What are the recommendations for Tdap (Tetanus, diphtheria, and pertussis) vaccine administration?

Tdap Vaccine Administration Guidelines

Core Recommendation

All adolescents aged 11-12 years should receive a single dose of Tdap, and all adults who have never received Tdap should get one dose regardless of the interval since their last tetanus-containing vaccine, followed by either Td or Tdap boosters every 10 years. 1, 2

Adolescent Vaccination (Ages 11-18 Years)

• Adolescents aged 11-18 years should receive a single dose of Tdap instead of Td for booster immunization, with the preferred age being 11-12 years. 1
• Adolescents who previously received Td but not Tdap are encouraged to receive a single Tdap dose to provide pertussis protection. 1
• While a 5-year interval between Td and Tdap is encouraged to reduce local reactions, shorter intervals can be used when the benefit of pertussis protection outweighs reaction risks. 1
• The dose is 0.5 mL administered intramuscularly, preferably into the deltoid muscle. 1
• Observe adolescents for 15-20 minutes post-vaccination due to increased syncope risk in this age group. 1

Adult Vaccination (Ages 19-64 Years)

• Adults aged 19-64 years should receive a single dose of Tdap to replace one Td dose if their last Td was >10 years ago. 1, 3
• Intervals <10 years since the last Td may be used to protect against pertussis, particularly in high-risk settings. 1
• After receiving Tdap, continue with Td or Tdap boosters every 10 years. 1, 2, 3
• As of 2019, either Td or Tdap can be used for decennial boosters, providing increased flexibility at the point of care. 1

Older Adults (Ages ≥65 Years)

• All adults aged ≥65 years who have not received Tdap should receive a single dose regardless of when they last received a tetanus-containing vaccine. 1, 2
• When feasible, use Boostrix for adults ≥65 years, though either Tdap product (Boostrix or Adacel) is considered valid and immunogenic. 2
• Safety and immunogenicity data demonstrate comparable adverse event profiles to younger adults, with no increase in local or generalized reactions. 2
• Continue Td or Tdap boosters every 10 years after the initial Tdap dose. 2

Pregnancy

• Pregnant women should receive one dose of Tdap during each pregnancy, regardless of prior vaccination history. 1, 2, 4
• Administer Tdap between 27-36 weeks' gestation, preferably during the earlier part of this period to maximize maternal antibody response and passive transfer to the newborn. 2, 4
• Tdap may be safely given at any time during pregnancy if needed for wound management or pertussis outbreaks. 4
• Women who are breastfeeding should receive Tdap in the immediate postpartum period if not administered during pregnancy, preferably before hospital discharge. 1

Special Populations

Healthcare Personnel

• Healthcare workers with direct patient contact should receive a single Tdap dose as soon as feasible if not previously received, with intervals as short as 2 years from the last Td acceptable. 1, 3

Contacts of Infants <12 Months

• Adults with close contact to infants <12 months (parents, grandparents <65 years, childcare providers) should receive Tdap at least 2 weeks before contact begins, with intervals as short as 2 years from the last Td. 1, 3
• This strategy reduces pertussis transmission risk to infants who are at highest risk for complications and death. 1

Wound Management

Clean, Minor Wounds

• No tetanus toxoid needed if last dose was within 10 years. 2
• If last dose was >10 years ago, administer Tdap (if never received) or Td. 2

Contaminated or Severe Wounds (Including Nail Punctures)

• If last tetanus shot was >5 years ago, administer tetanus vaccine—Tdap preferred if never received, otherwise Td. 1, 2
• For unknown or incomplete vaccination history, administer both tetanus vaccine AND Tetanus Immune Globulin (TIG) 250 units IM in separate syringes at different anatomic sites. 2
• Obtain vaccination within 24-48 hours as part of standard wound management. 2

Catch-Up Vaccination (Ages ≥7 Years)

• Unvaccinated persons aged 7-18 years should receive a 3-dose series: 1 dose of Tdap (preferably first), followed by Td or Tdap ≥4 weeks later, then Td or Tdap 6-12 months after the second dose. 1, 2
• The vaccination series does not need to be restarted regardless of time elapsed between doses—simply continue from where the patient left off. 2
• Children aged 7-10 years who received Tdap as part of catch-up should still receive the routine adolescent Tdap booster at age 11-12 years. 1

Contraindications

• Absolute contraindication: History of anaphylaxis to any vaccine component. 1, 2, 3
• Tdap-specific contraindication: History of encephalopathy (coma or prolonged seizures) within 7 days of a pertussis-containing vaccine not attributable to another cause—use Td instead. 1, 3
• History of Arthus reaction following a previous tetanus toxoid dose—do not administer more frequently than every 10 years. 2

Administration Details

• Dose: 0.5 mL intramuscularly, preferably into the deltoid muscle. 1
• Either Tdap product (Boostrix or Adacel) can be used interchangeably regardless of prior vaccine manufacturer. 1
• Tdap can be co-administered with other vaccines (including MCV4) using separate syringes at different anatomic sites. 1
• Tdap is licensed for single use only; no prelicensure studies evaluated repeat doses. 1, 3

Critical Pitfalls to Avoid

• Do not administer DTaP to persons aged ≥7 years—use Tdap or Td instead. 2
• Do not give tetanus boosters more frequently than every 10 years for routine immunization, as this can cause Arthus reactions (severe local hypersensitivity with pain, swelling, and induration). 2
• Do not restart the vaccination series if doses are delayed—continue from where the patient left off. 2
• Do not miss the opportunity to administer Tdap to adults who have never received it, regardless of when they last received Td. 2
• Do not delay Tdap administration based on interval concerns—when indicated, administer regardless of time since last tetanus-containing vaccine. 1

Safety Profile

• Pain at the injection site is the most common adverse event, occurring in approximately 75% of recipients, with severe pain in 4.6%. 3
• Most adverse events are mild to moderate in intensity and transient. 5, 6
• Serious vaccination-related adverse events are rare across all age groups. 5, 7
• A second dose of Tdap approximately 10 years after the first is well tolerated and immunogenic, though not currently part of routine recommendations. 8