VACCINE TYPE

  • DT (tetanus + diphtheria toxoids)
  • Td (tetanus toxoid+ reduced-dose diphtheria toxoid)
  • DTaP (DT + acellular pertussis)
  • Tdap (Td + reduced-dose acellular pertussis)
  • DTaP and DT: are given to children < 7 y/o
  • Tdap and Td: are given to older children and adults
  • For other combinations see formulations

INDICATIONS

ACIP RECOMMENDATIONS

  • Children (birth to 18 yrs):
    • All children should receive 5 doses of DTaP as a primary series
      • 1 dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 yrs
    • All adolescent between ages of 11 and 12 should receive a single dose of Tdap.
      • This can be administered regardless of the timing of the last TD containing vaccine administration.
    • Pregnant adolescent should get a Tdap during each pregnancy (preferably between the 27th and 36th week) [5].
    • Catch-up immunization:
      • Children (>7 yrs) should receive 5 doses of DTaP during the catch-up months.
        • Doses 1-3 doses should be given 4 weeks apart.
        • Dose 4 should be given 6 months after dose 3, followed by dose 5, 6 months later.
        • For more information see ACIP immunization schedule.
      • Children (7-10 yrs) who are not fully vaccinated with DTaP should receive a single dose of Tdap (preferably as the first dose in the catch-up series).
        • An additional dose of Tdap should NOT be administered at age 11-12.
        • Td should be administered instead 10 years after the Tdap dose.
      • Adolescent (11-18 yrs) who have not received Tdap vaccine should receive a single dose of Tdap, followed by Td booster doses every 10 years thereafter.
      • Inadvertent doses of DTaP vaccine, see ACIP immunization schedule.
  • Adults (≥19 yrs) [1]:
    • Td booster every 10 years.
    • All receive one single dose of Tdap.
      • This can be administered regardless of the timing of the last Td administration.
    • Women should get a Tdap during each pregnancy (preferably between the 27th and 36th week) [5].
  • All health-care workers should receive Tdap independent of their previous Td dose [6].

OTHER INFORMATION

  • Other indications:
    • Tetanus prophylaxis in wound care: < 3 prior doses, unknown vaccination or unvaccinated (additional doses should be given at 4 weeks and 6 months post-injury), >5 yrs post Td [7].
    • Tdap preferred if not previously received for ages > 19 yrs.
  • Td booster should be administered to patients presenting with tetanus

FORMS

brand name

preparation

manufacturer

route

form

dosage^

cost*

ADACEL

Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine adsorbed (Tdap)

Sanofipasteur

IM

vial, syringe

2-5-2.5/0.5 mL

$51.65

BOOSTRIX

Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine adsorbed (Tdap)

GlaxoSmithKline

IM

vial, syringe

2.5-5-8/0.5 mL

$45.88

DAPTACEL

Diphtheria and tetanus toxoids, and acellular pertussis vaccine adsorbed (DTaP)

Sanofipasteur

IM

vial

15-5-10/0.5 mL

$67.29

Td (generic)

Diphtheria and tetanus toxoids (Td)

Grifols USA LLC

IM

vial

2-2 LF/0.5 mL

$26.34

DT

Diphtheria and tetanus toxoids (DT)

Sanofipasteur

IM

vial

5-25/0.5 mL

$113

INFARIX

Diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed (DTaP)

GlaxoSmithKline

IM

vial, syringe

25-10-25/0.5 mL

$26

KINRIX

Diphtheria and tetanus toxoids, and acellular pertussis adsorbed and inactivated poliovirus vaccine (DTaP-IPV)

GlaxoSmithKline

IM

vial, syringe

25-10-25/0.5 mL

$58.62

PEDIARIX

Diphtheria and tetanus toxoids and acellular pertussis adsorbed, Hepatitis B (recombinant) and inactivated poliovirus vaccine (DTaP-HBV-IPV)

GlaxoSmithKline

IM

syringe

25-10-25/0.5 mL

$68.47

PENTACEL

Diphtheria and tetanus toxoids, and acellular Pertussis adsorbed, and inactivated poliovirus vaccine, and Haemophilus b conjugate vaccine (DTaP-IPV-Hib)

