What are the recommendations for DTP (Diphtheria, Tetanus, and Pertussis) vaccination in adults?

DTP Vaccination in Adults

Primary Recommendation

All adults aged 19-64 years should receive a single dose of Tdap (tetanus, diphtheria, and acellular pertussis vaccine) to replace one Td booster if they have not previously received Tdap, regardless of the interval since their last tetanus vaccination. 1 After receiving Tdap, adults should continue with Td boosters every 10 years. 1

Standard Adult Vaccination Schedule

Routine Use for All Adults

• Adults aged 19-64 years who received their last Td dose more than 10 years ago should receive a single Tdap dose to replace the next scheduled Td booster. 1
• The standard interval can be shortened to as little as 2 years from the last Td dose when protection against pertussis is needed, particularly in high-risk settings. 1
• Following the single Tdap dose, subsequent boosters should be Td every 10 years beginning 10 years after Tdap receipt. 1

Extended Age Recommendations

• Adults aged ≥65 years should also receive a single dose of Tdap if they have never received it, regardless of the interval since their last tetanus-containing vaccine. 2
• When feasible, Boostrix should be used for adults ≥65 years, though either Tdap product (Boostrix or Adacel) is acceptable and immunogenic. 2
• The safety profile and frequency of adverse events in adults ≥65 years are comparable to younger adults. 2

High-Priority Populations Requiring Accelerated Tdap

Healthcare Personnel

• All healthcare workers in hospitals or ambulatory care settings with direct patient contact should receive Tdap as soon as feasible if not previously vaccinated. 1
• An interval as short as 2 years from the last Td dose is specifically recommended for these workers, even though routine boosters are typically given every 10 years. 1
• This includes physicians, nurses, aides, respiratory therapists, radiology technicians, students, dentists, social workers, chaplains, volunteers, and dietary/clerical workers. 1
• Healthcare workers without direct patient contact should receive Tdap at the next scheduled Td interval (≤10 years), though they are encouraged to receive it as early as 2 years after the last Td. 1

Adults with Infant Contact

• Adults who have or anticipate having close contact with infants aged <12 months (parents, grandparents <65 years, childcare providers) should receive Tdap at intervals <10 years since the last Td. 1
• Ideally, these adults should receive Tdap at least 2 weeks before beginning close contact with the infant. 1
• An interval as short as 2 years from the last Td is suggested, though shorter intervals may be used. 1

Pregnant and Postpartum Women

• Women should receive Tdap before becoming pregnant if they have not previously received it. 1
• Women who did not receive Tdap before pregnancy should receive it in the immediate postpartum period before hospital discharge, or as soon as feasible thereafter. 1
• Breastfeeding is not a contraindication to Tdap vaccination. 1

Wound Management Protocol

Tdap Preferred for Wound Care

• For adults requiring tetanus toxoid-containing vaccine as part of wound management who have not previously received Tdap, a single dose of Tdap is preferred over Td. 1
• For adults previously vaccinated with Tdap, use Td if a tetanus toxoid-containing vaccine is indicated for wound care. 1

Timing Based on Wound Type

• Clean, minor wounds: No tetanus vaccination needed if the last dose was within 10 years; if >10 years, give Tdap (if never received) or Td. 2
• Contaminated or severe wounds: Tetanus vaccination needed if >5 years since last dose; give Tdap (if never received) or Td. 1, 2
• Adults who completed the 3-dose primary series and received tetanus vaccine <5 years earlier do not require additional vaccination for wound management. 1

Unknown Vaccination History

• Persons with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid-containing vaccine. 1, 2
• These individuals may require both tetanus toxoid and tetanus immune globulin (TIG) for contaminated wounds, administered in separate syringes at different anatomic sites. 1, 2

Administration Details

Dosage and Route

• The dose of Tdap is 0.5 mL, administered intramuscularly, preferably into the deltoid muscle. 1

Simultaneous Vaccination

• If multiple vaccines are indicated, administer them during the same visit using separate syringes at different anatomic sites. 1
• Experts recommend no more than two injections per muscle, separated by at least 1 inch. 1

Contraindications and Precautions

Absolute Contraindications

• History of serious allergic reaction (anaphylaxis) to any component of the vaccine. 1
• Persons with anaphylaxis to Tdap or Td components should be referred to an allergist to determine specific allergies. 1

