to another identifiable cause is a contraindication to both DTaP and Tdap.

What precautions should be observed when giving DTaP, DT, Tdap, or Td?

A history of Guillain-Barre syndrome (GBS) within 6 weeks of receiving a tetanus toxoid-containing vaccine, and a history of arthus-type hypersensitivity reaction after receiving a previous tetanus toxoid-containing vaccine is a precaution to further vaccination with any of these vaccines. As with all vaccines, moderate or severe illness is a precaution. Several additional precautions apply only to DTaP (see next question).

Do the same precautions that apply to DTaP also apply to Tdap?
No, many of the precautions to DTaP (e.g., temperature of 105°F or higher, collapse or shock-like state, persistent crying lasting 3 hours or longer, seizure with or without fever) do not apply to Tdap. This issue is discussed in the Tdap ACIP recommendations, available at www.cdc.gov/vaccines/pubs/acip-list.htm

Can an adult receive Tdap if they had a contraindication or precaution to DTP as a child?
Tdap has two contraindications and four precautions. The contraindications are (1) anaphylactic reaction to a prior dose of the vaccine or any of its components and (2) encephalopathy within 7 days of a previous dose of DTaP or DTP; in this case, give Td instead of Tdap. The precautions are (1) moderate or severe acute illness; (2) history of an arthus-type hypersensitivity reaction following a previous dose of a tetanus toxoid-containing vaccine; (3) Guillain-Barre syndrome (GBS) 6 weeks or sooner after a previous dose of tetanus toxoid-containing vaccine; and (4) progressive or unstable neurologic disorder, uncontrolled seizures or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized. CDC has published a Guide to Vaccine Contraindications and Precautions in its "General Recommendations on Immunization" published in MMWR on January 28, 2011. A 2-page user-friendly version, created by IAC, can be found at www.immunize.org/catg.d/p3072a.pdf
When assessing for precautions for administering DTaP in an infant, is the 105°F cutoff for DTaP a rectal, oral, or axillary temperature

A temperature of 105°F or higher recorded from any of these body sites following a dose of DTaP without another known cause constitutes a precaution to further doses of any pertussis-containing vaccine.

A 2-month old received her first dose of DTaP and then had inconsolable crying for greater than 3 hours. Should we give additional doses of DTaP or should we give just DT?
Persistent crying following DTaP (as well as other vaccines) has been observed far less frequently than it was following the use of DTP. When it occurred after DTP, it was considered to be an absolute contraindication to further doses of pertussis-containing vaccine. When it occurs following DTaP, it is considered a "precaution" (or warning). If you believe the benefit of the pertussis vaccine exceeds the risk of more crying (which, although unnerving, is otherwise benign), you can administer DTaP. Many providers choose to administer pertussis-containing vaccine if this is the only precaution the child has experienced. You and the parent will need to make this judgment.
Can we give further doses of DTaP to an infant who had an afebrile seizure within 3 hours of a previous dose?
An infant who experiences an afebrile seizure following a dose of DTaP requires further evaluation. An infant with a recent seizure or an evolving neurologic condition should not receive further doses of DTaP, or DT until the condition has been evaluated and stabilized. Other indicated vaccines may be administered on schedule. To assure that the child is at least protected against tetanus and diphtheria, the decision to give either DTaP or DT should be made no later than the first birthday.
Does tetanus toxoid contain horse serum?

Tetanus toxoid has never contained horse serum or protein. Equine tetanus antitoxin (horse derived) was the only product available for the prevention of tetanus prior to the development of tetanus toxoid in the 1940s. Equine antitoxin was also used for passive postexposure prophylaxis of tetanus (e.g., after a tetanus-prone wound) until the development of human tetanus immune globulin in the late 1950s. Equine tetanus antitoxin has not been available in the U.S. for at least 40 years.

Can Tdap be given to a pregnant teen or woman?
ACIP and AAP have different recommendations on the use of Tdap in pregnancy. ACIP voted to recommend using Td (not Tdap) during pregnancy if the woman is due for a routine tetanus booster. If she is not due for the routine booster (i.e., the previous Td booster was given within the preceding 10 years), the new mother should receive Tdap immediately postpartum. However there are situations when a clinician can consider the use of Tdap for a pregnant woman, such as if there is a risk of exposure because of a pertussis outbreak. Tdap is not contraindicated for pregnant women. The infant's other household contacts ages 10 through 64 years should also receive 1 dose of Tdap, if not already given. AAP has endorsed preferential use of the Tdap vaccine during pregnancy in adolescents who were not vaccinated at the visit at age 11-12 years (Pediatrics 2006; 117:965-78). Providers can follow either the AAP or ACIP recommendation.
Tetanus and wound management issues Back to top
When a patient seen in the ER needs tetanus protection, which type of tetanus vaccine should be given?

For children younger than age 7 years, give DTaP. Children and adults age 10 through 64 years should receive a single dose of Tdap instead of Td, if they have not previously received Tdap. Children who are ages 7 through 9 years and haven't had at least 3 doses of pertussis-containing vaccine prior to their seventh birthday (or are unsure), should be given Tdap. Adults ages 65 or older, especially those who have or anticipate having contact with an infant, and haven't had Tdap before (or are unsure), should also be given a dose of Tdap. If Tdap is not available, or was previously administered, these people should receive Td.
If a person gets a puncture wound or laceration on Friday night, does the person need to receive tetanus wound management that night or can it wait until Monday?

ACIP has not addressed this issue specifically. Puncture wounds, however, should be attended to as soon as possible. The decision to delay a booster dose of tetanus toxoid-containing vaccine following an injury should be based on the nature of the injury and likelihood that the injured person is susceptible to tetanus. The more likely the person is to be susceptible, the more quickly that tetanus prophylaxis should be administered. A person with a tetanus-prone wound (e.g., punctures, wounds contaminated with soil or fecal material) and who has no history of tetanus immunization must be vaccinated and given tetanus immune globulin (TIG) as soon as possible. A person with a documented series of at least three tetanus toxoid-containing products, with a booster dose within the previous 10 years ago is less likely to be susceptible to tetanus, and the need for a booster dose is not as urgent, particularly if the wound can be thoroughly cleaned. The more likely a person is to be completely susceptible to tetanus (i.e., unvaccinated or incompletely vaccinated), the sooner that TIG and Td/Tdap should be administered, even if it means a trip to the emergency department.

When should tetanus immune globulin (TIG) be administered as part of wound management?
TIG is recommended for any wound other than a clean minor wound if the person's vaccination history is either unknown, or s/he has had less than a full series of 3 doses of Td vaccine. TIG should be given as soon as possible after the injury.

How long after a wound occurs is tetanus immune globulin no longer recommended?
In the opinion of the tetanus experts at the CDC, for a person who has been vaccinated but is not up to date, there is probably little benefit in giving TIG more than a week or so after the injury. For a person believed to be completely unvaccinated, it is suggested to increase this interval to 3 weeks (i.e., up to day 21 post injury). Td or Tdap should be given concurrently.

Vaccine storage and handling

How should DTaP, DT, Tdap, and Td vaccines be stored?
Each of these products must be stored at 35° to 46°F (2° to 8°C). They should not be frozen or exposed to freezing temperatures.