Sanofipasteur

IM

KIT

15-20-5-10

$105

TENIVAC

Tetanus and diphtheria toxoids adsorbed (Td)

Sanofipasteur

IM

vial, syringe

2-5/0.5 mL

$70.8

QUADRACEL

Diphtheria and tetanus toxoids, and acellular pertussis adsorbed and inactivated poliovirus vaccine (DTaP-IPV)

Sanofipasteur

IM

vial

15-25-20/0.5 mL

N/A

*Prices represent cost per unit specified, are representative of "Average Wholesale Price" (AWP).
^Dosage is indicated in mg unless otherwise noted.

PATHOGEN DIRECTED PROTECTION

DOSE/ADMINISTRATION

Adult PRIMARY SERIES

  • ADACEL, BOOSTRIX (adult Tdap): one dose of 0.5 mL IM
  • TENIVAC (adult Td): three doses of 0.5 mL IM.
    • Dose 1 and 2 should be separated by 1-2 months.
    • Dose 2 and 3 should be separated by 6-12 months.
    • Note: one-time dose of Tdap can be substituted for one of the doses in the series, preferably the first.

Adult BOOSTER

  • 0.5 mL Td booster every 10 years.
  • Tdap x 1 (lifetime) should replace Td for adults without prior Tdap dose.

Pediatric PRIMARY SERIES

  • INFANRIX or DAPTACEL (DTaP): 0.5 mL IM (x 5 doses) 2, 4, and 6 months of age, followed by 2 booster doses, administered at 15 to 18 months of age and at 4 to 6 years of age.
  • DT (< 7 years old): starting at 6 weeks administer three doses of 0.5 mL IM 4 to 8 weeks apart, followed by 2 booster doses, administered at 15 to 18 months of age and at 4 to 6 years of age. (Used when pertussis vaccine contraindicated.)
  • PEDIARIX (DTaP + Inactivated Poliovirus Vaccine): 3 doses of 0.5 mL IM at 8-week intervals starting at 2 months of age.

Pediatric BOOSTER

  • INFANRIX or DAPTACEL (DTaP): 0.5 mL IM. As mentioned above, booster doses given at ages 15-18 months and 4-6 years.
  • DT (for children < 7 years of age in whom pertussis vaccine is contraindicated) 0.5 mL IM. As mentioned above, booster doses given at ages 15-18 months and 4-6 years.
  • TdaP (ADACEL or BOOSTRIX): single 0.5 mL IM in individuals 10 through 18 years of age.
  • TriHIBit (Tdap +Hib): 0.5 mL IM.

    Pediatric Dosing Author: George K Siberry, MD, MPH

ADVERSE DRUG REACTIONS

GENERAL

  • Generally well tolerated

COMMON

  • Pain and tenderness at injection site; rate increases with more doses

RARE

  • Anaphylaxis
  • Encephalopathy
  • Arthralgia
  • Fever
  • Guillain-Barre syndrome
  • Arthus reaction (severe pain, swelling, induration, edema, hemorrhage, and occasional local necrosis)

VACCINE/DRUG INTERACTIONS

  • The simultaneous administration of DT, MMR, OPV, or inactivated poliovirus vaccine (IPV), and Haemophilus b Conjugate Vaccine (HbCV) is acceptable.
  • Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs, and corticosteroids (used in greater than physiologic doses), may reduce the immune response to vaccines.

CONTRAINDICATIONS

  • History of anaphylaxis to vaccine components.
  • Encephalopathy within 7 days of administration of pertussis vaccine.
  • Use with caution with history of Guillain-Barre syndrome (within 6 weeks after previous tetanus toxoid-containing vaccine), moderate or acute severe illness, unstable neurological conditions, and Arthus hypersensitivity reaction.

IMMUNE RESPONSE

  • Response usually good, but reduced in elderly.
  • Anti-tetanus response: anti-tetanus levels >0.1 IU/mL achieved in nearly 100% and booster response was 90-93%.

