Diphtheria vaccine
VACCINE TYPE
- Types/abbreviations:
- DT (tetanus + diphtheria toxoids)
- Td (tetanus toxoid+ reduced-dose diphtheria toxoid)
- DTaP (DT + acellular pertussis)
- Tdap (Td + reduced-dose acellular pertussis)
- Usual administrations:
- DTaP and DT: are given to children < 7 years old
- Tdap and Td: are given to older children and adults
- For other combinations, see formulations
INDICATIONS
ACIP RECOMMENDATIONS
- Children, primary series, birth to 18 years:
- All children should receive 5 doses of DTaP
- 1 dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 years
- All adolescents between the ages of 11 and 12 should receive a single dose of Tdap
- Pregnant adolescents should get a Tdap during each pregnancy (preferably between the 27th and 36th week)
- All children should receive 5 doses of DTaP
- Catch-up immunization:
- Children < 7 years, utilizing DTaP:
- Doses 1-3 doses should be given 4 weeks apart
- Dose 4 should be given at least 6 months after dose 3 and after the child is at least 15 months of age
- Dose 5 should be given at least 6 months after dose 4 and between the ages of 4 and 6 years. If dose 4 was given after the child’s 4th birthday, dose 5 may be omitted
- For more information see the ACIP immunization schedule
- Children 7-9 years:
- The schedule depends on the previous number and type of vaccinations, see ACIP immunization schedule
- Children 10-18 years:
- The schedule depends on the previous number and type of vaccinations, see ACIP immunization schedule
- Inadvertent doses of DTaP vaccine, see ACIP immunization schedule
- Children < 7 years, utilizing DTaP:
- Adults (≥19 yrs):
- 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)
- All health-care workers should receive Tdap independent of their previous Td dose
OTHER INFORMATION
- Travelers: give booster (Td or Tdap, depending) if diphtheria acquisition risk high.
FORMS
brand name | preparation | manufacturer | route | form | dosage^ | cost* |
ADACELTetanus toxoid | Tetanus toxoid, reduced Diphtheria toxoid, and acellular pertussis vaccine adsorbed (Tdap) | Sanofi Pasteur | 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) | Sanofi Pasteur | 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) | Sanofi Pasteur | IM | vial | 5-25/0.5 mL | $113 |
INFANRIX | 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) | Sanofi Pasteur | IM | KIT | 15-20-5-10 | $105 |
TENIVAC | Tetanus and diphtheria toxoids adsorbed (Td) | Sanofi Pasteur | 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) | Sanofi Pasteur | 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
Corynebacterium diphtheriae, Diptheria
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.
- A 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 should replace Td for adults without a prior Tdap dose.
- Tdap can be used if Td is unavailable for any q 10-year dose.
- Pregnancy: give Tdap with every pregnancy (to help avoid pertussis in the infant).
Pediatric PRIMARY SERIES
- INFANRIX or DAPTACEL (DTaP): 0.5 mL IM dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 years for 5 total doses
- DT, when pertussis vaccine contraindicated: 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
Other combination vaccines exist that include DTaP/DT and may be substituted for DTaP or DT as appropriate
Pediatric BOOSTER
- INFANRIX or DAPTACEL (DTaP): 0.5 mL IM given according to ACIP primary schedule or catch-up schedule, see ACIP immunization schedule
- DT, for children < 7 years of age in whom pertussis vaccine is contraindicated: 0.5 mL IM given according to ACIP primary schedule or catch-up schedule, see ACIP immunization schedule
- TdaP (ADACEL or BOOSTRIX): single 0.5 mL IM at age 11-12 years. May be administered to children 7 years and older according to ACIP catch-up schedule, see ACIP immunization schedule
Other combination vaccines exist that include DTaP/DT/Tdap/Td and may be substituted for DTaP, DT, Tdap, or Td as appropriate
ADVERSE DRUG REACTIONS
GENERAL
- Generally well tolerated.
COMMON
- Pain and tenderness at the 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 should not receive Tdap.
- 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
- The response usually good, but reduced in the elderly.
- Anti-diphtheria response: 99.9% had seroprotective anti-diphtheria levels >0.1 IU/mL and booster response was 91-96%.
CLINICAL EFFICACY
- Clinical efficacy of ~ 97%
- < 5 diphtheria cases have been reported in the U.S. since 2000, but 7,100 reported to the WHO (2016).
OTHER INFORMATION
- Additional details can also be found in the Corynebacterium diphtheriae module
- Td preferred for adults (less local reactions) and during pregnancy
- DT: Pediatric preparation, contraindicated in persons >7 yrs.
- Use in HIV positive patients
- It is well-tolerated among people with HIV. Use general indications for vaccination. The immune response is likely best when CD4 count is >200 cells/mm3.
Basis for recommendation
- Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67(2):1-44. [PMID:29702631]
Comment: This report does not contain any new recommendations but rather consolidates all prior recommendations into a comprehensive document.
References
- Maple PA, Efstratiou A, George RC, et al. Diphtheria immunity in UK blood donors. Lancet. 1995;345(8955):963-5. [PMID:7715300]
Comment: The report suggests that to maintain protective immunity against diphtheria, a booster is needed based on waning protective titers over time.
Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger—United States, 2020.
www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdfComment:
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