Vaccines that contain diphtheria toxoid, tetanus toxoid, and acellular pertussis help protect against diphtheria Diphtheria Diphtheria is an acute pharyngeal or cutaneous infection caused mainly by toxigenic strains of the gram-positive bacillus Corynebacterium diphtheriae and rarely by other, less common... read more , tetanus Tetanus Tetanus is acute poisoning from a neurotoxin produced by Clostridium tetani. Symptoms are intermittent tonic spasms of voluntary muscles. Spasm of the masseters accounts for the name... read more , and pertussis Pertussis Pertussis is a highly communicable disease occurring mostly in children and adolescents and caused by the gram-negative bacterium Bordetella pertussis. Symptoms are initially those of... read more , but they do not prevent all cases.
For more information, see DTaP/Tdap/Td Advisory Committee on Immunization Practices Vaccine Recommendations and Centers for Disease Control and Prevention (CDC): Diphtheria, Tetanus, and Pertussis Vaccination. A summary of changes to the 2022 adult immunization schedule is available here.
(See also Overview of Immunization Overview of Immunization Immunity can be achieved Actively by using antigens (eg, vaccines, toxoids) Passively by using antibodies (eg, immune globulins, antitoxins) A toxoid is a bacterial toxin that has been modified... read more .)
Diphtheria (D) vaccines contain toxoids prepared from Corynebacterium diphtheriae. Tetanus (T) vaccines contain toxoids prepared from Clostridium tetani. Acellular (a) pertussis (P) vaccines contain semipurified or purified components of Bordetella pertussis. Whole-cell pertussis vaccine is no longer available in the US because of concerns about adverse effects, but it is still available in other parts of the world. There are 2 preparations of the acellular vaccine:
Diphtheria-tetanus-acellular pertussis (DTaP) for children < 7 years
Tetanus-diphtheria-pertussis (Tdap) for adolescents and adults
Tdap contains lower doses of diphtheria and pertussis components (indicated by the lower case d and p).
DTaP is a routine childhood vaccination ( see Table: Recommended Immunization Schedule for Ages 0–6 Years Recommended Immunization Schedule for Ages 0–6 Years ).
Tdap is routinely given as a single lifetime dose to children at age 11 or 12 years and to people ≥ 13 years who have never received Tdap (regardless of the interval since the last tetanus-diphtheria [Td] vaccine Tetanus-Diphtheria Vaccine A vaccine for tetanus alone is available, but the tetanus vaccine is typically combined with those for diphtheria and/or pertussis. The vaccine for diphtheria is available only in combination... read more ) or whose vaccine status is unknown. This dose is followed by a Td booster Tetanus-Diphtheria Vaccine A vaccine for tetanus alone is available, but the tetanus vaccine is typically combined with those for diphtheria and/or pertussis. The vaccine for diphtheria is available only in combination... read more every 10 years.
Additional boosters of Tdap are also recommended for
Pregnant women during each pregnancy (preferably at 27 to 36 weeks gestation), regardless of the interval since any previous dose of Tdap
Postpartum women who have never received Tdap
Adults who require a tetanus toxoid-containing vaccine as part of wound management and who have not previously received Tdap are given Tdap instead of tetanus-diphtheria (Td). Those who have previously received Tdap may be given Tdap or Td.
People who have had pertussis should still receive a pertussis-containing vaccine as per routine recommendations.
Contraindications and Precautions
Contraindications for DTaP and Tdap are
A severe allergic reaction (eg, anaphylaxis Anaphylaxis Anaphylaxis is an acute, potentially life-threatening, IgE-mediated allergic reaction that occurs in previously sensitized people when they are reexposed to the sensitizing antigen. Symptoms... read more ) after a previous dose or to a vaccine component
For the pertussis component: Encephalopathy (eg, coma, decreased level of consciousness, prolonged seizures) that occurred within 7 days of a previous dose of DTaP or Tdap and that is not attributable to another identifiable cause
Because tetanus vaccination is important, people who have had an anaphylactic reaction to components in DTaP or Tdap should be referred to an allergist to determine whether they are allergic to tetanus toxoid. If not, they can be vaccinated with tetanus toxoid (TT) vaccine. Adults with a history of encephalopathy can be vaccinated with tetanus-diphtheria, and children can be given diphtheria-tetanus (DT) instead of Tdap.
Precautions vary depending on the formulation.
For DTaP and Tdap, they include
Moderate or severe acute illness with or without fever (vaccination is postponed until illness resolves if possible)
Guillain-Barré syndrome Guillain-Barré Syndrome (GBS) Guillain-Barré syndrome is an acute, usually rapidly progressive but self-limited inflammatory polyneuropathy characterized by muscular weakness and mild distal sensory loss. Cause is thought... read more within 6 weeks after a previous dose to a vaccine containing tetanus toxoid
For the pertussis component only: A progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy (vaccination is postponed until a treatment regimen is established and the disorder is stabilized)
For DTaP only, precautions include
A seizure, with or without fever, within 3 days after a previous dose of DTaP
≥ 3 hours of persistent, severe, inconsolable screaming or crying within 48 hours after a previous dose of DTaP
Collapse or shock-like state (hypotonic hyporesponsive episode) within 48 hours after a previous dose of DTaP
Temperature of ≥ 40.5° C, unexplained by another cause, within 48 hours after a previous dose of DTaP
For Tdap only, precautions include
History of type III hypersensitivity reactions Type III Allergic (including atopic) and other hypersensitivity disorders are inappropriate or exaggerated immune reactions to foreign antigens. Inappropriate immune reactions include those that are... read more after a previous dose of a vaccine containing tetanus or diphtheria toxoid (vaccination is postponed ≥ 10 years since the last dose of tetanus toxoid-containing vaccine)
Dose and Administration
The dose for DTaP or Tdap is 0.5 mL IM.
The DTaP vaccine is given as 5 primary and 1 booster IM injections during childhood as follows: at age 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before school entry). The fifth dose is not necessary if the fourth dose was given at age ≥ 4 years and at least 6 months after the third dose.
A single booster of Tdap is given, except for pregnant women, who should have a dose during each pregnancy, preferably at 27 to 36 weeks gestation.
Pearls & Pitfalls
Adverse effects are rare and are mostly attributable to the pertussis component. They include the following:
Encephalopathy within 7 days
A seizure, with or without fever, within 3 days
≥ 3 hours of persistent, severe, inconsolable screaming or crying within 48 hours
Collapse or shock within 48 hours
Temperature of ≥ 40.5° C, unexplained by another cause, within 48 hours
Immediate severe or anaphylactic reaction to the vaccine
If the pertussis vaccine is contraindicated, a combined diphtheria and tetanus vaccine Tetanus-Diphtheria Vaccine A vaccine for tetanus alone is available, but the tetanus vaccine is typically combined with those for diphtheria and/or pertussis. The vaccine for diphtheria is available only in combination... read more is available without the pertussis component.
Mild adverse effects include redness, swelling, and soreness at the injection site.
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Advisory Committee on Immunization Practices (ACIP): DTaP/Tdap/Td ACIP Vaccine Recommendations
Centers for Disease Control and Prevention (CDC): Diphtheria, Tetanus, and Pertussis Vaccination: Information for Healthcare Professionals
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