CLINICAL EFFICACY

  • Vaccine is very effective, ~100% effective
  • 18 tetanus cases reported in 2009. Almost all cases were reported in the individuals who were never vaccinated or completed series but did not receive booster.

OTHER INFORMATION

  • Need: about 25% of U.S. adults > 70 yrs to have protective tetanus ab titers.
  • Most cases in U.S. occur in intravenous drug users, individuals with diabetes; presumed underimmunized, waning or no immunity.
  • DT: pediatric preparation, contraindicated in persons >7 yrs.
  • ADACEL contains the same tetanus toxoid, diphtheria toxoid, and five pertussis antigens as those in DAPTACEL (pediatric DTaP), but ADACEL is formulated with reduced quantities of diphtheria toxoid and detoxified pertussis toxin.

FOLLOW UP

  • Td preferred for adults (less local reactions) and during pregnancy.
    • Adults should receive Tdap x 1 as primary series, booster or with wound management.
  • Wounds
    • Minor:
      • < 3 prior Td doses or unknown: give Td
      • > 3 doses: Td if >5 yrs since last booster
    • Severe or contaminated:
      • < 3 prior Td doses: Td + TIG
      • > 3 doses: give Td if > 5yrs since last Td booster
    • TIG (tetanus immune globulin): administer if < 3 doses Td or unknown + contaminated wound (dirt, stool, saliva, soil), crush, burn or frostbite.
      • TIG: tetanus Immune globulin 500 units IM (prophylaxis), or 3,000-10,000 units (active tetanus).

Basis for recommendation

  1. Centers for Disease Control and Prevention (CDC): Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR Morb Mortal Wkly Rep 60:13, 2011  [PMID:21228763]

    Comment: Updated recommendations for Tdap to be used in place of Td booster for at least one dose despite lack of FDA approval recommended that un-immunized adults age 65 and older be immunized with Tdap if in contact with an infant. Since 2005, the ACIP has recommended Tdap for all adolescents aged 11 – 18 years with preference of administration ages 11 or 12and for adults 19 through 64 years who is and who have not received a dose.

  2. Centers for Disease Control and Prevention (CDC): Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older - Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep 61:468, 2012  [PMID:22739778]

    Comment: In 2012 ACIP updated its recommendations to include recommendation to vaccinate all adults ≥65 y/o with Tdap vaccine. In 2011, FDA approved expanding the age indication for Boostrix to aged 65 years and older. This recommendation supersedes previous recommendation about Tdap vaccination in adults 65 y/o.

  3. Kim DK et al: Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2016. MMWR Morb Mortal Wkly Rep 65:88, 2016  [PMID:26845417]

    Comment: Updated (2015) ACIP immunization schedule for adults ≥ 19 y/o.

  4. Kretsinger K et al: Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep 55:1, 2006  [PMID:17167397]

    Comment: The ACIP recommendations for 2006 were changed to include Tdap as a one time single dose vaccine for persons <65 yrs.

References

  1. Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention (CDC): Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 60:1, 2011  [PMID:22108587]

    Comment: ACIP recommends that all healthcare workers should receive a single dose of Tdap regardless of the time since their most recent Td vaccination.
    Rating: Important

  2. Centers for Disease Control and Prevention (CDC): Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women--Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep 62:131, 2013  [PMID:23425962]

    Comment: 2012 ACIP updated recommendations: Tdap is now recommended during every pregnancy to reduce the burden of pertussis in infants.
    Rating: Important

  3. Hospenthal DR et al: Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society. J Trauma 71:S210, 2011  [PMID:21814089]

    Comment: Tetanus vaccine recommendation for combat-related injuries.

  4. Gergen PJ et al: A population-based serologic survey of immunity to tetanus in the United States. N Engl J Med 332:761, 1995  [PMID:7862178]

    Comment: It appears that only about 27% of US citizens >70yrs have protective levels of tetanus antibody.

Tetanus vaccines is a sample topic from the Johns Hopkins Antibiotic (ABX) Guide.

To view other topics, please or purchase a subscription.

Johns Hopkins Guides provide diagnosis, management, and treatment guidance for infectious diseases, diabetes, and psychiatric conditions. Learn more.

Last updated: May 30, 2016