Precautions

• History of Arthus reaction following a previous tetanus or diphtheria toxoid-containing vaccine: defer Tdap until ≥10 years after the most recent dose, even for wound management. 1
• If Arthus reaction occurred with a vaccine containing only diphtheria toxoid (e.g., MCV4), consider checking serum tetanus antitoxin levels (>0.1 IU/mL is protective) or administer tetanus toxoid (TT) alone. 1

NOT Contraindications or Precautions

The following conditions do NOT preclude Tdap vaccination in adults (though some are precautions for pediatric DTaP): 1

• Temperature >105°F within 48 hours after pediatric DTP/DTaP
• Collapse or hypotonic-hyporesponsive episode within 48 hours after pediatric DTP/DTaP
• Persistent crying >3 hours within 48 hours after pediatric DTP/DTaP
• Convulsions within 3 days after pediatric DTP/DTaP
• Stable neurologic disorders (well-controlled seizures, resolved seizure disorder, cerebral palsy)
• Brachial neuritis
• Immunosuppression, including HIV (though immunogenicity may be suboptimal)
• Breastfeeding
• Minor intercurrent illness
• Use of antimicrobials
• History of extensive limb swelling after pediatric DTP/DTaP or Td that was not an Arthus reaction

Special Clinical Situations

Pertussis Outbreaks

• During community pertussis outbreaks or periods of increased activity, consider administering Tdap at intervals <10 years since the last Td or TT if Tdap was not previously received. 1
• The benefit of shortened intervals is particularly increased for adults with comorbid medical conditions. 1

History of Pertussis Disease

• Adults with a history of pertussis should still receive Tdap according to routine recommendations. 1
• This is preferred because protection duration after natural infection is unknown (may wane as early as 7 years), and pertussis diagnosis is difficult to confirm. 1
• Administering pertussis vaccine to persons with prior pertussis presents no theoretical safety concern. 1

Critical Pitfalls to Avoid

Do NOT Over-Vaccinate

• Never administer tetanus boosters more frequently than every 10 years for routine immunization, as this increases the risk of Arthus reactions (severe local hypersensitivity with pain, swelling, and induration developing 4-12 hours post-injection). 2
• For patients with previous Arthus reactions, do not give tetanus-containing vaccines more frequently than every 10 years, even for wound management. 2

Do NOT Use Pediatric Formulations

• Pediatric DTaP vaccine formulations should never be administered to adults. 1
• Use Tdap or Td instead for all persons aged ≥7 years. 2

Do NOT Restart Series

• If vaccination history is incomplete, do not restart the series regardless of time elapsed between doses—simply continue from where the patient left off. 2

Do NOT Miss Opportunities

• Every adult healthcare visit should be regarded as an opportunity to assess vaccination status and provide Tdap if not previously received. 3
• Do not miss the opportunity to administer Tdap to adults who have never received it, regardless of when they last received Td. 2

Rationale for Adult Pertussis Vaccination

Waning Immunity

• Immunity to pertussis wanes approximately 5-10 years after completion of childhood vaccination, leaving adolescents and adults susceptible. 3
• Seropositivity rates for antibodies against pertussis toxin begin to decline by 5 years after a Tdap booster in adolescents/adults. 4

Disease Transmission

• Adolescents and adults with waning immunity serve as a major reservoir for pertussis transmission, particularly to vulnerable infants. 3
• Infants aged <12 months have the highest risk for pertussis-related complications, hospitalizations, and death. 1
• Vaccinating adult contacts reduces the risk of transmitting pertussis to infants. 1

Vaccine Efficacy

• Acellular pertussis vaccine efficacy was 92% (95% CI = 32%-99%) against confirmed pertussis in U.S. randomized trials. 3
• Serum concentrations of anti-pertussis antibodies approximately 1 month after Boostrix administration were noninferior to those shown to have protective effects in infants. 5

Implementation Considerations

Current Coverage Gaps

• As of 2013, national Tdap vaccination coverage among adults aged ≥18 years was only 28.9%, with state-level coverage ranging from 17.7% to 47.6%. 6
• Among adults who received tetanus vaccination during 2005-2008, only 52.0% reported receiving Tdap rather than Td. 7
• Healthcare personnel had higher Tdap coverage (15.9%) compared to the general adult population, but this still represents substantial under-vaccination. 7

Maximizing Vaccination Rates

• Hospitals and ambulatory-care facilities should provide Tdap for healthcare personnel using approaches that maximize vaccination rates: education about benefits, convenient access, and provision at no charge. 1
• Maintaining personal vaccination records is important to minimize unnecessary vaccinations. 1