DIPHTHERIA-TETANUS-PERTUSSIS VACCINES

I. Whole cell pertussis vaccine

  1. Common adverse effects (some of 1st 4 in 96%; all more common in older kids, all more common if occurred with a previous dose)
  1. Low grade fever (42%, peaks @ 7-24h; not sig. ass'd with local inflamm.); n.b. if fever occurs > 24h after vaccination can't assume it's from the vaccine!
  2. Crankyness and increased crying (84%, peaks @ 6h; sig. ass'n with local inflamm.)
  3. Increased sleeping (58%, peaks @ 6h)
  4. Anorexia & vomiting (10-20%)
  5. Local inflamm. (85%, peaks @ 6h, last longer than other rxns)
  6. Increased risk of Sz (1:1750-13K immunizations), esp. in kids predisposed, esp. to febrile Sz (no evidence of sequelae or increased risk for epilepsy, however)
  1. Uncommon adverse effects--These reactions contraindicate further whole-cell PERTUSSIS (3% of vacc's; rarely recur with repeated admin.; used to be absol. contraind., but found not to be ass'd with permanent sequelae; decision to vaccinate should depend on pt's risk for b. pertussis exposure)
  1. Fever > 105'F (40.5c) <48h post-vacc, not due to other ident. cause; us. due to pertussis component; occurs in 0.3%
  2. Inconsolable crying x >3h <48h post-vacc; occurs in 1%; no neurol. sequelae; immuniz. series has been completed in such kids without probs; less likely to occur with subsequent doses
  3. Sz with/without fever <3d post-vacc (occur in about 0.06%); no evident sequelae, even if proceeds to status epilepticus; if occurs, delay further doses of DT or DPT until kid's neurol. status is w/u'd & stabilized; in future, co-administer acetaminophen 15mg/kg at time of vacc & Q4h x 24h. n.b. D & T components not known to carry any risk of sz.
  4. Hypotonic-hyporesponsive episode <48h post-vacc.; scary but no sequelae; give remainder of doses as DT; occurs in about 0.06%
  1. Severe and uncommon (1st 2 very rare) adverse effects; constitute contraindication to further whole-cell DPT
  1. Anaphylaxis: don't attempt further vacc. with any of DPT components; can refer to allergist for skin testing/desens.
  2. Acute encephalopathy <7d post vacc., not due to other identifiable cause
  1. Us. consists of major change in metal status, gen'lized/focal sz lasting > few hrs, recovery taking >24h)
  2. May cause long-term neurologic sequelae; "NCES" study estimated risk of this to be 1:330,000. NCES authors later reviewed data and concluded that no connection bet. vacc & brain damage and that no recognizable post-pertussis vacc. sd. existed
  3. Prob. occurs in about 0.001% of vaccinees. Whether a causeal relationship exists is a matter of controversy as of 1997
  4. Don't give more pertussis vacc., wait few mos. then give remainder of doses as DT.

II.  Acellular Pertussis Vaccine

  1. Shown in multiple controlled trials to give similar protective efficacy to whole cell (70-90%) when used for all doses; causes fewer local reactions, fevers, and other systemic adverse effects. "DTaP is preferred for all doses, but whole-cell vaccines remain acceptable alternatives." Also, for kids who got whole-cell for 1st 3 doses, can use DTaP for doses 4 and 5 (JAMA 277:371, 1997)

III. "Cocooning" for prevention of Pertussis in infants

  1. Since infants < 6mos of age are vulnerable to pertussis even if age-appropriately vaccinated, vaccination of adult household members with TdaP (including mothers before hospital discharge after birth if not previously immunizated with TdaP and no Td in last 2y) may help reduce risk of clinical pertussis in these infants.

IV. Tetanus toxoid, Reduced Diphtheria Toxoid-Acellular Pertussis Vaccine-"Tdap" (Adacel, Boostrix)

  1. For booster use in pts 11-64yo (Adacel) or 10-18yo (Boostrix); first pertussis boosters in adults
  2. CDC/AAP recommendations 2005 (MMWR Recomm Rep 2006 Mar 24;55(RR-3):1-34)
    1. Single dose of Adacel or Boostrix at 11-12yo (instead of Td) if have received the usual DTP or DTaP series in early childhood
    2. Also, "Adolescents aged 11-18 years who received Td, but not Tdap, are encouraged to receive a single dose of Tdap to provide protection against pertussis if they have completed the recommended childhood DTP/DTaP vaccination series...An interval of at least 5 years between Td and Tdap is encouraged to reduce the risk for local and systemic reactions after Tdap vaccination. However, an interval less than 5 years between Td and Tdap can be used." (may be safe with intervals as short as 2y between Td and Tdap
  3. ACIP recommendations 10/2006
    1. Single dose of Tdap at 19-64yo to replace the next tetanus booster (i.e. Td), and for health care personnel and adults having close contact with infants < 12mos of age.