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Appendix C
Summary of recommendations for tetanus toxoid,
reduced diphtheria toxoid and acellular pertussis vaccine (Tdap)
and tetanus and diphtheria toxoids (Td) use among adolescents
aged 11--18 years*
Routine Tdap vaccination for adolescents aged 11--18 years
Adolescents aged 11--18 years should receive a single dose of Tdap instead of Td for booster immunization against
tetanus, diphtheria, and pertussis if they have completed the recommended childhood DTP/DTaP vaccination
series† and have not received Td or Tdap. The preferred age for Tdap vaccination is 11--12 years; routinely administering Tdap to
young adolescents will reduce the morbidity associated with pertussis in adolescents [1-A].
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. The benefit of using Tdap
at a shorter interval to protect against pertussis generally outweighs the risk for local and systemic reactions after
vaccination in settings with increased risk for pertussis or its complications (see Pertussis Outbreaks and Other Settings with
Increased Risk for Pertussis or its Complications) [1-A].
Tdap (or Td) should be administered with other vaccines that are indicated during the same visit when feasible. Each
vaccine should be administered using a separate syringe at different anatomic sites. Some experts recommend administering no
more than two injections per muscle, separated by at least one inch [1-C].
Contraindications, precautions, and reasons to defer Tdap or Td among adolescents aged
11--18 years
Contraindications: History of serious allergic reaction (i.e., anaphylaxis) to vaccine components or
encephalopathy (e.g., coma or prolonged seizures) not attributable to an identifiable cause within 7 days of administration of a vaccine
with pertussis components (this is a contraindication for the pertussis components; Td can be used) [2-A].
Precautions and Reasons to Defer Vaccination: Guillain-Barré syndrome
<6 weeks after a previous dose of a
tetanus toxoid--containing vaccine; progressive neurologic disorder, including progressive encephalopathy, or
uncontrolled epilepsy, until the condition has stabilized (these conditions are precautions for the pertussis components; Td can
be used); acute illness; and history of an Arthus reaction after a tetanus toxoid--containing and/or diphtheria
toxoid--containing vaccine administered <10 years
previously [2-B].
Reporting of adverse events after vaccination
All clinically significant adverse events should be reported to the Vaccine Adverse Event Reporting System (VAERS), even
if causal relation to vaccination is not certain. VAERS reporting forms and information are available electronically at
http://www.vaers.org or by telephone, 800-822-7967. Providers are encouraged to report electronically at
https://secure.vaers.org/VaersDataEntryintro.htm.
Special situations for Tdap (single dose) and Td use among adolescents aged 11--18 years
Nonsimultaneous vaccination: If simultaneous vaccination is not feasible, inactivated vaccines can be administered at
any time before or after a different inactivated or live vaccine. Tdap (or Td) and MCV4 vaccines (which all contain
diphtheria toxoid) can be administered using any sequence. Persons who recently received one diphtheria toxoid--containing
vaccine might have increased rates of adverse reactions after a subsequent diphtheria toxoid--containing vaccine when
diphtheria antibody titers remain elevated from the previous
vaccination§ [3-B].
Pertussis Outbreaks and Other Settings with Increased Risk for Pertussis or its Complications:
Vaccine providers can administer Tdap to adolescents aged 11--18 years at an interval less than 5 years after Td, particularly when the benefit
of providing protection against pertussis is likely to be increased (e.g., pertussis outbreaks and close contact with an
infant aged <12 months). The safety of an interval as short as approximately 2 years between Td and Tdap is supported by
a Canadian study among children and adolescents. Postexposure chemoprophylaxis and other pertussis control
guidelines are available at
http://www.cdc.gov/nip/publications/pertussis/guide.htm and
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5414a1.htm [3-C].
Lack of Availability of Tdap or MCV4: If Tdap and MCV4 are both indicated for adolescents but only one vaccine
is available, the available vaccine should generally be administered [3-D].
Use of Td when Tdap is Not Available: When Tdap is indicated but not available, vaccine providers should administer Td
if the last pediatric DTP/DTaP/DT or Td dose was
>10 years earlier to provide protection against tetanus and diphtheria.
Td can be deferred temporarily when the last pediatric
DTP/DTaP/DT or Td was administered <10 years earlier and
the adolescent is likely to return for follow-up. Vaccine providers should maintain a system to recall adolescents when
Tdap/Td vaccination is deferred [3-D].
Tetanus Prophylaxis in Wound Management: Adolescents who require a tetanus toxoid--containing vaccine as part
of wound management should receive a single dose of Tdap instead of Td if they have not previously received
Tdap;if Tdap is not available or was previously administered, adolescents who need a tetanus toxoid--containing vaccine should
receive Td [3-E].
History of Pertussis: Adolescents who have a history of pertussis generally should receive Tdap according to the
routine recommendations [3-F].
No History of Pertussis Vaccination: Adolescents who have not received vaccines with pertussis components
but completed the recommended tetanus and diphtheria vaccination
series¶ with pediatric DT or Td generally should
receive Tdap according to the routine recommendations if they do not have a contraindication to the pertussis components
[3-G].
No History of Pediatric DTP/DTaP or Td/Tdap Vaccination:
Adolescents who have never received
tetanus-diphtheria-pertussis vaccination shouldreceive a series of three vaccinations. The preferred schedule is a single Tdap dose, followed by
a dose of Td >4 weeks after the Tdap dose and a second dose of Td
6--12 months after the earlier Td dose. Tdap can
be substituted for any one of the 3 Td doses in the series [3-H].
Vaccination during Pregnancy: Pregnancy is not considered a contraindication for Tdap or Td vaccination. Guidance
on the use of Tdap during pregnancy is under consideration by the Advisory Committee on Immunization
Practices. Pregnant adolescents who received the last tetanus toxoid--containing vaccine <10 years previously should
generally receive Tdap in the postpartum period, according to the routine vaccination recommendations and interval guidance,
and pregnant adolescents who received the last tetanus toxoid--containing vaccine
>10 years previously should generally receive Td in preference to Tdap (during the second or third trimester) [3-K, 3-L].
* Consult recommendations in text for details.
† Five doses of pediatric DTP/DTaP before the seventh birthday; if the fourth dose was administered on or after the fourth birthday, the fifth dose is
not needed.
§ A prelicensure study demonstrated that simultaneous vaccination with Td and MCV4 was acceptably safe; the safety of simultaneous vaccination with
Tdap and MCV4 has been inferred from this study. Td followed 1 month later by MCV4 was studied, and rates of local reactions were comparable to
simultaneous vaccination. Other schedules of MCV4 and Td and MCV4 and Tdap have not been studied (http://www.fda.gov/cber/label/mpdtave011405LB.pdf).
¶ Five doses of pediatric DT before the seventh birthday; if the fourth dose was administered on or after the fourth birthday, the fifth dose is not
needed. Children who began the tetanus and diphtheria vaccination series at age
>7 years required 3 doses of Td to complete the primary series.
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