Tetanus vaccines

Edina Avdic, Pharm.D.
Pediatric Dosing Author: Lisa Hutchins, Pharm.D.

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, 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.
    • A pregnant adolescent should get a Tdap during each pregnancy (preferably between the 27th and 36th week).
  • 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:
    • Children 10-18 years:
    • Inadvertent doses of DTaP vaccine, see ACIP immunization schedule
  • 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 healthcare workers should receive Tdap independent of their previous Td dose.

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[4].
    • Tdap preferred if not previously received for ages > 19 yrs.
  • Td booster should be administered to patients presenting with tetanus.
  • Studies have not found adverse events when the vaccine is used during pregnancy[3].

FORMS

brand name

preparation

manufacturer

route

form

dosage^

cost*

ADACEL

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

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: 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 x 1 (lifetime) should replace Td for adults without prior Tdap dose.
  • As of 2020, either Tdap or Td can be used for q 10 yr boosters.

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
  • 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
  • TdaP (ADACEL or BOOSTRIX): single 0.5 mL IM at age 11-12 years. It may be administered to children 7 years and older according to the ACIP catch-up 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.
  • 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 is usually good, but reduced in the elderly.
  • Anti-tetanus response: anti-tetanus levels >0.1 IU/mL achieved in nearly 100% and booster response was 90-93%.

CLINICAL EFFICACY

  • The vaccine is very effective, with ~100% efficacy.
  • 18 tetanus cases were reported in the U.S. in 2009 and have remained in this range annually since.
    • Almost all cases were reported in individuals who were never vaccinated or completed series but did not receive boosters.

OTHER INFORMATION

  • Need: about 25% of U.S. adults > 70 yrs to have protective tetanus ab titers.
  • Most cases in the 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.
  • Use in HIV-positive patients
    • This purified toxin vaccine is considered to be well-tolerated among people with HIV. Use general indications for vaccination. The immune response is likely best when the CD4 count is >200 cells/mm3.

FOLLOW UP

  • Td is preferred for adults (fewer local reactions) and during pregnancy.
    • Adults should receive Tdap x 1 as a primary series, booster or with wound management.
  • Wounds
    • Minor:
      • < 3 prior Td doses or unknown: give Td
      • > 3 doses: Td if >5 yrs since the 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. Havers FP, Moro PL, Hunter P, et al. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(3):77-83.  [PMID:31971933]

    Comment: ACIP recommendations have been updated to allow either tetanus and diphtheria toxoids (Td) vaccine or Tdap to be used for the decennial Td booster, tetanus prophylaxis for wound management, and for additional required doses in the catch-up immunization schedule if a person has received at least 1 Tdap dose.

  2. 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: Compiled, updated recommendations that serve as the basis for recommended schedules as well as booster needs.

References

  1. Gidengil C, Goetz MB, Newberry S, et al. Safety of vaccines used for routine immunization in the United States: An updated systematic review and meta-analysis. Vaccine. 2021;39(28):3696-3716.  [PMID:34049735]

    Comment: Analysis of existing studies found no evidence of increased risk (varied SoE) for key adverse events among pregnant women following tetanus, diphtheria, and acellular pertussis vaccine, including stillbirth (moderate SoE).

  2. Hospenthal DR, Murray CK, Andersen RC, 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. 2011;71(2 Suppl 2):S210-34.  [PMID:21814089]

    Comment: Tetanus vaccine recommendation for combat-related injuries.

  3. Gergen PJ, McQuillan GM, Kiely M, et al. A population-based serologic survey of immunity to tetanus in the United States. N Engl J Med. 1995;332(12):761-6.  [PMID:7862178]

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

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Last updated: September 3, 2021